Artigos

INTRODUCTION
Brazil’s Family Health Strategy has origins in community-based primary health care dating to, at least, the early 1970s.1,2 Originally piloted as a program employing Community Health Agents (known as Programa Agentes Comunitários de Saúde or PACS in Portuguese), its focus was initially addressing persistently high maternal and child mortality and morbidity in the Northeastern state of Ceará.3-5 In order to enhance the ability of this model of care to resolve a greater number of even more complex health problems, it began to encompass integrated health teams with a physician and nurse along with the community health agents and was given the name the Family Health Program (FHP) in the 1990s.6
The model continued to develop and incorporated theories regarding the nature and functions of PHC when in 2002, the National School of Public Health translated Barbara Starfield’s book Primary Care: Balancing Health Needs, Services, and Technology7 into Portuguese and distributed copies to all health teams in the country. Researchers also adapted and applied Starfield’s Primary Care Assessment Tools (PCAT) in monitoring and evaluation efforts.8-10 To facilitate their use, the adult PCAT tools were translated and published by the Brazilian Ministry of Health in 201011 and a short version of the tool was incorporated into the 2015 Vigitel telephone-based surveillance survey12 and 2019 National Health Survey.13,14
After subsequent refinements, establishment of payment and incentive mechanisms, and rapid scaling up, the FHP became seen as the main primary health care model for municipal health services in much of the country.3 In recognition of its key role as a highly effective primary health care approach, the Family Health Program was renamed the Family Health Strategy (FHS) in 2006 to reflect the fact that it was no longer a special program, but a fundamental strategy that placed PHC at the heart of the Brazilian Unified Health System (SUS) which had been enshrined in the 1988 constitution as a duty of the government to provide universal healthcare to all its citizens.6 The essential characteristics and functions of the FHS were formalized that same year through the country’s first National Primary Care Policy (PNAB).15
The establishment, impact, and scaling up the FHS is a remarkable success story in global health. Over the past thirty years, it has grown to include 52,000 teams covering over 70% of the population. An important element supporting this process has been the generation of strong evidence that the FHS was effective in improving access,16 health outcomes, 17-23 equity24-26, and reducing the need for some hospitalizations.27-29 While there is still room for continued improvement and expansion into some areas, in particular wealthier urban centers and remote parts of the Amazon, the FHS has been shown to be a robust, resilient, effective, and equitable approach to providing primary health care to the diverse realities across Brazil.30
Important to the spread of this innovation was literature describing and evaluating the impact of the FHS, not just for Brazil, but also for international audiences. This work served to disseminate important details regarding the technical and organizational aspects of the FHS with health professionals, researchers and political decision-makers in different parts of the world.31-33 Most notably, the FHS has been highlighted as an important case study in highly influential reports from international organizations. These include the 2008 World Health Report on primary health care,34 an influential case study published by the Commonwealth Fund in 2016,35 materials for the Astana meeting on renewing Primary Health Care in 2018,36 and the 2024 WHO primer on Primary Health Care, among others.37 Numerous international conferences as well as collaborative agreements between the Brazilian government, Brazilian universities and several other countries provided additional opportunities for knowledge of the FHS to spread to other countries and contexts.
This article analyses the influence that the FHS has had in strengthening primary health care policy internationally, through case examples of ongoing primary health care initiatives in Angola, Belgium South Africa, and the United Kingdom.

METHODS
This article is based on a comparative case study approach using best practice observation methods.38 This review identified four diverse countries where the FHS has inspired pilot projects or larger-scale initiatives. Given the lack of published evaluative data on these emerging projects, part of the rigor of this approach stems from being able to solicit information about the cases from experts with extensive knowledge of each case.
The process for identifying case studies stemmed primarily from networks of existing collaborators who had been instrumental in sharing knowledge and experience from the FHS to other contexts. Case studies were developed collaboratively by identifying key elements to guide the writing of the cases. Because expert knowledge is essential to the production of accurate case reports, we briefly describe the qualifying characteristics of each case study author below.
