Primary health care in Brazil: Implementing a comprehensive PHC approach - Limits and possibilities

In Brazil, a National Health Service (SUS) financed through taxes, was implemented during the 1990s. The SUS is based on the principles: health as a universal right and State duty, meaning universal access to health services for all citizens, regardless of income; decentralization with responsibilities shared between government levels; and citizen participation. PHC service provision is a municipal responsibility and implementation of a new PHC model –the Family Health Strategy (FHS)– began in 1998 with federal financial incentives. The FHS entails multi-professional health teams working in a specific territory with registered population. The family health team is expected to be the first-contact service and gatekeeper to a comprehensive health service network. This study aims to evaluate Brazil’s PHC strategy to reorganizing a PHC-led health system. It focuses on analyzing PHC service integration with other health care levels and intersectoral action. These are essential features of comprehensive PHC to address health system fragmentation and promote health. To evaluate the FHS, four case studies were conducted in large urban centres. The information sources were interviews of municipal health managers, a survey of health workers in FHS teams and a survey of registered families. The study results show that implementation of the FHS is permeated by ongoing dispute between the comprehensive PHC and the selective PHC approaches. Although public access to primary care has unquestionably been extended –the Family Health Strategy currently covers around 90 million people (48% of the total population) under the responsibility of 28,000 PHC teams–, differences in FHS implementation approaches were observed among the municipalities. Despite some advances, the FHS faces difficulties in implementing PHC as a first-contact service, in integrating with other levels of care as part of a resolutive care network, and suffers from insufficient intersectoral partnerships to promote health.