SocialJusticethroughSocialInvestment:

UsingStakeholderInterviewstoIdentifyImpact

APilotCaseStudyofSadeCrianaofBrazil

AmieR.Baron

HonorsThesis
StanfordUniversity






B.A.inPublicPolicy
with
InterdisciplinaryHonorsin
EthicsinSociety
January6,2011


Abstract


Foundations and nonprofits play a vital role in the provision of critical social services.
Recent data indicate that in the United States, charitable contributions exceeded $300 billion
annually, about 2.2% of the US GDP in 2008. By comparison, charitable contributions in Brazil
were about 0.3% of Brazils GDP in 2007. A recent estimate indicates there are about 1.5
million nonprofits in the U.S., and over 270,000 organizations in Brazil.

By drawing on ethical and theoretical arguments, combined with pilot field research
conducted in Rio de Janeiro, Brazil, this thesis develops an original characterization of the role
that the philanthropic and nonprofit sector may play in promoting social justice. The works of
Rawls and Sen are used as a basis to argue that nonprofits and foundations, providing certain
collective goods, reinforce the implicit social contract that binds the government and the
citizenry. In order to advance social justice, it is further argued that the clients served by a
nonprofit must be actively engaged when evaluating impact.

The pilot research presented in this thesis tests the hypothesis that stakeholder interviews can
be used to obtain significant information about impact from clients served, funders, community
or government partners, staff, and volunteers. Fieldwork for the pilot case study was performed
at Sade Criana, a health-based organization headquartered in Rio de Janeiro. Sade Criana
partners with government hospitals, monitors and evaluates its impact, and has demonstrated
scalability; all attributes that are germane to the pilot study. The study was designed to
determine if stakeholder interviews could provide a greater understanding of Sade Crianas
impact on the empowerment of its participating families. Arranging the thematic structure of
stakeholder interviews around empowerment provided the opportunity to learn about the nature
of any increase in empowerment of the program participants, as well as to discover hidden
impacts of the program through the use of open-ended interview questions. One significant
impact was that Sade Criana client families disseminated health information within their
communities. This included material about Dengue Fever (in the 2008 epidemic, there were
about 55,000 cases reported in Rio), and other information critical for public health.

The pilot study demonstrates that stakeholder interviews can unveil critical information,
which may not be identifiable through quantitative data. These insights can be vital for helping
program staff better meet the organizations mission, address issues of accountability and
transparency, and provide for a more effective distribution of social services. Stakeholder
interviews can also help funders to better assess the effectiveness of a nonprofits program,
thereby optimizing the power and benefit of their social investment to foster social justice.

















DedicadoatodasasfamiliasdaSadeCriana




Table of Contents

Acknowledgments................................................................................................................................1
Chapter1:Introduction.....................................................................................................................3
Section1.1:RiodeJaneiro-ACidadeMaravilhosaeACidadePartida...................................................3
Section1.2:StakeholdersandImpact....................................................................................................................5
Section1.3:CivilSociety,Politics,andtheFavelas...........................................................................................7
Section1.4:PilotCaseStudyofSadeCriana................................................................................................10
Section1.5:ThesisOverview..................................................................................................................................13
Section1:SadeCrianawithinBrazilsEconomic,Political,andCivilContext..........14
Chapter2:BrazilTheWorldsEighthLargestEconomy...............................................................15
Chapter3:ALegacyofInequality............................................................................................................19
Section3.1:ExtremesofWealthandPoverty..................................................................................................19
Section3.2:SocialContractFailureinRiosFavelas.....................................................................................25
Chapter4:BrazilsDemocracy-UsheringinaResponsetoContractFailure..........................33
Section4.1:AnOverviewofBrazilsCivilSociety..........................................................................................33
Section4.2:RecentGovernmentPolicytowardInequality.......................................................................41
Chapter5:SadeCriana-HelpingtoRepairtheSocialContract...............................................45
Section5.1:OverviewofServices.........................................................................................................................45
Section5.2:MonitoringPerformance,TrackingResults,andAssessingImpact..............................55
Section2:SocialJustice,GovernmentFailure,andtheRoleoftheNonprofitSector..65
Chapter6:SocialContractTheory-AFrameworkforSocialJustice..........................................66
Section6.1:IntroductiontotheSocialContract.............................................................................................66
Section6.2:LinkingtheSocialContractwithJustice....................................................................................67
Section6.3:Health,Inequality,andSocialJustice..........................................................................................71
Section6.4:Crises,LimitedResourcesandtheSocialContract...............................................................73
Section6.5:NonprofitsandConditionsofSystemicInstitutionalFailure..........................................75
Section6.6:TheNonprofitSectorsRoleinReinforcingtheSocialContract.....................................78
Chapter7:TheValueoftheNonprofitSectorinProvidingSocialServices:ATheoretical
andPracticalDiscussion............................................................................................................................81
Section7.1:TheThreeFailuresTheory.............................................................................................................83
Section7.2:CategorizingTheRelationshipbetweentheNonprofitandGovernmentSectors..87

Section7.3:TheNonprofitSectorandaStrongDemocracy.....................................................................91
Section7.4:TheNonprofitSectorasaLaboratoryforSocialInnovation...........................................92
Section3:UsingStakeholderInterviewsasaMeansofIdentifyingImpact:APilot
CaseStudyonSadeCrianaofBrazil........................................................................................95
Chapter8:ConsideringImpactandtheValueofStakeholderInterviews................................96
Section8.1:ThePhilanthropic/NonprofitSectorandImpactAvarietyofPerspectives..........96
Section8.2:TheEthicalSignificanceofStakeholderInterviews...........................................................101
Chapter9:ResearchOrganization,Preparation,andMethodology.........................................105
Section9.1:OverviewofPilotCaseStudy.......................................................................................................105
Section9.2:IndicatorsforEmpowermentandInterviewQuestions..................................................108
Section9.3:DatafromFamilyInterviews.......................................................................................................112
Chapter10:PilotCaseStudyFindings................................................................................................119
Section10.1:OverviewofFindings....................................................................................................................119
Section10.2:EmpowermentandSelf-Esteem..............................................................................................121
Section10.3:SadeCrianaandGovernmentProvisionofHealthServices....................................124
Section10.4:DisseminationofInformationbyParticipants..................................................................134
Section10.5:SocialAwarenessthroughCivicEngagement....................................................................138
Section10.6:EmpowermentofParticipants..................................................................................................141
Chapter11:Conclusions..........................................................................................................................155
Section11.1:ReviewoftheEthicalandTheoreticalFrameworkforthePilotStudy..................156
Section11.2:EvaluationofPilotCaseStudy..................................................................................................159
Section11.3:SummaryofKeyFindingsandDirectionsforFurtherResearch...............................162
AppendixA:StaffInterviewees..................................................................................................167
AppendixB:FamilyInterviewees..............................................................................................170
AppendixC:SadeCrianaLetterofAgreement..................................................................174
AppendixD:IRBNoticeofExemptReview.............................................................................175
Bibliography.....................................................................................................................................176


List of Figures and Tables

Figure1.Rocinha,RiodeJaneiro.OneofRioslargestfavelas..........................................................................10
Figure2.SadeCriana:BreakingtheCycleofMisery..........................................................................................12
Figure3.BrazilsGiniIndexin1999.............................................................................................................................23
Figure4.AGraphicalRepresentationoftheRelationshipbetweenLorenzCurvesandtheGiniIndex,
withBrazilandHungaryasExamples................................................................................................................23
Figure5.ComparisonoftheGiniIndexAcrossCountrieswiththeTenLargestEconomies.................24
Figure6.ComparisonofGDPAcrossCountrieswiththeTenHighestGiniIndices.................................24
Figure7.GDPandGiniIndicesusedtoderiveFigure5andFigure6..............................................................25
Figure8.HierarchyoftheDrugCartels........................................................................................................................28
Figure9.HomeofaSadeCrianaFamily...................................................................................................................51
Figure10.SadeCrianaBudgetinReis,YTDJan-Aug2010..............................................................................54
Figure11.ExcerptofSadeCrianasFamilyActionPlanforaRepresentativeFamily.........................57
Figure12.SadeCrianasIndicators(Indicadores)andStepsforCollectingandRecording
information.....................................................................................................................................................................57
Figure13.ReductionofHospitalCostsDuetoLowerRe-internment2009.................................................61
Figure14.ImprovementintheChildrensHealth,2009.......................................................................................61
Figure15.ImprovementintheFamilysIncome,2009.........................................................................................61
Figure16.CategoriesofNonprofit/GovernmentInteraction............................................................................88
Figure17.QuestionnaireonSelfEsteem(inPortuguese)..................................................................................123
Figure18.Self-Esteem2010,1
st
Semester.SadeCriana.................................................................................123
Figure19.SocialJusticeThroughSocialInvestment:ThesisFlowChart.....................................................157

Table1.BaronFieldResearchWorkFlow-byGoalsandTasks.....................................................................106
Table2.InterviewScriptforSadeCrianaPilotCaseStudy...........................................................................110
Table3.FamilyIntervieweeData..................................................................................................................................114
Baron 1
Acknowledgments
It is with deep appreciation that I wish to thank the many people who have provided me with
support, guidance, and advice.
Many Stanford faculty and staff have offered me invaluable assistance with this project. I
benefitted greatly from the support of Rob Reich and Bruce Sievers for my research interests.
Directed readings with them significantly shaped my thinking about civil society. All of their
insightful advice is appreciated. Monica McDermott, in Sociology, advised me on qualitative
research methodology, helped me structure the stakeholder interviews, and counseled me on the
execution of the field research. Debra Satz, Joshua Cohen, and Rob Barlow provided feedback
on sections of my thesis. Mary Sprague, in Public Policy, John Bravman, and Jeff Wachtel
provided guidance and support during my Stanford career. The pilot study research was funded
by a Stanford Undergraduate Research Grant, and many people at UAR offered assistance and
guidance. Lauri Kanerva helped me gain insight into institutional safeguards for protecting
human subjects.
At Sade Criana, in Rio de Janeiro, many individuals provided assistance during my field
research. I am honored to have had the opportunity to work with them and to learn from them.
Cindy Lessa, as my community mentor during my 2008 Haas Summer Fellowship in Brazil,
provided a gracious orientation to Brazilian civil society and introduced me to Sade Criana.
Conversations with Cindy were instrumental to developing the focus of the pilot case study.
Vera Cordeiro generously supported my interest in conducting research at Sade Criana.
Martha Scodro, Mariana Velloso, and Cristiana Velloso, provided invaluable help and assistance
by facilitating my research preparations, on-site interviews, and post-research follow up. All of
the staff at Sade Criana were warm, helpful, and accessible.
Many programs sponsored by the Haas Center for Public Service have played a pivotal role
in fostering my commitment to public service. I was first introduced to the power that
philanthropy has to effect positive change during my Sand Hill Fellowship at the Walter and
Elise Haas Fund. Mentorship from Pamela David and Stephanie Rapp has been invaluable.
Conversations with Perla Ni, of GreatNonprofits, influenced my thinking about the necessity for
stakeholder feedback. The Haas Impact Abroad Program in Bolivia introduced me to hands-
on international development challenges, geo-politics, and effective micro-finance solutions.
Baron 2
The Donald Kennedy Summer Fellowship for Public Service provided the catalyst and
inspiration for this thesis.
Several Brazilian friends helped guide me through Rio, and greatly contributed to my
understanding of the Cidade Partida e Cidade Maravilhosa Fernando Scodro, Marcus
Alfonseco, and Fernando Ribeiro.
While at Stanford, my introduction to philanthropy and the nonprofit sector began at Hillel,
with a Koret Development Internship. Adina Danzig Epelman, Mychal Copeland, Jon Kaplan,
Jon Katz, and all of the Hillel staff have provided me with warm mentorship. Hillel became a
home that I have cherished at Stanford. I wrote much of my thesis there.
There are two very special Brazilian families who welcomed me to Rio de Janeiro with
bountiful hospitality. They opened their homes and their hearts to me, as they introduced me to
their city. The home of Joo, Violeta, Tuta, and Flora Valle, is fondly regarded as Hotel Joo,
and is famous for its superb cooking, movie recommendations, and translation expertise. My
friendship with Raul, Marina, Ilan, Renata, baby David (who I am excited to meet), and the rest
of the Gottlieb clan now spans three continents with only four more to go! Delightful
Shabbat dinners and Sunday night pizzas were two weekly traditions that made me feel right at
home. Gottliebs and Valles, please know how very appreciative I am that you have welcomed
me into your families. You have enriched my life and touched my heart. I care about you very,
very much.
My spunky ninety-seven year old grandmother, Henrietta, was an excellent motivator
through her persistent encouragement. My cousin, Cindy Cooper, has been extremely caring,
and hosted me at a great San Francisco workspace. All of my family, roommates, and friends
have been very supportive and patient. Many of you read drafts, and were a sounding-board for
my ideas. Your enthusiastic cheerleading has lifted my spirits as I wrestled with this thesis.
To my parents, thank you for your boundless love and support.
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Chapter 1: Introduction


Section1.1:RiodeJaneiro-ACidadeMaravilhosaeACidadePartida

It is said that the residents of Rio de Janeiros favelas, urban slums that grow along the
citys mountainsides, lay claim to some of the most gorgeous views of a place known as the
Cidade Maravilhosa the Marvelous City. If your eyes can glance over, and avoid, the heaps
of trash, or the collapsing tin-roof houses that are spread out down the side of one hill, and up
another, you are rewarded with a beautiful vista within a city also known as the Cidade Partida -
the Divided City of Rio de Janeiro. This term, Cidade Partida, captures so much more
meaning than is conveyed by its humble English translation. In one city, at precisely the same
moment, Cariocas
1
of every possible background gather on Rios resplendent beaches,
2
while
child soldiers may fight in lethal drug wars and Rios middle and upper class citizens enjoy
sitting peacefully in the butecos (neighborhood bars) that dot every corner.
While the extraordinary contrasts of the Cidade Partida visually surround you during the
day, in the evening, the lights of the favelas flickering up and down the mountainsides are
deceptively tranquil and beautiful, as children sleep in the streets. But, the illusion of tranquility
is fleeting. Many of the favelas are self-governing islands. Self-governing because the
governments failure to abide by its social contract, through its neglect to provide security and
necessary social services to all of its citizens, has left a gaping hole in their societal structure,
which was readily filled by the violently enterprising drug cartels.

1
Portuguese term for residents of Rio de Janeiro.
2
My Brazilian host sister, Flora Valle, describes Rios beaches, as an inexpensive and democratic space where
everyone can go and meet people regardless of ones social status.
Baron 4
Everywhere you look across Rio, there are favelas.
3
Due to urban migration and poor
governmental policy, around 1,000
4
of these communities have grown to overwhelm the
landscape, such that stunningly affluent bairros (neighborhoods) directly border extraordinary
poverty. Although the middle class is growing, these socio-economic extremes define Brazil, as
does its skyrocketing economic growth, which is propelling this Latin American powerhouse to
international center stage.
During the summer of 2008, I spent three months in South America, working on two
public service projects. I began the summer in Bolivia, on a Stanford Haas Center three-week
International Service trip. We were based in Cochabamba, and spent much of our time helping a
micro-finance organization, ProMujer, to develop marketing materials to attract clients and
funding. In July, I continued on to Rio de Janeiro, on my own, as a Haas Summer Public Service
Fellow. I spent ten weeks working in association with Ashoka, a U.S. based international
nonprofit that offers funding and other support to social entrepreneurs. My intention over that
summer was to focus on the organizational challenges facing Ashoka Fellows and other
nonprofits, how they confronted these challenges, and how Stanford students might help. I could
not have fathomed the levels of poverty and social inequality I would witness.
Of all the many effective and innovative organizations that I had the opportunity to
experience that summer, one that has deeply touched me is Sade Criana, an organization based
in Rio de Janeiro and founded by an Ashoka Fellow, Dr. Vera Cordeiro, a pediatrician. Sade
Criana assists impoverished families with severely ill children in order to break an embedded

3
The conditions in favelas vary widely, but these areas are often sites of controlled criminal activity and are often
not patrolled by police. U.S. Department of State. (2010, January 12). International Travel Information: Brazil
Country Specific Information. Bureau of Consular Affairs, U.S. Department of State.
4
Sharmila Devi. (2010). Innovation and Education Improve Health in Rio's Favelas. The Lancet 376(9735), 83-84.
Baron 5
cycle that leads to the childrens constant hospital re-internment, further imperiling the familys
survival, while draining limited public health resources.
I was struck by the social value of Sade Crianas work, their ingenious methodology,
and their ability to dramatically scale, as they tackle Brazils social injustice head-on. Here was
an organization that believed that incorporating metrics into its methodology was critical for
insuring that its impact would advance its mission. However, it quickly became apparent to me,
that Sade Crianas impact far exceeded that which was readily measurable.
In April, 2010, I returned to Rio de Janeiro, to conduct research for a pilot case study on
Sade Criana. My work was funded by a Stanford Undergraduate Research grant, with
approval to carry out qualitative research from Stanfords Institutional Review Board. The
primary objective of my case study was to determine if stakeholder interviews would reveal and
identify additional, unforeseen, and possibly substantive areas of impact by Sade Criana, as it
tackles Brazils inequality through supplementing and complementing the governments
provision of social services.
Section1.2:StakeholdersandImpact

In general, my thesis argues that if a philanthropy or nonprofit engages in the provision of
social services to promote social justice, the organization implicitly accepts the ethical obligation
to actively involve stakeholders when evaluating the impact of an intervention. This argument is
supported through:
(1) establishing that those nonprofits which engage in the provision of collective
goods implicitly reinforce the social contract - a tool for conceptualizing
governments obligation to society;
Baron 6
(2) presenting empirical evidence which confirms that stakeholder interviews are a
means for accessing substantive information about a nonprofits impact; and,
(3) contextualizing this empirical evidence within the lens of Brazil as a young
democracy, with: an emerging civil society, a soaring GDP, a history of systemic
institutional failure,
5
and extreme socio-economic inequality.
In any discussion bridging impact and accountability in the philanthropic/nonprofit
sector, in which the ultimate objective is social justice, it is essential that the clients and
communities affected by an intervention be considered. In a significant review article entitled,
Accountability In Practice: Mechanisms for NGOs, by Ebrahim, functional accountability is
defined as, accounting for resources, resource use, and immediate impacts. Ebrahim
summarizes Najam, who suggests,
that while functional accountability of NGOs to patrons, operationalized
through reports and accounts, is typically high in practice, functional
accountability to clients and NGOs themselves is low.
6

Similarly, Forman and Stoddard write,
NGO accountability once meant simply answering to donors on how their
dollars were spent and to what effect. This practice resulted in donor-
driven projects more concerned with fulfilling donor requirements than
with addressing the actual needs of or offering long-term benefits to the
target population. Increasingly, relief and development NGOs are
attempting to be equally accountable to their customers or clients in
developing countries.
7


5
In this thesis, the term systemic institutional failure refers to situations in which a legitimate government such as
Brazils democratically elected government - fails to uphold the implicit social contract in certain critical areas.
Implications of systemic institutional failure are discussed throughout this thesis, and are evidenced by the absence
of police protection and other government services within the favelas. I argue that these services ought to be
equitably and universally provided. As defined in Chapter 6.2, I use the term systemic institutional failure to refer
to a real world manifestation of the failure of the implicit social contract.
6
Alnoor Ebrahim. (2003). Accountability in Practice: Mechanisms for NGOs. World Development 31(5), 815.
7
Shepard Forman and Abby Stoddard. (2003). International Assistance. In Lester M. Salamon (Ed.), The State of
Nonprofit America (pp. 240-274), 256.
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In building from this evolving understanding of accountability, how can a foundation or
nonprofit working toward social justice know that it has accomplished its mission, without
directly engaging critical stakeholders the clients and community affected - in a discussion of
its impact? In order to address this ethical imperative, my pilot case study explores the use of
stakeholder interviews as a tool for providing a vital source of information about impact.
Briefly, my findings support the hypothesis that stakeholder interviews can contribute
essential information about the impact of a nonprofit program that engages in the provision of
social services; this information may not be identifiable through quantitative data. Insights
derived from stakeholder interviews can be vital for helping program staff better meet an
organizations mission, address issues of accountability and transparency, and provide for a more
effective distribution of social services. Stakeholder interviews can also help funders to better
assess the effectiveness of a nonprofits program, thereby optimizing the power and benefit of
their social investment to foster social justice.
The need for a strong philanthropic/nonprofit sector, which is accountable to all of its
stakeholders, is especially critical in a society such as Brazils, with its dramatic socio-economic
challenges.
Section1.3:CivilSociety,Politics,andtheFavelas

Currently, Brazils creative, young culture fosters large numbers of well-educated social
entrepreneurs. Given that the fall of Brazils dictatorship occurred in 1985, and the first
democratic election was in 1989,
8
Brazils civil society is still in its relative infancy, compared to
that of the United States. A strong civil society is closely correlated with a strong democracy.
One of the first scholars to document the connection was de Tocqueville. After touring the

8
Arthur Ituassu. (2010, July 29). Brazil: Democracy Versus Poverty. OpenDemocracy.
Baron 8
United States in the 1830s, he wrote extensively about the utility of associations among a
democratic people,
9
and that the right of the people peaceably to assemble,
10
contributes to
the strength of democracy.
In light of the Brazilian governments failure to provide sufficient social services, some
Cariocas support civil-sector organizations out of charitable concern for social justice; others
realize that it is necessary to improve the standard of living across Brazils society in order to
prevent violence originating in the favelas from spilling into their own communities.
Interests in security and social justice, combined with the mandatory voting law, are
hopefully motivating the Brazilian government to find real solutions to its history of gross social
contract failure. In 2007, President Lula da Silvas administration launched the Programa de
Accelerao (Growth Acceleration Project), which is meant to entail the stable provision of
social services and to foster economic development for all of Brazil. The projects second
investment phase, which was initiated in 2010, focuses on,
investments in the areas of logistics, energy and social development,
organized under six major initiatives: Better Cities (urban infrastructure);
Bringing Citizenship to the Community (safety and social inclusion); My
House, My Life (housing); Water and Light for All (sanitation and access
to electricity); Energy (renewable energy, oil and gas); and Transportation
(highways, railways, airports).
11


Even though the mandatory voting law should give a voice to the poor, in many instances
politicians cut deals with the donos
12
in order to campaign in the favelas. The politicians may
make empty promises to the local populations, and because the drug factions have forcibly

9
Alexis de Tocqueville. (1990). Democracy in America. Phillips Bradley (Ed.). (Original published in 1835).
10
U.S. Const. amend. I.
11
Ihssane Loudiyi. (2010, March 30). Brazil Announces Phase Two of the Growth Acceleration Program. Growth
and Crisis Blog, The World Bank.
12
Rank within the drug cartel. Each dono has exclusive control over his favela, although the top of the cartels
hierarchy resides outside of the favela.
Baron 9
annexed their favelas from those of rival factions, it can be very hard for favela residents to
politically organize.
13

Characterizing Rios favelas is complicated. Some are well established, and support vast
populations. Rocinha, one of Rios largest and most well-known favelas (Figure 1) with an
estimated population of at least 100,000 residents, has historically tapped into the asfaltos
14

supply of electricity and water.
15
Favelas may have profitable businesses such as McDonalds (or
Bobs), cell phone stores, local juice bars, and pizzerias.
16
While some favelas are on the
hillsides throughout Rio proper, others lie on the outskirts of the city in the suburbs. A
Brazilian notion of a suburb is very different than one in the U.S.; in Brazil, a suburb may refer
to a poor, comparatively more rural location.
While some favela residents are unemployed, others work throughout Rio. Some
occupations include working as: maids, porteiros,
17
private security, secretaries, and employees
of service industries. Both adults and children sell items in the street and along the beaches,
forming an illegal market. Should the government seize the wares of these people, the
repercussions are crippling for their families.
In some favelas, residents have traded rule-by-drug-lord for rule-by-militia. While the
militia may be as corrupt and violent as the drug factions, a primary difference felt by the
residents is the lack of the drug trade and its supporting infrastructure in the communities.
18,19

Through its police force, the government has made a concerted effort to pacify certain favelas

13
Luke Dowdney. (2003). Children of the Drug Trade: A Case Study of Children in Organised Armed Violence in
Rio de Janeiro.
14
Definition of asfalto: the name given to the parts of the city built on asphalt, as opposed to the natural, unstable
hillside soil and sometimes trash (such as in Niteroi) that may provide a foundation for favelas.
15
Robert Neuwrith. (2005). Shadow Cities: A Billion Squatters, a New Urban World, 43.
16
For example, see Neuwirth.
17
Watchmen/doormen
18
Alexei Barrionuevo (2008, June 13). In Rio Slum, Armed Militia Replaces Drug Gang's Criminality with its Own.
The New York Times.
19
Amie R. Baron. (2008). Personal Communication with a Brazilian Colleague While on a Favela Site Visit.
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in recent years. This pacification of the communities has presented immense challenges,
including police/drug soldier warfare.
20
One of the issues facing legitimate state actors in
gaining authority over the favelas is that the local populace can develop a loyalty to those donos
who were raised in the community. This loyalty may develop out of fear of repercussions, lack
of a better alternative, and a belief that the donos who were born in their community know the
community, and may rule as benevolent dictators.
21
However, the government program does
appear to be having some success, as reflected in rising land values near some of these favelas.
22


Figure 1. Rocinha, Rio de Janeiro.
One of Rios largest favelas.
23

Section1.4:PilotCaseStudyofSadeCriana

Sade Criana exemplifies the spirit of social innovation that is able to counter systemic
institutional failure through the civic sector. At the core of Sade Crianas methodology, is its
partnership with Hospital da Lagoa, a public hospital. I conducted my interviews at the site of the
first Sade Criana program, founded in 1991. This office is now their headquarters, as Sade
Criana has scaled through the development of additional programs working in partnership with

20
Tom Phillips. (2009, October 17). Twelve Dead and Helicopter Downed as Rio de Janeiro Drug Gangs Go to
War. Guardian.
21
Dowdney
22
Amie R. Baron. (2010, April). Personal Communication with a Brazilian Friend.
23
Photo by Amie R. Baron, July 2008.
Baron 11
other public hospitals, both in Rio and throughout Brazil. Sade Criana has worked in
partnership with Hospital da Lagoa for nearly twenty years.
Sade Crianas attack strategy is two-pronged: (1) to provide basic support for the
family through its periods of instability; and (2) to help the family learn to cope with the illness
of the child such that within a two-year participation in Sade Criana, the mother is able to
support herself, while caring for the child. Part of the success of this approach is its give-and-
take. The provision for the familys basic needs (food, clothing, and medicine) is never
provided in a vacuum; receipt of these goods is conditional upon participation in all core aspects
of the program. The organization collects extensive data about its clients, both before and during
the programs intervention. The childs health, as a function of the familys welfare, is the
determinant of success. The familys welfare is rigorously tracked through several categories,
namely: income level, quality of housing, education, citizenship, and health.
Sade Criana made available to me their archival data, and provided me with the
opportunity to interview staff, volunteers, and participating families. The participating families
all had children in public hospitals.
In order to determine if stakeholder interviews are an effective means for identifying
substantive information about impact, I used several indicators to examine the role that the Sade
Criana program may have in empowering its participants. These indicators included: whether
Sade Criana participants shared information within their communities, if there was a shift in
how Sade Criana participants interacted with professionals (such as doctors), if Sade Criana
participants experienced changes in family dynamics, if Sade Criana participants increased
their civic engagement, and if Sade Criana participants experienced changes in overall
confidence levels.
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Arranging the thematic structure of the stakeholder interviews around empowerment not
only provided the opportunity to learn about the nature of any increase in empowerment of the
participants in the Sade Criana program, but also opened the door to discovering hidden
impacts of the program through the use of open-ended questions throughout the interview
process.


Figure 2. Sade Criana: Breaking the Cycle of Misery.
24


This graphic depicts the cycle of misery that Sade
Criana seeks to break. Translation of the Portuguese:
Misery Disease Hospitalization Discharge; Sade
Crianas mission is to prevent the perpetuation of this
cycle. In an effort to present a warm and friendly
environment for its families, all of Sade Crianas offices
proudly display the colorful, child-friendly logo of a menino
or menina little boy or girl.


24
Sade Criana. Breaking The Cycle of Misery. < http://www.saudecrianca.org.br/ingles/Index.htm>
Baron 13
Section1.5:ThesisOverview

Section 1: Chapters 2 through 5 provide background on Brazils current economy and
civil society, the governments failure to provide social services to all of its citizens, the narco-
cracy within many of the favelas, and the repercussions on the local populations. Current
government efforts to clean-up the favelas are presented. Brazils relatively young, post-
dictatorial civil society is discussed, along with details about the Sade Criana program and
methodology.
Section 2: Chapters 6 and 7 present frameworks for understanding the value derived from
nonprofits that promote social justice through providing social services. Chapter 6 uses social
contract theory to explain governments obligation to provide certain collective goods (such as
social services) universally and equitably to its citizens. The nonprofit sector will be shown to
foster social justice by reinforcing the implicit social contract. Chapter 7 presents certain
economic theories, which model the role of the nonprofit sector in providing collective goods to
compensate for legitimate government failure.
Section 3: Chapter 8 presents examples of the diversity of methods that funders or
grantees may use to consider the impact of their programs. This section is followed by a
discussion of the ethical imperative to engage stakeholders when evaluating impact and the vital
knowledge that can be derived from stakeholder input. Chapter 9 develops an overview of the
research organization, preparation, and methodology used in implementing the pilot case study.
Chapter 10 presents the findings from field research at Sade Criana. Chapter 11 concludes
with a review of the ethical, theoretical, and empirical framework of this thesis, using a flowchart
(Figure 19). The pilot case study is evaluated, key findings are summarized, and directions for
further research are suggested.
Baron 14
Section 1: Sade Criana within Brazils Economic, Political,
and Civil Context


The work of Sade Criana is best understood within the context of Brazils severe
inequality, history of contract failure, and growing civil society. This section illustrates Brazils
lack of universally provided security and social services as a practical representation of the harm
to society in the event of the failure of the social contract. Chapter 2 overviews Brazils
remarkable economic growth. Chapter 3 contrasts Brazils booming economy with its legacy of
inequality, and the consequent failure of the government to uphold its end of the social contract
within the favelas. Chapter 4 illustrates how Brazils 21st century democratic government, in
conjunction with a developing civil society, is engaged in tackling these challenges. Chapter 5
details Sade Crianas program methodology and its efforts to foster social justice through
improving childrens health.