For the Angolan case study, X (name redacted for peer review) qualifications include being a Brazilian physician, specialist in Family and Community Medicine, PhD in Epidemiology and professor at the Federal University of Rio Grande do Sul (UFRGS). She led the project “Developing Primary Health Care in Angola: A proposal for the assessment of the Community Health Workers Program” and worked as a medical coordinator with Médecins du Monde in Angola.
For the Belgian case study, Y (name redacted) and Z (name redacted) have conducted research in South Africa on Community Health Workers (CHWs) providing support for people living with HIV for over a decade. As a health system researcher, Y has extensive experience in developing testing and evaluating health system innovations with a particular focus on access to quality care. Z produced a documentary on the work of CHWs in South African townships and contributed to the development of the first Federal CHW program in Belgium and serves as the scientific expert on Belgium’s Steering Committee of the Federal CHW program.
Z (name redacted) is a South African Medical Sociologist working with lay health workers since the early 2000s. She has published on the evolution of this cadre of health workers, attended workshops in the early 2010s to map out the functions of these workers, and did a 2021-2023 study on CHWs in three districts in the Free State province, South Africa.
A (name redacted) is a British doctor who requalified in medicine through the University of Sao Paolo in 1999 and worked in a Family Health Strategy clinic in Camaragibe, in the northeastern state Pernambuco for four years, completing a specialization in primary care through National School of Public Health, Recife, Brazil. He was the former lead for the Brazil-UK Ministerial technical cooperation (2010-2012) and now leads the national scaling of the Community Health and Wellbeing Worker (CHWW) initiative in the UK in partnership with the National Association of Primary Care. B (name redacted) is a practicing GP in the UK and is the CHWW clinical lead in Westminster and a Public Health specialist with the local authority. With MH, she leads the national scaling of the CHWW initiative in the UK through the National Association of Primary Care.
C (name redacted) is a health service researcher who has written extensively about Brazil’s health system and the FHS for the past 20 years.
RESULTS
Table 1 shows characteristics of each country included in the study (see figure 1 in the appendix for a map showing the geographic location of each country). The country cases vary on nearly every dimension. Brazil is the largest in population and land mass and while South Africa and the UK have similar-sized populations, the former has a population density nearly 5 times greater than the latter. In the richest countries (Belgium and UK), health spending (in purchasing power parity-adjusted dollars) is about US$5400 per capita while in Brazil and South Africa it is about one tenth of this amount and in Angola it is less than 2% of that in the richest countries. Healthcare spending as a proportion of GDP is between 9 and 11% for all countries but Angola (3%), while the government share of this spending varies from a high of 83% in the UK to the lowest of only 45% in Brazil. Despite these differences, Brazil has a universal healthcare coverage index of 80/100, which is close to that of the other countries, with the exception of Angola (37). Health resources also differ considerably, with the UK having the most doctors per capita (35.1/10,000), similar to Belgium, nearly three times the number in Brazil, four times the number in South Africa and 7.5 times the number in Angola.39 Health outcomes also vary from life expectancy at birth in the low 80s in UK and Belgium, low 70s in Brazil, and low 60s in South Africa and Angola.
Table 1 here
The full case studies are presented in the appendix. A brief summary of each case follows. Spearheaded by UNICEF Angola, and in consultation with experts in Ceará Brazil, where the origins of the Family Health Strategy can be traced, Angola’s effort to translate the Brazilian Community Health Worker (like the PACS program) role was inspired by evidence of impact and recognition in the international literature. Technical visits by Luandan health officials and academic cooperation and partnerships were pivotal to this effort. The goal was to accelerate the reduction of maternal and child mortality through decentralized and accessible interventions, reinforcing the expansion and upgrade of primary health care (PHC) as a fundamental feature.
