Executive summary

The introduction of the Sistema Único de Saúde (SUS) in 1990 has been a major achievement for Brazil in increasing access to health care services and reducing health inequalities. The implementation of the Family Health Strategy, starting in 1994 and aimed at the reorganisation and strengthening of primary health care, has been a key component in this success. Since its implementation, the Brazilian population can benefit from free access to preventive and primary health care services delivered by multi-disciplinary family health teams (FHTs). Over the past two decades, reforms have sought to rebalance service delivery to move away from a health system that was historically very hospital-centric. Remarkably, reforms have focussed on developing modern models of care, introducing a range of quality initiatives and tools for monitoring the activities and quality of care. The expansion of the Family Health Strategy has contributed to measurable improvements in terms of infant mortality rates, maternal health, immunisation uptake and avoidable hospitalisation for chronic conditions. Life expectancy at birth increased by 5.7 years, from 70.2 years in 2000 to 75.9 years in 2019. Infant mortality rate has decreased by 60%, from 30.3 deaths per 1 000 live births in 2000 to 12.4 deaths per 1 000 live births in 2019. The implementation of the Family Health Strategy was associated with a reduction of 45% in hospitalisation rates per 10 000 inhabitants between 2001 and 2016, mostly for primary care conditions such as asthma, gastroenteritis, cardiovascular and cerebrovascular diseases. Brazil also makes spending on primary health care a high priority. In 2019, Brazil dedicated around 16% of its financial resources to primary health care, similar to OECD countries.

Despite this progress, key indicators suggest that Brazil primary health care is not working as effectively. Brazil is facing a dual challenge with still a primary health care system with marked inequalities in access and care quality, and with acute workforce shortages. The growing burden of chronic non-communicable diseases associated with the expansion in exposure to risk factors and rapid population ageing will compound existing challenges. In this context, the Review identifies scope for Brazil to building a stronger primary health care system, and to strengthen existing policies and practices to improve both access and care quality. It provides in-depth review of four priority areas: screening and prevention for major chronic non-communicable diseases, quality of primary health care provision, workforce shortages, and the digital transformation of primary health care in Brazil.

In Brazil, some cancers, hypertension and diabetes have screening and prevention strategies, but more could be done to improve depth and scope of such strategies. Breast and cervical cancer screening is opportunistic and does not happen within a population-based programme designed and managed at federal level. This contributes to low and uneven screening coverage. While breast cancer screening among the target group of women between 50 to 69 years of age increased from 15.2% to 24.2% between 2014 and 2019, it stands below all OECD countries and well below the 58% average in 2019. At the same time, mortality from breast and cervical cancer remains high and has been on the rise over the past decades, signalling shortcomings in terms of prevention, early detection and treatment at early stages. Between 2008 and 2019, breast cancer mortality increased from 19.2 to 20.8 deaths per 100 000 women in Brazil, compared to a decrease across OECD countries. Brazil should thus implement a strong national strategy for cancer prevention and screening, notably by moving towards population-based programmes, with a personalised approach to invite target populations. Improving data systems and health literacy are complementary strategies not to be underestimated to support stronger cancer prevention and screening. When it comes to screening for hypertension and diabetes, Brazil should further develop disease management pathways with a people centred perspective, integrating all health care providers across different sectors. Family health teams will need to have the right tools, capacities, and incentives to undertake these responsibilities.

There are also clear shortcomings with regards to access to high quality primary health care. Critically, only 65% of the population are covered by FHTs and too many patients bypass primary health care and directly seek care in outpatient specialties and hospitals. These give strong argument to strengthen the gatekeeping system in Brazil with a systematic registration system with FHTs, which will control and orient the patient’s into specialist care. At the same time, the federal government will need to play a more prescriptive role to strengthen comprehensiveness of primary health care evenly across the country. To embed a larger range of activities and effective interventions in FHTs, it will be critical to ensure that all municipalities are able to deliver actions and services properly. Introducing economic incentives, alongside appropriate educational programme in prevention, detection, and treatment are key approaches to consider. There are also several opportunities for extending further quality strategies toward primary health care. Particular attention should be given to transparency and the collection of richer performance data. A robust accreditation system that would apply uniformly across the country could help standardise primary health care quality, and to identify areas that may require greater financial and organisational support. The new Agency for the Development of Primary Health Care could act as an inspectorate for primary health care, for example to provide independent and external verification that standards are being met, identify good practice and support weaker centres to improve their standards.

When it comes to workforce challenges, Brazil primary health care sector faces acute shortages and imbalance in the distribution of primary health care doctors with a North-South gradient, where North and Northeast regions show a lower density of medical doctors. In addition, little attention has been devoted to building a strong credibility of the primary health care specialty, and to promote workforce quality. In 2018, only 5 486 medical doctors had a specialty training in family and community medicine, representing 1.4% of all specialists in Brazil. Going forward, Brazil needs to implement a coherent workforce planning based on an objective assessment of present and future needs to govern health care human resources, which is currently absent. In tandem, Brazil could look at the experiences of OECD countries to train more rural doctors and to provide both wage and non-wage related financial incentives linked with a return of service obligation. Brazil should take steps to expand the role of nurses and community health workers and explore the potential of task delegation. Perhaps more crucially, there are opportunities to make the primary health care specialty training compulsory for all doctors wishing to practise primary health care, and to implement stronger requirements around continuous medical education.

Brazil’s decentralised government creates challenges to digitalising primary health care. Brazil has made strides towards a digital transformation of primary health care, building on more than a decade of policies to digitalise health care and make better use of health data, and with key investments in networks, data, interoperability and skills. Yet, progress towards effective use of digital primary health care has been slow, and fundamentally unequal, with significant inequalities in the use of digital technologies and tools among health workers and citizens. In 2019, an estimated 78% of PHC units had electronic health record (EHR) systems. Adoption of EHR systems was highest in the South and Southeast regions (at 90% and 83% of facilities in those regions, respectively) compared to the Northeast and North regions (77% and 74% respectively). Other major barriers include human and technical capacities in municipalities, with potential diseconomies of scale resulting from setting responsibilities for digital health at municipal level. Tackling these challenges requires to digitalising all primary health care units and teams, while promoting inclusive connectivity for all Brazilian citizens, especially the most vulnerable. Brazil should also consider establishing a governance structure with clear well-funded mandates at the right levels of government.

Across all these areas, there is scope to strengthen oversight from the federal government and regional co-ordination and support from state governments. Better and stronger co-ordination mechanisms between levels of government have the potential to lessen regional inequalities, and prepare the health system against systemic shocks, such as the one observed in the COVID-19 pandemic. The Brazilian unified health system (SUS) has had high aspirations since its introduction by the Federal Constitution of 1988, which was the result of a society-wide mobilisation. Primary health care has been a cornerstone of the extension of health care coverage since the beginning of SUS. Continuing to strengthen and modernise primary health care remains the essential lever for the Brazilian health system to realise its potential of effectively achieving universal coverage of high quality services for all Brazilians.