Baron 15
Chapter2:BrazilTheWorldsEighthLargestEconomy


Brazil is a country of immense contrasts, highlighted by a soaring GDP and a vast natural
resource base containing prized commodities, along with ingrained socio-economic problems
including painfully high levels of inequality and crime. Brazil is the eighth largest economy in
the world;
25
and with a population of nearly 200 million,
26
it is the fifth most populous country.
Brazil is the worlds leading exporter of iron, coffee, soy, soybeans, orange juice, beef, chicken,
sugar, and ethanol.
27
Its Gross Domestic Product (GDP) is currently higher than the GDP of
any other Latin American country, including Argentina and Mexico. Further, Brazils GDP has
grown so dramatically, that it has surpassed the GDPs of Canada, Russia, and India.
28
While
China, the US, and Argentina are among Brazils major trading partners for both exports and
imports,
29
Brazils growth is now tied to China - the second largest economy in the world, partly
because of Chinas voracious appetite for oil, coal, iron ore and other natural resources.
30

Brazils treasure chest of commodities includes iron ore, which China requires for maintaining
its own soaring economic growth. To further add to Brazils commodity clout, massive oil fields
off of Rios coast were recently discovered. This area,
stretching hundreds of miles, is the biggest oil reserve being developed in
the world todayFor Brazil, the stakes are high. Many here see the oil as
a magic bullet for tackling the countrys biggest social challenges. Luiz
Incio Lula da Silva, Brazils popular president, wants to alter energy laws

25
International Monetary Fund. (2010, July 7). World Economic Outlook Database: Nominal GDP list of countries.
26
Andrew S. Ross. (2010, May 11). Brazil Reaches Out to Firms in Bay Area. San Francisco Chronicle.
27
Brazil: Global Partner in a New Economy. (2009, March 30). The Wall Street Journal, Special Advertising
Section. Also see: Paulo Prada. (2010, March 29). For Brazil, it's Finally Tomorrow. The Wall Street Journal,
Brazil: The Journal Report.
28
Andrew Batson. (2010, August 12). China Output Tops Japan's. The Wall Street Journal.
29
Central Intelligence Agency. (2010, October 27). The World Factbook.

30
David Barboza. (2010, August 15). China Passes Japan as Second-Largest Economy. The New York Times.
Baron 16
to funnel more revenue from the undeveloped fields to government coffers
and set up funds to improve education and health care.
31


National elections will occur in October 2010. The question is whether or not Lulas
policies will persist through continued support for his leftist Workers Party by the Brazilian
populace. Lulas favored candidate, Dilma Rousseff, his former chief of staff, is presently ahead
in the polls (as of August, 2010) with a rating of 41%, reflecting significant satisfaction with his
programs. Ms Rousseff vows,
to continue his policies of job creation through spending on big
infrastructure projects, expanding government payrolls and giving the
poor direct cash assistance... [Her] message of continuity hasresonated
well in a booming economy that grew 9% in the first three months of this
year.
32


Given Brazils huge economic and regional political power, its leadership in the Southern
Hemisphere is of great consequence to the United States.
33
As recently noted, Relations
between the U.S. and Brazil, though good, are relatively underdeveloped,
34
and both countries
have been trying very hard to foster meaningful cooperation, despite some trade disagreements.
35

Brazils increasing economic (soft) power supports its efforts to acquire greater international
presence. The recent joint initiative by Brazil and Turkey to institute an accord regarding Irans
nuclear program, has created some consternation in the West, as well as in Brazil.
36,

37

Brazil is marketing itself to foster even greater economic and geo-political opportunities.
On March 30th, 2009, The Wall Street Journal ran an eight page Special Advertising Section

31
Alexei Barrionuevo. (2009, August 17). Brazil Seeks More Control of Oil Wealth Beneath its Seas. The New York
Times.
32
John Lyons. (2010, August 16). President's Chosen Successor Widens Lead in Brazil Poll. The Wall Street
Journal.
33
John Lyons. (2009, February 7). World News: Economy Fuels Brazil's Ambitions Beyond South America. The
Wall Street Journal.
34
John Lyons. (2009, March 11). Brazil's Da Silva Warns Against Protectionism. The Wall Street Journal.
35
Ibid
36
Ahmet Davutoglu and Celso Amorim. (2010, May 26). Giving Diplomacy a Chance. The New York Times.
37
Alexei Barrionuevo and Ginger Thompson. (2010, May 14). Brazil's Iran Diplomacy Worries U.S. Officials. The
New York Times.
Baron 17
entitled, Brazil: Global Partner in a New Economy.
38
A year later, the Wall Street Journal ran
another (four page) advertisement, Investing in Rio de Janeiro, which highlighted a growing
middle class, providing opportunities for investment in consumer markets.
39
Importantly,
according to this advertisement, the Rio-based think tank Fundao Getulio Vargas, reported
that, the middle class, known in Brazil as Class C, increased by over 25 million people between
2003 and 2008, and now represents over 49% of the Brazilian population.
40
Recently, a
Brazilian trade delegation, led by Brazils Minister of Science and Technology, visited the San
Francisco Bay Areas Silicon Valley. We want to show how Brazil is growing, and how the Bay
Area should look at us as an alternative to China and Asia, said Augusto Gadelba, the
Information Secretary of Brazils Ministry of Science and Technology.
41

To further add to Brazils heightened global prominence, the World Cup of 2014 and the
summer Olympics of 2016 will be hosted by Rio de Janeiro. The government has vowed to
invest a great deal of money into increasing Rios security to ensure the safety of its future
international visitors, as well as bolstering its infrastructure.
42
When I was in Brazil in 2008,
some of Rios social entrepreneurs expressed concern, during a meeting that I attended, that
hosting international sporting events in the past (namely, the Pan American Games of 2007) had
been largely ineffective in helping to raise favela residents out of poverty. While these games
will provide opportunities for additional economic investment in Rios infrastructure, they may

38
Brazil: Global Partner in a New Economy.
39
Investing in Rio de Janeiro: Burgeoning City is Poised to be a Magnet for Foreign Funds. (2010, March 31). The
Wall Street Journal, Special Advertising Section.
40
Ibid
41
Andrew Ross. (2010, May 11). Brazil Reaches Out to Firms in the Bay Area. San Francisco Chronicle.
42
Devi
Baron 18
not lead to long-term job creation, as many countries find it hard to sustain related economic
growth (so called borrowed prosperity)
43
after such events conclude.
44

Brazils landmass is nearly as big as that of the United States,
45
and it is home to much of
the Amazon Basin, an area which holds immense environmental value to Brazil and to the world.
The destruction of the rain forest stemming from the value of its cut lumber and the
consequential use of that land to support agriculture is impacting world climate change.
Currently, multinational corporations are buying portions of the Amazon to offset their carbon
output, a somewhat controversial program.
46
Interestingly, the population of the Brazilian
Amazon has just recently acquired its first shopping centers, epitomizing Brazils economic
development.
47

As will be related in Chapter 3, Brazils extraordinarily high GDP - associated with the
worlds richest countries, is incongruent with its strikingly high inequality ranking - associated
with some of the worlds poorest countries.

43
Zhang Ziyang. (2010, June 22). Opinion: World Cup's Economic Effects Hardly Last in Struggling South Africa.
Global Times.
44
William C. Rhoden. (2010, July 12). Who Really Won in South Africa? The New York Times.
45
The World Bank. (2010, October 4). Brazil Country Brief.
46
Andres Cediel (Producer), Mark Schapiro (Reporter). (2010, May 11). Brazil: The Carbon Hunters. Frontline
World 901. [Television broadcast, available online].
47
John Lyons. (2010, May 12). In Amazon, Rain Forests make Room for Mall Rats. The Wall Street Journal.
Baron 19
Chapter3:ALegacyofInequality


The inequality embedded in Brazils socio-economic structure coincides with the
governments neglect to abide by a social contract through the universal provision of security
and social services. This chapter addresses both Brazils inequality and the break-down of the
social contract in the favelas. Chapter 4 will introduce how both the government and civil
society are attempting to change course and address these enormous social challenges.
Section3.1:ExtremesofWealthandPoverty

Brazils inequality in income distribution has been measured for over forty years.
48

Figure 3 (see page 23) shows Brazils relative inequality at the end of the 20th century: in 1999
nearly every country in the world had an income inequality ranking lower than Brazils. Even
with a growing middle class, Brazil still had the tenth highest level of inequality in the world as
of 2004, decreasing from the second highest position in 1989.
49
Brazils Institute of Applied
Economic Research, an agency working in association with the Brazilian Ministry of Planning,
Budget and Management, recently reported,
Despite the recent fall, income inequality in Brazil remains extremely
high: the income of the richest 1% of the population is equal to that of the
poorest 50%. Furthermore, the country continues to occupy a negative
position in the international scene, and 95% of the countries for which
there are data available show concentration levels lower than Brazils.
50

Brazils current ranking as the eighth largest economy in the world is incongruent with its
ranking as having the tenth highest rate of income inequality in the world. These concurrent

48
Institute for Applied Economic Research, Technical Note. (2006). On the Recent Fall in Income Inequality in
Brasil.
49
Francisco H. G. Ferreira, et al. (2006, March 3). The Rise and Fall of Brazilian Inequality: 1981-2004. World
Bank Policy Research Working Paper, no. 3867.

50
Institute for Applied Economic Research, 11.
Baron 20
statistics for Brazil are startling in light of the relative greater equality among other top
economies, and relative poverty among the other countries with a high Gini index.
The Gini index, a widely used method of ranking countries income inequality levels, is
derived from Lorenz curves. In a Lorenz curve, a countrys population is divided into
percentiles (such as 10 groups of 10% each) based on income; the summative income for each
group is divided by GDP to express the percentage of GDP that each income-level owns. The
Lorenz curve is plotted on a graph, where a positive-sloping diagonal line (see Figure 4, page 23)
represents absolute income equality. Although the statistics used in this figure are dated, derived
from information on Brazil in 1989, as compared to Hungary in 1993, the figure is included here
as a visual representation of how Lorenz curves are used to calculate the Gini index.
51
To find
the Gini index, the area between the line of absolute equality, and the countrys Lorenz curve, is
expressed as a percentage of the total area (the large triangle) under the line of absolute equality.
The charts that I have compiled depict the extremes of wealth and inequality in Brazil. In
order to physically plot GDP along the same X-axis as the Gini index, the numbers for GDP have
been divided by trillions of dollars for the high-GDP countries (Figure 5, page 24), and tens of
billions of dollars for the high inequality countries (Figure 6, page 24). Note Brazils extreme
inequality when it is plotted next to the ten wealthiest countries, and its extraordinarily high
GDP, when plotted next to the ten most unequal countries. Brazils GDP is huge - larger by
factors of 5 to nearly 1,000, as compared to the GDPs of other countries with high Gini indices,
although Brazils population is also far greater than that of the other countries. In both Figure 5
and Figure 6, I have included a blow-up of the Gini Index, which on the X-axis starts at 20, as
the lowest Gini index value (Sweden) is 23. By zooming in on cross-country comparisons, these

51
Tatyana P. Soubbotina and Katherine A. Sheram. (2000). Income Inequality. Beyond Economic Growth: Meeting
the Challenges of Global Development. The World Bank.
Baron 21
charts highlight Brazils pronounced separation from other countries; Brazil is separated from the
majority of the top GDP countries (all but the U.S.) by at least 15 points. As recently as 2006,
Brazils Institute of Applied Economic Research, based in Brazil, poignantly asserted that:
even at the accelerated pace at which inequality was reduced in the period
under analysis, it would take Brazil twenty years to start showing a
distribution pattern compatible with that of countries at a similar
development level.
52

As will be demonstrated in Chapter 3.2, concerning social contract failure in the favelas, such
drastic levels of inequality are crippling for a democracy. As Sandel wrote, in Justice, Too
great a gap between rich and poor undermines the solidarity that democratic citizenship
requires.
53
Inequality precipitates separations within society, causing citizens to lead
increasingly divided lives, as exemplified by the Cidade Partida. While the wealthy have the
option to seek out private, more expensive alternatives, the poorest must remain dependent on the
public institutions. Sandel further emphasizes that institutions will deteriorate if it is no longer in
everyones best interest to maintain them. For example, while Brazil offers public healthcare to
all, those who can afford it will likely purchase private insurance. This leaves public hospitals
underfunded, understaffed, and over-occupied. This was especially apparent during the Dengue
Fever crisis during 2008, which hit the favelas painfully hard.
As emphasized in the Associao Sade Criana Renascer (ASCR) Handbook, public
health provides a perspective for clearly understanding the social damage resulting from
embedded inequality. Dr. Cordeiro wrote,
In other developing countries, Public Health is one of the most complex
areas, because thats where the perverse income distribution difference
shows up more clearly. All distortions in our society, a clear picture of
injustice is present in public hospitals, which treat sick children whose
disease is starvation, hospitals that treat adults with high blood pressure

52
Institute for Applied Economic Research, 11.
53
Michael J. Sandel. (2009). Justice: What's the Right Thing to do? 266.
Baron 22
caused by unemployment and the inability to watch their families dying of
starvation.
54

Furthermore, Courtwright wrote in the journal, Bioethics:
many of the social determinants of health like education, income, and
social capital create health disparities through a common pathway; namely
chronic stress. Individuals who are less educated, poor, and with limited
social capital have less control over their lives, which leads to stress and
contributes to poor cardiovascular health.
55

The connection between inequality, poor health, and the resulting stress was encapsulated during
an interview with one of the mothers at Sade Criana. Marcela (#7) related to me that while she
was pregnant with her son, Mrio, her daughter, Julia, was seriously ill with leukemia. Marcela,
feared a miscarriage with Mrio because she was so nervous about Julia.
Sade Crianas multi-faceted approach to healthcare directly combats social injustice by
working toward the universal and equitable provision of healthcare - an essential component for
overcoming inequality. While healthcare is universally provided in Brazil, Sade Crianas
program works toward ensuring that healthcare is equitably and effectively distributed. Dr.
Amartya Sen, a philosopher and economist, writes,
Health equity cannot be concerned only with health, seen in isolation.
Rather it must come to grips with the larger issues of fairness and justice
in social arrangements, including economic allocations, paying
appropriate attention to the role of health in human life and freedom.
56

While public health is one lens through which inequality can be examined, the abandonment of
the security needs of favela residents provides another lens, which will be discussed in the next
section.

54
Sade Criana. (2007). Creating Institutions Based On The ASCR Model. 52.
55
Andrew M. Courtwright. (2009). Justice, Stigma, and the New Epidemiology of Health Disparities. Bioethics,
23(2), 90-96.
56
Amartya Sen. (2002). Why Health Equity? Health Economics, 11. 659.
Baron 23

Figure 3. Brazils Gini Index in 1999. Brazil was the second most unequal country in the world.
(Figure from Velez et al, 2004)
57


Figure 4. A Graphical Representation of the Relationship between Lorenz Curves and the Gini
Index, with Brazil and Hungary as Examples.
(Figure from Soubbotina and Sheram, 2000)
58


57
Figure from: C.E. Velez, et al. (2004), entitled, Brazils Inequality in the International Context, 1999. Inequality
and Economic Development in Brazil. A World Bank Country Study.
58
Figure from: Tatyana P. Soubbotina and Katherine A. Sheram. (2000), entitled, Lorenz Curves and Gini Indexes
for Brazil and Hungary. Income Inequality. Beyond Economic Growth: Meeting the Challenges of Global
Development. The World Bank.
BEYOND ECONOMIC GROWTH
28
10:1 in Sub-Saharan Africa, and 12:1 in
Latin America.
Lorenz Curves and Gini Indexes
To measure income inequality in a coun-
try and compare this phenomenon among
countries more accurately, economists use
Lorenz curves and Gini indexes. A Lorenz
curve plots the cumulative percentages of
total income received against the cumula-
tive percentages of recipients, starting with
the poorest individual or household
(Figure 5.2). How is it constructed?
First, economists rank all the individuals
or households in a country by their
income level, from the poorest to the rich-
est. Then all of these individuals or house-
holds are divided into 5 groups (20
percent in each) or 10 groups (10 percent
in each) and the income of each group is
calculated and expressed as a percentage of
GDP (see Figure 5.1). Next economists
plot the shares of GDP received by these
groups cumulativelythat is, plotting the
income share of the poorest quintile
against 20 percent of population, the
income share of the poorest quintile and
the next (fourth) quintile against 40 per-
cent of population, and so on, until they
plot the aggregate share of all five quintiles
(which equals 100 percent) against 100
percent of the population. After connect-
ing all the points on the chartstarting
with the 0 percent share of income
received by 0 percent of the population
they get the Lorenz curve for this country.
The deeper a country's Lorenz curve, the
less equal its income distribution. For
Figure 5.2
40
20
80
60
100
Percentage of total income
Lorenz curves and Gini indexes for Brazil and Hungary
0
100 0
Poorest
Percentage of total population
Richest
20 40 60 80
Hungary
(Gini index = 27.0%)
Brazil
(Gini index = 63.4%)
Line of absolute
inequality
L
i
n
e
o
f
a
b
s
o
l
u
t
e
e
q
u
a
l
i
t
y
Baron 24

Figure 5. Comparison of the Gini Index Across Countries with the Ten Largest Economies..
(Data retrieved August, 2010. See Figure 7)

Figure 6. Comparison of GDP Across Countries with the Ten Highest Gini Indices. (Data
retrieved August, 2010. See Figure 7)

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Baron 25

Figure 7. GDP
59
and Gini Indices
60
used to
derive Figure 5 and Figure 6.

Section3.2:SocialContractFailureinRiosFavelas

The Brazilian governments history of failure to uphold its social contract,
61
specifically
within the favelas, is correlated with the immense levels of socio-economic inequality discussed
above in Section 3.1. As Sandel continues (from the previous section),
the hollowing out of the public realm makes it difficult to cultivate the
solidarity and sense of community on which democratic citizenship
depends.[I]nequality can be corrosive to civic virtue.
62


Many residents of Rios favelas are trapped under the authority of totalitarian donos; the
plight of these citizens is emblematic of the corrosion of civic virtue.

59
Data retrieved August 17, 2010: International Monetary Fund. (2010, July 7). World Economic Outlook Database,
Gross Domestic Product, Current prices in U.S. Dollars.
60
Data retrieved August 15, 2010: Central Intelligence Agency. (2010). The World Factbook: Distribution of
Family Income Gini Index.
61
Social contract theory will be explored in Chapter 6. Briefly, this hypothetical contract is characterized by a
reciprocal relationship in which the polity accepts governments legitimacy in order to protect individuals rights
that are otherwise unprotected in the absence of government authority.
62
Sandel, 267.
Sorted by GDP GDP (in millions
of $US)
Gini Index
Value
United States 14,430,000 45
Japan 5,108,000 38.1
China 4,814,000 41.5
Germany 3,273,000 27
France 2,666,000 32.7
United Kingdom 2,198,000 34
Italy 2,090,000 32
Brazil 1,499,000 56.7
Spain 1,466,000 32
Canada

1,335,000 32.1
Sorted by Gini
Index

Namibia 9,039 70.7
South Africa 277,400 65
Lesotho 1,624 63.2
Botswana 10,810 63
Sierra Leone 2,064 62.9
Cent. African Rep. 1,983 61.3
Bolivia 17,550 59.2
Haiti 6,908 59.2
Columbia 228,600 58.5
Brazil 1,499,000 56.7



Baron 26
The governance of many of Rios favelas, by either militia vigilante groups, or the drug
factions, exemplifies gross failure of the social contract. Brazilian contract failure has occurred
for over fifty years, and predates the emergence of Rios drug factions:
It is due to the almost total abandonment by state government of favela
communitiesthat has made possible faction domination and control of
favelas. Drug faction control of favela populations has not come about due
to their ability to supersede the state from a political, social or military
perspective. They have simply filled a space that the government has
failed to occupy.
63

For many years, the favela residents have relied on their own efforts and the help of [nonprofits]
to ensure access to basic health care and other services, such as electricity or waste collection.
64

A Washington Post Photo Essay documented the lack of social service provisions in the favelas,
in describing an impromptu favela electrician, who was helping to connect a familys home to a
power line:
The man doesn't work for a public utility company -- such agencies
usually don't serve the favelas. If residents here have services like
electricity or running water, it's usually because they have connected the
wires or pipes to their homes themselves, or else had a frienddo it for
them.
65

In general, in the absence of government, other agents rise to assume some control over
society.
66
In Brazil, the States failure to abide by its half of the social contract and protect its
citizens has enabled urban bandits to subordinate security services, and displace the rule of
law.
67

In the 1970s, a group of imprisoned bank robbers organized, and formed what would
become known as the Comando Vermelho (Red Command). As inmates, they realized that their

63
Dowdney, 71.
64
Devi
65
Monte Reel. (2006). Life in Rios Favelas: Youth Torn between Gangs and the Government. The Washington
Post.
66
Brazils donos are far from the only example of illegitimate agents acting when the state has failed with a result of
pervasive social violence.
67
L. McLeod-Roberts. (2009, September 11). Bullet to Brazil. OpenDemocracy.
Baron 27
internal prison organization was actually able to exert a great deal of influence over the
members communities. The inception of the Comando Vermelho corresponded with the arrival
of cocaine in Rio, transported from Bolivia, Peru, and Columbia to be both sold and consumed
locally and exported to other countries in the West. Realizing the potential wealth in the drug
industry, ex-prisoners carried out a number of bank robberies and kidnappings in order to
finance a concerted move into the retail drugs business.
68
Between 1983 and 1986, the
Comando Vermelho gradually gained control of the favelas, which had been identified as ideal
sales points.
The first soldados do trfico soldiers hired by the donos to assert their territorial
dominance against both other factions and the police started to appear between 1984-1986. In
1986, an increase in the number of drug-related deadly conflicts and internal strife within the
Comando Vermelho led to its eventual fractioning, and the rise of the Comando Vermelho Jovem
(The Young Red Command), Terceiro Comando (Third Command), and Amigos dos Amigos
(Friends of the Friends). These organizations are now the major drug factions in Rio.
These organizations are multi-tiered (see Figure 8); the donos are the heads within the
favelas of the drug traffickers. The States absence, and the opportunistic donos success (as
Dowdney wrote, this social contract is something that factions do uphold very effectively), has
led to their authoritarian reign over the favelas. Apart from the donos connection to Brazils
drug trade, these self-appointed authorities have become institutionalized, overtime, in the
governance of the favelas, and the violent upholding of the social order.
69
The situation escalated
to such a degree that the police stayed clear of certain favelas, for if they entered, it would lead to

68
Dowdney, 30.
69
Ibid 28.
Baron 28
a war-grade engagement with the drug cartels.
70
The status-quo police policy has been that of
abandonment and containment.
71


Figure 8. Hierarchy of the Drug Cartels.
(Figure from Dowdney 2003).
72


Nanko van Buuren, a former World Health Organization physician, and founder of the
Brazilian Institute for Innovations in Social Healthcare, stated, Its now very easy for us to do
our work because we are very well-known in the slums, especially by the bosses of organized
crimeIt took years of building a confidence.
73
In no uncertain terms, the U.S. State
Department cautions individuals from going into the favelas:

70
Gary Duffy. (2009, February 4). Brazil's Battle for Shanty Town Residents. BBC News.
71
Alexei Barrionuevo. (2009, October 21). Outburst of Violence in the Newest Olympic City Rattles Brazil. The
New York Times.
72
Figure from Luke Dowdney. (2003), entitled, Diagram 2A. Children of the Drug Trade: A Case Study of
Children in Organised Armed Violence in Rio de Janeiro, 40.

73
Devi
Baron 29
The U.S. Embassy restricts travel of U.S. government employees where
narcotics traffickers and other criminals have recently resorted to violent
actions, usually directed against local security forces, local government
authorities, and some civilians. These areas include all favelas in Recife,
Rio de Janeiro, and Sao Paulo
74

During my public service fellowship in 2008, I was only able to participate on site visits because
a known community organizer was my guide and host within the favelas.
With the support of military-grade armaments, in part collected through the corrupt
transition of heavier arms from police to gang,
75
the donos establish their own rule of the
land and behavioral code which the citizens are forced to follow. This reciprocal obligation is:
protection and social services in exchange for obedience and compliance.
76
The donos reciprocal
arrangement with the residents protects them from the police, endowing the donos with the
authority to act as the absolute law. If someone breaks a rule such as stealing within the
community, committing rape, or fighting, they are subject not to punishment through due
process, but to the verdict of the totalitarian donos.
As one female favela resident explained: You cant go to the police and
make a statement if youve been raped or a child has been raped [] or
your husband beats you up, something like that, you cant because this
brings the police into the community.
77

The drug gangs need not actively recruit members. Even with a frighteningly low life
expectancy, some favela children see the gangs as a better opportunity a chance to be able to
afford stylish clothing, shoes, and other status symbols that are otherwise unattainable for many,
given the lack of opportunities.

74
U.S. Department of State
75
McLeod-Roberts
76
Dowdney, 28.
77
Ibid 63.
Baron 30
After a site visit, in 2008, with the Elas Fundo de Investimento Social (Fund for Social
Investment), founded by an Ashoka Fellow, I wrote the following narrative:
Santa Theresa is an artsy, bohemian neighborhood, and in one part of this bairro
lies the first favela, Morro dos Prazeres, I visited. In order to go on site visits in
the favelas, the organizations we met with had to make extensive prior
arrangements for our seguridade (security). With a representative from the Elas
Fundo de Investimento Social (essentially a philanthropy for womens
organizations founded by an Ashoka Fellow), a representative from the London
Institute for Philanthropy (LIP), and a translator, I visited one of the Fundos
grantees a group of women embroiderers. We met outside of the favela, in the
living room of one of their homes. The women shared with us their lives-- one
angry with the involvement of her son in drug trafficking, another sadly laughing
that she was very good at understanding domestic violence. All of these
women had very hard lives

Having previously taken precautions for our safety, the six women escorted the
four of us into their favela to show us their vegetable garden, and the house in
which they embroider. We walked up the hill, and reached a crossroads where if
you went one way, youd be in enemy territory to the one the women lived in. Not
knowing where this fine, invisible line lay, I treaded as carefully as possible along
the Gaza Strip, [a Rio term]... We first visited their organic vegetable garden,
which is so carefully and lovingly maintained! Recycled plastic bottles filled with
dirt/rocks form the fences between the sturdy, yet tender plants.

The women then took us up the hill to their embroidery house, the same piece of
real estate that other women in the favela have been afraid to go to during flare-
ups because it can be caught in the middle of cross-fire between their favela, and
one that is miles away (they pointed out the blue roofs in the other favela where
the shooting can come from). The representative from LIP, the representative
from the Fundo, our translator, and I were able to go with our escorts to the
house on that day because these women had a pulse on when the problems could
occur, and knew that this area was relatively calm and safe on the day we went.
However, there was no chance in the world that we could be in that favela after
nightfall As we walked up the hill, on the left we passed a boy, no more than a
young teenager, keeping watch behind a stronghold built into a wall with [what
appeared to be] a hefty machine gun while another boy walked down carrying a
walky-talky for the changing of the guard.
78

While each faction tends to have jurisdiction over distinct favelas (as in, two factions
would never operate within and govern the same favela), the same constant warring between

78
Amie R. Baron. (2008). Haas Summer Fellowship Final Report. Report presented to the Haas Center for Public
Service.
Baron 31
factions that trapped the embroidery group, coupled with the donos militant control of the
communities, leaves the favelas alienated from each other. This forced divisiveness has severe
repercussions on the favela residents ability to politically organize. Furthermore, the factions
territorial domination can lead to a restriction on the free mobility of favela residents; this
effectively prevents the favela residents from voicing unified support for political candidates
who would actually be able to represent them.
In 2008, the women from the embroidery group had started to form their own community
organization. In the embroidery house, they offered classes to teach other women the trade, and
the home was somewhat of a center within the favela. The women were very proud to share with
us a large sign they had embroidered and proudly marched with in a womens empowerment
rally. With the escalating violence, people were afraid to go to that house during fighting. The
women were reluctant to sell the property, because the only people who would purchase it were
the traffickers.
In my family interviews, I found many instances of political frustration. When I asked
the Sade Criana families if politics were important to them, many expressed extreme
discontent with the power that their votes would have to change the status quo, and with the
effectiveness of politicians to change the situation. Only one interviewee was engaged with a
community organization (though several were engaged with their churches); all the other
interviewees said that the neighborhood associations were ineffectual or too far away.
In light of the states failure, the donos are able to control their favelas, and claim
(forced) loyalty through a reciprocal relationship, including the provision of some goods.
Nonprofits are able to enter the communities with the permission of the local governance. In a
replication of legitimate state actors, the donos realize that by allowing nonprofits to enter their
Baron 32
communities, the residents can be better provided for. The donos maintain strict control over the
communities.
79

When government fails to this degree, the problem does not remain concentrated within a
marginalized fraction of society. While one million people live in Rios favelas, six million
people must cope with this neglect.
As will be discussed in Chapter 9, within thirty-six hours of when I arrived in Rio in
April 2010, floods inundated the area, killing at least 251 people.
80
Niteroi, a suburb adjacent to
Rio, suffered the greatest loss of life. Its favela Morro do Bumba was built atop a trash dump.
The rains,
appeared to weaken decades-old layers of compressed refuse and dirt upon
which some of the homes had been built[causing] the neighborhood [to
give] way. The landslide traveled more than about 2,000 feet, destroying
an estimated 60 homes and a church. Residents said the church might
have had as many as 30 people inside it at the timeHundreds of
residents watched from across the street and from hilltops above as earth-
moving machines dug through debris and dirt in the search for survivors
and bodies. The burnt odor of decomposing garbage was almost
overwhelming
81

Brazils systemic institutional failure undermines the social fabric of its society. While the
existing social structure of the favelas is reminiscent of Europes feudal societies, Brazil is a
democracy. The liberties of all of its constituents must be protected for the democracy to be able
to justly preserve the social order.

79
Dowdney
80
Alexei Barrionuevo. (2010, April 14). Rain Multiplies Woes of Rio's Squatters. The New York Times.
81
Alexei Barrionuevo. (2010, April 8). Rescuers Work to Save Scores Buried in a Brazil Landslide. New York
Times.
Baron 33
Chapter4:BrazilsDemocracy-UsheringinaResponseto
ContractFailure


Brazils civil society and government have shown great interest in working to repair the
social contract in the favelas through initiating social programs. Chapter 4.1 overviews Brazils
burgeoning civil society, and Chapter 4.2 summarizes the governments recent policies in the
favelas.
Section4.1:AnOverviewofBrazilsCivilSociety

Prior to the revolution of 1985, which led to the demise of the military dictatorship, third
sector organizations (other than those connected with the church) were prohibited.
82
Thus the
development of Brazils modern civil society, identified by a boom in civil associations, and
considerable growth of activities in both traditional and new areas of voluntary activism,
83
is
both culturally and legally connected with the birth of democracy, as cemented in 1989. Landim
further notes that,
Nonprofit organizations have pushed to center stage the issues of
democratization of State and society, of the necessity for profound
institutional reforms, and the creation of a genuine public sphere in Brazil.
Nonprofit organizations are increasing in size and scope, and are more
visible today than at any time in Brazils history. Analysis of Brazilian
society, which traditionally focused only on businesses and the public
sector, must now take into account the nonprofit sector as a significant
social and political actor.
84


Brazil, a historically Catholic country, has an ingrained charitable culture, as the Church
has played a prominent role in both popularizing the idea of philanthropy and providing the

82
Amie R. Baron. (Interviewer) and Fernando Ribeiro, Elas Fundo de Investimento Social (2008) and Conservation
International (2010). (Interviewee). (2010).
83
Leilah Landim. (1993). Defining the Nonprofit Sector: Brazil. Working Papers of the Johns Hopkins Comparative
Nonprofit Sector Project, no. 9. Lester M. Salamon and Helmut K. Anheier (Eds.). 7.
84
Ibid 18.
Baron 34
organizational framework for traditional as well as contemporary associations.
85
During the
post-dictatorial era, newly formed philanthropic organizations continued a close association with
the Church, spread[ing] throughout the social fabric without high visibility, and concentrated
on attending to the immediate [emphasis added] needs of the poorest and most marginalized
sectors of the population.
86
The charitable focus of these organizations was geared toward the
short-term - as the proverb goes, give a man a fish, and he eats for a day, as opposed to
developing long-term strategic solutions to Brazils embedded social problems teach a man to
fish, he eats for a lifetime.
Landims perspective in her paper written in 1993, contrasts with that of Kisil, writing in
2008, who identified an ongoing paradigm shift in the focus of Brazils civil society. Notions of
charity are shifting toward concepts of social investment so as to address Brazils multitude
of social problems with lasting effect. This philanthropic paradigm-shift is leading
philanthropists to, work more with the causes of the social problem and not just the effects; to
be more proactive, strategic, and professional; and to focus on impact.
87
The speed with which
Brazils civil society is expanding and reorienting around principles of strategic philanthropy is
evident, and readily exemplified through its large, and growing, number of influential social
entrepreneurs. Dr. Cordeiro explains that Brazils sizeable number of social entrepreneurs may
be attributed to an increase in peoples awareness of social issues, and Brazils innately creative,
affectionate culture of solidarity. Dr. Cordeiro added that in the favelas, if a parent dies, it is
common for the neighbors to care for the children the very poor are very concerned for each
other.

