Thirty years of the Family Health Strategy in the Brazilian Unified National Health System: milestones, advances, setbacks and challenges.

Abstract

This essay examines the trajectory and persistent challenges faced by Brazil's Family Health Strategy (FHS), stemming from concerns regarding the prospects for the full implementation this territory-based community-oriented approach to the delivery of primary health care within the Brazilian Unified National Health System. We look at the development of the strategy and provide a critical overview of the main institutional milestones over the last 30 years, focusing on the following: federal funding associated with the process of the municipalization of care; the expansion of multidisciplinarity in the work of health professionals in basic health units (BHU) and the local community; improvements in quality associated with the evaluation of team structure and work processes and performance-based funding; and emergency medical staffing in underserved areas and professional training. We outline how the expansion of FHS coverage and the adoption of practices centered on individuals, families and communities has impacted population health and access to care. Setbacks between 2016 and 2022 are critically addressed, including the undermining of the multidisciplinary community-based approach and threats to universality and comprehensiveness. We then go on to discuss the reprioritization of the FHS by the Federal Government in 2023. Data from the 2024 national BHU Census are used to illustrate the current status of the FHS. Challenges to implementing effective change in the care model and achieving universal FHS coverage include the following: ensuring adequate funding, employment stability, professional training and interprofessional collaboration; addressing the risks of commodification in primary health care (PHC); improving coordination of care and the strengthening the role of PHC in patient access management; and reducing geographical, social and racial inequalities in access to care.