El impacto de la Estrategia de Salud de la Familia de Brasil en Angola, Bélgica, Sudáfrica y el Reino Unido

Macinko, James; Harris, Matthew; Giugliani, Camila; Minton, Cornelia Junghans; Masquillier, Caroline; Wet, Katinka de; Wouters, Edwin

doi:10.1590/1413-812320253012.05942025

THEMATIC ARTICLE • Ciênc. saúde coletiva 30 (12) • Dic 2025 • https://doi.org/10.1590/1413-812320253012.05942025 linkcopiar

El impacto de la Estrategia de Salud de la Familia de Brasil en Angola, Bélgica, Sudáfrica y el Reino Unido

Autoría SCIMAGO INSTITUTIONS RANKINGS

El objetivo de este estudio fue evaluar el impacto internacional de la Estrategia de Salud Familiar (ESF) de Brasil mediante estudios de caso centrados en cuatro países que adoptaron elementos de la ESF para mejorar aspectos de sus propios sistemas de salud. Se solicitaron casos de Angola, Bélgica, Sudáfrica y el Reino Unido, y se analizaron mediante una metodología comparativa de estudios de caso. Los resultados muestran que cada país adoptó aspectos ligeramente diferentes de la ESF, con un elemento común: el rol de los agentes de salud comunitarios (PSC) como medio para extender la atención a la comunidad y, en el caso de Angola y Sudáfrica, para complementar la escasez de profesionales de la salud. En cada pais, investigadores estaban familiarizados con la ESF a través de literatura, contactos personales, experiencia directa u observación, y colaboraciones. Si bien cada caso presenta un nivel de madurez diferente, con los equipos angoleño y sudafricano en una etapa más avanzada, todos enfrentaron desafíos comunes en la adaptación e implementación de elementos del ESF, incluyendo la falta de categorías laborales formales para los trabajadores de salud comunitarios, la tensión entre las funciones más restringidas y las más integrales de los trabajadores de salud comunitarios, las dificultades para reclutar e integrar a los trabajadores de salud comunitarios en los equipos de atención médica, y las barreras para ampliar las iniciativas y lograr resultados a gran escala.

Palabras clave:
Atención Primaria de Salud; Estrategia de Salud Familiar; Estudio de caso comparativo; Difusión de la innovación

	Brazil	UK	Belgium	South Africa	Angola
Population (millions)	211.1	68.3	11.8	63.2	36.8
Geographic size (km²)	8,515,767	243,610	30,689	1,221,037	1,246,700
Population density per km²	25	287	383	53	31
GDP/capita, $US (purchasing power parity adjusted)	10,295	49,464	54,701	6,022	2,308
Health spending per capita (CHE), $US	849	5367	5405	570	101
GDP spent on health, %	9	11	11	9	3
Government spending on CHE, %	45	83	75	62	52
% of CHE on PHC	n/a	38	36	57	n/a
UHC service coverage index (0-100)	80	88	86	71	37
Healthcare access and quality index (0-100)	53.0	83.3	86.6	44.6	29.3
Doctors per capita	27	35.1	32.7	8.3	4.6
Life expectancy at birth	73	82	82	61	62
IMR/1,000 live births	13	4	3	28	46
Hypertension, % adults	45	26.4	30	44.1	38.7

