The Forum

How Brazil's community health agents became 'the most successful example of primary care reform in the world'

by Paul Trigonoplos and Vidal Seegobin

Editor's note: This story was updated on July 11, 2019.

Brazil's health care problems in the 1990s mirror the challenges that most industrialised countries are facing today. As Brazil's population boomed, hospitals did too, pushing aside traditional providers of primary care and leaving the acute sector to tend to basic health needs, often at too high a cost. As a result, millions of citizens—especially those in poor, urban settings—struggled to access the basic and preventive care that primary care provides.

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Brazil's federal government realised this was unsustainable, both from a cost and patient demand perspective, and intervened. In 1994, the government created its Family Health Strategy (FHS), a grassroots approach to integrated community care for underserved citizens.

Community health agents—what makes the Family Health Strategy work

The model works by assigning a health team to a geographically defined population of 1,000 households. Each team includes three clinicians: a doctor, a nurse, and a nurse assistant. Each FHS team member has defined roles and responsibilities, and national guidelines help structure FHS responses to most routine health issues.

But the FHS teams have one other critical non-clinical ingredient: community health agents. Each FHS team has four to six full-time community health agents, who serve as the team's eyes and ears.

They are trusted residents of their community, elected to be health agents in a democratic process at the community level. While each full team is assigned to approximately 1,000 households, each community health agent is assigned to only 150. These 150 households are part of a geographic 'micro-area' within the health team's larger geography.

Community health agents visit each household in their micro-area at least once a month. At these visits, they perform a wide range of responsibilities, such as reminding patients about appointments, collecting patient data, and flagging symptoms of patient deterioration. Several studies have demonstrated that the Family Health Strategy is associated with improved outcomes for its residents.

The Family Health Strategy's domestic and international growth

Since its inception in 1994, the model has expanded greatly. As of 2014, Brazil had 39,000 FHS teams with 250,000 community health agents serving 120 million people, or about 62% of the country's population.

It's been a winning combination of low-intensity monitoring executed by trained community staff. The model has contributed to increasing the country's immunisation rates, decreasing infant mortality, and reducing the number of hospitalisations because patients receive more frequent low-intensity care closer to home.

It's been so successful that other countries are experimenting with importing the model. A Welsh study in 2013 went so far as to call the Family Health Strategy "the most successful example of primary care reform in the world." Other international health systems looking to improve care access and quality can learn a key takeaway from Brazil's experience: low-intensity community care executed by trained community staff can be a highly effective and scalable way to reach underserved populations.


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