Brazil’s Family Health Programme
BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c4945 (Published 29 November 2010) Cite this as: BMJ 2010;341:c4945
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I have been working as a family physician in Sao Paulo for nine
months now, having worked for one year also seven years ago, and could not
agree more with all the benefits and challenges you outlined in the
editorial.
There are still many health units working without doctors, especially
in the more deprived regions of the country, namely the North and the
Northeast. Here in Sao Paulo, despite all the economical development, and
the astonishing rate of 4,30 doctors per 1000 inhabitants, there is still
an alarming shortage of qualified family physicians.
Being primary care so obviously crucial to maintaining a solid health
system, the low enthusiasm and unsatisfactory infrastructure for its
teaching is daunting. One of the most traditional medical schools in
Brazil, which is completing one hundred years this coming year, has only
offered specialisation in Family Medicine since 2005, and only nine jobs
this year (for the purpose of comparison, there are 44 jobs in General
Surgery and 28 in Anaesthesiology). The lack of spare consulting rooms in
the health units, for example, is a concrete obstacle to the expansion of
teaching.
There is also a generalised lack of interest in the career, which may
result from the historical underfunding of the public health system. This
left a hard to dissipate stigma against professionals who work for the
Unified Health System (SUS). Even though the Family Health Strategy is
slowly breaking that prejudice down, society has been miseducated for
centuries now. They would rather spend much of their salary to pay for a
private health insurance, so that they can choose which specialists to go
to (the random way private health care works in Brazil renders another
whole article). The culture of reaching out for primary care is still
germinating in Brazil. Even in the most educated ranks of the society,
Family Medicine is unknown and often not considered a specialisation.
I had the privilege of working for the NHS in the past few years, and
could witness the difference between the way the NHS is well financially
supported by the government in comparison to the SUS.
Overall, the Family Health Programme is changing the way primary care
is seen and practised, and is establishing a promising future for both
patients and health professionals in the sphere of SUS. I am glad it is
finally gaining some international visibility, and hope the newly elected
president will support and generously fund its advancement.
Competing interests: Family Physician at Programa Saude da Familia
Many people are surprised to find that the dental service (and many
others) in the UK have been atrocious sorry to say. There have been huge
problems with even finding a dentist for the population in Wales. My
Brazilian friends always wait until they can afford to go back home to get
any dental and some other health problems dealt with as they are shocked
by the quality of some of the public services here. They are not rich or
privileged in any way, they pay taxes and National Insurance, but choose
not to as the quality in some areas is better in Brazil. Bravo Brazil
susanne stevens
UK/cf14
Competing interests: No competing interests
Exactly the same as you read in the paper.
Even better.
I've worked last 10 ys as public health dentist, most of then as a family
health dentist and manager.
I could say, family health would not be the same without the community
health worker!
Competing interests: No competing interests
Suspect I am not the only older GP reading this fascinating editorial
to be struck by the similarities of the Family Health Programme teams to
the practice based multidisciplinary teams that were the pinnacle of
British General Practice during the 1980s and 1990s. Although we never had
that many of them and, because of this, they were never quite able to
fulfil their promise health visitors in those days had a role description
that sounded very similar to that of the Brazilian community health
workers.
Now we have a completely fragmented and non-practice based system
with health visitors who seem only to have time for the under 5s and who
are supplemented by a confusing array of community matrons / practitioners
/ case managers and the like.
Could we not learn from the Brazilians and keep it simple and keep it
local?
Competing interests: No competing interests
Editorial is brief, documented with precision in clear language, on
very important subject of need for the management of national family
health services with equity globally. Editorial statements are well
supported by the findings of the cited references. Conclusion of the
editorial argument that the model under editorial evaluation provided
material for learning to get the system right in other nations round the
glob, and that the results were likely to follow even with limited
resources, appeared convincing. However, the editor did not cite any
references for the entered statement that, 'Health policy makers in the UK
have a history of looking to the United States for innovative examples of
healthcare delivery, despite the relatively poor outcomes and high costs.
