Wednesday, November 9, 2011

Can the United States Learn from Brazil's Primary Care Model?

Brazil has seen huge changes in the past several decades in their political and social structure. Prior to democratization in the 1980’s, the country had been under several decades of military rule. After the authoritarian rule, socio-political reformation began to take shape which included an overhaul of their health care system. The belief that health is a universal human right became more widespread throughout the Brazilian culture and with this in mind, the National Health System (SUS) was created in 1988 and implemented in 1990. Since implementation of SUS, Brazil has seen huge improvements in health outcomes including increased life expectancy, decreased infant mortality, and decreased deaths from infectious diseases.

A cornerstone of the SUS is the Family Health Program (PSF) which functions as their primary care delivery system. The PSF was established in 1994 as a way to meet universal access goals, better coordinate care, and focus on prevention. The PSF’s focus is on family and community health which encompasses prevention and public health goals. Under PSF, family health teams, which consists of one doctor, a nurse, an auxiliary nurse, and 4-6 community health workers cover a geographic area which includes no more than 5,000 patients. Community health workers are vital to the team as each community health worker is responsible for about 120 families and they make home visits to each of these families once per month. The community health workers’ primary focus is on child and maternal health, but they have been instrumental in health promotion, education, medical adherence, public health actions (i.e. sanitation), chronic disease management, and triage support.

The PSF is highly decentralized with most authority placed on the municipalities. The PSF program has been successful in getting to the majority of the population as family health teams are found in 85 percent of municipalities serving over 98 million people. Despite the large coverage, the PSF program only takes up 8 percent of the federal health care budget.

The PSF program has been shown to be very effective in improving health outcomes for Brazil. Access to care has increased by over 25 percent since its origination in 1994. Life expectancy has increased from 67 to 72 years, immunization rates for Tetanus, Diphtheria, and Pertussis is over 95 percent for all children 1 year of age, and infant mortality has decreased from 48 per 1000 to 17 per 1000. A reputable study by Guanais and Macinko focused on postneonatal mortality as a proxy to assess success of primary care delivery. It is argued that the postneonatal period, ranging from 30 days to one year, reflects success in primary care goals of nutrition, immunization, sanitation, breast feeding, and prevention of respiratory and diarrheal infections. They found that between 1998 and 2006, the postneonatal death rate decreased from 14.24 to 6.92 per 1000 children while at the same time PSF coverage increased from 8.74 percent of municipalities to 60.90 percent. Their published paper accounted for increases in clean water, decreased illiteracy rates, and other confounders and through regression analyses determined that the family health teams decreased postneonatal death rates by 0.86 per 1000 compared to communities without teams.

The PSF does not come without some problems, however, and need to be mentioned. The decentralized nature of the program makes it difficult to ensure quality between geographic regions. The federal government collects money, but the money is allocated to municipal governments who are ultimately in charge of managing their budget and health care delivery. Problems seem to arise most in the northeast region which is more socioeconomically depressed than the central or southern regions. As a result, the northeast has a higher infant mortality rate, more deaths from infectious diseases, and lower life expectancy. Not surprisingly, many municipalities in the northeast do not have family health programs, partly because it is difficult to recruit and retain health providers for this region. Additionally, corruption is a problem with some municipalities which results in allocated money not being used for health care expenditures. These problems create conspicuous disparities in access and health care outcomes between different municipalities.

Another problem faced is the difficulty of integrating the family health teams with local hospitals and specialist care. Some municipalities have more success than others in working with the private sector. Naturally, the more coordinated and integrated the care is, this results in better available health care for Brazilians. Lastly, the emphasis on improving primary care has come at the sacrifice of providing good hospital and tertiary care. Brazil’s public hospital system only provides 35 percent of hospital beds in the country with the remainder made up of by private hospitals. The public hospital system is overcrowded and has large variability in quality.

As the United States works to come up with solutions for improved primary care delivery and access, it may be prudent to look outside of Europe and Canada for ideas. Arguably, Brazil’s primary care model has seen some of the greatest health improvement of any country in the world through their innovative decentralized method. I feel that U.S. could benefit from a team based approach. Teams are seen to an extent in our patient centered medical homes, but the addition of community health workers could facilitate improved chronic disease management, health promotion, behavior change and support, and medical adherence. Most importantly, Brazil has shown us that by investing in primary care, the health of the population can be greatly improved. As we continue to work towards improved health systems and primary care delivery, let’s not forget to keep Brazil in mind.



Frederico C. Guanais and James Macinko, The Health Effects of Decentralizing Primary Care in Brazil, Health Affairs, 28, no 4 (2009): 1127:1135

Michael Kemp, Cracks Appear in Brazil’s Primary Health Programme, The Lancet, vol 372 (2008): 877

Mathew Harris and Andrew Haines, Brazil’s Family Health Program, BMJ 2010; 341: c4945

Paim, J., Travassos C., Almeida, et al., The Brazilian Health System: history, advances, and challenges, The Lancet, 2011; 377: 1788-97


  1. This is the second time that i have heard an impressive health reform come out of Brazil. Had you heard about their movement to get all of their HIV+ citizens onto ARVs? The Brazillian government set-up a similar decentralized HIV care / ARV distribution system that did what no one else could do in other parts of the world at the time - reverse the rate of new infections.

    Brazil seems quick on its feet when it comes to getting new health ideas disseminated throughout their country quickly and robustly. To learn from their success, I am interested in knowing more about quickly setting up infrastructure and getting all the different states on board.

    Thanks BWC!

  2. Thanks BWC.

    As we spoke about today in class, the challenge in a program like this in the US may be enrollment. I am in favor of decentralization, but having community teams is only beneficial insofar as they are able to reach those in need and patients are willing/able to work with them. We must find innovative solutions to hook up difficult to reach patients (like the rural, the poor, those "off the grid," etc) with programs that might benefit them.

    Lastly, until we move to a system whereby all are funded, it must not be forgotten, reaching these patients consistently will be difficult. I am envious of the Brazilian system where universal coverage has been attained. They have the ability to focus on those without access and those with the greatest need without worry about payment or if the program saves money. Helping the poor and sick is expensive but that should not matter.

    Thanks again for the thoughts.