85
Ibid 7.
86
Ibid 14.
87
Marcos Kisil. (2008, September). Brazil: From Charity to Social Investment. Philanthropy UK: Newsletter, Issue
34.
Baron 35
One reason for this shift, as I touched upon in my introduction, is the general
populations growing fatigue with living in a perpetually insecure and unsafe environment.
While at times drug-related fighting can be compared to a war, such levels of combat are mostly
confined to the favelas. However, due to the close-knit nature of the favela communities and
authority of the donos, many of the residents are shielded from petty crime. Alternatively, the
impoverished situation in the favelas precipitates certain types of crime that spill onto the asfalto.
Muggings can be commonplace, even in the wealthiest neighborhoods. My Brazilian friends
warned me against walking with my cell phone visible, even in broad daylight, on the streets of
Rios affluent Zona Sul.
Regardless of this situation, Cariocas are not without an easy sense of humor. The
opening joke of a light-hearted English guide to Rio, given to me by one of my Brazilian host
families, connects with the high crime rate in the city:
Three men were in an airplane: a New Yorker, a Parisienne, and a Carioca. The
New Yorker put his hand out the window of the plane and said, Ah, we are flying
over New York.
The others asked, How do you know?
I just touched the Statue of Liberty!
A little while later the Parisienne put his hand out the window and sighed, Ah,
we are flying over Paris.
The others asked, How do you know?
I just touched zee Eiffel Tower!
A little while later the Carioca put his hand out the window and said, Ah, we are
flying over Rio.
The others asked, How do you know?
Someone just stole my watch!
88

But, the humor in the joke is derived from the reality. Entering some homes in the wealthiest
areas of Zona Sul are tantamount to entering a bank vault. The windows are entirely tinted from
the outside. Visitors must state their business before the porteiro opens the door to a high-

88
Priscila Ann Goslin. (1992). How to Be a Carioca: The Alternative Guide for the Tourist in Rio, 11.
Baron 36
security chamber with cameras and double doors; the outer one locks before the inner one opens,
finally enabling access to the lobby.
The result is that the Brazilian governments failure in the favelas now affects an
increasingly larger segment of the population. This further motivates the wealthier population to
problem-solve by taking matters into its own hands, entailing a more active support for, and
engagement in, third-sector organizations. Dulany writes:
The fact that people had to surround themselves with bodyguards day and
night and were still having their watches and rings stolen while in their car
or on the street or increasingly having to contend with a member of their
family being kidnapped had an impact. It made many wealthy individuals
and corporate leaders realize that they had to do something much more
significant and way beyond charity to address the problems in their
country. This has led in Brazil to the emergence of a group of strong and
innovative corporate foundations.
89


Within the private sector, corporate giving has played a huge role in Brazils
philanthropic endeavors. In 2003, the Institute of Applied Economic Research reported that,
462,000 companies spent a total of $2.5 billion in 2000 on social projects,
from improving adult literacy to financing local dance troupes. While that
is only a quarter of what corporate America spent in absolute terms on
similar projects, it is four times as much as companies in the United States
spend when calculated as a percentage of the economys size.
90

In order to acquire political favor, corporations may donate to the government, and the
government has made it clear that if corporations wish to gain government favor, they best
donate to social causes. As reported by the New York Times,
Business always tries to please the government currently in office, said
Oded Grajew, special aide to Mr. da Silva for mobilizing corporate
support for social projects. If you want to impress this government, then
your visiting card has to be the social question.
91


89
Peggy Dulany and David Winder. (2001, October). The Status of and Trends in Private Philanthropy in the
Southern Hemisphere: A Discussion Paper for the Executive Session on the Future of Philanthropy of the
International Network on Strategic Philanthropy. The Synergos Institute.
90
Tony Smith. (2003, March 03). The Business World - A Philanthropy Rush in Corporate Brazil. The New York
Times.
91
Ibid
Baron 37
However, there are instances of corporate philanthropy not waiting for government to act. For
example, a Brazilian aviation manufacturer - out of a need for more qualified people in its
workforce - started its own private school.
92
While the growth in corporate philanthropy has
helped Brazil to move away from the Church-state, top-down, charity-like paradigm in
philanthropy, many of the corporate programs are operated in-house, leading to an ill-defined
line between corporate social responsibility and civil society organizations engaged in the
provision of collective goods.
93

In the United States, donors receive a tax deduction for charitable contributions.
Alternatively, in Brazil, there is no financial incentive to donate directly to an organization; one
may only receive a tax break by depositing a charitable contribution into a government-
administered fund. I find three problems that result from inserting the government as the
middleman between the funder and grantee.
First, government bureaucrats may funnel donations into organizations of their choice (or
elsewhere); consequently it may be challenging for the intended recipient organization to lay
claim to a particular donors contribution. Second, if a government official becomes mired in a
corruption scandal, associated nonprofits run the risk of becoming embroiled as well. In 2005,
there was a surge of government scandals:
Brazil's politicians and legislators often run afoul of the law, as well. The
country's Federal Police, its most respected law-enforcement body and the
agency charged with fighting corruption, currently has nearly 30,000
active investigations related to public corruption and fraud, according to a
recent report. The deposed governor of Braslia, Brazil's capital, at the
moment sits in jail awaiting trial over alleged kickbacks from public
construction projects.
94


92
Simon Marks. (Reporter) (2008, June 9). Brazil's Economic Boom Marred by Social Inequalities. PBS Newshour.
[Television broadcast, available online].
93
Candace Lessa and Fernando Rossetti. (2005, December). The Future of Philanthropy in Brazil: Creating a More
Diverse Sector. The Synergos Institute.
94
Arthur Ituassu. (2009, November 2). Brazil's New Political Identity. OpenDemocracy.
Baron 38
Finally, turnovers in administration can lead to rapid changes in policy, potentially affecting
nonprofits that are the recipients of government funds. Marcela (#7), one of my family
interviewees, told me that her local government had supported free transportation between her
community and Hospital da Lagoa the two are several hours away. But, the next mayor ended
the program, while a third mayor then proceeded to re-implement it, so now she is able to return
to her family because her transportation is subsidized. In 2008, I met with an organization that
supported children from the favela; its budget was largely dependent on the government. When I
returned in April, 2010, I learned that the organization had essentially needed to close its doors
because its government support had been cancelled.
A trend spanning philanthropy in the Southern Hemisphere is an increase in community-
based foundations. Such foundations increase societys interest in philanthropy through
strong(er) community roots, and their ability to engage donors.
95
Such foundations not only
advance a new model for giving, based on strategic philanthropy, they also strengthen civil
society. Namely they may foster capacitao a term employed by Latin American
organizations to refer to either capacity-building within the third sector, or capacity-building
(securing economic independence) among the clients of nonprofits. Specifically, community
foundations,
[I]n addition to channeling grants and technical assistance to civil society
organizations, they convene groups to identify solutions to a range of
social problems at the local and national levels. At the outset they all may
receive significant external funds but over time their capacity to mobilize
local funds increases.
96


Data on the size and monetary value of the philanthropic/nonprofit sector in Brazil is
limited, and challenging to obtain. I emailed my 2008 Haas Summer Fellowship mentor in Rio

95
Dulany and Winder
96
Ibid
Baron 39
de Janeiro, Cindy Lessa, former Director of Ashoka in Brazil, for some information. Ms Lessa
was also the former Country Director of Synergos, and is a current member of Sade Crianas
Board of Directors. She wrote to me,
It is hard to compile numbers of individual and family philanthropy
because since there are no incentives, there [is] no registration of the
incentivesThere is an emerging independent, group of grantmaking
foundationsbut these [issue grants] in a limited (either monetary,
geographic or theme) scope and apart from being important models, are
not important sources of money for the ocean of NGOs in Brazil. Brazil
is in quite a turning point: many international organizations are no longer
working in Brazil because Brazil is a rich country; the philanthropic
culture is not evolved (small-scale, charity-like).
97


Ms Lessa directed me to a 2008 McKinsey report on the effectiveness of social
investments in Brazil (A Eficacia dos Investimentos Sociais no Brasil), which stated that,
overall donation volume in Brazil is around R$7-10 billion/year. Based on
our best estimates, we believe Brazil has progressed in the past ten years,
however philanthropic levels are still below the countrys potential.
98

This report also indicated that giving levels in Brazil, including, private capital given by
individuals or corporations to the social sector, were about 0.3% of GDP. As a means of
comparison, in 2009, it was estimated that charitable giving in the United States was about
$303.75 billion, or approximately 2.1% of GDP.
99

Corporate social investments in Brazil are quite sizeable, and Brazilians appear to be
more eager to support corporations that make social investments than are Americans or
Europeans. McKinsey also states that approximately 20% of the Brazilian population is engaged
in some sort of philanthropic activity, and that as is expected, participation tends to drop
significantly among lower-income families. While there are over 276,000 CSOs (civil sector

97
Candace Lessa. (2010, October 14). Personal Email Communication to Amie R. Baron regarding Brazils
Philanthropic/Nonprofit Sector.
98
Heinz-Peter Elstrodt. (2008, June). Effective Philanthropy in Brazil: A Study of Existing Barriers and Potential
Actions to Increase and Improve Effective Philanthropy in Brazil. McKinsey and Company, 7.
99
Edith H. Falk, et al. (2010). Executive Summary. The Annual Report on Philanthropy for the Year 2009.
Baron 40
organizations), only a small percentage of them are actually effective. In fact, a staggering
77% of these organizations do not have paid staff members, and only 2% have 50 or more
employees.
100
Further, Oversight, evaluation, and monitoring are not regularly practiced by
NPOs in Brazil. Importantly,
The very low level of evaluation and monitoring, even in the largest and
most professional foundations (e.g., more than half of the NPO members
of the GIFE network do not monitor the impact of any project) exemplifies
the lack of professionalism seen in the sector. GIFE members represent
120 of the largest and most professionally run foundations.
A major repercussion is that,
There is no systematic analysis available that points to where investments
are most needed. As a result (and also as a consequence of a non-
coordinated effort from major donors), capital is not necessarily flowing to
where it would do the most good.

That said, Brazils advancing civil society as a tool for social change is garnering much
interest. Ashokas 2009 publication, Leading Social Entrepreneurs, showcased the projects of
three Ashoka Fellows, who are dedicated to fostering civil engagement and a resulting
improvement in cross-sector accountability. One of these programs is the Guacira de Liveira
project, which improves the access of citizen organizations (COs) to information on the
legislatures budgetary appropriations across a range of social issues, in order to improve
womens inclusion in governments decisions. The improved access to information enables the
COs to lobby for additional legislation or [to] work to see that funding is directed where it is
most needed.
101
Andr Sobrinho mobilizes youth, helping them to see their participation as an
important strategy for social transformation in Brazil. He addresses the perception that
public policies are inaccessible to average people, and it adds to
widespread disillusionment about the possibilities for change.Despite
the increase in citizenship initiatives across Brazil, the government bodies

100
Heinz-Peter Elstrodt. (2008, July). A Eficcia Dos Investimentos Sociais no Brasil. McKinsey and Company.
101
Kelly Hicks (Ed.). (2009). Leading Social Entrepreneurs, 9.
Baron 41
that should include representatives from a broad swath of society actually
include only members of influential minorities.
102

Jos Brasiliense couples Brazils increased civic participation and the governments
decentralization to fill the enormous gaps between civil society and local government.
Brasiliense values cross-sector collaboration in his work with leaders from a variety of sectors
to realize their collective potential.
103

Section4.2:RecentGovernmentPolicytowardInequality

As suggested by Mr. Grajews statement in the previous section, President da Silvas
administration has made a concerted effort to address Brazils problems of inequality.
Throughout his presidency, Lulas policies have focused on repairing contract failure through
improving the situation for Brazils poor.
104
As of 2009,
2 million households received electrical power for the first time; 11
million very poor families began to receive the Bolsa Familia minimum
income benefit; the minimum wage grew 45% in real terms (thus
benefiting 42 million people); 8 million registered jobs were created; 17
million people were lifted out of poverty; and the income of the poorest
50% of the country grew 32%, twice the increase of the richest 10%.
105

The Bolsa Familia, a wealth-redistribution program, incentivizes poor families to send their
children to school through direct transfers of funds. The World Bank, which supports the
program, reports that,
Bolsa Familia has two important results: helping to reduce current
poverty, and getting families to invest in their children, thus breaking the
cycle of intergenerational transmission and reducing future povertyThe
virtue of the Bolsa Familia is that it reaches a significant portion of
Brazilian society that has never benefited from social programs. It is
among the worlds best targeted programs, because it reaches those who
really need it. Ninety-four percent of the funds reach the poorest 40

102
Ibid 11.
103
Ibid 3
104
Marks
105
Ituassu, Brazils New Political Identity.
Baron 42
percent of the population. Studies prove that most of the money is used to
buy food, school supplies, and clothes for the children. Indicators like
these mean that the program has made a decisive contribution to the
unprecedented reduction in poverty and inequality that has occurred in
recent years.
106

At least twenty countries are adapting some version of the Bolsa Familia program to their needs.
Interestingly, the United State, through a program offered in New York City, is among these
countries.
Lulas policy also includes a pacification project for infusing the favelas with police-
presence in order to acquire control of the communities from the donos.
107
The stated aim of this
revised policing strategy, launched in 2008, is to plant legitimate state agents squarely within the
favelas. Lula has declared, We are working in a way that the state is present in the day-to-day
life of poor people.
108
The president also stressed that this policy for pacification must be
combined with development programs:
We have the biggest investment programme of shanty-town urbanization,
basic sanitation and house building that Brazil has ever had. When we
created our growth acceleration programme in 2007, we invested more
than 100bn reais (30bn pounds [currently valued at $58 billion US]) to
take care of basic sanitation and build houses.
109

But even as the State throws its weight behind solving Brazils deep-seated problems stemming
from vast socio-economic inequality, it is hard for the favela residents to simply shepherd in a
new era after years of neglect.
110
The transition is extremely tough, underscoring the challenges
in cleaning-up Rio in time for the 2014 World Cup and 2016 Olympics. The drug cartels are
not willingly relinquishing their territories to the government, leading to violent conflicts

106
The World Bank. (2010). Bolsa familia: Changing the Lives of Millions in Brazil. News and Broadcast.
107
Duffy
108
Ibid
109
Ibid
110
Ibid
Baron 43
between the police and the donos armies. Even though the pacification project has had some
success,
The majority of the citys favelas are still controlled by members of three
drug factions, which possess an increasingly sophisticated arsenal,
including anti-aircraft guns and automatic rifles, often sourced form
inventory intended for the Bolivian and Argentinean armies and smuggled
into Rio.
111

The struggle between the favela donos and Lulas police force came to a head in October of
2009, when drug soldiers shot down a police helicopter, an incident that drew international
attention given that Rio had only recently been named as host for the Olympics.
112
Even as I
write this thesis, the violence from the favelas finds its way into the rest of the city. On August
22, 2010, militants connected with Rocinhas drug gang held 35 people hostage in one of Rios
luxury hotels, as it hosted a dental conference. This occurred during broad daylight in the midst
of a violent confrontation with the police.
113

The eighteen-month-old favela pacification project has met with some initial success:
special police units have moved into twelve favelas,
114
out of the citys approximate one
thousand. And, the favela Dona Marta has largely become a success story for how to make one
of the citys most dangerous communities safe.
Dona Marta is the first favela to have (legal) electricity, water on tap,
internet and most notably [is] the first drug free favela in Rio. Less than
10 years ago Dona Marta was considered to be one of the most dangerous
favelas in RioHowever things have changed to such an extent that Dona
Marta is now considered an example of a safe favela.
115


111
Phillips
112
Police Helicopter Shot Down in Olympic City Rio De Janeiro. (2009, October 18). The Times.
113
Alexei Barrionuevo. (2010, August 21). Gunmen Invade a Hotel in Rio de Janeiro. The New York Times.
114
Ibid
115
Philip Sever. (2009, April 7). Building Walls Around Favelas. The Rio Times.
Baron 44
However, Rios secretary of public security, Jos Mariano Beltrame, said in an interview [in
August, 2010] that the police had no plans to move into Rocinha [population 100,000] this
year.
116

While some critics say that Lulas Programa de Accelerao is a political ploy to gain
support for his National Labor Party in the October 2010 election, many other Latin American
presidents have manipulated the constitution to extend their term limits; Lula has refrained from
doing so, and Brazils democratic approach to its problems of inequality stands out from that of
other Latin American countries. Nonetheless, Brazil,
must prioritize domestic social and economic inequality[T]he goal of
building an egalitarian, free and democratic society that respects and
works with international institutions is more essential than ever.
117

Accordingly, Sade Crianas work to help repair the social contract through its innovative and
proactive engagement in Brazils third sector, will be the focus of the next chapter.


116
Barrionuevo, Gunmen Invade a Hotel in Rio de Janeiro.
117
Ituassu, Brazils New Political Identity.
Baron 45
Chapter5:SadeCriana-HelpingtoRepairtheSocial
Contract


This chapter provides information about the Sade Criana program and methodology. It
is contextualized within the previous discussion of Brazils inequality, civil society, and contract
failure. The content of this chapter is derived from my interviews with staff, volunteers,
members of the board of directors, and families, along with Sade Criana materials.
Section5.1:OverviewofServices

The mission of Sade Criana is:
To break [emphasis added] the constant admission/readmission cycle of
children treated at the Hospital da Lagoa [Rio de Janeiro]

POVERTY ILLNESS ADMISSION RELEASE RE-ADMISSION
DEATH

[By] Offering them the opportunity to improve their health and the
families well being, by promoting their bio-psycho-social development,
by rescuing their rights as citizens and by giving them means to achieve
self-sustainability.
118


Sade Crianas methodology developed from an understanding that the program needed
to track its results in order to effectively fulfill its mission. The organization follows each
familys improvement in several areas, namely: health, income level, quality of housing,
citizenship, and education, prior to release from the program. In order to complete the program,
the family must have achieved the minimum threshold in three of the following five
categories:
119


118
Sade Criana. Mission Statement.
119
Sade Criana. Creating Institutions Based On The ASCR Model.
Baron 46
Health: Childs health is satisfactory, he is not suffering from malnutrition, and his
immunizations are documented as up-to-date.
Income: At least one adult is earning a formal (or informal) wage. For families of
five or fewer members, one minimum salary per family is considered acceptable.
For families with more than five members one fifth of a minimum salary per
person is considered acceptable. That this is the level necessary for release from
the program is a real indicator of the extreme poverty of many of the families upon
entering Sade Criana.
Quality of Housing: The familys home has a ceramic or cemented floor, and the
ceiling and walls are in good condition. With respect to sanitation, the bathroom
has at least a toilet and shower, and there is a sewer or cesspool/septic tank. The
water and electric installations are in good condition.
Citizenship: The familys documents are in order, and their constitutional rights
are recognized by the familys receipt of all of the government services for which
they are eligible, including the bolsa familia (described in the previous chapter),
free medicine, and special formula.
Education: All children between ages 5-17 attend school.
Families are referred to Sade Criana by Hospital da Lagoas social workers and
doctors. If a hospital employee feels that a childs home-environment may be a contributing
factor to his illness, s/he will refer the family to Sade Criana to follow up. While there are
some families with an active mother and an active father, or only an active father, the majority of
the parents are single mothers. Of my twenty-five family interviews (see Table 3: Family
Interviewee Data and the accompanying Notes on Table 3, in Chapter 9), there were only four
Baron 47
couples; seventeen mothers came to Sade Criana on their own and four with a friend or family
member. Of the women who were not accompanied by a spouse, only eleven said that they are
presently living with a husband, or domestic partner, and that he is good with the children.
Seven mothers said that the father was either presently abusive to his family, or had been, which
led to the parents separation.
The Lagoa branch of Sade Criana, where I conducted my research, is able to assist
approximately 200 families at a time. The mothers are assigned a specific day and week of the
month to come into Sade Criana. Each monthly visit includes: a healthy lunch, the receipt of
food, medicine, and clothing, a meeting with the social assistant, a meeting with the nutritionist,
and an optional meeting with a psychologist. As it takes many of the families hours on public
transportation to come into the clinic, and Sade Criana is within walking distance of the
hospital, their visits to Sade Criana often coincide with doctor appointments. By coming in on
a specific date each month, the mothers get to know each other while they are waiting to be seen
by the social assistants; in my interviews, several mothers identified the other mothers at Sade
Criana as their friends (their friendliness with the other mothers is likely to be partially
correlated with how long they have been in the program). This is important because many of the
women are living in an isolated environment (nine mothers said that they did not really have any
friends) and as noted above, may be victims of abuse; through Sade Criana, the mothers are
able to build a friendship (and hence support) network. The following describes certain Sade
Criana services:
Baron 48
WorkshopsandGroupTherapy

All of the parents are required to participate in a series of monthly workshops and group
therapy sessions, with the option of also meeting privately with a psychologist. The group
therapy sessions are designed to help empower the women in several ways:
120

(1) The physical contact (such as a hug) gradually undermines the fear of touch that
comes from an abused past.
121

(2) During each session, the group will discuss a problem suggested by a participant.
For instance, the mothers may discuss managing teenagers, or coping with loss. I
learned from the staff that even if the mother initially feels that she has nothing to
give, she can learn that she can give to others through her advice.
(3) By sharing their experiences with each other, the mothers are able to motivate
each other: the thought is that the parents learn that there is always someone who
is worse off in one way or another, and if this other parent is able to pull her life
together, so too can they. Fatima (#5), one of my family interviewees, shared
with me that at Sade Criana she sees families who are worse off than she is, and
then she tells her neighbors you can complain, but it can be even worse.
The workshops cover a range of topics, including: sexual health, family planning, and disease
(such as Dengue or H1N1) prevention, and are an important opportunity for Sade Crianas to
disseminate public health information. One workshop that several mothers mentioned as
valuable was on the effects of advertising on children, and how to manage their childrens
resulting desire for unhealthy (sugary) foods.

120
Amie R. Baron (Interviewer) and Frances Piltz, Psychologist. (Interviewee). (2010, April 5). Note: 40% of the
mothers choose to seek one-on-one psychological assistance. The need for additional psychological assistance is
tied to the stability and support available in their home environment; additionally, women with low self-esteem,
and women with an abusive spouse, are encouraged to see the psychologist.
121
Amie R. Baron (Interviewer) and Marta Scodro, Deputy CEO (Interviewee). (2010, April 5).
Baron 49
Citizenship

There are government programs to cover certain medical costs (such as medicine), but
these require that the family knows of the opportunity, and connecting with the services demands
a substantial effort. Emilia (#12) told me during her interview that because her neighbors were
wondering how she was able to pay for Marcelos costly medicine, she shared with them that
there was a government resource for subsidized medicine, but that Emilias neighbors did not
receive the free medicine, because they did not try hard enough.
122
This, coupled with
information from the Social Assistants, indicates that while the services are available, they are
not easy for the families to connect with.
Part of Sade Crianas exit strategy for each family is to connect them with all of the
government programs for which they are eligible; a large part of the responsibilities of the social
assistants and volunteer lawyer(s) is to help each family navigate the governments bureaucracy.
The volunteer lawyer also helps the family to procure documentation regarding their claim to
their home, for example if Sade Criana will be rebuilding or remodeling a home for the family.

122
Note that any parts of an interview that I place in single quotation marks are aimed at preserving the sentiment of
the interviewees voice as related to me through the translator, but might not reflect the exact Portuguese phrasing
used by the interviewee. All interviews were conducted in Portuguese; I conducted one interview in Portuguese
on my own. I transcribed all other interviews as they were translated into English. I will use single-quotation
marks as follows: Interviewee/Translator quotation.
Baron 50
HousingProject

Comparatively mild illnesses, such as bronchitis or diarrhea, can quickly turn dangerous
if the child is released from the hospital into an insanitary environment.
123
A poor home-
environment can develop from damp and mildewed walls, improper sanitation, and a lack of
running water or electrification. Through its housing program, Sade Criana builds and
refurbishes four houses each year.
124
Sade Criana manages to keep the cost of building a new
home comparatively low to approximately R$10,000, or about US$6,000 (depending of course
on the year and exchange rate). These homes go to families where the living environment most
directly inhibits the childs ability to improve his health, or to those families who have already
met the requirements in three of the five previously mentioned categories. As reported in Sade
Crianas handbook,
The childs health is the main goal of home repair. When a house where a
child with respiratory problems lives has lots of pipes leaking, non-tiled
floor, mould on the walls, etc., we have enough reason for repair work.
We apply ceramic tiles on the floor, on the walls, and on the kitchen sink,
we provide a sewerage system, build a septic tank, and put a roofing tile.
Our main concern is the childs health in the environment she lives.

In 2008, I attended two domiciliar visitas (home visits) in Belfor Roxo, a suburb that is
home to many Sade Criana families, with Nadia Ackar Tetrilo de Melo Coe, Social Assistant.
Figure 9 shows a photograph of one of these homes. In my Haas Summer Fellowship Final
Report, I described the following:
The first was a family of 10 each member sick with something, including
chronic bronchitis from the damp environment due to flooding; diarrhea
from un-filtered, filthy drinking water; and serious handicaps including
blindness. We next proceeded up a hill to visit a second familya single

123
Hospital da Lagoa now sees fewer cases of bronchitis and diarrhea due to its specialization in childrens illnesses
such as leukemia; however the reduction in bronchitis and diarrhea cases does not mean that these ailments occur
at any lower frequency.
124
Amie R. Baron (Interviewer) and Karina Borgatti, Database Coordinator (Interviewee). (2010, April 7).
Baron 51
mom with six children whose husband had been shot before their eyes.
Fearful of the man who killed her husband, the family members were now
refugees in their own community, taking up lodging where they could.
When we met with them, they lived in a very small one-room shack at the
top of the hill. The padlock they used on their front door was smaller then
the lock I use for my bicycle.
125

The ten family members in the first home shared two small rooms, with approximately four
mattresses for everyone. The home was in a state of decay; mildew covered the walls. When I
conducted interviews at Sade Criana in April 2010, Ms Coe told me that the older teenage
daughter - also a mother who was being assisted by Sade Criana, was doing well, and would
be receiving her own home, which was critical for her sons health. Obviously, for those women
who are so fortunate to receive a new or refurbished home, Bruna Loschiavo, Housing
Coordinator, said that these women are, really happy because (1) the condition of the home
affects the child, and (2) she is proud to have a better environment.


Figure 9. Home of a Sade Criana Family.
Seven family members live in this home.
126


125
Amie R. Baron. Haas Summer Final Fellowship Report.
126
Photo by Amie R. Baron, 2008
Baron 52
ProfessionalizationCourses

Prior to the illness of a child, many of Sade Crianas families are only marginally
surviving. The parent(s)s salary may be far too minimal, and may fluctuate on a day-to-day
basis, to adequately support the family. A childs illness, even one that is neither terminal nor
highly debilitating (such as allergies or lactose intolerance), may completely crush a family. The
constant trips and long hospitalization-stays may force parents to quit their jobs. Six of my
twenty-five family interviewees specifically mentioned this problem when I asked them about
their income.
Given this situation, the purpose of the Professionalization Project is to train the women
to earn an income and to be able to support their families while simultaneously being able to take
care of their children. This model for creating employment opportunities stands in direct
contrast to New Yorks subsidy program, which was recently reported on in the New York
Times.
127
In order to be able to work, these mothers in New York must leave their children with
babysitters, who receive compensation from the state for caring for the children of other
women.
128
Alternatively, at Sade Criana, the program trains mothers in a profession that
enables them to support the family while caring for their children.
Sixty percent of Sade Criana families participate in the professionalization courses.
129

The courses offered teach the women skill sets for cosmetology, and now cooking as well. In

127
Susan Dominus. (2010, August 13). Child Care Thats Paid, Unless Its From Mom. The New York Times.
128
As reported in the article:
For her hard work as a waitressMs. Maldonado estimates that she earns less than $20,000 a year. For her hard
work taking care of Ms. Maldonados children, Ms. Barbosa will probably earn upward of $20,000, courtesy of the
city, state and federal governments, through a program that covers child-care costs for poor people so they can
work. The basic premise inspiring so many government subsidies that any work, even menial work, is a first
step out of poverty has a hearty hopefulness to it and some logic. But arrangements like the one Ms. Barbosa
and Ms. Maldonado share illustrate the absurdities that sometimes ensue especially when there is little
expectation in this jobless recovery that Ms. Maldonados waitressing would lead her to a career ladder with a gold
watch at the end of it.
129
Amie R. Baron (Interviewer) and Karina Borgatti (Interviewee).
Baron 53
addition to trades, instructors also teach professionalization skills.
130
All of the mothers who
successfully complete the cosmetology courses receive a start-up package from Loreal, so that
they can open up shop either in their own homes, or through home visits to local community
members.
TeenProgram

Sade Criana also offers special sessions for its teens. Elisangela Silva de Barros,
Social Assistant, coordinates the program. There are currently approximately 30 teenagers in the
program, and the group meets two times per month. The main focus is on teen pregnancy,
sexually transmitted diseases, and drugs. The families are very worried about their children
becoming involved with drugs. Ms Barros feels that the program is effective because, currently,
there are only two teen pregnancies (coincidently, the two girls are sisters from one of the
families that I met in 2008), and one boy who is involved with drugs. In 2008, Ms Barros started
a program, called Multiplication. The objective was for the Sade Criana teenagers to
replicate this project in their schools. They would then become enablers and disseminators of
this information by learning to teach the curriculum to their peers. Due to limited funding, the
outreach-component of the program needed to be curtailed and it was outsourced to a different
nonprofit.

130
Amie R. Baron (Interviewer) and Rosa Monteiro de Oliveira, Coordinator of Professionalization Courses
(Interviewee). (2010, April 14).
Baron 54
Finances

Sade Crianas budget, which was R$3,198,014.79
131
(approximately US$1.8 million)
in 2009, is covered exclusively through private giving, a considerable portion of which is
international. Figure 10 shows their budget from January through August 2010.


Figure 10. Sade Criana Budget in Reis, YTD Jan-Aug 2010.