Beginning in Luanda in 2007, the CHW role (called ADECOS) expanded rapidly to other provinces. This role is closer to that of the PACS model in Brazil because the CHWs are not part of a larger interdisciplinary team, as in the FHS model. In 2014, the Angolan government launched the National ADECOS Program. The pilot program (from 2007-2009) provided training for 2,548 CHWs, covering 261,357 families. Currently there are 4,127 ADECOS and the program is moving towards a consolidated national strategy. ADECOS began with specific focus on MCH, vector-borne diseases, water treatment, and oral rehydration. More recently, ADECOS have been given formal status, paid close to full time, with a more comprehensive health and social care remit, including community development and social protection. Initial evaluation has indicated increased access to care and demand for health services, especially for mothers and children. The pilot has expanded geographically, as well as in terms of the CHW’s responsibilities, and now includes additional population groups.
The implementation of a CHW program in Belgium started during the COVID-19 pandemic – which demonstrated CHW’s potential in ensuring access to necessary care for people living in vulnerable contexts.40 Inspired by these examples of CHW programs abroad, the Belgian Federal Government gave the National Institute for Sickness and Disability Insurance and the National InterMutualist College the task to develop the first nationwide Belgian CHW program to improve access to care: employing 50 CHWs in socio-economically vulnerable neighborhoods in ten Belgian cities.41 However, to date, the Belgian federal CHW program is not structurally linked to the broader health system, while a lack of integration and synchronization between CHW programs and local health systems has been found to create fragmented service delivery and to restrict the effectiveness of CHW programs. 42-44
In response to this need, the Community Health Workers for Primary Healthcare Access (COMPASS) project aims to design, implement and evaluate in what way CHWs can be linked to the primary health care system to improve access to care for people living in socio-economically vulnerable groups in Belgium. This initiative is heavily inspired by the Brazilian FHS (and the South African Re-Engineering PHC program,45 itself inspired by the Brazilian FHS): expert consultations and field visits in Brazil, including informal conversations with policymakers and health professionals at three PHC clinics in Rio de Janeiro and four PHC clinics in Brasília helped to deepen understanding of the mechanisms and contextual factors influencing the CHW role, with the goal of informing their adaptation to the Belgian context. Several co-creation sessions with people living in socio-economically vulnerable circumstances and GPs in Belgium helped to adapt the lessons learned on FHS to the Belgian context. The current approach is through a four-year cluster-randomized controlled trial implemented in 18 general practitioner (GP) practices in Antwerp, evaluating how CHWs can be linked to the primary health care system to improve access to care for people living in socio-economically vulnerable conditions. Compared to usual care, the intervention involves CHWs linked to GP practices that offer a comprehensive package of support to persons living in socio-economically vulnerable circumstances during home visits. Lay members of the community who provide culturally-sensitive support, through trusted relationships and community connection, motivate patients to seek and access healthcare, and to help them navigate the PHC system. Early evidence suggests CHWs are empowering and making a positive change during patients' initial visits. An international network has facilitated global learning however GP practice recruitment was challenging.
The South African initiative to adopt and adapt the Brazilian CHW role began in 2010 after a visit to Brazil by the then Minister of Health, Dr Aaron Motsoaledi and the provincial Members of the Executive Council (MECs) for health. Initially, the proposition was for Ward-based Primary Health Care Outreach Teams (WBPHCOT) composed of 6-10 CHWs covering around 6000 households to ensure more equitable health outcomes, particularly around maternal and child mortality, HIV/AIDS, TB and other communicable diseases, and to strengthen the overall health system. Since the adoption of the program in 2011, a first National skills audit of Community Health Workers (CHWs) and Outreach Team Leaders (OTLs) took place in 2023. In this audit, the number of CHWs stood at 42 323 CHWs and 2 234 OTLs in eight of South Africa’s nine provinces. As in Brazil, CHWs receive detailed and intensive training, but in South Africa they receive an Occupational Health Promotion certificate. The establishment of the National Union of Care Workers of South Africa in 2016 has given the cadre job security and recognition.
