Primary health care in Brazil has a well-organised approach which is the result of sustained commitment to providing high quality primary health care for the whole population. The Family Health Strategy, launched in 1994, has been a key pillar of the efforts to reorganise and strengthen primary health care in Brazil. Since its implementation, a growing share of the Brazilian population can benefit from free access to a community-based approach to preventive and primary health care services. An extensive body of academic research has provided evidence of the key contributions of the Family Health Strategy to the reduction of almost 18 deaths per 1 000 birth in infant mortality rate observed between 1990 and 2019 in Brazil. The programme has also been associated with reduction in mortality and hospitalisations for chronic disease. Recent estimations also show that the implementation of the Family Health Strategy was associated with a reduction of 45% of the standardised hospitalisation rates per 10 000 inhabitants between 2001 and 2016, mostly for primary care conditions such as asthma, gastroenteritis, cardiovascular and cerebrovascular diseases. However, as some challenges are overcome, new ones approach, as Brazilian population ages, population risk factors such as obesity are on the rise, and emerging pandemic threats require resilience and adaptability.

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.

Primary health care (PHC) in Brazil has a well-organised approach, the result of sustained commitment to providing high-quality PHC for the entire population. Brazil has introduced a comprehensive package of policies designed to modernise and strengthen PHC. However, a number of key challenges remain, including the increasing prevalence of chronic non-communicable diseases, large disparities across regions in the supply and quality of PHC, and a low and unequal use of digital technologies. This chapter assesses Brazil’s PHC system. It considers four topics in detail: screening and prevention for major chronic non-communicable diseases, enhancing the quality of PHC provision, tackling workforce shortages and promoting the digital transformation of PHC in Brazil. It provides a set of recommendations on improving PHC in the country.

The expansion of PHC in Brazil has been remarkable, contributing to significant improvements in many measures of population health over the past decades. SUS prioritisation on PHC permitted to offer services free of charge to the Brazilian population, allowing an easier contact with the health system at the community level through the development of modern multi-disciplinary family health teams. But gains have not been equal across the country, with North and Northeast regions faring worse than South and Southeast regions in terms of health improvements and health outcomes. There has also been a rise in the number of elderly patients and an increasing prevalence of risk factors for health and chronic non-communicable diseases. Tackling these challenges call for more effective PHC, responsive to people’s changing needs, capable of offering preventive, continuous and co‑ordinated care.

In Brazil, chronic non-communicable diseases such as cancer, diabetes and hypertension are of high public health importance. Brazil has already built mechanisms in the PHC sector to screen for some of the most epidemiologically relevant diseases. Some cancers, hypertension and diabetes have screening and prevention strategies, but more could be done to improve depth and scope of such strategies. Key priorities are to move towards population-based screening programmes for breast and cervical cancer, with a personalised approach and more communication strategies. In the area of diabetes and hypertension, Brazil will need to 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. Last but not least, a more comprehensive information system based on registries, and allowing linking different data sources will also be important.

Looking to expand access to high quality PHC, Brazil has taken important steps to improve the distribution of doctors, develop new forms of service organisations, introduce new financing models, and implement a range of quality initiatives, well aligned with the experiences of OECD countries. However, the Brazilian PHC system is still characterised by a relatively low population coverage, large disparities in care quality, and a weak referral system. PHC has also traditionally provided few low-complexity procedures, and is not comprehensive enough to meet evolving patients’ needs. Tackling these challenges requires strengthening the gatekeeping system while expanding the range of services provided by family health teams. Efforts are also needed to ensure implementation of quality initiatives throughout the country. Greater guidance and support from the federal government will be necessary to help municipalities with low capacity.

Brazil is struggling with a shortage and an uneven distribution of medical doctors across regions, compounded with a low credibility and recognition of the PHC specialty. To secure a greater number and distribution of primary care doctors and ensure a high-quality workforce, the first priority for Brazil is to implement a coherent workforce planning based on an objective assessment of present and future needs to govern health care human resources. In tandem, Brazil could look at the experiences of OECD countries to train more rural doctors and to provide both financial and non-financial incentives linked with a return of service obligation. A smarter use of nurses and community health workers is another option to cope with workforce gap. There are also opportunities to make the PHC specialty a mandatory requirement to be allowed to practise PHC, and to implement stronger requirements around continuous medical education.

Brazil has made strides towards a digital transformation of PHC, 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. The COVID‑19 pandemic has only provided further impetus. Yet, progress towards effective use of digital PHC has been slow, and fundamentally unequal, with significant inequalities in the use of digital technologies and tools among health workers and citizens. 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: 1) digitalising all PHC units and teams; 2) promoting inclusive connectivity for all Brazilian citizens, especially the most vulnerable; and 3) establishing a governance structure with clear well-funded mandates at the right levels of government.