Expenses for Sade Criana in Lagoa are 1.3 million reis (~$781,250.6); the remainder is for
the Sade Criana franchises across Brazil.
132, 133


Sade Criana has received recognition and support from many prestigious philanthropic
organizations, including Ashoka, Skoll, Schwab, and Avina. The Schwab Foundations online
description of Sade Criana captures the root problem that Sade Criana strives to address:
According to the UN Development Programme, Brazil has one of the
highest inequality rates in the world in terms of income distribution, both
between regions as well as social strata. As a consequence, health and
sanitary conditions vary widely. While Brazil offers a public healthcare
system, its coverage is not extensive. State-of-the-art facilities exist but

131
Amie R. Baron (Interviewer) and Cristiana Velloso, Operations Manager (Interviewee). (2010, April 9).
132
Figure from: Sade Criana. Accounts Rendering. (2010)
133
Cristiana Velloso, Operations Manager. (2010, October 17). Personal email communication to Amie R. Baron.
Baron 55
are only available for those who can afford them. For the 60% of the
population using public healthcare, though, service is limited to basic
immunization and emergency care. Even if Brazil was to uniformly offer
high-quality health services to all, it could not address the health
challenges presented by poverty. Most diseases are caused by unclean
drinking water, inadequate sewage disposal, poor housing conditions and
malnutrition. Sade Criana set out to tackle the multifaceted factors
related to poverty that make children sick.
134


Sade Criana has a God-mother/God-father program, in which a specific donor
sponsors a specific family. The organization also has Friends of Sade Criana programs in
England and New York, which also help garner international donations. In addition, Sade
Criana produces a line of gift products.
Section5.2:MonitoringPerformance,TrackingResults,andAssessingImpact

In their recently published book, Money Well Spent: A Strategic Plan for Smart
Philanthropy, Paul Brest and Hal Harvey list three criteria for impact assessment,
135
which are
presented below. I have included examples of how Sade Criana addresses each of these
categories:
Monitoring performance: Sade Criana monitors the performance of each family
through its Family Action Plan (Figure 11).
Tracking Progress: Sade Criana tracks the progress of all of its families through
its database.
Assessing Impact: Sade Criana assesses its impact according to goals met in the
following five categories (as discussed above): health, income, citizenship,
education, and housing. Sade Criana also considers the dollar value associated

134
Schwab Foundation for Social Entrepreneurship. (n.d.). Social Entrepreneur Profile:
Cordeiro Vera R.G.
135
Paul Brest and Hal Harvey. (2008). Money Well Spent: A Strategic Plan for Smart Philanthropy, 135.
Baron 56
with a reduction in hospital days summed over all of the participating children, as
illustrated in Figure 13 below.
MonitoringPerformance

Sade Criana uses a Family Action Plan (see Figure 11) to track each familys
progress according to several key categories (see Figure 12). Figure 12 accompanies Figure 11
for each family. Translating Figure 12 from the Portuguese, these performance indicators (the
far left row) include such variables as: health (information regarding: initial state, vaccination,
and nutrition), housing, and income. This information is recorded and further detailed to
include: descriptions of each variable, sources of information, units of measure/scale,
instruments for collecting/recording the data, and frequency of observations. Each individual
cell contains a precise note for the information to be recorded. For example, reading the row that
starts with Moradia (Housing), data in the cells will record: initial condition of the familys
residence, the social assistant who records the information, its classification as, good, regular, or
bad, and a record of three examinations (initially, upon finishing an alteration, and a final
evaluation).

Baron 57

Figure 11. Excerpt of Sade Crianas Family Action Plan for a Representative Family.
136



Figure 12. Sade Crianas Indicators (Indicadores) and Steps for Collecting and
Recording information
137

136
Figure from: Sade Criana. (2009) Our results, 2009. [PowerPoint Presentation]
137
Chart from: Sade Criana. Indicadores - Renascer. [Excel Spreadsheet]
ASCR - ASSOCIAO SADE CRIANA RENASCER
Quadro de Indicadores
Obs: Nossa metodologia considera o acompanhamento mensal pelo PAF - Plano de Ao Familiar, cuja frequncia de sistematizao mensal.
A frequncia de sistematizao apresentada no quadro refere-se sistematizao que feita para divulgao a pblicos externos.
Descrio da Varivel Fonte
Unidades de
Medida/Escalas
Instrumentos de
Coleta/Registro
Frequncia de
Observao/C
oleta
Estado Clnico
Estado geral de sade da
criana assistida Mdicos
Boa
Regular
Reservada
Formulrio de Avaliao
Mdica Quadrimestral
Vacinao
Vacinao da criana
assistida Posto de Sade
Atualizada
Desatualizada Carteira de Vacinao Mensal
Nutrio
Peso e altura da criana
assistida de acordo com
sexo e idade
Nutricionista da
ASCR ou
Mdicos
Sobrealtura/Sobrepeso
Altura/Peso adequados
Risco Nutricional
Desnutrido
Avaliao pela nutricionista
ou Formulrio de Avaliao
Mdica Bimestral
MORADIA
Situao de
moradia
Condies da residencia
da famlia
1
Assistente
Social e
Engenheiro da
ASCR
Boa
Regular
Ruim
2
Formulrio de Avaliao
Inicial, Ficha de Alterao
Cadastral e Formulrio de
Avaliao Final
(varia conforme
atividades em
curso)
Renda mdia Renda familiar declarada Responsvel
< 1/2 Salrio Mnimo
Entre 1/2 e 1 SM
> 1 SM
Lista de Verificao do
Plano de Ao Familiar
(PAF) Mensal
Frequncia nos cursos
oferecidos pela ASCR
Professores da
ASCR
Presente
Faltou
Folha de Presena e
Acompanhamento Mensal
Aproveitamento nos
cursos oferecidos pela
ASCR
Professores da
ASCR
Bom
Regular
Insatisfatrio
Folha de Presena e
Acompanhamento Mensal
Curso Externo
Aproveitamento nos
cursos oferecidos por
instituies parceiras
Instituio
Externa
Aprovado
Reprovado
Desistiu
Acompanhamento
telefnico e Formulrio de
Registro de
Aproveitamento da ASCR
(conforme
durao do curso)
Instrumento de
Trabalho
Capacidade de doao de
instrumentos de trabalho
necessrios
Gerente de
Atendimento
ASCR % doados/necessrios
Formulrio de Solicitao
Aprovado pela equipe
ASCR Eventual
Curso Interno
INDICADORES
SADE
GERAO DE
RENDA
Baron 58
TrackingProgress

Monitoring results are critical to the success of the Sade Criana Program. Sade
Criana uses a data tracking methodology established for them by McKinsey consultants to
computerize its client data. All of the approximately 12,000 people (2783 families and 9266
children) whom Sade Criana has helped have been registered in an electronic database, which
provides the means for a comparison of each familys status upon admittance and graduation
from Sade Criana. McKinsey, through assistance from Ashoka, donated 5,000 hours over a
four-year time period to Sade Criana. In 2004, McKinsey offered training to Sade Criana on
how to collect, use, and evaluate their quantitative and qualitative data.
138

The database is a fundamental tool for ASCR. It allows us to generate
reports that provide a detailed overview of operating procedures. We can
compare the conditions when [the family] was admitted and at the time of
discharge from the program, measure [the familys] progress, and check
whether or not [the family] met the established goals. Reports check the
effectiveness of ASCRs actions and point out areas for improvement.
139

This assistance was critical for Sade Criana to be able to develop their database, results
tracking system, and the family action plan, which is central to their program method. In my
interview with Dr. Cordeiro, she indicated that it would not have been possible for Sade
Criana to accomplish all of this without the help of Ashoka and McKinsey.
Maintaining Sade Crianas database does require significant manpower. As reported in
the Sade Criana handbook,
One major obstacle is keeping the database up to date, with the correct
information. For instance, it is difficult to keep track of the number of
times a child has been admitted to the hospital. Every month, we have to
ask the responsible person and enter the information on the database,
including the date of admission and the date of discharge. If such

138
Sade Crianas categorical data is distinct from the qualitative data that I gathered through stakeholder
interviews, which includes impacts that may fly under the radar, and are not necessarily quantifiable.
139
Sade Criana. Creating Institutions Based on the ASCR Model, 33.
Baron 59
information is not properly entered, our evaluation is not reliable.
Therefore, we must have a constant control of database information and,
as a result, we need to train the whole team that assists and supports
families...
140

AssessingImpact

The objective of measuring impact, according to Brest and Harvey, is to show both the
causation and correlation of an improved situation due to an intervention. Evaluating impact
should establish that, the rate of malaria infections [for example] in a village goes down (1)
when residents use bed nets and (2) because they use bed nets.
141

When I asked about the impact that Sade Criana has on Hospital da Lagoa during my
interviews, both Dr. Cordeiro and Dr. Odilon Arantes, the former Chief of Pediatrics at Hospital
da Lagoa, mentioned that while there is a clear correlation between Sade Crianas growth as an
organization and Hospital da Lagoas developing sophistication, this is not to be confused with
causation. Dr. Arantes said that over the eighteen years he was the Chairman of Pediatrics at
Hospital da Lago, the hospital has developed new skills, brought in new specialists, and is able
to treat more sophisticated diseases. The hospital has a specialty in pediatrics, and serves as a
referral hospital for other public hospitals.
The estimated drop in re-internment among Sade Criana families is approximately 60%
(see Figure 13); this number was derived by comparing the number of days that a child spent in
the hospital before and after the family participated in the Sade Criana program. During our
interview, Dr. Arantes said that,
If it were not for Sade Criana, it would have been impossible for me to
stay [at the hospital] for so long Sade Criana makes it possible to
release the child [from the hospital] without the threat of deathNow, the
doctor feels secure that the needs of the child will be met at home, which
adds value to their work.

140
Ibid 34. Slightly edited from the English translation of the Handbook.
141
Brest and Harvey, 139.
Baron 60
And, Dr. Cordeiro indicated that the long-term close relationship between the two institutions,
would of course affect the behavior of the physicians and health professionals.
Sade Criana also evaluates their impact in several other areas, including the childs
health (Figure 14), and the familys income (Figure 15). Most recently, Sade Criana has
introduced a system for assessing the mothers improvement in self-esteem, which will be
discussed in Chapter 10.
Baron 61


Figure 13. Reduction of Hospital
Costs Due to Lower Re-internment
2009.
142


Figure 14. Improvement in the
Childrens Health, 2009.
143



Figure 15. Improvement in the
Familys Income, 2009.
144



142
Figure from: Sade Criana. Our Results 2009.
143
Ibid
144
Ibid
Source: : BD - ASCR
Health
Our Results
2009
Sample: 147 Families
0%
20%
40%
60%
80%
100%
Initial Evaluation Final Evaluation
23%
5%
46%
31%
27%
40%
Good
Regular
Severe
Source: : BD - ASCR
Our Results
2009
Income
Sample: 147 Families
0.00
100.00
200.00
300.00
400.00
500.00
600.00
700.00
Initial Evaluation Final Evaluation
495.00
630.00
27%
Baron 62
RelationshipwithHospitaldaLagoa

My interview results, which will be described in detail in Chapter 10, are consistent with
the hypothesis that a strong connection exists between the presence of the nonprofit institution
(Sade Criana) and an improved quality of care at the government-run hospital (Hospital da
Lagoa). Many families reported extreme discontent with other public hospitals around the city,
but spoke quite favorably about the doctors at Hospital da Lagoa (some mothers even identified
these doctors as friends). And, I learned from Dr. Arantes and the Sade Criana staff, the
doctors at the public hospital and social workers at Sade Criana are in constant communication
with each other. Dr. Cordeiro told me that because Sade Crianas social assistants visit
Hospital da Lagoa a couple of times each week, Sade Criana essentially, acts as a lawyer on
behalf of the families at the hospital. While the doctors at Hospital da Lagoa and Sade Criana
social assistants can work closely together, Dr. Arantes said he never told a patient that he knew
of the changes in her life, because he did not want to the family to feel like a charity case, which
would be very bad.
Through my observations and interviews during my field research, it is evident that
Sade Crianas efforts are correlated with: (1) a decrease in re-internment rates among children
who are discharged from partnering public hospitals, enabling a more effective allocation
of limited government resources, and (2) strong evidence that Sade Criana, as a nonprofit
institution, propels the partnering government-run hospital to perform more effectively than
other non-partnering hospitals in the area. Further, by providing guidance to its program
participants, Sade Criana is able to (3) connect these families with government (welfare)
services to which the participants are entitled. In order to obtain these services, Sade Criana
helps the families navigate the extensive government organizational bureaucracy. Therefore, a
Baron 63
byproduct of Sade Crianas work is that it clearly assists the Brazilian government in the
provision of health care to its citizens.
Both Dr. Arantes and the Sade Criana staff expressed to me that the work of Sade
Criana as the public hospitals nonprofit partner, added substantial value to the doctors
treatment; the doctors knew that when they released a child with an impoverished background
from the hospital, participation in the Sade Criana program would improve the childs chance
of survival. Further, reductions in re-internment enable the hospital to focus its limited resources
on helping other patients.
Scaling

Sade Criana is scaling through two primary means: the first is through the
governments adaptation of the Sade Criana methodology, the second is through franchises;
twenty-three satellite offices of Sade Criana are partnering with other local public hospitals
both in Rio de Janeiro, and throughout Brazil. Brest and Harvey write, with respect to impact,
that,
An evaluation that seeks to demonstrate that a strategy has impact and is
generalizable to other contexts can be of great value to a field...
145

As illustrated in Section 5.2, Sade Criana takes care to monitor, track, and assess its impact.
This information is useful for demonstrating that the Sade Criana methodology is suitable for
scaling. The Sade Criana handbook offers guidelines for how to duplicate the program, in
which they state that their work is acknowledged in the country and internationally and its
impacts have been measured and evaluated.
146
In addition to the formation of twenty-three
Sade Criana franchises throughout Brazil, the Sade Crianas Family Action Plan has been

145
Brest and Harvey, 146.
146
Sade Criana. Creating Institutions Based on the ASCR Model, 5.
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integrated into public health policy in Belo Horizonte (a Brazilian city west of Rio). Dr.
Cordeiro further stated that Rios Public Health Secretary wishes to create seventy new clinics,
and as such approached Sade Criana about adapting the Family Action Plan because of its
value as an integrated perception of health. As part of this scaling project, Sade Criana is
now training professionals to work in these clinics.
To lay the theoretical foundation for the nonprofits role in helping to foster social
justice, Chapter 6 will present certain relevant properties of social contract theory. These
attributes will be used to illustrate the ethical responsibility of government to its citizens, and to
argue that the provision of basic services to the polity is part of governments responsibility.
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Section 2: Social Justice, Government Failure, and the Role
of the Nonprofit Sector



Brazils failure to provide universal and equitable access to critical social services, as
explored in preceding chapters, has deep ethical consequences, not only for its individual citizens
but also for the strength of its society. How Brazil overcomes this legacy of inequality, given its
vast wealth, will serve as an example for other democracies. Chapter 6 builds from elements of
social contract theory in order to establish the rationale for government to universally and
equitably provide access to public goods, such as security and health services, within the context
of a democracy. Chapter 7 presents frameworks for understanding the role of the nonprofit
sector in complementing and supplementing the governments provision of collective goods.
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Chapter6:SocialContractTheory-AFrameworkforSocial
Justice


Section6.1:IntroductiontotheSocialContract

If a fundamental purpose of government is to foster a just society, then there are clear
ethical implications, should government fail to do so. The social contract as explored by
Rousseau, an early philosopher, illuminates the concept of a legitimate order. In his social pact,
the government agrees to protect the people, in exchange for the politys recognition of the
governments legitimacy and authority. The relationship implied in the social contract is
necessary for the preservation of a civil society.
147
In this pact, the governments authority
enables citizens to live in greater harmony with each other, while exercising their individual
freedoms, within such bounds that allow others to simultaneously exercise the same freedoms.
As Rousseau wrote,
The problem is to find a form of association which will defend and protect
with the whole common force the person and goods of each associate, and
in which each, while uniting himself with all, may still obey himself alone,
and remain as free as before. This is the fundamental problem of which
the social contract provides the solution.
148

John Rawls also uses social contract theory to develop his theory of justice. The Stanford
Encyclopedia of Philosophy notes that Rawls,
aims to provide principles of justice that can be applied to determine both
the justice of political constitutions and their laws, as well as the justice of
social and economic arrangements in the distribution of educational and
work opportunities, powers and position of office, and income and
wealth.
149



147
In this case, civil society refers to political society, as opposed to a term for the Third Sector.
148
Jean-Jacques Rousseau. (1993). The Social Contract and the Discourses. (G.D.H. Cole, Trans.) (Original work
published 1750-1778), 191.
149
Samuel Freeman. (2008, December 20). Original Position. The Stanford Encyclopedia of Philosophy.
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Whether examining Rousseau or Rawls, a basic premise of the social contract remains
constant: a reciprocal relationship arises wherein the people accept governments legitimacy in
order to preserve interests that are unprotected in the absence of its authority. Dowdney, who
has been referenced in earlier chapters, expresses his concept of the social contract colloquially:
abide by the law and pay your taxes and the state will support your basic needs and protect you
from harm.
150
Interestingly, he includes basic needs in his perspective.
Section6.2:LinkingtheSocialContractwithJustice

I posit that there are three elements of social contract theory, primarily stemming from
Rawls objective of distributive justice, that, in combination, help a legitimate government to
foster a just society. These elements are: protection, universality, and equity. A legitimate
government protects its people through the universal and equitable provision of minimum levels
of security and certain other collective goods. This definition implies that:
The universal and equitable provision of protection and certain collective goods to
all members of society is necessary to preserve and uphold a civil society. The
corollary is that,
Extreme levels of inequality and government neglect are indicative of the
government failing to uphold its end of its contractual obligation with the people.
The absence of either universal or equitable protection highlights the injustice of inequality
facing Brazil. In addressing this challenge of inequality, it must be recognized that Brazil is still
a young democracy, which threw out a social contract imposed by a military dictatorship in
exchange for a democratic government. With the overthrow of the military dictatorship, the
populace redefined the social contract. But, this fledgling democracy inherited a legacy of

150
Dowdney, 58.
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neglect and poor social policy; hence, it can be particularly difficult for the current Brazilian
government to uphold its end of the social contract.
The following discussion defines protection, universality, and equity within the context
of the implied social contract. Protection of the liberties and property of the citizenry is a
primary objective of the social contract. Cranston characterizes Rousseaus belief that, the
state was the outcome of a covenant or agreement among men. The purpose of the state was the
protection of those people to which it owed its being...
151

In accordance with the universality element of the social contract, Rousseau emphasizes
that all individuals who accept the governments authority have a right to receive the
governments protection. A just society is an utter impossibility if some factions within society
(e.g. Brazils favela residents) fail to receive the protection that the government purports to
universally offer (e.g. - government neglect of the favelas). Brazils present efforts to pacify
the favelas through an increased police presence directly contrast with its history of
abandonment. As reported in the New York Times,
With the community policing effort, police officers try to establish a more
permanent presence within the shantytowns. That differs from the
prevailing approach for more than a decade, in which the police guarded
the entrances to the favelas and ventured in only for select operations that
often turned into deadly gun battles with traffickers.
152


Rawls theory of justice
153
emphasizes the need for an equitable distribution of the
governments services and protection, in order to protect everyones liberties to the same degree.

151
Jean-Jacuqes Rousseau. (1968). The Social Contract. (Maurice Cranston, Trans.), 26.
152
Barrionuevo. Outburst of Violence in the Newest Olympic City Rattles Brazil.
153
For clarity, Rawls two principles of justice, as articulated in both the original and revised edition of his Theory of
Justice, are included here:

Original Edition:
First: each person is to have an equal right to the most extensive basic liberty compatible with a similar liberty for
others.
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Rawls writes, The distribution of wealth and income, and the hierarchies of authority, must be
consistent with both the liberties of equal citizenship and equality of opportunity.
154

Furthermore, his liberty principle emphasizes: each person is to have an equal right to the
most extensive scheme of basic liberties compatible with a similar scheme of liberties for
others.
155
Rawls also advocates for a fair distribution of primary goods (i.e. distributive
justice), which includes: rights, liberties and opportunities, income and wealth, and the social
bases for self-respect.
156
In this thesis, the absence of any of these three conditions discussed
above, i.e. protection, universality, or equity, is designated as systemic institutional failure.
Systemic institutional failure is a real-world manifestation of situations in which a legitimate
government (such as Brazils democratically elected government) fails to uphold the implicit
social contract in certain critical areas (as evidenced by the absence of the police and other
government services, which ought to be equitably and universally provided, within the favelas).
In light of Brazils systemic institutional failure, an objective of Sade Criana, which is
in complete accord with Rawls theory of justice, is to even the playing field for the provision
of healthcare to the nations children. Specifically, in the event of an onset of illness, the goal is
that each child, regardless of socio-economic background, has the same opportunity to recover.
Vast levels of inequality as catalogued by the Gini index have far-reaching repercussions.
Most importantly, victims of inequality are stripped of the ability to exercise their liberties. In
order for the government to meet its implicit contractual obligation to protect the liberties of its

Second: social and economic inequalities are to be arranged so that they are both (a) reasonably expected to be to
everyones advantage, and (b) attached to positions and offices open to all.
Revised Edition:
First: each person is to have an equal right to the most extensive scheme of equal basic liberties compatible with a
similar scheme of liberties for others.
Second: See above

154
John Rawls (1971). A Theory of Justice, 61.
155
John Rawls (1999). A Theory of Justice (Rev ed.), 53.
156
Amartya Sen. (2000). Development as Freedom, 72. [citing Rawls]
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people, the government must also provide a basic level of social services such that distributive
justice is realized. These services may include: police and fire support, electricity, water,
education, healthcare, and sanitation. Sen, a firm advocate of promoting freedom through
equality of opportunity writes,
[T]he freedom of agency that we individually have is inescapably
qualified and constrained by the social, political and economic
opportunities that are available to us. There is a deep complementarity
between individual agency and social arrangements. It is important to
give simultaneous recognition to the centrality of individual freedom and
to the force of social influences on the extent and reach of individual
freedom.
157

For Sen, freedom is the ability for individuals to actually realize those liberties that ought to be
protected.
If the government is to abide by its implicit contractual obligation to enable universal
equality of opportunity, then it is necessary for the government to provide certain social services
that either directly or indirectly benefit the whole society. If a society offers an opt-out choice
to use or not use a service (i.e. private schools or private hospitals relative to public schools and
public hospitals), the government has still upheld its end of the contract. The government need
not enforce equal consumption, so long as the goods are fairly offered.
158

Even though social services are not public goods according to a strict economic
definition,
159
social services and collective goods may positively affect the entire society. For
example, education has the potential to greatly impact an entire population; two consequences of
increased levels of literacy are the facilitation of social change and the fostering of economic

157
Sen, Development as Freedom, xii.
158
Sen expresses a similar concept throughout his writing, in which he emphasizes the capability of an individual to
achieve freedom, rather than whether or not the person chooses to pursue an opportunity.
159
The economic definition of a public good is that it is both nonrival and nonexcludable. These terms will be
defined in more detail in the following chapter.
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growth.
160
The provision of collective goods and social services will be discussed in more detail
in the following chapter.
Section6.3:Health,Inequality,andSocialJustice

Sade Crianas efforts to enable children from poor or impoverished families to have the
same opportunity for survival as children from wealthier socio-economic groups act on the
principles for health articulated by the World Health Organization, which are Rawlsian in nature
because of their promotion of distributive justice:
During the past decade, health has achieved unprecedented prominence as
a key driver of socioeconomic progress, and more resources than ever are
being invested in health. Yet poverty continues to contribute to poor
health, and poor health anchors large populations in poverty. Health
development is directed by the ethical principle of equity: Access to life-
saving or health-promoting interventions should not be denied for unfair
reasons, including those with economic or social roots. Commitment to
this principle ensures that WHO activities aimed at health development
give priority to health outcomes in poor, disadvantaged or vulnerable
groups.
161

However, a large percentage of the Brazilian population is unable to adequately access or benefit
from public health resources. This failure is correlated with extreme levels of socio-economic
inequality. Since access to health is included as a right in the Brazilian constitution, it is already
written into the hypothetical social contract.
Sade Crianas approach to equitable access to health also embodies Rawls argument
for distributive justice,
162
As Tolchin writes in Developing World Bioethics, Rawls second
principle of justice obligates a society to intervene medicallyto provide all members with the

160
Sen, Development as Freedom, 128-9.
161
World Health Organization. (2010). The WHO Agenda: Promoting Development.
162
In conducting a literature search on Rawls and topics relevant to this thesis, I found many articles which were
largely concerned with global justice, building from Rawls, The Law of Peoples, and the obligations of wealthy
countries to assist poorer countries (Tolchin, Dwyer, and van Niekerk). Other articles that consider Rawls
argument that health is a primary good, try to identify how to justly allocate health resources (Daniels, and
Sachs). While both of these topics are extremely important, they are beyond the scope of this thesis.
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opportunity for survival.
163
And, according to van Niekerk, Rawlss theoryimplies that each
member of society, irrespective of wealth or position, must, for the sake of justice as fairness, be
provided with equal access to adequate (though obviously, in the light of limits on resources, not
maximal or the best available) levels of healthcare.
164
Additionally, Bommier and Stecklov in
Defining health inequality: why Rawls succeeds where social welfare theory fails, write,
[W]e propose that access to health resources is a basic freedom, and that
health access should be distributed equally in the ideal society. Thus, all
individuals should have the same opportunity to achieve their potential
health levelsOnce we recognize health accessas a basic freedom,
Rawls First Principle of Justice provides a natural step towards defining
the concept of health inequality. Rawls First Principle then indicates that
health access should be equally distributed.
165


Sade Crianas holistic approach to the inequity of healthcare in Brazil places the
organization squarely at the front of considerations of social justice; for, in any discussion of
social equity and justice, illness and health must figure as a major concern.
166
Sen further
emphasizes the necessity of such an approach:
What is particularly serious as an injustice is the lack of opportunity that
some may have to achieve good health because of inadequate social
arrangements...[A]n illness that is unprevented and untreated for social
reasons (because of, say, poverty...)has a particularly negative relevance
to social justice.
167

Hence, Sade Crianas objective - to offer children from impoverished backgrounds the same
chance of survival as those from wealthy backgrounds helps answer a rallying cry for social
justice.

163
B. Tolchin, (2008). Human Rights and the Requirement for International Medical Aid. Developing World
Bioethics, 8(2), 152.
164
Anton A. van Niekerk. (2004). Principles of Global Distributive Justice: Moving Beyond Rawls and Buchanan.
South African Journal of Philosophy Philosophical Society of Southern Africa. 180.
165
Antoine Bommier and Guy Steckov. (2002). Defining Health Inequality: Why Rawls Succeeds Where Social
Welfare Theory Fails. Journal of Health Economics, 21(3), 503.
166
Sen, Why health Equity? 659.
167
Ibid 660.
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Section6.4:Crises,LimitedResourcesandtheSocialContract

Given that the government has an implicit contractual obligation to protect the liberties of
its citizens, there are clear ethical consequences should the government fail in this regard. For
example, a famine would be a case of injustice only if it could have been prevented, and
particularly if those who have undertaken preventive action had failed to try.
168
Thus, if a
government has the necessary means and infrastructure to prevent a disaster, but neglects to do
so, the government is guilty of committing a grave injustice through its failure to act.
The objective of this chapter, thus far, has been to establish that there are clear ethical
ramifications should government fail to uphold its obligation to provide universal and equitable
protection, along with other services. But limited resources present significant challenges for
government to be able to fulfill its obligation, and raise concurrent ethical questions, for instance,
how can we meet competing healthcare needs fairly under reasonable resource constraints?
169

Below are two relevant examples (one in the U.S. and one in Brazil) of crises that led to contract
failure because of the unmanageable strain on already insufficient resources.
The severe downturn of the U.S. economy has necessitated budget-cuts in local
government programs throughout the country. As a result, there are instances of police forces
needing to lay off employees. With reduced manpower, critical decisions need to be made about
how police and local government allocate their diminishing resources.
If you come home to find your house burglarized and you call, we're not
coming, said Oakland Police spokeswoman Holly Joshi. The city laid
offofficerslast month and the department can't respond to burglary,
vandalism, and identity theft. It's amazing. It's a big change for us.
170


168
Amartya Sen. (2009). The Idea of Justice, 4.
169
Norman Daniels. (2001). Justice, Health, and Healthcare. American Journal of Bioethics, 1(2), 2.
170
Kevin Johnson. (2010, August 25). Home Burglarized? Fill Out a Form Budget Cuts Force Police to Curtail
Calls for Lesser Crimes. USAToday.
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The cutbacks mean that the government is no longer able to sufficiently protect its citizens,
indicated by the 8.5% rise in robberies and assaults in Oakland over one month, which coincided
with the layoff of 80 of its 687 officers.
171

To return to the Southern Hemisphere, in 2008, Brazils Rio State was plagued by an
epidemic of Dengue Fever, which hit Rio de Janeiro and its favelas especially hard, and
presented a formidable challenge for the government. In just four months (from January to
April), 55,543 cases were reported;
172
and, on March 20 alone, 2,053 cases of dengue fever
infection were confirmed 1 case per minute on average.
173
There were not enough physicians
to treat all those who were suffering, and make-shift field clinics overflowed with patients. The
government had to ask other Brazilian states to send physicians to help staff their ranks. The
situation further intensified when,
Some healthcare units failed to stay open 24 hours because they were
located in high-crime areas, local media said. confrontations between
police and drug trafficking gangs in the slum Vila Cruzeiro caused panic
among patients and physicians at a hospital [nearby]
174

The lack of the governments presence in the favelas exacerbated an already dire situation.

171
Harry Harris. (2010, August 25). Robberies, Assaults Rose Since Layoffs, Oakland Police Union Says. Oakland
Tribune.
172
Sun Yunlong. (2008, April 19). Rio Health Chief Fined For Failing To Keep Open Centers Against Dengue.
173
P. Ribeiro. (2009). Dengue Fever Outbreak in Rio de Janeiro: Brazilian Ministry of Health Opens Crisis Center.
174
Yunlong
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In the two examples above, limited resources inhibit the governments ability to enforce
its end of the social contract. This raises critical questions, including:
Is government ethically accountable for failure due to its inability to either
anticipate, or have available resources in extreme situations? And,
What can be done in certain circumstances to counteract legitimate government
failure?
Clearly, government is fallible, and can contribute to the failure of the hypothetical social
contract. The first question above merits consideration, given that social contract theory
requires that the government protect the polity; however exploring the answer to this first
question lies beyond the scope of this thesis. The latter question will be addressed in the next
chapter, but, for clarity, it is important to further explore systemic institutional failure.
Section6.5:NonprofitsandConditionsofSystemicInstitutionalFailure

As will be discussed in the following chapter, government failure occurs when a
legitimate government successfully fulfills its contractual obligation with the people, but due to
economic or political checks on the governments ability to provide certain social services, or to
serve certain subsets of the population, the nonprofit sector is incentivized to complement and
supplement the governments provision of certain collective goods.
175
And, in this chapter, the
failure of the implicit social contract refers to the governments failure to uphold its conceptual
contractual obligation with its constituents. However, both of these terms failure of the
implicit social contract and government failure are independently insufficient for
understanding the overall environment within which Brazilian NGOs operate.