They could learn a lot from looking to Brazil.'
Competing interests: No competing interests
It's with pride and absolute agreement that I greet this editorial.
For it is mind-boggling how the Unified Health System (SUS) and the Family
Health Program are more appraised abroad than in Brazil itself.
The timing of this editorial could not be more appropriate, as Sao Paulo
state is opening its Community and Family Medicine Congress which will
certainly discuss a proposed attempt by state health secretaries to curb
some important challenges of the program. Although some questions are
legitimate, modifications to the program without pilot studies or any
evidence-based support for the change (mainly shorter hours for the
doctors in the strategy and inclusion of other medical specialists in the
core team) seem reckless. Hopefully we will keep on building more evidence
to support this extraordinary public program in Brazil. And support people
who have being struggling to build a less inequitable society in the
country.
Competing interests: No competing interests
The recognition by the international scientific community of the high
achievements of the Brazilian Programa de Saude da Familia will be of use
not only to other countries, but also serve as a lesson to Brazil itself.
Most physicians in Brazil are still very seduced by the high-cost, gadgets
lead medicine from the United States, blinded to our own Brazilian
effective solutions.
Competing interests: No competing interests
Lessons that Brazil health policy makers must (re)learn
According to the document that guides policy for primary healthcare
(1), the Family Health Programme has established itself as a strategic
priority for the reorganization of primary healthcare in Brazil in
consonance with the principles of the Unified Health System. This model,
until the December 4 issue of the BMJ [2010, 341 (7784)], has not
received international recognition for its success as it deserves, which
can be read in articles of Godlee (2), Harris and Haines (3 ), Hennigan
(4) and Guanais (5). In this issue of the BMJ, the Brazilian model earned the
cover of the journal with the heading "A Revolution in Primary Healthcare"
(the cover can be viewed at: http://www.bmj.com/content/341/7784.cover-
expansion) and was considered the most impressive example worldwide of a
rapidly scaled up, cost effective, comprehensive primary care system.
However, the current and successful model of primary healthcare (5)
can be threatened by health policy makers, as they now prepare to discuss
policy strategies for improving the health of the newly inaugurated
president, Dilma Rousseff, who during the election campaign, supported
their proposals for public healthcare in a curative model of high cost,
high complexity and emergency, in other words, centered on the hospital.
The message for other countries is clear and learning from Brazil
is clear (2-5). Ironically, the lessons that were given by Brazilians are
useful for the Brazilians--health professionals and especially for the
health policy makers. The future challenges that would be
guided in establishing equity in health of Brazil, a country with
continental dimensions and differences, could be forgotten by the health
policy makers, who are fascinated with the flashes of excellence from
curative model of high complexity and high cost, or simply, interested in
securing votes, election or re-election, through works that draw attention
from the population and media.
In this way, if future actions for health are guided by the logic of
the discourse of President Dilma Rousseff, the threat becomes imminent to
equity, integrity and universality of access to health services and, above
all, the cornerstone of the health service from Brazil, the Family Health
Programme. Even in the face of progress achieved and now recognized.
Contact: v.silva@ymail.com or janainaralo@gmail.com
References
1. Brazil. Ministry of Health. Secretaria de Atencao a Saude.
Departamento de Atencao Basica. Politica nacional de atencao basica /
Ministerio da Saude, Secretaria de Atencao a Saude, Departamento de
Atencao a Saude. - Brasilia: Ministerio da Saude, 2006.
http://bvsms.saude.gov.br/bvs/publicacoes/politica_nacional_atencao_basi...
2. Godlee F Lessons from around the world. BMJ 2010;341:c6936.
3. Harris M, Haines A. Brazil's Family Health Programme. BMJ
2010;341:c495.
4. Hennigan T. Economic success threatens aspirations of Brazil's
public health system. BMJ 2010; 341:c5453.
5. Guanais FC. Health equity in Brazil. BMJ 2010; 341:c6542.
Competing interests: No competing interests