Brazil’s Family Health Strategy — An article by James Macinko and Matthew J. Harris

June 2015


By James Macinko, Ph.D., and Matthew J. Harris, M.B., B.S., D.Phil

In this article featured on The New England Journal of Medicine James Macinko and Matthew J. Harris explain how 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.

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.

Macinko and Harris go a step further to explain the Family Health Program (now called the Family Health Strategy, or FHS), which has evolved into a robust approach to providing primary care for defined populations by deploying interdisciplinary health care teams. 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.

Designed to perform several important primary care functions, the FHS reflects many best practices. Some of which are: access and first-contact care, which are facilitated by locating health care teams near people’s homes. Lists of all residents in each geographic area permit delivery of longitudinal care, and each team is responsible for everyone in its catchment area. Comprehensive care is provided by interdisciplinary teams whose scope of practice has gradually increased. Such care is proactive, since the community health agents seek out problems before patients arrive at the health post. Teams also deliver public health interventions, such as contact tracing and immunization campaigns.

According to the authors: “Evidence suggests that the FHS provides better access and quality and results in greater user satisfaction than do traditional health posts and centers or even some private-sector health care facilities.”

Health care teams have expanded over time and increasingly include professionals such as dentists and dental technicians. Further support has been provided through the development of multidisciplinary primary care support teams known as Núcleos de Apoio à Saúde da Família that may include nutritionists, psychologists, social workers, psychiatrists, community pharmacists, physical education specialists, speech and hearing therapists, occupational therapists, gynecologist–obstetricians, geriatricians, general internists, public health specialists, and others.

Over the past decade, expansion of the family health program from its initial focus on poorer-than-average municipalities and regions has played an important role in reducing inequities in access to and utilization of care. There is also evidence that the FHS has improved detection of cases of neglected tropical diseases, reduced disparities in oral health, and even enhanced reporting of vital statistics.

Despite its many accomplishments, the Brazilian health system faces serious financial and organizational challenges, which are discussed further in the article. “Still, the world can learn some lessons from the Brazilian experience”, believe Macinko and Harris.

The future of Brazil’s FHS, its sustained expansion to the remaining urban centers and the middle classes, and its effective integration into secondary and tertiary care will require continued engagement by health care providers and the public and continued financial, technical, and intellectual investments — all of which ultimately depend on sustained political support.

Read the full article here:

Macinko, James and J. Harris, Matthew. Brazil’s Family Health Strategy — Delivering Community-Based Primary Care in a Universal Health System. The New England Journal of Medicine. [viewed 10 June 2015]. Available from

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