175
As defined in the introduction to Chapter 7, collective goods are goods that are rival and excludable, with
collective benefits, such as many social services
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As defined in Section 6.2, systemic institutional failure is used in this thesis to refer to
actual situations in which a democratically elected government has not satisfactorily upheld its
social contract for certain pockets of society. As discussed in earlier chapters, Brazil has failed
to universally and equitably provide social services and protection for its constituents including
its sizeable poor socio-economic class and favela population, with spill-over effects outside of
the favelas.
Alternatively, the commonly used term state failure refers to the complete or partial
collapse of state authorityFailed states have governments with little political authority or
ability to impose the rule of law. They are usually associated with widespread crime, violent
conflict, or severe humanitarian crises
176
The State Failure Index, formulated by a United
States think tank, the Fund for Peace, uses twelve indicators, subdivided according to social,
economic, and political categories, to determine how at risk a state is of failing. These
indicators are,
177

Mounting demographic pressures,
Massive movement of refugees or internally displaced persons creating complex
humanitarian emergencies,
Legacy of vengeance-seeking group grievance or group paranoia,
Chronic and sustained human flight,
Uneven economic development along group lines,
Sharp and/or severe economic decline,
Criminalization and/or delegitimization of the state,
Progressive deterioration of public services,
Suspension or arbitrary application of the rule of law and widespread violation of
human rights,
Security apparatus operates as a State within a state,

176
Gary King and Langche Zeng. (2001). Improving Forecasts of State Failure. World Politics, 54(4). 623.
177
The Fund for Peace: Promoting Sustainable Security. (2010). The Twelve Indicators.
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Rise of factionalized elites, and,
Intervention of other states or external political actors.
Moving downward on the State Failure Index from the highest ranking country - 1 for Somalia
- to the lowest ranking - 177 for Norway, Brazil is presently ranked in the 113
th
position,
falling into the Warning Category (The State Failure Index categories include: alert, warning,
moderate, and sustainable; the U.S. is in the moderate category). For comparison, countries
ranking within five positions of Brazil include, Ukraine, Belize, Libya, Malaysia, and Botswana.
Notably, none of these countries have GDPs comparable to that of Brazil, and only Botswana has
a greater socio-economic inequality ranking.
178
The five countries with the highest level of state
failure are: Somalia, Zimbabwe, Sudan, Chad, and the Democratic Republic of the Congo. The
lowest levels of state failure are thought to occur in: Ireland, Switzerland, Sweden, Finland, and
Norway. The United States is ranked 159/177 on the list.
As of 2010, Brazil is improving but remains on the warning list, because of its high
levels of inequality, urban overcrowding (as in the favelas), poor provision of social services,
and crime as discussed in Chapter 3. It is interesting to note that criminalization and
delegitimization of the state are coupled together in one ranking criteria, which bears on the
concept of systemic institutional failure used here. The Fund for Peace also identified activity in
the Tri-Border Area (Argentina, Paraguay, and Brazil) as a major security threat. In 2009, they
wrote,
Powerful local elites tied to a regional and ultimately global infrastructure
of crime and violence are involved in overlapping crimes that enhance the
operations of criminal and terrorist networks in the region and throughout
the world.
179

The prognosis by the Fund For Peace for Brazil was that,

178
The Fund for Peace: Promoting Sustainable Security. (2010). Failed States Index.
179
Patricia Taft, et al. (2009, June). The Crime-Terrorism Nexus: Threat Convergence Risks in the Tri-Border Area.
The Fund for Peace.
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Although Brazil is relatively stable and the economy is performing well,
Brazil faces a number of challenges, the most pressing of which is the high
level of inequality. Organized crime and gang violence are also major
problems in the larger cities, and more needs to be done to address the
high levels [of] corruption in government.
180


Clearly, state failure is not an accurate description of the situation in Brazil. However,
the definition of state failure includes the partial collapse of state authority, which does occur
through the donos (illegitimate agents) control of some favelas, and the concurrent absence of
the police or other government agents. The governments failure to equitably and universally
uphold the implicit social contract has harmful implications for all of society. Conditions of
systemic institutional failure precipitate a void within which nonprofits may need to operate,
depending on their client base and the nature of their mission. The provision of critical social
services by these nonprofits may provide significant support to the government as it struggles to
create and maintain legitimate societal order; hence, these non-profits can be instrumental in
promoting a stronger democracy. Nonprofits, such as Sade Criana, operate within two
environments: (1) legitimate government failure, and (2) systemic institutional failure. While the
Sade Criana program complements and supplements the governments provision of health
services by partnering with the public hospital, simultaneously most, if not all, of their clients
must contend with systemic institutional failure on a daily basis.
Section6.6:TheNonprofitSectorsRoleinReinforcingtheSocialContract

As will be illustrated by the economic models to be presented in Chapter 7, the nonprofit
sector has the opportunity to assist government in upholding the social contract and
counteracting legitimate government failure. Representative causes of failure by a democratic

180
The Fund for Peace: Promoting Sustainable Security. (2006). Country Profiles: Brazil.
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government within a market economy will be shown to originate from both inherent structural
constraints within the system of government, and the limitations of such an economy.
Nonprofits that are engaged in the provision of social services not only assist government
in upholding the social contract, but are also postulated here as being incorporated into the
implicit social contract, for the following three reasons:
(1) The existence of the nonprofit sector is a byproduct of the government upholding
its contractual obligation to protect the liberties of its polity. By protecting the
right to associate, nonprofits are able to form.
(2) As will be discussed in Chapter 7, nonprofits may supplement and complement
the governments provision of social services, thereby directly assisting the
government in its own ability to uphold its contractual obligation. Additionally,
if the nonprofits mission is to provide the same (or similar) social services that
the government is obligated to universally and equitably proffer, then the
nonprofit tacitly reinforces the strength of the social contract through contributing
to the supply of these social services. Further, an enhanced supply of these social
services better enables the polity to have the freedom to exercise their liberties,
reinforcing the strength of the society and social contract.
(3) If a nonprofit provides social services, it is likely concerned with promoting a
distributively just society. To be effective, such a nonprofit must be accountable
to its stakeholders, in accord with basic ethics of grantmaking. This third point
will be further discussed in Chapter 8.2.
In summary, those nonprofits that engage in the provision of social services to promote
social justice become inserted into the implicit social contract by default, as these organizations
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have accepted an obligation to work toward a just society. This position necessitates that such
nonprofits also accept the ethical obligation to actively involve stakeholders when evaluating the
impact of an intervention, a topic which will be discussed in Chapter 8.
Before discussing stakeholders and impact, Chapter 7 uses economic models to
demonstrate the nonprofit sectors contribution as a vital economic player, thus contextualizing
the argument presented here that nonprofits theoretically reinforce the social contract through
actively engaging in the provision of social services.


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Chapter7:TheValueoftheNonprofitSectorinProviding
SocialServices:ATheoreticalandPracticalDiscussion


The primary objective of this chapter is to demonstrate how the nonprofit sector is able to
counteract legitimate government failure through engaging in the provision of collective goods,
including social services. In 1975, Weisbrod presented a seminal work in which he characterized
the nonprofit sector as a distinct economic unit, operating side-by-side with the government and
the for-profit sectors. Over time, his theory was combined with formulations by Salamon and
Hansmann to develop what is now commonly known as the three-failures theory. In the
aggregated form of their work,
each sector responds to failures to deliver the appropriate quantity or
quality of services or to make those services available to appropriate
constituencies.
181

This theory considers the nonprofit sector to be a vital economic player, and presents a clear
means for laying the foundation for the nonprofit sectors contribution to society from an
economic perspective.
182
Notably, in the United States, charitable contributions have exceeded
300 billion dollars annually, with a nonprofit sector comprised of approximately 1.5 million
organizations.
183
Even though charitable giving has decreased during the current economic
downturn, the nonprofit sector continues to play a vital role in the provision of social services.
In this chapter, Section 7.1 presents aspects of the Three Failures Model to illustrate why
the government fails to fully satisfy demand for goods, and by extrapolation, social services.
Section 7.2 presents an overview of the ability of the nonprofit sector to counteract government

181
Walter W. Powell and Richard Steinberg. (2006). Introduction. In The Nonprofit Sector: A Research Handbook
(2nd ed.). Walter W. Powell and Richard Steinberg (Eds.), 2.
182
I use Steinbergs synthesis of The Three Failures Theory from The Nonprofit Sector Handbook, 2006.
183
Kennard Wing, Katie L. Roeger, and Thomas H. Pollak. (2010, April 1). The Nonprofit Sector in Brief: Public
Charities, Giving and Volunteering, 2009. Urban Institute.

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failure through contributing to the provision of social services. A discussion then follows in
Section 7.3 on the relationship between the nonprofit sector and a strong democracy, followed by
Section 7.4, in which the ability of the nonprofit sector to serve as a laboratory for social
innovation is presented.
The following terms, defined below, will be used within this chapter:
Public Good: In economic terms, a good, which all enjoy in common in the sense
that each individual's consumption of such a good leads to no subtractions from
any other individual's consumption of that good.
184
In political theory, this
definition can be extended to include goods that provide collective benefits to the
entire society.
Non-rival good: A good that may be consumed by more than one individual at a
given time, with an additional persons consumption of the good not limiting
others enjoyment. Alternatively, a
Rival good is a good for which one persons consumption prevents another
persons concurrent consumption.
Non-excludable good: A good for which it is impossible, or extremely costly, to
prevent additional people from consuming. Alternatively, an
Excludable good is a good for which it is possible to prevent an additional person
from consuming.

184
Paul A. Samuelson. (1954). The Pure Theory of Public Expenditure. Review of Economics and Statistics, 36(4),
387-389.
Baron 83
Collective Good: Goods that are rival and excludable, with collective benefits.
The challenges associated with providing collective goods are similar to the
challenges associated with providing public goods.
185

The Three Failures Theory, discussed below, is applicable to the provision of social
services by the nonprofit and government sectors. The provision of social services largely falls
under the same set of conditions that enables the government and nonprofit sectors to provide
collective goods. Two such examples are education and health care services. Both are rival and
excludable goods with collective (universal) benefits. Education, improves the quality of
democratic decisions and provides a common language and set of understandings that helps
business and social interactions.
186
And, with respect to health care, Steinberg writes that, the
treatment and prevention of contagious diseases provides a collective benefit for those who have
not yet suffered from them.
187

Section7.1:TheThreeFailuresTheory

MarketFailure:TheGovernmentsResponse

According to the Three Failures Theory, there are several primary reasons for why the
market is not incentivized to provide collective goods: under-provision, over-exclusion, and
contract failure. Under-provision occurs when demand exceeds supply for a good. Because
public goods often suffer from the free-rider problem, wherein there may be a profusion of non-
paying consumers, for-profit firms are incentivized to under produce public goods. Over-
exclusion occurs when a collective good is excludable, but still non-rival. Steinberg uses the

185
Amie R. Baron. Personal Communication with Bruce Sievers. (2010, September 22)
186
Richard Steinberg. (2006). Economic Theories of Nonprofit Organizations. In Walter W. Powell and Richard
Steinberg (Eds.), The Nonprofit Sector: A Research Handbook (2nd ed.), 123.
187
Ibid 123.
Baron 84
performing arts to illustrate the condition of over-exclusion; allowing an additional person to
attend a performance, for example, does not harm the paying customer (a necessary condition for
a non-rival good), but it is possible to prevent additional people from attending (a necessary
condition for an excludable good). Contract failure results from an asymmetry of available
information. A consumer will be hesitant to purchase a good if he believes that the producer has
no reason to be completely forthright about the quality of the product, or that the producer has a
much more detailed perspective on the good or service than the consumer does. Steinberg uses
nursing homes as an example of contract failure; here, an adult child often pays for the good,
while the consumer of the good is often an elderly parent. As the adult child is not the direct
consumer of the good that he purchases, there is an asymmetry of information biased toward the
nursing home.
Government can respond to market failure in several ways. Government solves the free-
rider problem through producing public goods, and then coercing payment through taxes. The
government may also be able to control for over-exclusion by: (1) producing the good directly,
(2) regulating the for-profit sectors provision of a good, or (3) issuing subsidies to help
consumers gain access to excludable goods. For instance, in Brazil, the government has a
number of programs that offer free or subsidized medicine and infant formula (which would
otherwise be very expensive) to low-income families. In order to limit contract failure, the
government may bar untruthful advertising claims, limit who may enter the market with
asymmetric information, and educate consumers about possible abuses.
188


188
Ibid 122.
Baron 85
GovernmentFailure

However, due to institutional constraints, the government may still fail to meet the
demand for the provision of public goods or social services. Two obvious reasons include: the
government is not able to provide a good that violates its constitution (in the United States, this
would include a religious service); and, the government may not offer two policy options that
directly contradict each other.
Additionally, a democratic government is most responsive to the median voter in the
supply of public goods, while minorities or groups lacking a political voice or clout typically
suffer from the under-provision of public goods.
189
Within the context of a universal system of
compulsory taxation, government frequently lacks justification to compel payment from the
entire polity when a minority of the population demands a service.
190

Governments actions are further constrained through a natural gravitation toward
bureaucracy, which is in part attributable to the need for public accountability. Smith and
Gronbjerg elaborate,
[G]overnment [can not] bypass demands for public accountability with
impunityGovernment must therefore demonstrate that it has followed
legal mandates and acted fairly and equitably in carrying out authorized
activities if it is to maintain broad public support. To do so, government
must document its actions[hence,] it will gravitate toward bureaucratic
procedures and red tape
191


Government can also fail by funding ineffective programs. While markets are profit-
motivated to scrap ineffective ideas, fruitless government programs may become entrenched
within a quagmire of government bureaucracy, and continue to receive support while draining

189
Ibid 122.
190
James Douglas. (1987). Political Theories of Nonprofit Organizations. In Walter W. Powell (Ed.), The Nonprofit
Sector: A Research Handbook, 46.
191
Steven Rathgeb Smith and Kirsten A. Gronbjerg. (2006). Scope and Theory of Government-Nonprofit Relations.
In Walter W. Powell and Richard Steinberg (Eds.), The Nonprofit Sector: A Research Handbook (2nd ed.), 224.
Baron 86
limited resources. As Brest and Harvey write, whereas markets tend to discard useless ideas,
the same cannot be said for governments, which have sometimes persisted in supporting useless
programs for preventing AIDS and unplanned pregnancies in the face of all the evidence.
192

MarketandGovernmentFailure:TheNonprofitSectorsResponse

A defining property of the nonprofit sector is the non-distribution constraint, which
prohibits a nonprofit organization from redistributing its financial surplus among those who
oversee the nonprofit. This constraint necessarily shifts the motives and objectives of those
founding, managing, and directing the nonprofit organization, away from a profit-orientation.
Importantly, the non-distribution constraint reduces (or eliminates) any financial incentive to
misrepresent the quality or quantity of services delivered.
193
Accordingly, the lack of a profit-
motive may increase the perceived trustworthiness and accountability of nonprofits, which drives
consumers to turn toward this sector, and away from the market sector, for social services. As
Steinberg explains,
A process of entrepreneurial sorting takes place and those residing in the
nonprofit sector will have different personal objectives regarding what
they want to accomplish in their role
Donors, members and clients are demand-side stakeholders, who
presumably want the organization to offer higher quality than others
charging the same price and lower prices than others producing the same
quality. This is in contrast with for-profit organization, controlled by
supply-side stakeholders (stock and debt holders) who want high prices
(given the same quality)...
194

This desire to optimize the ratio of service-quality per dollar-invested underscores the value of
comprehensively identifying impact for those nonprofits providing social services, a topic which
will be discussed further in Chapter 8.

192
Brest and Harvey, 181.
193
Steinberg, Economic Theories of Nonprofit Organizations, 124.
194
Ibid 124.
Baron 87
Since the nonprofit sector is not subject to the same institutional restrictions, or enmeshed
in the excessive bureaucracy that can constrain governments actions, this sector can offer a
diversity of policy options and supplement the provision of social goods for high-demanders and
minorities, thus counteracting government failure. Steinberg concludes,
After observing that nonprofits commonly provide collective goods, that
government provision of these goods is limitedWeisbrod (1975)
suggested that high demanders who are dissatisfied with government turn
to the nonprofit sector to meet their desires for higher levels of service
provision. Governments meet majority demands, and nonprofits meet
those demands that do not yet or will never obtain majority support.
195

The opportunities presented to the nonprofit sector due to the nondistribution constraint, and the
sectors ability to pursue diverse policy options, will be explored in Section 7.3-7.5.
Section7.2:CategorizingTheRelationshipbetweentheNonprofitand
GovernmentSectors

In situations of legitimate government failure, Young categorizes nonprofit/government
relations as:
(4) complementary: the provision of collective goods by the nonprofit sector is
integrated with the provision of collective goods by the government;
(5) supplementary: the nonprofit provides collective goods in addition to those
provided by the government; and
(6) adversarial: the government and the nonprofit sectors try to influence each
others policies.

195
Ibid 123
Baron 88
Figure 16 sketches these relationships; note that they are not mutually exclusive. The adversarial
and supplementary models, which are most relevant to this thesis,
196
work in tandem when the
nonprofit sector engages in social innovation; Sade Criana is a prime example of such social
entrepreneurship.
197



Figure 16. Categories of
Nonprofit/Government Interaction.
(Figure from Young, 2006).
198

Note: NP = nonprofit; G = government

When the scope and responsibilities of government grow, an increase in transaction costs
is precipitated. As Coase suggested, given such organizational growth, it is eventually more
efficient to outsource service-provision to programs from the ground-up.
199
In the
complementary relationship, the government and nonprofit deliberately and proactively engage
and collaborate with each other and the government finances the nonprofits provision of
collective goods.

196
Given that Sade Criana does not receive government funding, this thesis is concerned with the opportunity for
nonprofits to contribute to or influence governments provision of collective goods without introducing a fiduciary
relationship as the primary source of support for the nonprofit.
197
Dennis R. Young. (2006). Complementary, Supplementary, or Adversarial? In Elizabeth T. Boris and Eugene C.
Steurle (Eds.), Nonprofits & Government: Collaboration & Conflict (2nd ed.), 39-41.
198
Figure from: Dennis R. Young. (2006), Figure 1.1: Three Dimensions of Government-Nonprofit Relations, in
Complementary, Supplementary, or Adversarial, 42.
199
Ibid 43-46.
Baron 89

Additionally, by transacting with nonprofits, government is able to offer social services
that are often more community-specific and less expensive than if the government had needed to
reinvent the wheel. Two benefits of such collaborations include:
(1) lower costs which translate to more bang for buck, due to a more efficiently
administered program, and
(2) the opportunity for the program to benefit from the nonprofits more substantial
local knowledge.
An in-depth knowledge of a community is dependent on the active engagement of stakeholders.
Successful outcomes are more likely when the provision of social services is connected to a
close, collaborative relationship with the recipient community, which enables the nonprofit to
better provide needed collective goods than could a diffuse government agency.
200,201

An example of the complementary model can be illustrated through one of Sade
Crianas methods for scaling. In Belo Horizonte, a city about 300 miles from Rio de Janeiro,
the Secretaria Municipal de Polticas Sociais (government Secretary of Public Policies) is
implementing Sade Crianas Family Action Plan as part of the governments Programa Belo
Horizonte Cidadania, (Belo Horizontes Citizenship program). However, the government is not
able to offer the Housing Project component of the Sade Criana program, so it is partnering
with a nonprofit to do so.
Given that government tends to provide collective goods for the median voter, the
nonprofit sector is able to supplement the governments provision of collective goods for
societys high and low demanders, and for individuals seeking a more diverse set of options. In
the supplementary relationship, nonprofits react to the governments under-provision of

200
Ibid
201
Smith and Gronbjerg
Baron 90
collective goods and social services by providing additional goods so as to serve voters
heterogeneous demand preferences. The relationship between the nonprofit and government
sectors is both dynamic and inversely related. When government takes more responsibility for
the provision of collective goods, voluntary provision may wane. Sade Criana offers a
microcosmic pro-active example of this shift in provision.
202
One of Sade Crianas objectives
in its provision of infant formula and food to its client families, is that as the families learn how
to connect with the government programs that provide such goods, they shift their dependency
from Sade Criana to the government.
In the adversarial relationship, as illustrated in Figure 16, a push-pull dynamic exists
between the nonprofit and government sectors, wherein each tries to influence the others policy
decisions. The adversarial model is less concerned with the explicit provision of collective
goods and social services; instead, this model shifts its focus to the political relationship between
the two sectors. As Young writes,
[N]onprofits prod government to make changes in public policy and to
remain accountable to the public. Reciprocally, government attempts to
influence the behavior of nonprofits by regulating their services and
responding to advocacy initiatives.
203

Incorporated into Youngs adversarial model is its portrayal of the nonprofit sectors ability to
offer a voice to political minorities (recollect that the government provides collective goods to
meet the demands of the median-preference voter), and the potential for the broad-scale impact
that nonprofits may have on influencing policy. By offering a forum (within civil society)
through which minorities may become politically empowered through their own formation of

202
Young, 42.
203
Ibid 40.
Baron 91
voluntary organizations, the nonprofit sector enables these groups to enter into a stronger
relationship with the government.
204

A principle benefit of engaging minority groups, and identifying their needs and demands
through the nonprofit sector, is that government may be better able to universally and equitably
provide social services. Thus the ability of the nonprofit sector to engage a diversity of citizens
emphasizes my argument in Chapter 6, that the nonprofit sector plays a vital role in reinforcing
the strength of the implicit social contract, and as such furthers a just society.
Section7.3:TheNonprofitSectorandaStrongDemocracy

This benefit of engaging more diverse segments of the polity is corroborated by the
positive correlation between the strength of the nonprofit sector and the strength of a democracy.
Further, the freedom to associate is characteristic of all democracies.
205
A strong civil society
provides an outlet for civic engagement, through which the polity can directly interact in, and
with, its government.
206
In the United States, civil society has long contributed to the stability of
its democracy. After traveling to the United States in the 1830s, Alexis de Tocqueville observed
that citizens,
become powerless if they do not learn voluntarily to help one another.
In democratic countries the science of association is the mother of
science; the progress of all the rest depends upon the progress it has
made.
207

This circumstance is due to a circular relationship, wherein: a strong nonprofit sector leads to
increased civic engagement, and civic engagement then enhances democracy through generating
social capital. (Social capital is defined as the bonds among individuals that generate trust and

204
Ibid 46-47.
205
Douglas, 45.
206
Ibid
207
de Tocqueville, Democracy in America, Volume II, Section II, Chapter V.
Baron 92
reciprocity which are necessary for the furtherance of democracy.)
208
The method by which
social capital,
translates into improved government is presumed to be an indirect one, in
which social capital both facilitates and promotes collective action for the
common good so that citizens come to demand and expect more from
government officials.
209

Thus, as citizens become engaged with one another, they can become empowered and learn to
speak up for themselves. This circumstance was reported by Dr. Arantes, and several
members of the Sade Criana staff, during our interviews. One of the signs that a mothers
self-esteem was increasing was that she would start standing up for herself, and proactively
making requests (and sometimes demands) to doctors, hospital employees, and Sade Crianas
social assistants. As Dr. Arantes said, this change in behavior is extremely important because it
shows that, the woman grew another step as a citizen.
210
This observation epitomizes the
transition from weak to stronger agency through empowerment, and the subsequent self-
awareness to exercise ones rights.
Section7.4:TheNonprofitSectorasaLaboratoryforSocialInnovation

The nonprofit sector can be envisioned as a laboratory for innovation when models for
nonprofit/government relationships are integrated. Since the nonprofit sector is able to offer a
diversity of policy options and circumvent government bureaucracy, it may actively supplement
the governments provision of social services by being able to innovate new methods for
providing social services in its response to government failure. Furthermore, if these programs
are proved successful, they may cause a change in governments policy through their adoption as

208
Helmut K. Anheier and Lester M. Salamon. (2006). The Nonprofit Sector in Comparative Perspective. pp 93 and,
Steinberg and Powell (2006). Introduction. pp 4. Both from Walter W. Powell and Richard Steinberg (Eds.), The
Nonprofit Sector: A Research Handbook (2nd ed.)
209
Smith and Gronbjerg, 230.
210
Amie R. Baron (Interviewer), and Dr. Odilon Arantes, Former Chief of Pediatrics at Hospital da Lagoa
(Interviewee). (2010, April 8).
Baron 93
policy. When I was in the Philippines in March 2008, I met with Dr. Arnel Onesimo, a Business
School professor at De La Salle University, in Manila. He postulated that a country can be
considered prime for social entrepreneurship (which, here, I use to refer to nonprofits
innovating new forms of social change programs) when the people have essentially given up
on the ability for the government to mediate or solve social problems including poverty,
education, or healthcare.
While the nonprofit sector has the flexibility to engage in social innovation, as a program
is proved successful and starts to scale, the government might, in fact, administer it better. This
exit strategy wherein the government subsumes management - reflects the adversarial model
because the nonprofit has now influenced the governments policy. As Steinberg reiterates,
Sometimes, the service in question is innovative, and the majority is reluctant to support it due
to its newness. Then, the nonprofits pioneer the idea, and government takes over funding or
provision after the idea is proven.
211
The benefits for society are plentiful. Once an effective
program is developed, proven, and garners public interest, it provides a flag for the government
(and possibly the market sector) to adopt the program or methodology, and bring it to scale
through incorporating it as policy. Boris writes,
Nonprofits have a long history of pioneering programs that other sectors
subsequently take over. Nonprofits popularized primary education,
kindergartens, and disease control, which government then took over
when demand outpaced nonprofit providers ability to supply services
Nonprofits are often lauded for being flexible and innovative, a source of
ideas for improving society; those ideas transcend sectors.
212

In David Bornsteins book on social entrepreneurship, How to Change the World, he recounts a
dramatic case of scaling whereby the government assumes administration of a program. Gloria

211
Steinberg. Economic Theories of the Nonprofit Sector, 123.
212
Elizabeth T. Boris. (2006). Introduction - Nonprofit Organizations in a Democracy. Varied Roles and
Responsibilities. In Elizabeth T. Boris and Eugene C. Steurle (Eds.), Nonprofits & Government: Collaboration &
Conflict (2nd ed.) 16
Baron 94
de Souza, an early Ashoka fellow, introduced a powerful environmental curriculum into Indian
schools that revolutionized how students were taught.
in 1982, de Souza founded an organization called Parisar Asha,
Sanskrit for hope for the environment, and began building a team to
spread her ideas. In a few years, she was able to demonstrate that her
Environmental Studies (EVS) approach significantly increased students
performanceBy 1985 de Souza had persuaded Bombays municipal
school board to introduce EVS in 1,700 schools through a pilot program.
Within three years, almost a million students were learning with her
methods. By the end of the 1980s, the Indian government had
incorporated EVS into its national curriculum, making it Indias official
standard of instruction in grades one through three.
213

In this remarkable example, the governments adoption of de Souzas curriculum represented her
programs exit strategy.
As shown in this chapter, a vibrant nonprofit sector can: serve as a laboratory for
innovation, develop scalable solutions to social problems, offer policy options in addition to
those offered by the government, and build closer relationships with the local community. A
strong nonprofit sector is also correlated with civic engagement, which is essential to building
and maintaining a strong democracy. Through assisting the government in its provision of
collective goods and social services, the nonprofit sector can help the government to uphold its
implicit contractual obligation to its constituency.
All of these intrinsic properties of the nonprofit sector highlighted above are critical, yet
they can make it difficult to comprehensively assess the impact of a philanthropic investment or
nonprofit program. In Section 3, it will be shown that stakeholder interviews have the potential
to significantly contribute to a comprehensive understanding of the impact of philanthropic
investments and nonprofit programs, specifically those programs that involve the provision of
social services.

213
David Bornstein. (2004). How to Change the World: Social Entrepreneurs and the Power of New Ideas, 19.
Baron 95
Section 3: Using Stakeholder Interviews as a Means of
Identifying Impact: A Pilot Case Study on Sade Criana of
Brazil


Chapter 8 considers the value of stakeholder interviews in identifying impact. Chapter 9
describes the background and methodology for this research project and includes the list of
interview questions used in the pilot case study, as well as pertinent data about the interviewees.
Chapter 10 details results of the pilot case study, which are subdivided by both major findings,
and indicators for empowerment. Chapter 11 presents conclusions and directions for further
research.
Baron 96
Chapter8:ConsideringImpactandtheValueofStakeholder
Interviews


Foundations and nonprofits have many different methods, criteria, and approaches for
evaluation of impact. My pilot case study findings illustrate that through actively engaging
constituents when assessing the impact of a philanthropic investment or nonprofit program,
stakeholder interviews can: serve as a substantial information resource for an organizations
impact, provide a volume of critical information that may otherwise be unattainable, and
supplement the diversity of options that an organization may use for examining impact.
Section8.1:ThePhilanthropic/NonprofitSectorandImpactAvarietyof
Perspectives

In the for-profit sector, the profit-motivated bottom line is a standard for judging the
success of a company. However, in the philanthropic/nonprofit sector, because of the non-
distribution constraint, there is no bottom-line. Accordingly, as discussed in Chapter 7, many
of the benefits of a strong philanthropic/nonprofit sector are derived from a unique set of
characteristics that differ from those of either the for-profit or government sectors. Sievers
explains,
Unlike businessesphilanthropic and nonprofit organizations operate in
two worlds. One of these is defined by instrumental objectives such as
financial stability, numbers of people served, inches of press coverage.
The other world, however, is defined by different end goals of human
action: education, artistic expression, human advancement, personal
security, freedom of thought and action, concern for future generations,
and preservation of cultural and environmental legacies.These ends are
the goals and aspirations of the human experience and are not reducible to
the same kinds of categories that define profit margins...
214



214
Bruce Sievers. (2004). Philanthropy's Blindspots. In Michele Courton Brown and H. Peter Karoff (Eds.), Just
Money: A Critique of Contemporary American Philanthropy, 132-3.
Baron 97
Albert Einsteins famous quote, Not everything that counts can be counted, and not everything
that can be counted counts can be used to reflect this intrinsic value of the nonprofit sector.
215

As mentioned in Chapter 1, and delineated in Chapter 5, Sade Criana, as a health
organization working toward social justice, does monitor, track, and assess its intended impact in
specific program areas through its database, family action plan, and various indicators. Prior to a
familys completion of the Sade Criana program, it must meet minimum standards in three out
of five areas. While this effort requires significant manpower and time resources, it is important
to emphasize that the data tracked by Sade Criana is compatible with measurement, e.g. -
increases in family income, or changes in childrens health, due to participation in the program.
However, as noted earlier in this thesis, during my public service fellowship in Brazil, in 2008,
it quickly became apparent to me that Sade Crianas impact far exceeded that which was
readily measurable. In this section, a sample of approaches that other nonprofits have used to
examine impact will be briefly highlighted. In each of these approaches, stakeholder interviews
can provide additional insight.
IntendedImpactandTheoryofChange

In linking mission to impact, Colby, Stone, and Carttar in, Zeroing in on Impact, in the
Stanford Social Innovation Review (SSIR), write, intended impact and theory of change provide
a bridge between a nonprofits mission and its programmatic activities.
216
This approach can be
used internally for strategic planning. The authors use a broad iterative structure to examine the
linkage between intended impact, and a theory of change, which enables:

215
As quoted by Brest and Harvey (15), in their discussion of the possibilities and limitations of counting
philanthropic impact.
216
Susan Colby, Nan Stone, Paul Carttar. (2004, September 1). Zeroing in on Impact in an Era of Declining
Resources, Nonprofits Need to Clarify their Intended Impact. Stanford Social Innovation Review.
Baron 98
an organizations leaders to clarify what success will look like in the
near-to-medium term,[by] creat[ing] a coherent framework for
making tradeoffs that reflect the aspirations of the organizations
mission as well as the constraints of its bottom line.
217

Reproduced below is Colby, Stone, and Carttars framework for examining impact:
218


HowDoYouKnowYouveArrived? HowDoYouGetaGoodDiscussionGoing?
ANACTIONABLEINTENDEDIMPACT
Linksinacompellingwaytoyourmission
andvisionforsocialchange.
Specifiestheoutcomesyouseektocreate
foryourbeneficiaries.
Affordssufficientcontroloveroutcomesto
enablerealaccountability.
Isrealisticandachievable,givenyour
capabilities.
Ismeasurableonanaccurate,timelybasis.
Providesaneffectiveplatformformaking
strategictradeoffs,especiallythose
relatedtoprogramfocusandresource-
allocationdecisions.

