The case of a successful local health initiative in northern Brazil, which involved
both a judicious combination of tight central staffing controls (because of the pervasiveness
of local patronage networks) and high levels of local operational autonomy is instructive in
this regard.18 Local autonomy afforded the health teams a sense of empowerment, which
encouraged them to respond flexibly to local needs. However, this autonomy was constrained
in ways that ensured that potential abuses could be avoided. The centre not only imposed
tight personnel controls, but it also set performance standards, publicized them and sought
feedback, deliberately encouraging local populations to monitor outcomes