S
ince the beginning of the 2000s, the Family Health Strategy (Estratégia de Saúde da Família, ESF) has been a crucial component of Brazil’s approach to primary health care and the universalization of its public health coverage.Similarly to other countries, it relies on the work of multi-disciplinary teams bound to a particular territory and primarily devoted to health promotion and prevention.
At the same time, the ESF has distinguishing features that stem from the specific challenges faced by Brazil. This is a country where access to healthcare is still a major issue even in urban centres; where income inequalities and the emergence of a new middle class have resulted in the rise of private health plans in the context of a chronically under-funded public health system; and where recent economic growth has led to a combination of health challenges of developing nations (like tropical diseases and poor sanitation), alongside the problems of affluent societies (such as obesity and heart disease).
The current ESF is the result of a long process that has its origins in the 1970s, when local initiatives began to promote the collaboration between health professionals and voluntary community members. Placing community agents at the forefront of primary health care signified a recognition of the deficiencies of the Brazilian public health system—namely the dearth of medically-trained staff and
its limited ability to reach populations on the peripheries of major cities and particularly in the communities commonly known as favelas. The notion of ‘family health’
was first introduced in official documents in 1994; in 1998, family health programmes were recognized as a structuring principle of the Universal Health System (Sistema Único de Saúde, SUS). The beginning of the 2000s saw the reorganization of family health into a full-blown strategy.
According to Ministry of Health data, in October 2014 there were almost 39,000 family health teams working on the ground—each of them comprising at least one physician, one nurse, one nursing assistant and a variable number of community agents. An estimated 120 million people were covered.
The ESF must be framed within the overall context of the SUS, particularly the latter’s attempt to develop a new healthcare model. At the most immediate level, the ESF seeks to promote the goals of the SUS by enhancing coverage. Arguably, however, its more radical elements pertain to the kind of coverage envisaged. Three ideas are particularly noteworthy. The first is the aim of providing humanized healthcare, going beyond the hospital-based model and avoiding as much as possible pharmacological and technological interventions deemed intrusive. The ESF seeks to humanize healthcare by its proximity to
populations, by the promotion of certain habits and practices (such as natural birth and breastfeeding), and by the establishment of a dialogue with alternative medical practices (including popular and non-Western medicine).
In connection with this, the ESF upholds an integral vision of healthcare. The term ‘family health’ already hints at a departure from medical models centred on the health of individuals. In addition to this, ESF teams are tasked with promoting a holistic approach to health comprising prevention of disease, promotion of healthy life-styles, health education, post-disease or post-injury rehabilitation, and even interventions in the social environment (such as the promotion of social activities for old people or initiatives against domestic violence). These tasks are supplemented by special attention to vulnerable groups and supported by permanent data collection and monitoring of the health status of populations.
Finally, the ESF speaks to one of the core objectives of the SUS: increased public participation in health policymaking and in the provision of healthcare. Public participation in the definition and delivery of policies is a cross-sectoral requirement in Brazil, enshrined in the country’s constitution. In the case of health, this is reflected by the engagement with neglected groups, community movements (including patient and carer organizations) and lay knowledge.
Taken together, these three features show the extent to which the ESF, as part of the SUS, has sought to resist the encroachment of the Western biomedical model
characterized by curative, pharmaceutical and hospital-based interventions.
The ESF has had very important achievements, including decisive steps in vaccination coverage, maternal health and the reduction of infant mortality. It is, nonetheless, still dogged by numerous challenges. One of the most serious problems paradoxically results from the decentralizing principle underpinning the SUS. The ESF teams’ dependence upon municipal authorities means that they are subject to political vagaries. This results in unevenness—for example, technologically-developed units sitting alongside others where even electricity is unreliable—and also in difficulties with guaranteeing the sustainability of medium- or long-term health interventions, which often rely on the personal initiative of health professionals and community agents.
An interrelated problem is that the work and goodwill of many of these professionals is sometimes affected by the precarious employment situation in which they find themselves.
A further challenge relates to the difficulties of monitoring health indicators in regions where population is highly mobile and susceptible to significant seasonal fluctuations. This ties in with the challenge of improving these indicators: like any other primary health strategy, the successes of the ESF are not always measurable or quantifiable, and part of the ability to achieve outcomes relies upon the existence of relations of trust with the population. These long-term, ‘soft’ targets are vulnerable to the encroachment of the managerial, outcome-centred and efficiency-based approach to healthcare that is becoming
dominant in many societies. Brazil is not immune to these latter tendencies, with the growth of private health and the funding pressures upon the SUS demonstrating the coexistence of diverging visions of healthcare.
Finally, the ESF has not been able to completely escape the influence of the Western biomedical model. Such influence is visible in the clash between the purposes of ESF and the expectations of the populations. Many people, especially those from traditionally-neglected backgrounds, still find it difficult to understand the purpose of healthcare units that do not have curative procedures or the dispensing of medicines as their primary objectives. Hence, some ESF units are actually hybrids—places where primary health care sits alongside the functions of traditional hospitals and emergency units.
Dr João Nunes University of York United Kingdom