Adoption of the Brazilian CHW role in the UK (called Community Health and Wellbeing Workers, CHWWs) has developed slowly over a twenty-year period, beginning with in-depth personal experiences of the FHS over many years. Despite a series of unsuccessful attempts to pilot the Community Health Worker role or gain policy traction, multiple research and advocacy publications were produced during 2010 and 2020, and it was the COVID-19 pandemic that lent renewed emphasis on the opportunity to focus on community-centered initiatives. Studies of national impact in Brazil were very influential along with continued advocacy by key local champions in the UK. Pilot programs have emerged in several localities since 2021. A bidirectional partnership with FIOCRUZ emerged in 2023 further strengthening the campaign. CHWWs fill a much-needed gap around ensuring continuity of care at the household level and provide a preferred point of contact for residents’ needs to enable conversations around their care and proactively identify problems, in order to reduce need for formal services. Over 27 localities across England have, or are in process of implementing, CHWWs in varying numbers with the largest sites in Cornwall and Westminster, in London. Some sites are successfully maintaining, others have been unable to secure continued funding. Overall, the national picture is of growth in number of CHWWs and awareness of the initiative, including visibility and recognition in several key national policy reports.46,47 Lay community members are recruited and paid to work full-time in small geographies of 100-150 households, integrated into primary care and wider social care system, with a comprehensive remit to address any and all problems in all households in a given area. A strong social franchise approach, led by the National Association of Primary Care, has taken to scale the CHWW role across many localities, with well codified guidance around the CHWW role.48 However, there is no national policy or program yet supporting CHWWs.
Table 2 summarizes results from the four country cases studies. The table shows that each case has adapted only certain elements of the FHS to meet different needs. For example, the Angolan approach is meant to accelerate the reduction of maternal and child mortality, the Belgium initiative focuses on enhancing access to healthcare, South Africa’s has the overriding objective to reduce health inequities, and the UK focuses on more appropriate use of formal health services and uptake of preventive services. In each case, the main element adopted was that of the Community Health Worker, rather than the entire ESF team.
Table 2 here
The table also presents variations in how each case developed and expanded. The Angolan and South African approaches are both closer to the Brazilian model in the sense that these are initiatives at the national level that have been under development for over a decade. Belgium is perhaps the smallest in scale because it is still in the piloting stages, while the UK represents the stage of scaling up a successful pilot but is not yet a nationally-supported program.
While each case was inspired by the FHS and most teams had contact with Brazilian institutions, including field visits to different parts of the country, the specific elements of the FHS that have been adopted are also varied by each location, perhaps reflecting the differences in the overall objective of each initiative.
Challenges also vary across cases. In Angola, the main challenges have been that the CHWs are not well supported by a solid health system and health centers are fragile in structure. In addition, there has been no consistent health policy for including CHWs with sustainable financial resources. Late payments, lack of a formal contract, lack of support, low morale, lack of data all impede the potential impact the approach can have on improving population health. In Belgium some of the main challenges involved setting up and performing the study trial, such as an inability to recruit CHWs from the communities surrounding the participating GP practices. In South Africa, challenges include that CHW numbers vary across districts and by supervisor posing problems to productivity, supervision and mentoring. The system suffers from a lack of effective referrals and reporting and WBPHCOTs often function under difficult and dangerous working conditions. In the UK, the model faces challenges given the highly fragmented funding and delivery systems and varied political support makes the CHWW role, which cuts across health and social care, challenging to implement and expand.
Table 3 shows key features of the Family Health Strategy adopted by these four countries: mainly the CHW role. Brazil, uniquely, deploys CHWs across defined, small geographies of households, with a mandate to visit each household at least once per month, and more frequently according to need. Brazilian CHWs do not focus only on specific ages, or conditions, but have a broad health promotion, supportive role across any area of health and social care. They are principally problem-solvers with a strong and enduring connection to the community they work in, mostly resident in that community and paid full-time to fulfill their mandate. Integrated fully into the local primary care team, they can refer to the clinic and participate fully in day-to-day primary care activities. These features have been synthesized by Younan et al49 as being Comprehensive, Hyperlocal, Universal and Integrated. The presence of all four features is critical to the CHW role in Brazil.