ACOHERENTTHEORYOFCHANGE
Identifiesthemostimportantneedsof
yourchosenbeneficiaries.
Articulatesthemostimportantleverage
pointstomeetthoseneeds.
Linksyoursolutionstoyourbeneficiaries
needsthroughachainofcause-and-effect
relationships.
Isempiricallyplausibleifnotproven.
TOCLARIFYANORGANIZATIONSINTENDED
IMPACT,ASK:
Whoareourbeneficiaries?
Whatbenefitsdoourprogramscreate?
Howdowedefinesuccess?
Whatwontwedo?
Whatwouldmakeusobsolete?

TOCLARIFYANORGANIZATIONSTHEORYOF
CHANGE,ASK:
Whatisthecause-and-effectlogicthat
getsusfromourresources(peopleand
dollars)toimpact?
Wherearethegapsorleapsoffaithinthis
logicchain?
Whatarethemostimportantelementsof
ourprogramscontentandstructure?
Whatassumptionsledustochoosethese
particularprogramelements?
Arethereotherwaysinwhichwecould
achievethedesiredoutcomes?
Whatistheminimumlengthoftimeour
beneficiariesneedtobeengagedto
achievetheseoutcomes?
Whatelsedoourbeneficiariesneedto
achievetheseoutcomes?


217
Ibid
218
Ibid
Baron 99
SocialReturnonInvestment

Social Return on Investment, (SROI), expresses the dollar amount expected from every
dollar invested, and is analogous to the return on investment considered in the for-profit world.
Brest and Harvey state that a primary value of an expected return analysis is that it,
presses you to clarify your goals, to make your assumptions explicit, to be
realistic about the power of philanthropy to effect social change, and to be
aware of the risks involved along the way.
219

A sample formula for how the Hewlett Foundation calculates its SROI for a specific program
follows:
220


BenefitsinaPerfectWorldLikelihoodofSuccessHewlettContribution

Cost

DEFINITIONOFVARIABLES:
BenefitsinaPerfectWorld:thesocialbenefitsthatwouldberealizediftheproposedtheoryofchange
succeededperfectly.
LikelihoodofSuccess:reflectedthefactthatvirtuallyallphilanthropictheoriesofchangefacestrategic,
organizational,andexternalrisks.
HewlettFoundationsContribution:anestimateoftheportionofsuccessforwhichthefoundations
effortcouldbecredited,bothintermsoftheamountofmoneyinvestedandtheinfluenceofthat
money.
Cost,inthiscase,included:supportingnongovernmentalorganizationsengagedinbudgetandrevenue
monitoring,inexpendituretracking,andintraininggovernmentofficialsintheimplementationof
freedom-of-informationlaws

IdentifyingResultsthroughDashboards

Another approach for examining impact is described in Dashboards that Guide Good:
How funders can help grantees track their progress more effectively, (also in SSIR). Burgoyne,

219
Brest and Harvey, 162.
220
Ibid 156-158.
Baron 100
of the Draper Richards Foundation, writes about a specific grantees dashboard, which uses a
simple matrix. Data is captured in three columns on scale, impact, and sustainability, and two
rows represent[ing] program and finances; anecdotes can be added to personalize the numbers:
Each metric has a target outcome and green, yellow, and red bubbles
indicate if the goals are being exceeded, met, or missed. Although
simple and uncluttered, One Acre Funds dashboard shows donors like
us what we need to know. To convey its impact more clearly, One
Acre Fund even includes anecdotes alongside its dashboards. These
stories vividly portray just how much of the nonprofits programs
affect the lives of individual farmers and their families.
Stakeholders
221
can then connect the dots between these moving
stories and the statistics, understanding that many of the other 12,000
families that the nonprofit serves are experiencing similar stories.
222


StakeholderReviews

Greatnonprofits (GNP) collects stakeholder reviews through an online forum. The site,
collect[s] stories and reviews of peoplewho have seen the impact of nonprofits up close, and
can speak personally and firsthand about it.
223
As Perla Ni, Founder of GNP, wrote,
Anyone is free to use these reviews to evaluate the effectiveness of
nonprofits, as one input among many used in determining how well
they are performing compared to their peers.[R]eviews of nonprofits
by people who have had direct experience with them help the
organizations find out what they are doing well (or not so well) in
ways that can improve their daily operations going forward.
224


221
Here it appears that Burgoyne may be referring to stakeholders as, donors, board of directors, government
supporters, and partners. The definition of stakeholders, as used in this thesis, is presented in Section 9.2.
222
Anne Marie Burgoyne. (2010, February 23). Dashboards that Guide Good. How can Funders Help Grantees
Track their Progress More Effectively? Stanford Social Innovation Review.
223
GreatNonprofits. About us: What is GreatNonprofits.
224
Perla Ni. (2010, August 5). Can Stakeholder Reviews by Beneficiaries Bring New Perspectives to Philanthropy.
Stanford Social Innovation Review.
Baron 101
Section8.2:TheEthicalSignificanceofStakeholderInterviews

In this thesis, a stakeholder is defined as: an individual who has a vested interest in, or is
directly affected by, a nonprofit program or philanthropic investment. Such individuals include:
clients served, funders, the board of directors, community or government partners, staff, and
volunteers. Sade Crianas stakeholders also include those members of Hospital da Lagoas
staff who interact with the organization or its clients.
Concern with the impact that a program may have on stakeholders is rooted in a
commitment to accountability (defined as, a means through which individuals and organizations
are held responsible for their actions
225
), and principles of ethical and effective service.
Frumkin writes,
[A] feature of giving that makes philanthropy quite different from other
forms of private consumption stems from the effect it has on other
people Donors use funds in public ways and the nature of their work in
communities and neighborhoods unavoidably influences others.
Sometimes these effects are direct, such as when human services are being
offered, other times the effects are more indirectly felt, such as when a
policy is being researched and advocated (Ferris and Mintrom 2002; Smith
2002). The fact, however, that philanthropy is public in its intentions and
seeks to enact a private vision of the common good raises accountability
issues precisely because the act of giving projects private values and
commitments into the public sphere. The individuals and communities
[stakeholders] on which these values are projected can and do make
accountability demands on donors (Collins, Rogers, and Garner 2000).
226

Even though Frumkin specifically writes about philanthropy, I extend his position that
stakeholders are entitled to, make accountability demands on donors, to argue that stakeholders
ought to be engaged when evaluating the impact of an intervention (either a philanthropic
investment or nonprofit program). In the previously cited summary article by Ebrahim, entitled,

225
Ebrahim, 814.
226
Peter Frumkin. 2006). Accountability and Legitimacy. In Kenneth Prewitt (Ed.), The Legitimacy of Philanthropic
Foundations: United States and European Perspectives, 100.
Baron 102
Accountability in Practice: Mechanisms for NGOs, (see Section 1.2), he cites several scholars
in order to develop a matrix for examining accountability according to several classifications,
one of which is the stakeholder group, i.e., funders, clients, and the NGOs themselves. Ebrahim
states that,
What is missing from much of the debate on accountability is an
integrated look at how organizations deal with multiple and sometimes
competing stakeholder demands. Stakeholder perspectives from the
organizational behavior literature have only just begun to fill this gap.
227

Accountability demands are placed on both funders and nonprofit organizations. In this thesis, in
order to identify the impact of an intervention, downward accountability is emphasized.
Ebrahim argues that downward accountability may be fostered or promoted through assessing
impact. He defines downward accountability as follows:
NGO accountability to clients refers primarily to relationships with
groups to whom NGOs provide services although it may also include
communities or regions indirectly impacted by NGO programsThis has
also been termed downward accountability.
228

Further,
Downward accountability can also be enhanced through participatory
evaluation
229


Valuing the input of stakeholders, specifically the clients served or communities affected,
through the stakeholder interview process, is not only a means of realizing downward
accountability, but it also adheres to principles for ethical and effective service. These principles
are designed to ensure that a public service program is accountable to its stakeholders.

227
Ebrahim, 814.
228
Ibid 814-815.
229
Ibid 819.
Baron 103
According to Stanfords Haas Center for Public Service, the first principle is reciprocity through
partnership, which necessitates that a public service program,
Develop collaborative relationships with community partners and
recognize their role as educators of student participants.

Involve potential community partners in the design of service projects to
ensure the value and relevance of the work.
230

Deriving the case for stakeholder interviews, from both the concept of accountability and
principles of ethical and effective service, builds from my argument in Chapter 6 that nonprofits
that engage in the provision of certain social services tacitly reinforce the social contract, and as
such accept an obligation to help work toward a just society. Again, as Frumkin expressed,
implicit to the philanthropic/nonprofit sector is that philanthropyseeks to enact a private
vision of the common good, to (hopefully) benefit the public. What is actually considered
publically beneficial - or just - can be quite subjective. The standard of distributive justice
(equality of opportunity), posited by Rawls, is critical to this thesis. As previously discussed,
Sen argues that distributive justice is essential so that all people have the freedom to exercise
their liberties. In order for the philanthropic/nonprofit sector to advance this vision of social
justice, it is critical that funders and nonprofit program staff evaluate the effectiveness of their
programs, according to impact on stakeholders, specifically the clients served or communities
affected. This is not to say that current methods, such as those discussed in Section 8.1, do not
take stakeholders into consideration they surely may. But, it is to say that directly engaging
stakeholders, through employing qualitative research methods, can enhance other evaluation
methods by contributing essential knowledge about the impact of a nonprofit program through
the eyes of those directly affected by the intervention. These insights, which may fly under the

230
Haas Center for Public Service, Stanford University. Principles of Ethical and Effective Service Document.
Baron 104
radar, and may not be identifiable through quantitative data, can be vital for helping program
staff better meet an organizations mission, directly address issues of accountability and
transparency, and provide for a more effective distribution of social services, thus promoting
social justice. Stakeholder interviews can also help funders to better assess the effectiveness of a
nonprofits program, thereby optimizing the power and benefit of their social investment to
foster social justice.
The next chapter will detail the stakeholder interview methodology that I developed and
tested in order to better understand the impact of Sade Crianas program on the empowerment
of its participating families.
Baron 105
Chapter9:ResearchOrganization,Preparation,and
Methodology


Section9.1:OverviewofPilotCaseStudy

The goal of this study was to determine if stakeholder interviews could provide a greater
understanding of the impact of Sade Crianas program on the empowerment of its participating
families.
BackgroundandPreparation:

The academic and research work for this project has spanned over two years.
Throughout this time period, I was in extensive communication with my Brazilian partnering
organization, Sade Criana, in order to lay the groundwork for this research project. I was
awarded a Stanford UAR Student Research Grant to fund this pilot case study, and as Protocol
Director, I was in communication with Stanfords Institutional Review Board (IRB), which
reviewed my study protocol. Learning about the IRB process provided me with a great deal of
insight into institutional safeguards for protecting human subjects. Please see Appendix C for
Sade Crianas Letter of Agreement, and Appendix D for the IRB Notice of Exempt Review.
The research preparation, execution, and follow-up are delineated in Table 1, Baron Field
Research Work Flow by Goals and Tasks.
Baron 106

Table 1. Baron Field Research Work Flow - by Goals and Tasks
Preparation for Pilot
Study
(1) Submitted Human Subjects Research Protocol.
(2) Created a preliminary study protocol; prepared interview
questions and themes, and discussed research methods
and anticipated results with Stanford advisors.
(3) Arranged for housing and work space in Rio de Janeiro.
(4) Finalized travel and research arrangements in
coordination with Sade Criana.
(5) In order to create a streamlined framework for
effectively completing my research project while on site,
I reviewed detailed information sent by Sade Criana
regarding their methodology and efforts to track results
prior to leaving for Rio de Janeiro. Extensive advance
work was necessary because I would need to use my
research time as effectively as possible, and begin my
research immediately upon arrival.
Goal:
To create an unbiased and effective set of interview questions
that would increase an understanding of the intricacies of the
impact of Sade Crianas program on the empowerment of its
participating families.
Research Execution in Rio
de Janeiro:

(1) Coordinated all project activities with Sade Criana.
(2) Interviewed Sade Criana staff, volunteers, members of
families participating in the program, and hospital
personnel.
(3) Began analysis of data and summary of results.
(4) Reviewed findings with Sade Criana staff.
Goal:
To effectively and efficiently implement pilot study so as to
interview as many families, staff, and hospital personnel as
possible given time constraints and challenging circumstances.
Upon my arrival in Rio de Janeiro, a State of Emergency was
declared.
Research Analysis/Post-
Rio Follow-up:

(1) Transcribed approximately 30 hours of interviews.
(2) Compiled and evaluated data.
(3) Analyzed data and summarized results.
(4) Obtained feedback from both faculty and field mentors.
Goal
To explore the role that stakeholder interviews could play in
contributing to an understanding of an organizations impact.
Baron 107

StateofEmergencyDeclared:

As mentioned in Chapter 3.2, within 36 hours of my arrival in Brazil, a State of
Emergency was declared in Rio de Janeiro due to extraordinary rains that precipitated flooding
and landslides, causing great loss of life, primarily in the favelas. There were mudslides
throughout the city, sewage washed into the streets, the lake near Sade Crianas offices
flooded, and ocean waves were dangerously high. For one day, the city was closed down and
almost no one reported to work. After the worst of the rains subsided, it was challenging for the
families to come in to Sade Criana during the remainder of that week. The Sade Criana staff
were taxed with coping with the challenges of the flooding: all of the staff were working in very
limited office space, and all hands were on deck the weekend after the flooding to prepare the
satellite building for receiving the families the following week. Within a few days after the State
of Emergency had been declared, only one family managed to make it in and said that they had
lost their home to the flooding. Because of the flooding, all of Sade Crianas
professionalization courses, seminars, and group therapy sessions were suspended for the
duration of my research project; I would otherwise have observed these programs. As the
flooding began to abate, the city began to operate more normally; however a bus strike the
following week further prevented many of the families from coming to Sade Criana.
Baron 108
Section9.2:IndicatorsforEmpowermentandInterviewQuestions

Interview questions were developed to address indicators of empowerment. These
indicators included:
If the mother reported:
(1) an increase in her overall confidence.
(2) a shift in how she interacts with professionals, such as her childs
doctors. In the context of the pilot study, the doctor represents
someone of authority.
(3) a shift in her familys dynamics.
(4) sharing information from Sade Crianas programming with others
in her community.
(5) an increase in her level of civic engagement.
For most indicators, it was necessary to develop a line of questioning that brought out a before-
and-during response; the before referring to the mothers actions prior to or at the beginning of
joining Sade Criana, and the during referring to the mothers current state. While the theme
for each of my interviews remained constant, since I was seeking information about pre-
determined indicators, there was some variation in the specific questions that I asked each
parent; this depended on such factors as, if the parent was with a spouse/partner, and the length
of time the family had been in the program.
Additionally, as I noticed trends across interviews, I started expanding my questions as I
progressed through the families in two significant ways:
Baron 109
(1) After Interview (#4), I started to regularly ask whether the interviewee attempted
to acquire more information about her childs illness, in addition to that which she
learned at the hospital.
(2) By Interview (#13), after noting that several interviewees were very upset with
the treatment that they had received at other hospitals relative to the treatment
they received at Hospital da Lagoa, I began to directly inquire how their
child/grandchild came to Hospital da Lagoa, and how treatment had been different
between Hospital da Lagoa and other hospitals.
Several Sade Criana staff members, and one volunteer, assisted me in providing
translations for my family interview questions. Collectively, they contributed many hours of
their time to this project. During each interview, after I asked each question, my translator
repeated the question to the interviewee in Portuguese. The interviewee then responded to me in
Portuguese, after which the translator communicated the interviewees answer to me in English.
This enabled me to tailor my interview questions, as appropriate, to each interviewee, and to ask
pertinent follow-up questions. I conducted Interview (#10) with Daniela on my own, in
Portuguese. Through this process, I was able to refine the quality of information I gathered
through the interviews. The family interview script used for the Sade Criana pilot case study
is provided in Table 2, on the following two pages.
Baron 110

Table 2. Interview Script for Sade Criana Pilot Case Study
General I introduced myself (the interviewer), in Portuguese, as a university
student conducting research on Sade Criana. The interview
questions follow:
What is your name (first only)?
What are your childrens names (first only), and ages?
How long does it take you to commute from your residence to Sade
Criana?
How long has your family been at Sade Criana?
General questions about the childs illness, including which child was
in Sade Criana.
Interactions with
Doctors
When was the last time you were at the doctor?
What did the doctor say? (usually led to description of childs illness)
Did you understand?
Did you ask questions? If so, what did you ask?
Have you always asked questions?
Did you ask the doctors questions prior to your family entering Sade
Criana?
Did you feel comfortable with the doctor?
Do you do any outside research (internet, ask friends, etc.)?
Did you always feel comfortable with the doctors?
How did your family enter Hospital da Lagoa?

Table 2 is continued on the following page.
Baron 111
Family Dynamics Marital Status?
Is it the same father for all of your children?
(If separated) If its not too personal, do you mind my asking why
you are no longer together?
Is/was your partner good with the children? (When asking why the
couple separated, I placed emphasis on understanding the dynamic
between the father and children.)
Did your participation in Sade Criana have any impact on your
decision to separate?
Income How does your family support itself?
Community/Sharing
Information
Have you taken a professionalization course at Sade Criana?
Who are you close to? (Family, friends, neighbors, etc.)
With whom do you share any problems?
Do you share anything that you learn from Sade Criana seminars
(nutrition, etc.) with these people?
Please give specific examples
Civic Engagement Do you vote? (As voting is mandatory in Brazil, everyone answered
affirmatively.)
Is it important to vote? If yes, do you know who the presidential
candidates are?
Does your community have a neighborhood organization?
Are you involved with the neighborhood organization?
Impact of Sade
Criana
How has Sade Criana helped you?

Table 2 is continued from the previous page.

Baron 112
As will be discussed in Chapter 10.2: Empowerment and Self-Esteem, my family
interviews focused on indicators (2) through (5). In Chapter 10.6: Empowerment of Participants,
Change in Self-Esteem and Overall Confidence, findings related to a joint self-esteem/confidence
indicator are presented.
Interview questions about changes in family dynamics were influenced, in part, by my
2008 site visit with the Elas Fundo de Investimento Social that I described in Chapter 4. During
this site visit, many of the women I spoke with described their extremely difficult family
environments.
When interviewing the staff and volunteers, my questions were thorough, but did not
follow the same interview format that I developed for the families; I tailored the staff and
volunteer interviews to the interviewees specific area of expertise, work responsibilities, and
personal experiences related to Sade Criana.
Section9.3:DatafromFamilyInterviews

During the extraordinary time period of the flooding and associated problems in Rio de
Janeiro, Sade Criana continued to assist me in every way possible. The Sade Criana staff
was always poised, thoughtful, and good-natured in providing me with continuous support under
the extreme circumstances. In an email correspondence to Professor Rob Reich that I sent from
Rio de Janeiro on April 22, 2010, reporting on the course of my research project:
One of the Sade Criana offices was closed down because of a mudslide,
and all of the employees were camped out at their other site, which is
where my interviews took place. During my first week, I interviewed staff
because the families were completely unable to come in that week.
Interviewing the staff first actually provided me with an extremely
valuable context for the family interviews, which then followed I believe
making them all the more detailed.
231



231
Amie R. Baron (2010, April 22). Personal Email Communication with Professor Rob Reich.
Baron 113
All told, I conducted 25 interviews with families, and 20 interviews with staff,
volunteers, and members of the board of directors; I accumulated over 30 hours of interview
material, with my (typed) interview notes spanning approximately 112 pages. In addition to the
staff and volunteers, I conducted back-to-back interviews with the families as they waited to see
the social assistants for their monthly appointments. The purpose of each family's visit was to
collect supplies (food, clothing, medicine, and highly-specialized milk), and to meet with social
workers, a nutritionist, and a psychologist (optional). Some of the families came to Sade
Criana after visiting the partnering public hospital, Hospital da Lagoa; others came directly to
Sade Criana for their monthly meeting. Please refer to Appendix A, which lists the staff,
volunteers, and members of the board of directors, whom I interviewed. The following table,
Table 3: Family Interviewee Data, includes information obtained on age of interviewee, length of
time in the Sade Criana program, number of children, marital status, the fathers relationship
with his children as a component of family dynamics, and commute time of interviewee to Sade
Criana.
Baron 114

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Baron 115
NotesonTable3:FamilyIntervieweeData

(1) Participation in the Sade Criana program may extend beyond two years if the
family is actively engaged in improving its situation, but is not yet able to support
itself. Two mothers I interviewed had different reactions to exiting the program.
Mariana (#25) said that she was, worried because her family will be released, and
will not be able to count on Sade Criana. Alternatively, Flavia (#11) said that
because she was going to undergo surgery, her family would stay a little longer
before exiting the program. Flavia said she was, ready to go. It is time to leave
and give my familys place to others.
(2) Discussion of Fathers Relationship with Children:
A. The left-most column in this category indicates that:
i. the mother said the father/stepfather lives with her and the children,
and that he treats them well, or,
ii. if the parents are separated, the mother said that the father cares
about the children, and that he continues to offer financial support to
his family.
B. The second column indicates that while the father cares about the children
and is not abusive, he is not substantively involved in their lives or offering
financial support. In several instances, the father lived far away from the
children. Marianas (#25) ex-husband lives far from the family, so I marked
his contribution to his childrens lives in this column. However, she added
that when one of their older sons was in jail, the father returned to help.
Maria (#14) said that Rafael has a good relationship with his father, but she
Baron 116
did not mention whether or not he was financially contributing to Rafaels
upbringing, or how involved the father was in caring for his son;
accordingly, I marked his contribution to his family in this category.
C. The third column indicates that the father is physically abusive toward his
family.
D. I assumed that if the father/grandfather was present at the interview, the
father/grandfather was engaged in raising the child. However, because the
interview was conducted in front of the father/grandfather, there would have
been no opportunity for the mother/grandmother to share whether or not the
father/grandfather was abusive to his family. During the course of the
interview, it did appear that all of these couples had comfortable
relationships.
(3) Daniela (#10) is in a relationship with her daughters father, but they are not
living together.
(4) As noted in the Age column, I interviewed several grandmothers responsible for
raising their grandchildren. However, while Marina and her husband (#9) had
accompanied their daughter, Clarisse, to Sade Criana, they were not responsible
for raising their grandchild.
(5) Some mothers had children from different fathers. I marked the mothers marital
status, and the father/stepfathers treatment of the children, according to the
mothers current relationship.
(6) Most of the women had long commutes between their homes and Sade Criana.
These commutes could be extremely challenging, especially if the women were
Baron 117
carrying their children along with large packages from Sade Criana, and needed
to travel up steep hills into and within their favelas. The commute from the
families homes to Sade Criana appears to be an indicator of a strong
commitment to the program. If the day of the visit to Sade Criana
corresponded with a doctors appointment at Hospital da Lagoa, the family would
first go to the hospital, which is very close to Sade Criana. Alternatively, if
there were no need for a doctors appointment that day, the families would make
this commute specifically to go to Sade Criana. For example, Flavia (#11)
visited Sade Criana for her monthly appointment eight days after her sons last
doctors appointment; alternatively other mothers came straight from the hospital
to Sade Criana, sometimes after several doctors appointments, e.g. Fatima
(#5), whose son, Maiko, saw both an orthopedic specialist and a pediatrician
before arriving at Sade Criana.
While there are some fathers who are involved in the Sade Criana program, the fathers
whom I had an opportunity to interview had accompanied their wives. I learned from Leticia
Milanez Bosisio, Attendance Manager, about differences in how the fathers may become
empowered relative to the mothers; namely, she connected the fathers empowerment with their
ability to find employment. However, as the majority of the attendees are mothers, the scope of
this pilot case study is confined to considering how women, specifically, are empowered through
participation in the Sade Criana program.
Triangulation

As I noticed while conducting my interviews - within the staff stakeholder group, within
the family stakeholder group, or between the staff and family stakeholder groups - similarities in
Baron 118
many responses occurred. For example, many of my family interviews corroborated the reports
from Sade Crianas staff on the benefits of group therapy sessions, which will be discussed in
section 10.5. Triangulation occurs when two or more interviewees corroborate information,
which strengthens the validity of a researchers conclusions.
SelectionBiasandVoluntaryResponse

Voluntary response and selection bias may have influenced the data that I collected.
Voluntary response samples are particularly prone to large bias because the respondents
choose themselves.
232
I had no systematic way for choosing the mothers with whom I spoke
it was strictly voluntary my results may be skewed to reflect the responses of more outgoing or
talkative personalities, or women who are already more empowered, and therefore willing to
share their stories with me. Further, any conclusions on the effect of the Sade Criana program
on empowering women may be confounded by selection bias. These women choose to
participate, and from the on-set, understand that in order to remain in the program, they are
expected to make a concerted effort to participate in all core aspects. Hence, as a group, the
Sade Criana participants may be more prone to empowerment than other women from
comparable socio-economic backgrounds and family situations.
The next chapter provides a compilation of findings regarding empowerment from
interviews with families, staff, volunteers, and members of the board of directors of Sade
Criana. Additionally, hidden impacts, revealed through the stakeholder interview process are
discussed.

232
David Moore. (2003). The Practice of Business Statistics: Using Data for Decisions, 185.
Baron 119
Chapter10:PilotCaseStudyFindings


Section10.1:OverviewofFindings

This chapter presents the compilation of Sade Criana impacts that were revealed
through on-site stakeholder interviews with 25 families and 16 staff members,
233
during April
2010. Arranging the thematic structure of stakeholder interviews around empowerment provided
the opportunity to:
(1) learn about the nature of any increase in the empowerment of the participants in
the Sade Criana program, and
(2) discover hidden impacts of the program through the use of open-ended questions
throughout the interview process.
As discussed earlier, hidden impacts may be thought of as flying under the radar of an
organization. Such impacts may be very significant, but difficult to identify without stakeholder
interviews. In this study, several hidden impacts came to light through the interview process.
This was possible because many of the interview questions were open-ended, and I tailored the
interviews to the interviewees by asking follow-up questions. For example, during the sharing
information segment, I first asked the interviewee, Do you share information? which usually
elicited a yes/no reply. I then asked, Can you give examples? and would continue the
interview with follow-up questions, as appropriate.
Interestingly, the reach of these impacts extend beyond Sade Crianas nucleus
community, a term used here to refer to the families in the program. These impacts affect: the
partnering public hospital, communities related to Sade Crianas families, and communities
related to Sade Crianas staff and volunteers.

233
There were 20 staff interviews in total, since I interviewed some staff members multiple times.
Baron 120
ReportingNotes:

The full name and title of each staff member is included when (s)he is first introduced. In
Appendix A, all staff members whom I interviewed are listed. Family interviewees are
referenced only by first names; first names of all family members have been changed to take
further care to protect each familys privacy. Table 3 (Chapter 9.3), can be consulted for
background data about each interviewee. In Appendix B, photographs of the 25 families
interviewed are included with permission granted by Sade Criana, per my communication with
the organization.
234

As previously footnoted in Chapter 5.1: Overview of Services, Citizenship, any parts of
an interview that are placed in single-quotation marks are aimed at preserving the sentiment of
the interviewees voice as related to me through the translator. I will denote such remarks with
single-quotes, for example: Interviewee/Translator quotation.
After completing family interviews, I followed up, as appropriate, with Sade Criana
staff to better understand each familys response. The staff reminded me that the truth is not
always clear, and is influenced by the person who is recounting her story. I have presented each
of the mothers comments as faithfully as possible to the manner in which each of them directly
recounted their stories to me, and have made no effort to judge their comments.
ChapterSynopsis

In Section 10.2, empowerment is distinguished from self-esteem, and Sade Crianas
current efforts to track its participants changes in self-esteem, are discussed. In Sections 10.3
through 10.5, findings on hidden impacts are explored. Section 10.3 discusses findings on how

234
Cristiana Velloso, Operations Manager. (2010, September 8). Personal email communication to Amie R. Baron.
Ms Velloso wrote, Feel free to use the photos you took in your thesis, we have written consent from all the families
in our project to use their images to divulge [convey] our work.
Baron 121
Sade Criana positively impacts the governments provision of social services. Section 10.4
presents examples of the dissemination of Sade Crianas health information by the
participating mothers within their communities. Section 10.5 describes findings on social
awareness through civic engagement. Section 10.6 examines stakeholder responses for each of
the indicators for empowerment.
Section10.2:EmpowermentandSelf-Esteem

It is important to differentiate between empowerment and self-esteem. However, in
certain circumstances these terms can overlap. Maslow, who is known for developing a
hierarchy of human needs, writes, with respect to self-esteem, that:
Satisfaction of the self-esteem need leads to feelings of self-confidence,
worth, strength, capability and adequacy, of being useful and necessary in
the world. But thwarting of these needs produces feelings of inferiority, of
weakness and of helplessness. These feelings in turn give rise tobasic
discouragement
235

Alternatively, self-empowerment can be defined as a willingness to take action to improve ones
social position; this concept can be represented on a continuum, as it can develop with time.
236

Much of the Sade Criana program is targeted toward improving the self-esteem of its
participants, which is critical for the family to be able to improve its overall circumstance. Ms
Bosisio
237
stated that self-esteem is a major focus of all aspects of Sade Crianas program.
When I interviewed Dr. Cordeiro, she said that at various times, staff tried to track improvements
in self-esteem. Upon returning to Brazil to conduct my research in April 2010, I learned that
Frances Piltz, Psychologist and Coordinator of Volunteers, had designed a survey regarding self-
esteem that she issued to the mothers upon their entering and exiting the Sade Criana program.

235
Abraham H. Maslow and Deborah Stephens. (Eds.). (2000). The Maslow Business Reader, 261.
236
Amie R. Baron. (2010, September). Personal Communication with Professor McDermott.
237
The Attendance Manger manages the social assistants.
Baron 122
Ms Piltzs survey directly corresponds with one of my five indicators for empowerment, If the
mother reports a change in overall confidence levels. I discussed the confidence indicator in
depth with the staff, and focused my interviews with the families on the four other indicators.
Ms Piltzs survey questions are presented in Figure 17. As she first implemented the
survey in 2009, and the Sade Criana program is geared toward a two-year turnaround, Ms Piltz
will be able to compare the before and after results for the same group of women in 2011.
Currently, she is comparing the responses of one group of women who exited the program in
2009, with another group of women who entered the program in 2009. Ms Piltzs compiled
results show dramatic progress in perceptions of self-esteem. After participating in the Sade
Criana program, approximately 90% of survey respondents were reported to have good or
very good self-esteem, as shown in Figure 18.
In Ms Piltzs survey, the mothers respond to questions regarding their perception of their
state of being. Each mother is asked to consider how she perceives herself - for example, her
self-confidence, her intelligence, or if other people are better than she is. The Auto-Estima
Questionrio focuses on how each mother perceives herself to be.
In this pilot case study, the stakeholder interview questions have a different focus: the
willingness of the mothers to act, which is central to empowerment (and agency).
Baron 123


AUTO-ESTIMA /INICIAL/QUESTIONRIO
2010 / 1 sem
Penso que tenho mais qualidades do que defeitos.
Creio que a maioria das pessoas so melhores do que eu.
Estou descontente comigo mesmo(a).
Sinto-me muito confiante.
Os meus amigos e familiares gostam de mim.
No sirvo para nada.
Geralmente, as pessoas gostam de mim.
Ningum gosta de mim.
Sou uma pessoa com pouco valor
Considero-me to inteligente quanto os meus amigos.
Sinto-me muito auto-confiante.
No sou capaz de resolver os meus problemas.
Considero-me atraente.
Com frequncia, no sou capaz de enfrentat as dificuldades.
s vezes sinto-me orgulhoso(a) pelas minhas conquistas.
Pensam que sou bobo(a).
Sinto-me satisfeito(a) comigo mesmo(a).

