Perspective
INTERNATIONAL HEALTH CARE SYSTEMS
Brazil's Family Health Strategy — Delivering Community-Based Primary Care in a Universal Health System
James Macinko, Ph.D., and Matthew J. Harris, M.B., B.S., D.Phil.
- Article
- References
- Brazil has made rapid progress toward universal coverage of its population through its national health system, the Sistema Único de Saúde (SUS). Since its emergence from dictatorship in 1985, Brazil — which has the world's fifth-largest population and seventh-largest economy — has invested substantially in expanding access to health care for all citizens, a goal that is implicit in the Brazilian constitution and the principles guiding the national health system.1 The SUS comprises public and private health care institutions and providers, financed primarily through taxes with contributions from federal, state, and municipal budgets. Health care management is decentralized, and municipalities are responsible for most primary care services as well as some hospitals and other facilities. All publicly financed health services and most common medications are universally accessible and free of charge at the point of service for all citizens — even the 26% of the population enrolled in private health plans (see table
Selected Characteristics of the Health Care System and Health Outcomes in Brazil. and case histories; to compare this country with others, see the interactive graphic).1
An important innovation in the system has been the development, adaptation, and rapid scaling up of a community-based approach to providing primary health care. After originating in the northeastern state of Ceará in the 1990s as a maternal and child health program relying on community health agents (lay members of the community who are paid members of the health care team), the Family Health Program (now called the Family Health Strategy, or FHS) has evolved into a robust approach to providing primary care for defined populations by deploying interdisciplinary health care teams. The nucleus of each FHS team includes a physician, a nurse, a nurse assistant, and four to six full-time community health agents. Family health teams are organized geographically, covering populations of up to 1000 households each, with no overlap or gap between catchment areas. Each FHS team member has defined roles and responsibilities, and national guidelines help structure FHS responses to most health problems. The pace of FHS scale-up has been remarkable: from about 2000 teams including 60,000 community health agents providing services to 7 million people (4% of the Brazilian population) in 1998 to 39,000 teams incorporating more than 265,000 community health agents, plus 30,000 oral health teams, together serving 120 million people (62% of the population) in 2014.2/.../
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