Table 3 here
In Angola, CHWs had only a limited focus on MCH but this has since expanded in scope and tasks. ADECOS cover all ages, and have an increasingly important social role, such as supporting community development, mobilizing local leaders, and making the connections between the identified needs and the health and social services available, including cash transfer programs. CHWs are recruited locally, live in the same community (micro-area) where they work, speak the local language (besides Portuguese), have good relationships with the community, as well as with traditional leaders, health workers, and local managers. They are paid to work 32 hours per week, but CHWs often have other jobs to supplement their income. CHWs are responsible for a micro-area with approximately 100 households each, geographically defined, after mapping of the territory. The CHWs visits take place in the home. Every household must be visited at least monthly (routine follow-up visit). More frequent visits should take place as special needs are identified. CHWs are not officially integrated in a health team, but they are meant to make the connections between the families’ needs and the local primary care unit which requires good relationships with the health workers. Each CHW has a supervisor, who sometimes is an official member of the local health team (e.g. as a nurse assistant). Lack of resources e.g. not having a mosquito net or a water treatment pill to deliver, remain significant challenges. The functioning of the wider health care system remains precarious and limits CHW effectiveness.
In Belgium, the intervention arm of the COMPASS cluster-Randomized Controlled Trial (RCT), people living in socio-economically vulnerable circumstances receive comprehensive health-related support from a CHW across the life course, without any specific restriction or targeting by age, clinical condition or ethnicity over the course of twelve months. Through monthly home visits or contact moments, CHWs build trust with their individual clients, gain insight into their health situations, personal health goals, and the barriers they face in achieving these goals. In addition, attention is paid to prevention activities. The CHWs aim to address these barriers, thereby enabling individuals to gain more control over their health in the long term. The CHWs are employed at 80% Full-Time Equivalent (FTE) and receive a salary and were selected based on familiarity with vulnerable neighborhoods in the Antwerp metropolitan area, proficiency in local languages, strong communication skills, and an understanding of the healthcare challenges faced by individuals (gained through interest and/or personal experience). Some CHWs do not reside within close proximity to the households they are assigned to serve. Unlike in Brazil, each CHW is linked to two GP practices furthermore the number of residents supported is smaller than in Brazil (approximately 100 residents each). As this is a research study, the participants need to provide consent to be included in the study.
South African CHWs are supposed to provide community outreach services, preventive, promotive, curative, rehabilitative and palliative services, however, the role has evolved from vertical and disease specific (especially focused on HIV and TB) activities and a more comprehensive approach can be challenging to achieve with little evidence of the frequency/ distribution of this specific service rendered. CHWs are recruited from their communities and visit residents within walking distance from the facility. CHWs are paid a monthly stipend, which varies according to province and clinic, and has been precarious particularly during annual contract renewal. CHWs are expected to work half a day each day but often end up working longer hours, to accommodate for long distances between households. Each WBPHCOT has around 6-10 CHWs and is responsible for approximately 6 000 individuals or 1000 households, although this can vary based on rurality. Regular feedback on the district health information system (DHIS) ensures a level of monitoring to track team activity. CHWs sometimes get tasked with facility-based activities but regular contact is made with patients, and those on chronic medication are often assisted by CHWs, who deliver their prescriptions. WBPHCOT offer integrated services to households and individuals within their catchment area, the unit being the district health system (DHS) where primary health care is implemented. More experienced CHWs refer patients to a variety of health and non-health related sectors (e.g. to access government grants, a social worker, to apply for IDs, birth or death certificates, etc.). WBPHCOTs work with the primary health care facility (clinic manager, professional nurses, pharmacist, etc.), and with non-health services (social development, Home Affairs, etc.) but there is tremendous variability with regards to degree of integration.
In the UK, CHWWs cover all aspects of health and social care across the life course, without any specific restriction or targeting. This includes health promotion, signposting to services, supporting behavior change, early identification of illness, and promoting uptake of preventative services of any kind. The role is fully comprehensive integrating health and social care issues and taking a whole-household approach. Some additional tasks, e.g. blood pressure monitoring, are being included in some areas. CHWWs are recruited locally, however, some CHWWs live up to 30 mins travel to the neighborhood they work in, particularly in the rural areas such as Cornwall. CHWWs are paid, and generally fulltime, but some areas have created job-share solutions. In London, it can take 11 door knocks to engage with the resident and it takes around one year for CHWWs to reach all their households and create an enduring relationship with them. However, similar to Brazil, CHWWs are allocated to neighborhoods of between 100-150 households each and this is geographically defined. In urban areas, CHWWs work within networks of GP practices that cover wider geographies, but only visit residents registered to those practices. Visits mostly take place in the home. Although the mandate is universal, the achievement of this has been gradual and over time. CHWWs are integrated into primary care, like in Brazil, and are an official member of the primary care teams, have NHS emails and ID cards, and can enter information into the electronic patient record, but this is not uniformly implemented and has been achieved only in some localities. CHWWs are recruited based on their motivation to be problem-solvers for all families, and irrespective of the level of integration into the wider system, they achieve this well.