Figure 17. Questionnaire on Self
Esteem (in Portuguese).

The survey respondent was asked
to mark if she agreed or
disagreed with each statement,
and received a point for each
positive response.
0-5 points: Poor self esteem
6-10 points: Regular self esteem
11-14 points: Good self esteem
15-17 points: Very good self-
esteem.

Designed by Frances Piltz,
Psychologist and Coordinator of
Volunteers.
238





Figure 18. Self-Esteem 2010, 1
st

Semester. Sade Criana.
239




238
Survey from: Frances Piltz. Auto-Estima 1st Semestre. Sade Criana. [Excel Spreadsheet]. Received via an
email correspondence with Mariana Ferreira Velloso, 2010, September 17.
239
Figure from: Frances Piltz. Auto-Estima 1st Semestre. Sade Criana. [Excel Spreadsheet].
Baron 124
Section10.3:SadeCrianaandGovernmentProvisionofHealthServices

One of my indicators for empowerment is if the interviewee reports a shift in how she
interacts with professionals, such as her childs doctors; in the context of this pilot study, the
doctor represents someone of authority. As shown in Table 2: Interview Script for Sade
Criana Pilot Case Study, this indicator included the following questions:
When was the last time you were at the doctor?
What did the doctor say? (usually led to description of childs illness)
Did you understand?
Did you ask questions? If so, what did you ask?
Have you always asked questions?
Did you ask the doctors questions prior to your family entering Sade Criana?
Did you feel comfortable with the doctor?
Do you do any outside research (internet, ask friends, etc.)?
Did you always feel comfortable with the doctors?
How did your family enter Hospital da Lagoa?
Strikingly, asking the mothers about their comfort with their childs doctors revealed
substantive information about Sade Crianas impact on the public hospital, Hospital da Lagoa.
Obtaining critical information about this impact is a significant, yet unexpected, result of
conducting the pilot case study. Through interviews with the staff, Dr. Arantes, Dr. Cordeiro,
and the mothers, I was able to both contribute to and triangulate data about Sade Crianas
impact on the governments provision of social services.
Family/PhysicianInteractions

Before discussing the relationship between Sade Criana and its partnering public
hospital, it is important to characterize the comfort of the mothers with the doctors. Many of the
mothers reported that (1) they felt more comfortable with the Lagoa doctors, and (2) the Lagoa
Baron 125
doctors offered better explanations than those offered by doctors at other hospitals. Many of the
mothers directly contrasted their positive experience at Hospital da Lagoa with very unpleasant
experiences at other hospitals. Once their child was referred to Hospital da Lagoa, at least seven
mothers reported that their comfort with the doctors improved. Examples include:
Leila (#2) said that her daughter Rafaella was hospitalized at a different hospital
with a very high fever, and risked not surviving. She was in and out of the
hospital several times before being sent to Hospital da Lagoa. Leila was not
comfortable with the doctor at the previous hospital because she did not know
what was happening, the doctors explanations were not clear, and she believed
that the doctor was trying to hide the problem. Now that Rafaella is being
treated at Hospital da Lagoa, Leila has a better understanding of her daughters
illness, and said that the doctors at Hospital Lagoa are different, they explain
better.
Aline (#15) said that her daughter, Monica, was in a different hospital for one
month, was released, and almost died. The family then went to Hospital da
Lagoa. Aline feels that the doctors at the hospital where Monica was born
offered no explanation. At Hospital da Lagoa, they explain everything well. If
she doesnt understand, she asks questions.
Gilda (#6) said that her daughter, Alice, stayed for a long time in a different
hospital. Alice went through many wrong diagnoses, and Gilda was very
concerned for her daughters life. There was no specialist to treat Alice at the
other hospital, so she was finally referred to Hospital da Lagoa. When she
Baron 126
arrived at Lagoa, it was better because Alice could see a specialist in blood
disease. Now Gilda feels more comfortable.
Elena (#8) said that at Hospital da Lagoa, the doctors have lots of experience.
But at the hospitals at home, they (the doctors) were not so kind.
Vnia (#18) said that the best doctors in Rio are at Hospital da Lagoa. Vnia is
moved to speak about them. They are not doctors, but a family. They explain
well, and give as much support as possible.
Joana (#19) said that her child spent three years at two different hospitals. She
was finally referred to Hospital da Lagoa two years ago, and said that, the
doctors at Hospital Lagoa are much better than at the other hospital. They show
more interest and concern. She is more comfortable with the doctors at Hospital
da Lagoa than before at the other hospital.
Rosana (#23) said that she is, very comfortable with her childs doctor, who is
also a mother.
Only a couple mothers reported dissatisfaction with their childs treatment at Hospital da Lagoa.
For instance,
Leonor (#16) does not understand the doctors. Her daughter, Viviane, recently
had throat surgery. Viviane now has a problem with her legs; she was in a cast
for four months, and is currently confined to a wheelchair. Leonor said that
prior to Vivianes throat surgery, her legs were fine. She believes that, the
throat surgery caused the problem with Vivianes legs, although she does not
know how. Leonor is not comfortable because the doctors cut her off while she
is speaking.
Baron 127
As part of this interview segment on the mothers comfort when interacting with the doctors, I
also inquired if the mother: asked the doctor any questions, felt comfortable asking questions,
and had examples of questions asked. The majority of the mothers did report asking questions,
and seemed to try hard to understand the childs illness. Sample questions the mothers asked
included:
What can Fabio eat? How long will he be sick? Is there a cure for the allergy?
(Gabriela (#1) - son Fabio (2.5 yrs) has severe food allergies. One container of
his special formula costs $R100, approximately $60 U.S.).
Many of the parents asked the doctors about the long-term effects of the disease
on their child. For instance, Emilia and Ricardo are concerned if Marcelo will
be able to relate to other children as he gets older.
Rosangela Alves, Pre-Attendance Coordinator, said that many of the mothers reported greater
satisfaction at Hospital da Lagoa, because the doctors are always very caring for the children,
and Hospital da Lagoa is in a good location. Only a few of mothers said that they were not
comfortable asking questions. These responses included:
Marina (#9) said that while the doctor helps her to feel comfortable, she is
sometimes afraid of asking the doctor (and Sade Crianas social assistants)
questions, and their reaction. She is, not sure if someone will react kindly or
not.
Elena (#8) said that she was very close with her sister, who always used to
come with her to the hospital and ask the questions. But Elenas sister passed
away three years ago, so now Elena must ask questions. While she said that
she is comfortable doing so, Elena also said that she is, sometimes ashamed for
Baron 128
no specific reason. Elena added that prior to her death, her sister had been
hospitalized, but ran away from the hospital to help care for her nieces and
nephews.
As Hospital da Lagoa is strong in pediatrics, the doctors are better equipped to treat
challenging childrens diseases. Given that many of the mothers said that their children were
improperly diagnosed at other hospitals prior to referral to Hospital da Lagoa, accurate
information about a childs disease appears to strongly correlate with the mothers ease in coping
with and caring for her child. While the mothers were uncomfortable at previous hospitals where
their children were treated, and many reported improved comfort with the doctors at Lagoa, this
improved comfort may be the result of a number of variables.
The factors contributing to the mothers comfort with the doctors are difficult to unpack.
A simple formulation may be helpful. In using stakeholder interviews to examine empowerment
among the Sade Criana program participants, the variable Y may be considered to represent
empowerment, and Y
1
through Y
5
to represent each of the empowerment indicators (see Chapter
9.2) used in the pilot study. Here, if Y
1
refers to the indicator, how the mother interacts with
professionals, such as her childs doctors, Y
1a
represents a given mothers comfort with the
doctor, X
1
represents a given familys participation in Sade Criana, and X
2
represents a given
childs treatment at Hospital da Lagoa. The relationships among these variables may be
conceptualized in a simplified formulation, as shown below:
Y
1a
(Mothers Comfort) = F(x
1
, x
2
,x
n
), where
x
1
= participation in Sade Criana,
x
2
= childs treatment at Hospital da Lagoa, and
x
3
x
n
= other factors affecting a mothers comfort.
Baron 129
While Y
1a
(Mothers comfort) is likely a function of many variables,
240
interview responses
reflect that family participation in Sade Criana provides the mothers with an important support
network. This network assists the women in caring for their children, and in better
communicating their rights to doctors and others. These responses were triangulated by families,
staff, and Dr. Arantes.
Cross-CommunicationbetweenSadeCrianaandHospitaldaLagoa

As previously discussed in Chapter 5, frequent cross-communication between Sade
Criana and the hospital, as well as Sade Crianas advocacy on behalf of its families, assists
the government in its provision of healthcare. The staff and Drs. Arantes and Cordeiro offered
details on Sade Crianas relationship with the hospital, including the extensive cross-
communication between Sade Criana staff and hospital staff. For instance, the Sade Criana
staff encouraged the doctors to improve their handwriting so that the mothers are, better able to
understand. Ms Alves specifically stated that some time ago it was very hard to read the
doctors notes, which, for example, included information for the mothers about what a child
needed to drink on a specific day. Even though it was difficult for her to read these notes, she
needed to be able to explain them to the mothers. Ms Alves stated that there is now a
government law that requires doctors to write legibly.
241
She added that Sade Criana
continues to regularly converse with the doctors about the patients. Furthermore, if the hospital
was out of a medicine that a child needed, Sade Criana purchases the medicine at a pharmacy
and brings it to the hospital. Sade Criana also pays for lab tests at private hospitals. The
closeness of this relationship - between Sade Criana and Hospital da Lagoa - may be a

240
As noted in Chapter 11.2, variables such as educational level may also play a role in interviewee response.
241
See Pires, New Code of Ethics Outlines Doctor-Patient Relationship: It is clearly stated the handwriting on the
prescription and the doctors signature must be legible and accompanied by the doctors CRM, the professional
registration number given to licensed doctors.
Baron 130
contributing factor to the doctors awareness of needing to clearly explain the childs illness to
the mothers.
Dr. Arantes said that it is often very difficult for the doctors to explain the complexities
of a childs illness to mothers who are uneducated. Patients will understand at different levels,
because there is not just one Brazil. A sample explanation would be something such as, This
is a serious disease, and if you do not follow through with our suggested treatment, your child
will die. Hospital da Lagoas doctors usually appear to be successful in communicating with the
parents, for most of the mothers said they understood the doctors. Marialice Matheus da Silva,
Nutritionist, also expressed that there are some challenges in reinforcing the need for the
mothers compliance in treatment. For example, with regard to lactose intolerance, a mother
needs to understand that she should not arbitrarily suspend her childs dairy-free diet.
Furthermore, the mother also has to understand that dairy is not just in milk, but also in yogurt,
cheese, cookies, etc. Flavia (#11) learned that compliance is important. Her son, Jos, is lactose
intolerant, and when she asked if he could change to regular milk, the doctor said no. Now,
Flavia understands that, she still must only feed him soymilk.
Alternatively, the following interview is presented in detail to illustrate a particular
mothers (non)compliance with the doctors treatment, (dis)comfort with the doctors, perception
of her childs illness, and information she said she received from her neighbor.
Camilia (#13) said her son, Miguel, sees both the pediatrician and allergist. He
throws up, faints, and turns purple. The doctor said that Camilia should not give
Miguel anything with milk. Camilia understood, and asked no questions.
Sometimes she is embarrassed. Camilia is shy, but will try to start asking
questions. Miguel has a stretched belly. She keeps asking the doctor what it is
Baron 131
it is diagnosed as worms. The doctor doesnt give any answers; Camilia doesnt
feel comfortable continuously giving Miguel the worm medicine. Her neighbor
had a similar problem with her son (an enlarged liver), and asked for an
ultrasound. Camilia asked for an ultrasound, but the doctor said, no because
the problem is worms. Camilia feels the problem is not worms, and wants the
ultrasound. When she feels the problem is worms, she gives Miguel the
medicine. If she does not feel it is worms, she does not give him medicine. She
is not happy with the pediatrician because he did not ask for any exams. The
allergist asked for one exam. When I asked Camilia if she did any research
about Miguels illness, outside of that which the doctor told her, Camilia said
that, her neighbor suggested she be referred to another hospital because Miguel
might have other allergies. The neighbors son also had a problem, but is now
o.k., so Camilia feels there must be another problem. Later in our interview,
Camilia said that, she does not have any friends, and is not close to her
neighbors; she feels being close to them causes gossip. I asked Camiilia about
her income. When she replied that she picks up recycling, she looked down, her
shoulders slumped, and she avoided eye contact. She is separated from
Miguels father, but he thought it was a good idea that she join Sade Criana
because they cannot afford Miguels milk. He also gives Camilia,
R$140/month from working in construction, and she receives the Bolsa
Familia.
This interview presents many complexities. Miguel appears to have several different medical
problems; Camilia received advice from her neighbor, although she said that she is not close to
Baron 132
anyone besides her mother and two sisters; and she said that she both does and does not ask the
doctors any questions. Furthermore, while other mothers expressed discontent with the hospital
that Miguel is receiving some of his treatment in (not Hospital da Lagoa), Camilia appeared to be
more comfortable at that hospital, than at Hospital da Lagoa, which is an anomaly expressed by
only one (and possibly two)
242
other parent(s).
As noted earlier in Chapter 5, there is a clear collaborative relationship between Sade
Criana and the public hospital. In my interview with Dr. Cordeiro, she said that Sade Criana
has had a twenty-year partnership with Hospital da Lagoa, and it is a model hospital. Dr.
Arantes stated that, the wall between the doctor and the family starts to fall because of Sade
Criana, shifting instead to that of a curtain. The women start to understand that they are
important; that they are part of their childs treatment; and that they must be aware of their
childs disease. Dr. Arantes said that Sade Criana influences how the women think about the
childs disease; that they are less ashamed or afraid to ask questions. My interview with Dr.
Arantes also revealed that doctors at Hospital da Lagoa see Sade Criana as instilling greater
value in their work through offering the participating children a greater chance of survival. It
seems quite reasonable to conclude that Sade Criana helps Hospital da Lagoa to better assist
the mothers. Sade Criana appears to be an enabler through its ability to support the doctors
work, advise the doctors on how to improve their interactions with the mothers, and lower re-
internment rates, all of which are critical for freeing limited hospital resources for other ill
children.

242
Fernanda and Carlos are normally very pleased with their childrens treatment at Hospital da Lagoa. However,
when their primary doctor (who Fernanda even described as a close friend) was on vacation, they had a very bad
altercation with the substituting physician.
Baron 133
ConnectingParticipantFamilieswithotherGovernmentServices

Sade Criana has an important role in connecting families with other government
services. While this is an explicit component of their methodology (prior to release, families
ought to be receiving all of the government services for which they have a right), the nonprofit
is, in fact, temporarily supplementing the governments provision of these services, and helping
the families to transition to the governments support. The Sade Criana handbook offers a
testimony from a lawyer:
Work consists in guiding families in the pursuit of their fundamental
rights,
243
and referring them to the Office of Public Defense whenever
necessary. Needs vary from medications and other medical supplies to
special milks. The Brazilian constitution warrants the right to such items,
as well as to legal services, such as alimonies, paternity
investigation/acknowledgement, and so on).
When a suit is filed, I try to monitor its progress, and explain the several
steps involved whenever necessary.

Guidance covers several areas, including civil responsibility, personal
documents, social security, labor rights, even criminal law.
244


Given that these government programs may not be readily accessed by the families,
(Emilia (#12) said that her, friends didnt try hard enough to receive the free government
medicine), the nonprofit is a valuable intermediary. Sade Crianas legal services include,
Guidance on citizenship rights, such as getting in touch with the Office of Public Defense for
the acquisition of special milks and medications for the children, alimonies, and paternity
acknowledgment.
245
Joana (#19) said that the lawyer helped her by telling her what she needed
to do to secure the necessary paperwork such that Sade Criana would be able to refurbish her
home.

243
The Brazilian constitution and later amendments specify certain rights, such as food, education, and healthcare.
244
Sade Criana. Creating Institutions Based On The ASCR Model, 24-25. Slightly edited from the English
translation of the Handbook.
245
Ibid 24.
Baron 134
Section10.4:DisseminationofInformationbyParticipants

One of my indicators for empowerment is if a mother shared information from Sade
Criana with others in her community. The underlying assumption for using this indicator is that
an ability and desire to share information is indicative of empowerment. Through the interview
process, most of the mothers expressed not only a willingness, but also an eagerness, to share
information from Sade Criana with others.
It became apparent through many family interviews that certain information the mothers
reported sharing within their communities was often vital to family and public health. This
impact of Sade Crianas programming is striking and has important implications.
I initiated this segment of the interview re: sharing information - by first establishing
who the mother defined as members of her community. For most interviewees, this included
close family, neighbors, and a few close friends. Many of the women reported a close friend or
two with whom they shared everything, although some said that they did not share anything
personal with others, as they desired to keep their problems to themselves (i.e., Laura,
referenced below). Notably, several mothers characterized a doctor at Hospital da Lagoa as a
close personal friend. Some responses included:
Marcela (#7) said that, she does not talk with anyone (friends nor neighbors)
because she, does not trust people since she has seen so many incidences of
violence on television. Marcela knows of many cases of abuse, and is afraid of
someone becoming close to her family, and then she can not control it if it leads
to abuse; by becoming close, an opportunity may arise. But, Marcela did say
she is friendly with the Sade Criana mothers, and mothers whom she sees in
Baron 135
the hospitals. They speak on the phone, but do not see each other outside of
their Sade Criana or hospital visits.
Laura (#3) said that, her friends are not close to the situation (i.e., her son
Marcos illness), because her husband prefers to keep their problems to
themselves.
Fernanda (#4) is close to her priest and doctor she classified both of them as
friends, along with one neighbor.
Gilda (#6) said that she lives with her mother, older brother, and two children.
Family is very important to her. She is also close to Alices godmother and
neighbors they are good to have as friends, because she can count on them,
sometimes for money or diapers.
Vnia (#18) said that she has no friends (but is very close to her children and
husband), shares her problems only with God, and tries to solve them on her
own. If she is very upset, she takes a natural tranquilizer or makes tea.
Joanas (#19) neighbor accompanied her to Sade Criana to help her carry the
supplies home.
Daniela (#10) appeared comfortable with another Sade Criana family I was
interviewing (Marina and her husband); Daniela handed her baby, Jair, to the
grandfather I was interviewing to hold while she prepared his bottle.
Lucia (#21) said that she does not have any friends because she does not like to
talk about her private affairs with anyone, including her mother and sisters.
Elena (#8) has no contact with her family; her father (who she said was a, great
father) died, and her mother and three sisters live far away. Elena speaks with
Baron 136
friends in her community, and has one very close friend with whom she
emphasized that she, shares everything. Elena said that she is more discrete
with other people. Elena was extremely close to a sister who passed away
recently.
Flavia (#11) said that she is close to an aunt and a good friend who moved
away; she speaks with her friend over the phone. Flavia said that she shares
with the aunt and her friend, and that they also share with her - they open up to
each other. Flavia connected with Sade Criana through a different aunt, who
introduced Flavia to another Sade Criana family.
Only five mothers are involved with a community organization or a church. But, most of the
mothers said that they would share what they learned, through their involvement with Sade
Criana, with their neighbors. I asked for examples of the information that they shared. Primary
examples included:
Mariana (#25), does not like to talk with others because it leads to gossip.
However, she introduced her neighbors to condoms, explained their importance,
and gives the neighbors condoms if they need them; the neighbors, ask her for
them, because they know that she has them. Condoms are included in the
familys monthly packages from Sade Criana.
Rosana (#23) told me that she received flyers from Sade Criana on preventing
the spread of H1N1 (swine flu) and Dengue fever. As mentioned in Chapter 6,
Dengue, a mosquito-born virus, is a very serious phenomenon that can lead to a
break bone fever, hemorrhagic bleeding, dehydration, and possible death.
246


246
Leandra Barcelos Figueiredo, et al. (2008). Dengue Virus 3 Genotype 1 Associated with Dengue Fever and
Dengue Hemorrhagic Fever, Brazil. Emerging Infectious Diseases Journal, 14(2).
Baron 137
Sharing information about eliminating areas where mosquitoes can breed is a
crucial step to controlling outbreaks. Rosana said that, she showed the
brochures to her neighbors, and they followed the advice. Rosana also said that
she, brought the information to her childs school, and that the school also
followed the advice.
Both of the findings from the pilot study, above, are very significant. Sade Crianas
dissemination of information to its program participants educated not only Mariana and Rosana
and some of their neighbors, but for Rosana, an entire school benefitted from information about
preventing the spread of Dengue an extremely important health issue for Rio. Other
representative responses included:
Maria (#14) said that a recent meeting at Sade Criana was about the impact of
commercials on children. She shared this with her sons. She also talked with
them about, a group-therapy session that was about people they miss, who may
live elsewhere, or who have passed away.
Leila (#2), like Maria, said that, last month there was a session about how
television ads are marketed to children, which she shared with others. Leila
also said that she shares information about cooking, because she took the Sade
Criana cooking course.
Marta Scodro, Deputy CEO, told me that in the group sessions, the mothers
learn how to listen, and how to ask, how are you/feeling? Ms Scodro also
said that Sade Criana stresses teaching the mothers different ways to
discipline their children (without physically hurting them), and teaching them
how to learn to listen to their children. Fernanda (#4) personally triangulated
Baron 138
this impact of the group sessions when she said that she used to be violent, but
is not so anymore. She realized that in the future it would be bad for Luiz, but
she did not know how to change. Fernanda also said that she passes on
information, and encourages her friends not to beat their children. For example,
parents should take away a video game instead of hitting a child if he does
poorly in school.
Section10.5:SocialAwarenessthroughCivicEngagement

As discussed in Chapter 7, engagement in the nonprofit sector can promote broad-scale
awareness of social issues, and strengthen society. Sade Crianas Handbook mentioned
heightened social awareness through the engagement of their donors. As the coordinator of the
Godmother Project wrote, with respect to the engagement of donors who sponsor a specific
child, we would be able to assist the children for longer periods while raising societys
awareness of the problem.
247

Through my interactions and interviews with Sade Criana staff and volunteers, I
learned that they shared their experiences from working at the organization with their families
and circles of friends. For several of the staff who had been with Sade Criana for many years,
it was quite apparent that their deep awareness of Brazils social issues garnered the attention
and support of their own families, hence further multiplying Sade Crianas impact.
However, Mariana Velloso, Fundraising Coordinator, added that part of society does not
want to see, which is a cultural thing that needs to change. For instance, when I asked one
volunteer if she shares her experiences working at Sade Criana with her friends, she said that,
some people do not want to hear about such suffering, and change the topic (like her father).

247
Sade Criana. Creating Institutions Based On The ASCR Model, 37.
Baron 139
She also stated during our interview that, most people do not ask because they know that she is
working with sad things; she shies away from speaking about it, because people do not care, and
her friends have no interest.
That said, Ms Velloso also stated that the younger generation is more engaged, and wants
to help, while others are blind to problems. She said that people from lower socio-economic
classes are more willing to help each other than are the rich. Ms Bosisio echoed this, saying that,
sometimes moms want to volunteer as a way of giving back. Examples include:
Several of the mothers were referred to Sade Criana, or had referred other
families to Sade Criana. For instance, Marcia said that her aunt introduced
her to a Sade Criana family who then referred Marcia to the program.
Ms Velloso told me the following: A fathers son did not use all of his
medicine. Even though he needed to borrow money for the bus fare from a
neighbor to travel to Sade Criana, he came on a day that was not even his
assigned day of the month, to return the surplus medicine. (Sade Criana
reimburses the families for bus fares.)
Patricia (#24) works with several community organizations, including, a
private school that organizes dance, ballet, theatre, and futball programs in
Rocinha.
248
She also places children in another community organization. She
started volunteering with both organizations 20 days before our interview.
Patricia said that, she has been volunteering at her church for 12 years, and
helps sort the donations. She said she, helps because she likes to.

248
As discussed earlier, Rocinha is a very large favela with a population of approximately 100,000, and with
significant differences in income among its residents.
Baron 140
Maria (#14) said that she and her husband had come to Sade Criana years
ago. Once she and her husband found employment, they no longer needed the
assistance, and wanted to give their place to someone else. Now that she is
separated from her husband and has had other problems, she has returned to
Sade Criana.
Joana (#19) said that, many of her neighbors and members of her church help
her with food, gas for her stove, and accompany her to Sade Criana (different
neighbors will come different times). This echoes what Ms Velloso said about
people from poorer socio-economic backgrounds assisting each other.
According to Dr. Cordeiro, the culture of volunteering in Brazil is relatively new and has
become more common in the past ten or fifteen years. During out interview, she also said that
over its history, Sade Criana has had approximately 500 volunteers. Ms Bosisio said that Ms
prospective volunteers are first evaluated by Ms Piltz, to determine if they have good
intentions, and a profile conducive to working with the families. Ms Piltz looks for empathy,
sympathy, a capacity to take their shoes (in English: the ability to walk in another persons
shoes), motive, a history of helping, warmth, and kindness. While compassion is critical, it is
also necessary that the volunteers not assume the problems of the mothers. Wealthy people
frequently become aware of Sade Criana when someone in their own family suffers from a
serious illness. I was told, once they come to help, they do not stop.
Ms Scodro said that therapists might prescribe volunteer work for their patients. Ms
Velloso said that volunteering enables people to: (1) contextualize their own problems relative to
those of the participating mothers, (2) feel part of something (Sade Criana) that makes sense,
(3) have something worthwhile to do, and (4) feel less guilty. Ms Velloso explained that just as
Baron 141
poor women may not feel like citizens, the same applies to wealthy women whose primary
responsibilities are to be house wives. The volunteers participation with Sade Criana may
lead to a change in their own family dynamics. When a volunteers husband comes to visit
Sade Criana, it is very clear that this is the wifes domain she is the one who is known, and
whose work is respected.
One volunteer, Ana Linn Wiedemeyer, said that she, stays happy through seeing the
evolution of the children. Smiling children leave her with a good feeling. Ms Wiedemeyer also
said that volunteering influenced her impression of people from the favelas: she sees their
strength in light of their poverty and sickness. This leaves her with a strong desire to change the
situation.
Section10.6:EmpowermentofParticipants

This section presents findings for each of the empowerment indicators, which are:
If the mother reported:
(1) an increase in her overall confidence.
(2) a shift in how she interacts with professionals, such as her childs
doctors. In the context of the pilot study, the doctor represents
someone of authority.
(3) a shift in her familys dynamics.
(4) sharing information from Sade Crianas programming with others
in her community.
(5) an increase in her level of civic engagement.

Baron 142
ChangeinSelf-EsteemandOverallConfidence

Maslow wrote, as noted in Section 10.2, satisfaction of the self-esteem need leads to
feelings of self-confidence....
249
Since self-esteem and confidence can overlap, the findings
presented below are based on a joint self-esteem/confidence indicator. Representative findings
from the mothers, related to this indicator, include:
When I asked Claudia (#22) about the impact of Sade Criana on her life, she
said that, after she came to Sade Criana, she was a different person. She did
not care for her clothes, or hair. She was very down, and only worried about her
(grand)children. Now, Claudia cares for her clothes, hair and body.
Leila (#2) mentioned both a psychological improvement, and that she was
incentivized to return to school.
Fernanda (#4) said that Sade Criana gives her faith in the future.
Elena (#8) said that she is a, stronger person.
Asking the staff interviewees general questions about the empowerment of the Sade
Criana participants typically returned to a discussion of whether there were improvements in
self-esteem, and how to discern such improvements. While the staff often referred directly to
self-esteem, much of their insight can further an understanding of how the mothers may become
empowered through participating in the Sade Criana program.

