Brazil’s Family Health Programme

Healthcare reforms in Brazil began in 1988 as part of a broader sociopolitical movement at the end of nearly 20 years of military rule. The new constitution was underpinned by principles of budgetary and political decentralisation, community participation in local budget setting, and the acknowledgment that health and access to health care is a universal human right. This laid the foundation for the Sistema Único de Saúde, or Unified Health System, and began a nationwide shift from tertiary centre based health care to comprehensive primary health care, free at the point of use, funded by the taxpayer, and inspired by the Alma-Ata Declaration of 1978.

Over the past 15 years progress in Brazilian public health has been remarkable. Infant mortality has dropped from 48 per 1000 to 17 per 1000. In just the past five years, hospital admissions due to diabetes or stroke have decreased by 25%, the proportion of children under 5 years old who are underweight has fallen by 67%, over 75% of women now receive seven or more antenatal consultations, and diphtheria, tetanus, and pertussis (DTP) vaccine coverage in children less than 1 year old is greater than 95% in most municipalities.1 Even the United Nations Millennium Development Goals aspire to achieve less than this.2

Although these measures reflect improvements in the entire health system, evidence suggests that the lynchpin for the successes of the Unified Health System is the Programa Saúde da Família, or Family Health Programme, implemented a few years after the constitutional reforms.3 4 This programme has expanded nationally and now provides comprehensive primary care services in 95% of all municipalities, covering over 55% of the population—more than 85 million people.

The Family Health Programme is based on a simple model—multidisciplinary teams, comprising a doctor, nurse, nurse auxiliary, and four to six community health workers, work in health units located in geographically defined areas, each covering no more than 5000 residents. A community health worker is responsible for up to 120 families in a defined area, and aims to provide home visits to every household at least once a month. Community health workers are fully integrated into the primary care team. They are multifunctional, and although child and maternal health forms the bulk of their work, they also provide curative care, triage and referral into the health unit, health promotion for chronic disease, and support and encouragement for community participation: community health workers must be from and live in the area where they work.

Budgetary and logistical responsibility for the health units has been devolved to the municipality level, which permits flexibility and autonomy in the delivery of this model of primary health care. However, healthcare expenditure is federally mandated, with contributions from the regional and national coffers. The scale of this healthcare reform is unprecedented, and it is expanding to reach universal coverage. In just 15 years, Brazil has recruited an army of 250 000 community health workers and 30 000 medical generalists.

Despite these remarkable achievements, the Family Health Programme is confronting challenges that can provide useful lessons for other countries. These challenges include difficulties in the recruitment and retention of doctors trained appropriately to deliver primary health care, large variations in the quality of local care, patchy integration of primary care services with existing secondary and tertiary care,5 and the slow adoption of the Family Health Programme in large urban centres,6 where the middle classes are more accustomed to private health care. Furthermore, although the Family Health Programme costs only $31-50 (£20-32; €24-39) per capita per year,7 the maintenance of adequate financing to support the expansion of primary care nationally has sometimes been problematic.8

Brazil’s Family Health Programme is probably the most impressive example worldwide of a rapidly scaled up, cost effective, comprehensive primary care system. But its successes have not been given the international recognition they deserve. The potential of the healthcare reforms in Brazil and, specifically, of the Family Health Programme, to deliver affordable health care was noted 15 or more years ago in the BMJ.9 10 In many ways that promise has been more than fulfilled, but Brazil’s primary healthcare success story remains poorly understood and not yet widely disseminated, or translated into other contexts.

High income countries could also learn from how the programme has affected chronic disease, demand for tertiary care services, and health promotion. Through the Family Health Programme, community health workers proactively identify problems in chronic disease management and medication adherence; they support healthy lifestyle choices through home based health promotion and education; they provide continuously updated population registers and ensure disease surveillance is population based, not just based on those who interface with formal healthcare services; and, finally, they can also proactively identify simple acute health problems that can be dealt with in the home. These are all tasks that the UK NHS still struggles with. The lessons from Brazil may be particularly relevant in the current economic climate.

In many respects, Brazil has got it right: a cost effective, large scale primary healthcare programme that addresses the public health problems typical of low income countries and those undergoing the epidemiological transition, but one that is also relevant to high income countries. Brazil’s growing global political and economic ascendency11 should encompass its leadership role in primary health care. We all have a lot to learn—get the system right, and the results will follow, even with limited resources.

Health policy makers in the UK have a history of looking to the United States for innovative examples of healthcare delivery, despite the relatively poor outcomes and high costs. They could learn a lot from looking to Brazil.