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Ceará hired thousands of mostly female, low-paid health agents to make home visits promoting vaccination, oral rehydration and prenatal care, and infant mortality fell sharply within a few years. The agents performed with high dedication despite minimal pay and training because the job carried unusual prestige and a sense of calling in their own communities.
The state government used radio, public ceremonies and prizes to publicize the health programme and its agents to citizens, not just to recruit workers. This public recognition raised agents' status and created an informed public that expected good service. External monitoring by communities disciplined workers more effectively than internal bureaucratic supervision.
Health agents were selected through a highly visible competitive process that the hiring committee ran in the open, and many who applied were turned down. Rejected applicants and their families became watchdogs who reported agents who shirked, and those hired felt chosen and proud. Visible selectivity converted a patronage-prone job into one carrying earned status.
Health agents voluntarily took on tasks beyond their formal job description, such as helping with births or domestic problems. This built client trust, which then made families receptive to preventive advice. Tendler argues that task variety and discretion, usually criticized as vague mandates, can raise performance when they build trust with the people served.
Good performance did not come from decentralization alone. It came from a strong central state that set standards, hired workers and appealed directly to citizens, bypassing local mayors and elites who might capture programmes. Analysts should examine how the center, local government and civil society interact rather than assume local control is inherently better.
Ceará directed purchases of school furniture and similar goods to local small-firm clusters in its drought-relief and procurement programmes. The guaranteed demand came with quality requirements and technical assistance, and firms upgraded their production as a result. This shows demand-side support, meaning a buyer paired with performance standards, doing more for small enterprises than conventional supply-side credit and training.