249
Maslow and Stephens, 261.
Baron 143
Nadia Coe, Social Assistant, offered seven reasons for the mothers self-esteem to
increase through participation in Sade Criana:
(1) Through inclusion in a group, the families support each other.
(2) The families receive food, milk, and medicine for their children, which give them
basic or material support.
(3) The mothers obtain useful information from lectures on topics including: health,
family violence, working, and how to care for children.
(4) The mothers participate in group therapy sessions and may receive psychological
assistance.
(5) The mothers feel more secure because the family has greater stability for survival.
(6) The mothers learn their rights and receive a lawyers support.
(7) The mothers incomes may increase. In emphasizing the limited incomes of the
families, Ms Bosisio adds that Brazilians typically think of income by the month;
Sade Criana families consider their income on a day-to-day basis. Both Elena
(#8) and Camilia (#13) told me that aside from the bolsa familia, their income
came from picking up cans in the street. During a case-study meeting among the
social assistants that I observed, it was stated that one of the Sade Criana
families lost its primary means of support when the police raided their home,
because the father was illegally selling wares on the street.
During an interview with Ms Piltz, she said that she starts seeing positive changes in the
mothers self-esteem after around six months in the program. She also said that, in the group
therapy sessions, the mothers learn strategies for coping with their problems, and that they learn
from each other. The mothers will vote on a subject to discuss - for example, alcohol abuse.
Baron 144
One person will start, and others will follow, giving the first person suggestions. The mothers
learn to: vote (through choosing topics), think, talk, not to judge, offer advice, speak in the first
person, and feel comfortable speaking about themselves. Through these interactions, the
mothers may realize that if they feel that, they have nothing to offer, they do have something
positive (in the form of advice) to offer others. Ms Scodro said that the group therapy sessions
give the participants an opportunity to speak, which is good for their health, as many of them do
not have anyone to share their problems with at home. This type of exchange is very important,
as one mothers improvement in self-esteem tends to feed off of anothers with the thinking
that if she can be happy so, too, can I. Part of the group therapy includes hugs (representative
of exercises involving touch). If the mother shies away from hugging, it is likely because she
has been hurt by violence. Ms Scodro mentioned that the womens self-esteem improves by
having someone to listen to, look at, and speak with. Ms Scodro also said that the mothers
learn from each other. If a participant sees a mother who is worse off than she is, but also
working to improve her familys well-being, it encourages the participant to try harder. This was
corroborated by several interviewees. For instance:
Fatima (#5) stated that she would tell her neighbors, you can complain, but
others are worse off.
Marcela (#7) said that while she was pregnant with her son Mrio, she was very
worried about her daughter Julia who has leukemia. While in general she feels
strong, her self-esteem is low because of her pregnancy (Mrio was four months
old at the time of our interview). She had not accepted Julias disease, because
she was afraid of loosing her daughter. Marcelas doctor prescribed medicines
for depression, but Marcelas husband did not let her take them because he was
Baron 145
afraid that she would develop a dependency. But, sharing with the other
mothers and Social Assistants did help Marcela.
Valria (#17) said that, she learns a lot from the experiences of others. She
thought her own problem was serious, until she heard of other families
challenges. Valria said she, learns about life, through interacting with the
Sade Criana families.
Joana (#19) said that she is, happy to come to Sade Criana, and that she
feels and looks well. She is happier now, but there was a time when she was
quite down.
Ms Scodro gave me an example of families networking with each other through
the group therapy sessions. She recounted that a father was homeless. A mother
knew his community leader and offered her assistance to the father.
Additionally, Ms Piltz stated that an objective of Sade Criana is to build a
network among the community. Approximately ten mothers mentioned
networking or development of friendships through group therapy. These women
either identified Sade Criana mothers among their friends, or explicitly said
that they found value in the group programming.
Ms Scodro and other staff members stated that a change in posture and appearance is
indicative of an improvement in self-esteem. It is very common that when the women start at
Sade Criana, they do not look the staff in the eyes, and may answer questions with simple
yes/no responses. The parents are going through a very hard time, as their child is constantly
in the hospital and suffering from a challenging disease. But, Sade Criana offers them hope,
Baron 146
and the women start to discover that the world has not ended. Even if the mothers lives are
plagued with troubles, they deserve to be happy.
The cosmetology courses also offer a primary means through which the womens self-
esteem noticeably improves. Through the courses, the mothers take care of each other by doing
each others hair and nails for practice. Ms Coes impression was that among the women who
take the professionalization courses, there is a substantial change in their appearance, posture,
and how they speak.
It is helpful to contextualize responses about an increase in self-esteem as reflected
through an improvement in appearance. Brazils beauty-oriented culture transcends socio-
economic status. I asked Rosa Monteiro de Oliveira, Professionalization Coordinator, if she
noticed a change in the self-esteem in the professionalization course participants. Ms Oliveira
said that, when the mothers arrive, they are not doing well, and are not taking care of their
appearance. Since they have a severely sick child, a house to care for, and need an income, the
last thing they care about is themselves, as women. Through the courses, Ms Oliveira said she
can see the increased happiness in the mothers faces, as they learn that they are beautiful. Ms
Oliveira said there are many instances of husbands commenting on the mothers improved
appearance, which would be reflective of a positive shift in family dynamics. Ms Velloso later
added to this when she said that the mothers graduation from the Sade Criana courses is a
very joyous and touching ceremony. The mothers dress in their finest, bring their families, and
are very proud. In summary, the professionalization courses offer the women an opportunity to
practice the tools of the trade on each other; through touch, they both give and receive care.
Ms Oliveira has many examples of women who have done very well through taking the
professionalization courses. One example that Ms Oliveira shared with me is that of Silvana
Baron 147
who took five Sade Criana courses. She has now earned enough income that she wants to rent
a larger salon and hire another Sade Criana mother. After a mother told Silvana that she was
struggling to attract clients, Silvana helped her by coming to her neighborhood and advertising
on foot.
During my interview with Ms Oliveira, I asked her if she knew of any changes in the
mothers family dynamics as a result of their participation in the professionalization courses. Ms
Oliveira was interested in my questions about this impact, and said that she would ask her
students about any related changes in their family dynamics.
My final family interview was with Mariana (#25), who had taken a professionalization
course to learn how to make (decorate) Havaianas a very popular Brazilian sandal. She was
very proud of her business initiative, and during our interview, she asked me if it would be
possible to sell her Havaianas in the U.S.
InteractionwithDoctors:

This topic was covered in depth in Section 10.3. Also, as stated earlier in Section 7.3:
The Nonprofit Sector and a Strong Democracy, Dr. Arantes and several staff members reported
during our interviews that one of the signs that a mothers self-esteem was increasing was that
she would start standing up for herself, and proactively making requests (and sometimes
demands) to doctors, hospital employees, and Sade Crianas social assistants. Dr. Arantes said
this change in behavior was extremely important because it showed that the women grew
another step as citizens. Ms Coe said that with an increase in self-esteem, the mothers believe
that they can be right. Ms Bosisio also said that, at some point in the process, mothers are more
demanding. They ask questions, and for their rights. Even if they are told no, they ask for
everything. She added that, this is very good, for it means that their depression is over, and that
Baron 148
they want their rights as a person. When these behavioral changes occur, they epitomize
empowerment through the transition from weak to stronger agency.
FamilyDynamics:

Even though six mothers separated from abusive partners, none of the mothers felt that
their involvement with Sade Criana played a role in their decision. Interview responses related
to abuse include:
Claudia (#22) said that, her husband was not nice in any way, and he was like
an animal. He disappeared for eleven years, and only returned when he was sick
with AIDS. He had shrunk substantially, and only weighed thirteen kilos. But
because he did not stay at home, he did not beat the children.
Ins (#20) said that, she separated from her husband three years ago. He drank
and threatened her. Ins left him, and said that if she were still with him, she
would be dead.
Leonor (#16) is in the process of legally separating from her husband. She
said, he beat her, and was on drugs. Leonor was always talking with the police.
He tried to beat the children, which Leonor did not allow. Although, it did
happen one time when Leonor was not at home.
Ms Piltz said that as the mothers self esteem increases, they are able to deal with their
problems more effectively; with low self-esteem, they feel that they have to accept the
situation. Through working with Ms Piltz, the women learn to set rules, not to accept bad
treatment, and to let the man know that he cannot beat her. Also, issues concerning abuse are
frequently covered in the monthly group therapy sessions; the women who are victims of abuse
are encouraged to attend one-on-one counseling sessions with a Sade Criana psychologist.
Baron 149
Only two of the mothers who were separated from the childs father, said that the father
continued to help support his children. Three mothers said that they separated from their
husbands because the husband had betrayed them or had had an affair. Thirteen mothers said
that they are with the childs father, of whom only one woman, Maria, is currently in an abusive
relationship. Elena (#8) said that she lives with the father of five of her children. He is not
good with the kids, and argues especially with the oldest (who is not his). Sometimes he beats
them. When Elena leaves, she is worried about leaving the father at home with the kids.
Involvement in Sade Criana has, helped a lot with this situation, but the problem is harder
than they (Sade Criana staff and volunteers) imagine. The oldest son argues with the father,
in a very bad way, and since they are always fighting it leads to domestic violence. While
Sade Criana helps, it is hard to control themselves at home. Elena also said that she had a
panic attack, and is now taking medicine and seeing the psychiatrist, which is, helping her to
feel better.
Four out of twenty-five of my interviews were with a mother accompanied by her
partner. However, one of these couples (#9) were at Sade Criana to support their daughter
who was the active program participant. Portions of the interviews with the other three couples
are presented below:
Emilia and Ricardo (#12) have three teenage children, and recently adopted
their nephew, Marcelo (age 2), by Emilias brother. Marcelo was, mistreated in
his parents home, and is very ill, largely due to his mothers destructive
behavior while pregnant. Counting off on his fingers, Ricardo provided a list of
all the mothers harmful behaviors: She drank, she smoked, she took drugs.
Pregnant women shouldnt do these things. A judge, removed Marcelo from
Baron 150
his parents, and sent him to two different shelters. An employee of the
governments child services agency asked Emilia to care for Marcelo. Since
Emilia and Ricardo adopted Marcelo, he has been constantly in and out of the
hospital because of a severe heart and lung problem. Emilia had to stop
working. Both of Marcelos adopted parents are involved in his care. Emilia
always takes him to the doctor as needed, and Ricardo comes if he is able to
leave work early. Both Emilia and Ricardo were smiling when I interviewed
them, and seemed quite close.
Aline and Gabriel (#15) have been together for 19 years. Their oldest son, who
bore his fathers name, was killed in the cross fire of a drug gang war in his
favela. They said that, their youngest daughters brain was injured during birth
and the child is prematurely aging; at age 5, she is already developing. Monica
has trouble with speech, sight, and hearing. She is totally dependent on others
for assistance with eating and walking. But, Aline shared that she, can tell
Monica has her taste because when she has good food, her face is bright.
Fernanda and Carlos (#4) met three years ago at Fernandas church, and each
has his/her own child. Carlos needed a babysitter to watch his daughter while he
worked in a shipyard. They have since married. Prior to Fernanda and Carlos
becoming romantically involved, their children (who are two years apart in age),
grew close and started referring to both parents as Mom and Dad. Their
children, now treat each other like siblings. Fernanda said she had been,
raped about ten years before. Both Fernanda and her son, Luiz, are HIV-
positive. Fernanda is afraid to tell her family that she and her son have HIV. A
Baron 151
previous boyfriend had left Fernanda after he learned that she had HIV.
Fernanda said that when she told Carlos about her situation, Fernanda stated,
His love wouldnt be smaller. Carlos has custody over his daughter, Clara,
because the mother was negligent. Last year, Claras mother asked if Clara
could come sing at her engagement party. Claras mother disappeared with
Clara. Someone who worked at the mothers home abused Clara, but Carlos
and Fernanda have no means of proving this. Clara managed to phone Carlos.
Carlos and Fernanda reported the kidnapping to the police, who brought Clara
and her mother into police custody. But, Claras mother managed to run away
with Clara (again) from police custody. Clara was, kept in a very bad home,
and she was starving. She managed to call Fernanda, and even though she did
not know the exact address of where she was, she gave the name of an uncle
[male neighbor], who did know where she was. Carlos and Fernanda brought
the police with them to rescue Clara a second time. Now, Claras mother is not
allowed to see her daughter unless Carlos is present. Clara was only six years
old when she was kidnapped, and managed to notify her parents, twice, where
she was held. At the time of our interview, Fernanda was eight months
pregnant with Carlos child. They said, the baby will be named either Samuel
or Keisa.
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SharingInformation:

This topic was covered in depth in Section 10.4. As discussed earlier, many of the
women responded enthusiastically to questions about sharing information. Their stated
eagerness to actively share information corresponds with empowerment. For instance, Marina
(#9) said, if she learns something, she wants to share it with everyone. Even if people do not do
anything, they can absorb the information.
CivicEngagement:

The following questions were asked during this segment of the family interviews:
Do you vote? (As voting is mandatory in Brazil, everyone answered affirmatively.)
Is it important to vote? If yes, do you know who the presidential candidates are?
Does your community have a neighborhood organization?
Are you involved with the neighborhood organization?
Only one mother was engaged with a community organization. Other interviewees said
that their neighborhood associations were ineffectual or too far away. Four mothers were
involved in their churches.
As noted in Chapter 3.2: Social Contract Failure in Rios Favelas, I found many instances
of political frustration during the family interviews. As discussed earlier, when I asked the
mothers if politics were important to them, many expressed extreme discontent with the power
that their votes would have to change the status quo, and with the effectiveness of politicians to
bring about change.
Since voting in Brazil is mandatory, voting as an expression of increased civic
engagement was not a good indicator for empowerment. Also, I found no clear connection
between mothers reports of political apathy, or interest in voting, with their responses to other
Baron 153
indicators of empowerment used in the pilot study. That said, it was apparent through the
responses of many of the mothers that they identified themselves as citizens, and valued their
rights. Representative responses include:
Gilda (#6) said that, the president is not important she is disillusioned with
the candidates because they make promises and dont deliver.
Marcela (#7) said that, the president is not important because he does not solve
any problem. A former mayor had taken away a program that offers
transportation from her hometown to the hospital. The new mayor brought the
program back, so now she can return to her home, which is 6 hours away.
Marina (#9) said that, she has faith that change is possible, although politicians
do not always do what they promise.
Ricardo (#12) said that, voting is important. He expressed support for
President Lula, but dissatisfaction for Rios mayor and governor.
Maria (#14) also said that, who is in government is important. She is interested
in the elections, and watches them on television. But, Maria added that, the
politicians fail to fulfill their promises.
Vnia (#18) feels that, the wrong councilmen are elected by the community.
Once elected, they leave the community to live in a better area, because they are
now receiving a higher salary. Near her home, the government is building a
hospital for women. But, the government is not helping with the floods and
mudslides. It is a common problem for politicians to want to change things that
show.
Joana (#19) said that, voting is important, but she is unsure why.
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Lucia (#21) said that, it is important to vote to choose the right person. She
tries to find out about the candidates through reading and talking with others.
Rosana (#23) said that, it is important because people have a right to try to care
about health and education.
And finally, Mariana (#25) said that, voting is important because, it is time to scream for what
we want.
The next chapter concludes with a review of the thesis and evaluation of the pilot case
study. Key findings are summarized, and directions for further research are suggested.

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Chapter11:Conclusions


The structure of this thesis is based on the argument that if a foundation or nonprofit
engages in the provision of social services to promote social justice, the organization implicitly
accepts an ethical obligation to actively involve stakeholders when evaluating the impact of an
intervention. This argument was supported through:
(1) establishing that those nonprofits which engage in the provision of collective
goods implicitly reinforce the social contract;
(2) presenting empirical evidence, through the completion of a pilot case study at
Sade Criana, which confirms that stakeholder interviews are a means for
accessing substantive information about a nonprofits impact; and,
(3) contextualizing this empirical evidence within the lens of Brazil as a young
democracy, with: an emerging civil society, a soaring GDP, a history of systemic
institutional failure, and extreme socio-economic inequality.
My findings confirm that stakeholder interviews, based on qualitative research methods,
can serve as a substantial information resource for understanding an organizations impact by:
providing critical information that may not be identifiable through quantitative data,
supplementing the diversity of options that an organization may use for examining impact, and
engaging diverse stakeholders in an assessment of the impact of a philanthropic investment or
nonprofit program.
This final chapter reviews the ethical, theoretical, and empirical framework of this thesis,
evaluates the pilot case study, summarizes key findings, and suggests directions for future
research.
Baron 156
Section11.1:ReviewoftheEthicalandTheoreticalFrameworkforthePilot
Study

In any analysis of the bridge between impact and accountability in the
philanthropic/nonprofit sector, it is essential that the clients and communities affected by an
intervention be actively engaged, in order to further social justice. This ethical imperative forms
the foundation for my pilot case study which explores the use of stakeholder interviews as a tool
for providing vital information about impact. Figure 19 is a visualization of the thesis flow. In
this diagram, original contributions are designated in red.
Line (1) identifies those foundations and nonprofits to which this thesis applies, i.e.
organizations that engage in the provision of social services in order to promote social justice.
Social justice is understood, here, within both a Rawlsian framework that mandates distributive
justice, and by the work of Sen, who maintains that a basic level of certain social services must
be universally available to the populace, in order for individuals to have the freedom to exercise
their liberties; Sen also links health to social justice. The first part of my ethical argument is: if a
nonprofits mission is to provide the same (or similar) social services that the government is
obligated to universally and equitably proffer, then the nonprofit is implicitly inserted into the
social contract. Through this insertion, the nonprofit tacitly reinforces the strength of the social
contract through contributing to the supply of these particular social services. An enhanced
supply of these services better enables the polity to have the freedom to exercise their liberties,
thus promoting social justice, and reinforcing the strength of the society. In Line (1), Social
Justice is shown in red.
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Figure 19. Social Justice Through Social Investment:
Thesis Flow Chart





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Baron 158
As indicated in Line (2), with arrows feeding into lines (3) and (5), the pilot case study
was conducted within the context of Brazil's young democracy, emerging civil society, growing
economy, history of systemic institutional failure, and extreme socio-economic inequality.
Line (3) reflects my understanding that nonprofits operating in countries such as Brazil
must contend with two (or possibly more) sets of operating environments; line (4) identifies
these co-existing environments as characterized by: legitimate government failure - as shown on
the left, and systemic institutional failure - as shown on the right. Systemic institutional failure
(designated in red) is a term that I created to describe situations where a legitimate government
fails to uphold its end of the implicit social contract in certain critical areas. In countries like
Brazil, a void exists because the government has failed to universally and equitably provide
certain social services and protection for all its constituents. Nonprofits may need to operate
within this void, depending on their client base and the nature of their mission. Provision of
critical social services by nonprofits under conditions of systemic institutional failure may
provide instrumental support to a government in its struggle to create and maintain legitimate
societal order, thereby fostering democracy. Alternatively, legitimate government failure occurs
when a legitimate government successfully fulfills its contractual obligation with the people.
Due to economic or political checks on the government's ability to provide certain social
services, or to serve certain subsets of the population, the nonprofit sector is incentivized to
complement and supplement the government's provision of social services.
Line (5) refers to the pilot case study on Sade Criana (in red), which was conducted in
order to determine if stakeholder interviews could provide a greater understanding of the impact
of Sade Crianas program on the empowerment of its participating families. In Section 11.2,
the pilot case study is evaluated, and key findings are summarized in Section 11.3.
Baron 159
Line (6) refers to Sade Crianas intervention, i.e. the specific services that it provides to
further its mission, which is also shown in the diagram to foster social justice. Sade Crianas
mission is: To break the constant admission/readmission cycle of children treated at the
Hospital da Lagoa [by] offering them the opportunity to improve their health and the families
well being, by promoting their bio-psycho-social development, by rescuing their rights as
citizens and by giving them means to achieve self-sustainability.
Line (7) identifies the evaluation of impact, a necessary step for understanding the effect
of a philanthropic investment or nonprofit program. In Line (8), two methods for impact
evaluation are shown, metrics and stakeholder interviews. On the left, under Metrics, Sade
Criana monitors, tracks, and assesses the progress of its participants, through their family action
plan, indicators spreadsheet, and database, in order to confirm that the Sade Criana mission is
furthered through its intervention. On the right, Stakeholder Interviews (in red) are
investigated in this research project as a tool for accessing substantive information about Sade
Crianas impact on empowerment. Implicit in conducting stakeholder interviews, is the active
engagement of stakeholders in the assessment of impact. Information derived from each of these
methods for impact evaluation can serve to supplement and complement information derived
from the other. Accordingly, arrows are drawn from line (8), Metrics and Stakeholder
Interviews, back to line (1), Social Justice.
Section11.2:EvaluationofPilotCaseStudy

As discussed in Chapter 9: Research Organization, Preparation, and Methodology, one of
the objectives of the pilot case study was to develop and implement an unbiased and effective
framework for conducting stakeholder interviews. In returning to Table 1 entitled, Baron Field
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Research Work Flow by Goals and Tasks, in Chapter 9, three goals are listed for the pilot case
study. The first goal was developed during study preparation:
To create an unbiased and effective set of interview questions that would
increase an understanding of the intricacies of the impact of Sade
Crianas program on the empowerment of its participating families.
As evidenced by the novel information garnered from the participant responses, excellent
progress was made toward developing an effective set of interview questions.
One of the lessons learned from this pilot study is that scripting the interviews is an
iterative process. For example, future studies should include questions about the participants
educational level. Before conducting the pilot interviews, I had assumed that all of the
interviewees would have a similar socio-economic, and hence educational background.
However, I learned that some of the mothers conducted research about their childs illness on the
internet (Interview numbers 2, 3, 7, and 25), indicating both computer access and computer
literacy. Therefore, educational level could be a lurking variable that influenced the participants
responses to certain questions. For example, in the interview segment, Interactions with Doctors
(see Table 2: Interview Script for Sade Criana Pilot Case Study), educational level may have
influenced how well the interviewee understood the doctors explanations of her child's disease.
The second goal of the pilot study was developed to direct the execution of the study:
To effectively and efficiently implement the pilot study so as to interview
as many families, staff, and hospital personnel as possible given time
constraints and challenging circumstances
The extensive organization and preparation for implementing this pilot study, prior to leaving the
United States, for Rio de Janeiro, was both critical - and in retrospect - very effective. This
rigorous pre-field work helped carry the research study through a State of Emergency, which
was declared within hours of my commencing the project on-site. The support and assistance
provided by the Sade Criana staff was critical to the success of the project.
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The third key goal concerned post-fieldwork follow-up and analysis:
To explore the role that stakeholder interviews could play in contributing
to an understanding of an organizations impact.
Through (1) arranging the thematic structure of the stakeholder interviews around empowerment,
and through (2) the use of open-ended questions, I was able to learn about the nature of any
increase in the empowerment of the participants in Sade Criana, and to discover hidden
impacts of the program.
During the pilot study, I interviewed 45 individuals, across five stakeholder groups. This
included 25 families (four mothers were accompanied by their husbands, who contributed to the
interview), and 16 individuals representing the staff, board of directors, hospital, and volunteer
stakeholder groups (I was also able to interview some staff members multiple times.). I
conducted back-to-back interviews with the families as they waited to see the social assistants for
their monthly appointments.
Pivotal to meeting my goals was the relationship I built with Sade Criana, which
enabled me to interview individuals from five of their stakeholder groups. Family responses to
interview questions about Sade Crianas impact often triangulated with responses from staff at
both Sade Criana and Hospital da Lagoa.
It would have been informative to spend additional time with each family in order to
gather more information pertaining to hidden impacts as well as empowerment by asking follow-
up questions. However, scheduling more time with the interviewees, either through increasing
the length of each interview, or scheduling follow-up interviews, would have presented some
difficulties. In order to meet with me, many families stayed later at Sade Criana than they
normally would have, because of the interview session. Alternatively, arranging follow-up
interviews with the same families over a two-month span (each family is scheduled to come into
Baron 162
Sade Criana once per month) was not feasible due to the time and funding constraints of the
pilot study. Also, the 25 family interviews that I conducted were with families who were
scheduled to come to Sade Criana during the time period I was conducting my research; there
are a number of circumstances that could have prevented the same families from returning for
follow-up interviews.
Section11.3:SummaryofKeyFindingsandDirectionsforFurtherResearch

The interview framework enabled me to learn substantive information about Sade
Crianas impact. The data I collected during stakeholder interviews unveiled significant hidden
impacts, and provided significant information about empowerment and Sade Crianas impact
on the governments provision of services. While the questions developed for the pilot study
were meant to explore the empowerment of Sade Crianas participants, these open-ended
questions also led to an understanding of impacts that affected a far greater population, including
Hospital da Lagoa, and the communities of Sade Crianas clients, staff, and volunteers.
Throughout the interview process, I tried to be as thorough as possible in order to obtain
information on: Who, What, When, Where, Why, and How. For instance, with respect to the
interview segment on sharing information, I first tried to understand who was in the mothers'
communities, what the mothers shared, and how they shared, by asking for specific examples.
Mariana (#25) shared information about the use of condoms (what), with her neighbors (who and
where), by explaining their purpose and having them available should neighbors request them
(how). (Sade Criana provides condoms in the families monthly supply packages.)
During the interview process, many of the participants directly, or indirectly corroborated
impacts described by Sade Crianas staff. With respect to an improvement in self-esteem,
which as discussed in Chapter 10, can overlap with empowerment, responses by family
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interviewees triangulated with impacts described by Sade Crianas staff. Aline (#15) describes
her participation in Sade Criana as a rebirth in life. Mariana (#25) says it is important to vote
because, it is time to scream for what we want. And, Leila (#2) wants to return to school.
Other mothers characterized how the group therapy sessions had helped them to improve their
lives.
For many Sade Criana parents, the admission of their children to Hospital da Lagoa,
corresponded with the family joining Sade Criana. Both events correlated with the increased
satisfaction of Sade Criana parents with their childrens treatment and doctors. As mentioned
earlier, these three variables are difficult to unpack. Accordingly, I adjusted my interview
questions so that I could also learn about Sade Crianas impact on the government-run
hospital. Mothers frequently reported that the doctors communication at Hospital da Lagoa was
much better than at other hospitals. As extensively discussed in Chapters 5 and 10, there is
considerable cross-communication between Sade Criana and Hospital da Lagoa, and a clear
collaborative relationship, suggesting that the public hospital has benefitted from this long-term
relationship with Sade Criana.
Sade Crianas partnership with Hospital da Lagoa, and other Brazilian public hospitals,
provides a number of valuable lessons for successful nonprofit/government collaborative efforts
in the provision of social services. This is an area that merits further exploration, especially
given that Sade Criana operates under conditions of both systemic institutional failure and
legitimate government failure.
Within the Sade Criana program, some mothers take the professionalization courses,
and some do not. Enrollment in these courses may be influenced by a number of variables,
including the mothers' family dynamics, and the nature of her childs illness. If a child is very
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sick, the mother may not have the ability to take a professionalization course (many mothers with
ill children had to quit their jobs).
With regard to family dynamics, of the ten women who mentioned the
professionalization courses (4 took a course, 4 are taking a course, and 2 would like to take a
course), none of them are presently with a partner who is physically abusive. And, only one of
these mothers had been in a relationship with a physically abusive partner, from whom she
separated. There may be a connection between a non-abusive home environment and the
mothers enrollment in a professionalization course.
Extensive examination of the relationships between family dynamics, the mothers'
participation in the Sade Criana professionalization courses, and empowerment would entail
expanding the family dynamics indicator. This would be an essential step toward gathering more
information about the connection between home environment and proclivity or ability to take the
professionalization courses. Researching these relationships could provide insight into the
pursuit of financial stability and/or financial independence by women from poorer socio-
economic backgrounds. Such insights could be very significant, given that the strategy of many
economic development programs especially in microfinance is geared toward engaging and
empowering women, so that they can then lead their families into financial security.
During the interview segment on civic engagement, I asked the mothers if they voted, and
their impressions about the significance of voting. Their responses varied, and I did not find a
correlation between interest in voting (voting is mandatory in Brazil) or political apathy, and
empowerment. While the responses of some of the mothers captured challenges endemic to life
in the favelas, several mothers powerfully conveyed to me their awareness of their rights as
citizens.
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The economic models for nonprofit/government relations discussed earlier in this thesis
focus on the nonprofit sector's response to legitimate government failure. However, in many
countries like Brazil, nonprofits must operate under conditions of both systemic institutional
failure, as defined in this thesis, and legitimate government failure. Given this reality, further
academic and field-based research may be warranted on those models that can be extended to
encompass systemic institutional failure. Such research may help enhance an understanding of
global nonprofit/government relations.
One of the most significant hidden impacts uncovered through the stakeholder interviews
was that the mothers frequently shared information with their local communities about family
and public health, acquired through Sade Criana. Two of the most striking examples included:
Mariana (#25), who taught her neighbors about the importance of condoms.
Brazils government has taken an aggressive approach to combating AIDS, and,
Mariana's initiative may have a significant impact on her local community.
Rosana (#23), who received flyers from Sade Criana regarding the prevention
of Dengue Fever and H1N1 (swine flue). Rosana showed these flyers to her
neighbors, and brought them to her grandchild's school. She reported during our
interview that the school followed the advice. Eliminating areas where
mosquitoes can breed is a crucial step to controlling Dengue outbreaks. In the
2008 epidemic, approximately 55,000 cases were reported in Rio de Janeiro;
clinics and hospitals over-flowed with patients. Through Rosana, Sade Criana
reached a pivotal, at-risk, and sizable group.
Learning about this impact was a direct result of asking open-ended questions about the
relationship between participation in the Sade Criana program and increased empowerment.
Baron 166
Had the stakeholder interviews been oriented around a different theme, other hidden impacts
may have been discovered. Given that the mothers shared information within their communities,
be it with their families, neighbors, or children's schools, the mothers may be both aptly suited
and powerful agents for educating favela residents about issues that are of paramount public
health importance. Perhaps, clients of Sade Criana and of other organizations that have close
relationships with favela residents, could be mobilized to educate their communities, which
could lead to the viral dissemination of public and family health information. Only a few of
the Sade Criana participants whom I interviewed were involved in a community organization
or a church. Health information shared by these women might reach a different favela-
population than that targeted by community organizations, thereby helping to inform a broader
cross-section of Rios population.
..


Foundations and nonprofits, such as Sade Criana, play a vital role in the universal and
equitable provision of critical social services. The work of such organizations illustrates that
powerful solutions can be created by civil society through civic engagement and effective social
investment.
My Haas Summer Fellowship in 2008 provided the catalyst for this thesis. During that
summer, the children at Sade Criana provided me with my greatest joy. Their smiles shone in
bright contrast to the conditions that precipitated their families involvement at Sade Criana.
Their mothers are an inspiration. I only wish that these families have an inkling of how blessed I
am to have met them.



Baron 167
Appendix A: Staff Interviewees

Baron 168

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Baron 169

8osa MonLelro de Cllvelra

rofesslonallzaLlon
CoordlnaLor


(Left)

Marlallce MaLheus da Sllva

nuLrlLlonlsL



(Right)

8osangela Alves

re-ALLendance
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Ana Llnn Wledemeyer

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(Right)



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Baron 170
Appendix B: Family Interviewees






Baron 171




Baron 172



Baron 173




Baron 174
Appendix C: Sade Criana Letter of Agreement


LeLLer of AgreemenL
!anuary, 23rd, 2010

1o Lhe SLanford lnsLlLuLlonal 8evlew 8oard (l88):
l am famlllar wlLh Amle 8aron's research pro[ecL enLlLled Maxlmazlng Soclal lmpacL ln Clvll
SocleLy, wlLh Saude Crlana 8enascer as a case sLudy. l undersLand Saude Crlana's
lnvolvemenL Lo be allowlng employees, volunLeers and members of Lhe famllles parLlclpaLlng
ln Lhe program Lo be lnLervlewed, provldlng archlval daLa, allowlng our work wlLh Lhe famllles
Lo be observed and arranglng lnLervlews wlLh personnel from Lhe hosplLal.
l undersLand LhaL Lhls research wlll be carrled ouL followlng sound eLhlcal prlnclples and LhaL
parLlclpanL lnvolvemenL ln Lhls research sLudy ls sLrlcLly volunLary and provldes confldenLlallLy
of research daLa as descrlbed ln Lhe proLocol.
1herefore, as a represenLaLlve of Saude Crlana, l agree LhaL Amle 8aron's research pro[ecL
may be conducLed aL our lnsLlLuLlon.
Slncerely,

COO
Cristiana F. Velloso
Associao Sade Criana


Baron 175

Appendix D: IRB Notice of Exempt Review


STANFORD UNIVERSITY
Stanford, California 94305 - 5401
Penelope D Eckert, Ph.D.
CHAIR, PANEL ON MEDICAL HUMAN SUBJECTS
(650) 723-2480
(650) 725-8013
February 12, 2010 Date:
Amie Ranynne Baron, Public Policy, Public Policy To:
Penelope D Eckert, Ph.D., Administrative Panel on Human Subjects in Medical Research From:
Monica McDermott
Protocol
Protocol ID: IRB Number:
Maximizing Impact in Civil Society, with Sade Criana Renascer as a Case Study.
18313 349 (Panel: 2)
The IRB reviewed your research protocol on February 12, 2010 and determined that the only involvement of human
subjects in the research activities will be in one or more of the categories that are exempt from the regulations at 45
CFR 46 or 21 CFR 56. If this protocol is used in conjunction with any other human use it must be re-reviewed. The
IRB requests prompt notification of any complications or incidents of noncompliance which may occur during any
human use procedure.
Penelope D Eckert, Ph.D., Chair
EXEMPT - NEW Review Type:
Undergraduate Research Programs Funding:
FWA00000935 (SU) Assurance Number:
Please remember that all data, including all signed consent form documents, must be retained for a minimum of
three years past the completion of this research. Additional requirements may be imposed by your funding agency,
your depart ment , or ot her ent i t i es. (See Pol i cy on Ret ent i on of and Access t o Research at
ht t p: / / . st anf ord. edu/ dept / DoR/ rph/ 2-10. ht ml )
Notice Of Exempt Review
2 Exempt Under Category:
Baron 176
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