DISCUSSION
This article identified four different case studies of elements from the Brazilian FHS being adapted to very different healthcare contexts to enhance essential PHC needs. Some key insights can be drawn from this comparative case study approach. In each of these cases, countries adopted only one aspect of the FHS, the Community Health Worker approach. In Belgium and the UK, the CHWs fill a gap in an otherwise well-defined primary care team. In the cases of South Africa and Angola, this decision may have been informed by the lack of other qualified health professionals. The translation of the FHS into these international contexts was driven by personal experience, networks and interministerial collaboration. Local and national champions drive the adoption in the early stages and this can take many years before traction through piloting and then scaling takes place. Reciprocal partnerships have played an important part in many of these trajectories. Each context has had to overcome several challenges, many of which are typical for health service transformation. For example, the system level changes required to incorporate such a far-reaching role are often after-thoughts and under-funded. It can take many months, sometimes even longer, after recruiting a CHW for them to deliver their responsibilities as planned. It can take time for the necessary culture shift from a reactive system to a proactive system based on relationship-building and home visits. As a result, despite best efforts, there can be significant local level variation in the way CHWs are deployed. Creating a national program eventually helps to systematize the role and embed it within the wider health and social care system – something that was very effectively delivered in the early 2000s in Brazil. The role of CHWs as a bedrock of primary care is not yet fully established in these settings in the same way as it has become in Brazil. It is sometimes viewed as a stepping stone into ‘higher’ roles rather than a uniquely important role, requiring uniquely important skills, within primary care.
There are many other lessons that can be drawn from Brazil’s successful scaling of the CHW role throughout the country. The creation of an effective research agenda and extensive data infrastructure are needed to underpin the evidence and support for scaling. A universal national health service with financial participation of federal, state, and municipal contributions along with financial incentives (such as the fixed and variable per capita payment systems) played an enormous role in helping Brazilian municipalities adopt the FHS approach to primary care. While the UK (national health service) and Belgium (national health insurance) have somewhat different approaches to healthcare financing, each country provides universal coverage with a strong primary care focus. South Africa and Angola, however, are still in the process of developing their national health systems. Despite their differences, in each case study there remains a need to define how community health workers can be sustainably financed, not as a stand-alone program, but as a valued part of a multidisciplinary healthcare team and an integral part of the health system. Incentives and administrative support to expand and integrate CHWs should be considered in national arenas in these four countries.
Constructing a common language, as was achieved through Starfield’s work identifying key themes and objectives of primary care and the use of appropriate evaluation instruments, such as the Brazilian adaptation of the Primary Care Assessment Tools, are important to documenting progress and communicating accomplishments as well as challenges. Each case study country will need to build on progress to inform new policy narratives around proactive, relational and community-based care that moves away from a reliance on reactive and transactional medical models. At the same time, flexibility is required so that national programs do not overly bureaucratize or administer the CHW role. In this regard, caution must be taken not to generate data that will not or cannot be used, or to restrict CHW activity through overly burdensome training or credentialling. This is admittedly a difficult balance to achieve.
Ultimately, the deployment of community health workers as comprehensive, hyperlocal, universal and integrated functions, as defined in the SUS, requires a far-reaching transformation of the system in these contexts, moving from vertically oriented, transactional and reactive systems to a system of relational, community-oriented and person-centered healthcare. Based on experiences in Brazil, such a transformation has the power to enhance health outcomes and health equity in each of the case study countries.
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