Local experiences in primary health care in Brazil: Inter-sectoral approaches in large towns

The purpose of this study was to analyze the strategies adopted by municipal governments in Brazil for constructing an inter-sectoral approach in Primary Health Care. Public intervention in the social sphere in Brazil is marred by institutional fragmentation, parallel endeavors and duplication, with adverse repercussions on the efficiency and efficacy of public policies. In recent decades, the subject of inter-sectorality has gained prominence on government agendas in connection with social policy reforms. The intention is to overcome the fragmentation of interventions and maximize available resources. This is not a new concern in the health field, but efforts over the last decade to reinforce Primary Health Care and to introduce the Family Health Strategy have contributed to bringing inter-sectorality onto the public agenda at all levels of government. This, however, is a complex, dynamic process constantly at odds with the tradition of hierarchically vertical, competitive sectors characteristic of Brazil’s public sector. This study examined the experiences of the towns of Aracaju, Belo Horizonte, Florianópolis and Vitória, by way of case studies based on interviews of local health system managers, practitioners and users. The municipal administrations were observed to adopt different strategies for constructing inter-sectoral actions, whose impacts also differed in the extent of integration achieved among the sectors involved. In municipalities where the town administration made constructing inter-sectorality a central guiding principle, bringing managers of various departments together to address social problems, needs and demands, the experience of inter-sectorality is more successful. Meanwhile, in municipalities where actions are more localized and occasional, involving only part of the sectors, efforts towards inter-sectoral practice suffer from limitations, by occupying a hierarchically lower position, acting at the local level, and depending on how problems are addressed by higher levels.