	Angola	Belgium	South Africa	UK
Objective	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.	To design, implement and evaluate how 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.	Ward-based Primary Health Care Outreach Team (WBPHCOT) ensures more equitable health outcomes, including maternal and child mortality, HIV/AIDS, TB and other communicable diseases, and to strengthen the overall health system.	Existing community roles unable to ensure continuity of care at the household level. Provides 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.
Population covered	The estimated coverage is 412,700 families/households across the country.	46 CHWs in 10 cities registered a total of 8313 people and provided 14,574 interventions.	46,672 Community Health Workers visited 17.9 million households in 2023/4.	170 CHWWs are in 15 sites that cover approximately 21,000 households or about 50,000 people in total.
Initiative stage (pilot, trial, other)	Beginning in Luanda in 2007, the CHW role (ADECOS) expanded to other provinces. In 2014, the Angolan government launched the National ADECOS Program, funded by the Government and external aid. Currently there are 4,127 ADECOS moving towards a consolidated national strategy.	Currently a cluster-randomized controlled trial implemented in 18 general practitioner (GP) practices in Antwerp. Compared to usual care (control), 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.	Since the adoption of the program in 2011, a first “National skills audit of Community Health Workers (CHWs) and Outreach Team Leaders (OTLs) employed by the NdoH” 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	Over 27 localities across England have, or are in process of implementing, CHWWs in varying numbers. Some sites successfully maintaining, others have been unable to secure continued funding. Overall national picture is of growth in number of CHWWs and awareness of the initiative.
Specific inter vention(s)	ADECOS began with specific focus on MCH, vector-borne diseases, water treatment, and oral rehydration. Recently, ADECOS given formal status, paid close to full time, with more comprehensive health and social care remit, including community development and social protection.	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	The team composition of WBPHCOTs was approved as six to ten community CHWs, one data capturer, and one Outreach Team Leader (usually a nurse).	Lay community members 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.
How did FHS inspire it?	Spearheaded by UNICEF Angola, consultation with experts in Ceará, and inspired by evidence of impact and recognition in international literature. Technical visits by Luanda-based health officials and academic cooperation and partnerships with Brazil.	During co-creation sessions with people living in socio-economically vulnerable circumstances and GPs in Belgium, we adapted the lessons we learned on FHS and Re-engineering PHC from the fieldwork in South Africa and field visits from Brazil to the Belgian context.	This approach came to fruition after a 2010 visit to Brazil by the then Minister of Health, Dr Aaron Motsoaledi and the provincial MECs for health.	In-depth personal experience of the FHS over many years. Studies of national impact in Brazil were very influential. Established MoUs with FIOCRUZ and visits to local health centers in Brazil amplified the campaign.
Successes	Initial evaluation indicated increased access to care and demand for health services, especially for mothers and children. The pilot has expanded geographically, in the CHW’s responsibilities, and now includes additional population groups.	A solid co-creation process with all stakeholders ensured suitability and feasibility and collaboration; early evidence suggests CHWs are empowering and making a positive change during patients’ initial visits. Established an international network to facilitate global learning.	Detailed and intensive CHW training followed by 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.	Strong social franchise approach has taken to scale the CHWW role across many localities, with well codified guidance around the CHWW role. Research infrastructure has permitted flexibility to support rollout without specific research funding available.
Challenges	CHWs were not supported by a solid health system; health centers were fragile in structure; there was 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.	GP practice recruitment was challenging, unable to recruit CHWs from the communities surrounding the GP practices. This is a four-year research project so funding is temporary	CHW numbers vary across districts and by supervisor posing problems to productivity, supervision and mentoring. Lack of effective referrals and reporting. WBPHCOTs often function under difficult and dangerous working conditions.	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.

Characteristics	Angola	Belgium	South Africa	UK
Comprehensive Do CHWs support their assigned (note how they are assigned) patients continuously throughout their lives? Are the services they provide comprehensive or more limited? If more limited, what areas do they concentrate on?	Initially, CHWs had a more limited focus on MCH but 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.	In the COMPASS study, CHW models from Brazil and South Africa were adapted to the Belgian context through a co-creation process. Through monthly home visits or contact moments, CHWs build trust with individual clients, gain insight into their health situations, health goals, and barriers. CHWs address these barriers, enabling individuals to gain more control over their health in the long term.	While CHWs are supposed to provide community outreach services, preventive, promotive, curative, rehabilitative and palliative services, this role has evolved from vertical and disease specific (especially HIV and TB) activities and a more comprehensive approach can be challenging to achieve.	CHWs cover all aspects of health and social care across the life course, without restriction or targeting. This includes health promotion, signposting to services, supporting behavior change, early identification of illness, and promoting uptake of preventive services. Their role integrates health and social care issues and takes a whole-household approach.
Hyperlocal Do CHWs have a strong and enduring connection to the community they serve? Are they recruited from the same community? Do they live within easy reach of the households they are responsible for? Are they paid for the work? Is it full or part time work?	CHWs are recruited locally, live in the same community (micro-area) where they work, speak the local language (besides Portuguese), have good relationships community, as well as with traditional leaders, health workers, and local managers. They are paid to work 32 hours per week, but it is common that CHWs have other jobs to increase their income.	CHWs are employed at 80% of the time and receive a salary. CHWs were selected based on familiarity with vulnerable neighborhoods in the Antwerp metropolitan area, proficiency in local languages, strong communication skills (managing difficult or emotional conversations, handling sensitive information confidentially), and an understanding of local healthcare challenges.	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.	CHWs are recruited locally, however, some CHWs live up to 30 mins travel to the neighborhood they work in. CHWs 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 CHWs to reach all their households and create an enduring relationship with them.
Universal About how many people/families do CHWs look after? How is the population served defined (patient list, geography, other?) Where do visits take place (home, clinic, both, other locations?) How often do CHWs make visits/have contact with patients?	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.	Each CHW is linked to two GP practices and supports a total of 42 clients once a month. GP teams identify patients in need of additional support. Whenever possible, the CHW will meet clients in their home or an alternative location, such as the GP practice. During each intervention visit, clients are encouraged to invite and, where possible, bring other household members to the next visit.	Each WBPHCOT has around 6-10 CHWs and is responsible for approximately 6,000 individuals (1000 households), although this may vary based on rurality. Regular feedback on the district health information system tracks team activity. CHWs sometimes perform facility-based activities and those on chronic medication are often assisted by CHWs, who deliver prescriptions.	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 covered by those practices. Visits mostly take place in the home. Although the mandate is universal, the achievement of this has been gradual and over time.
Integrated Are CHWs an official member of an integrated health team? Is that team involved in primary care only or does it involve other sectors? How well are CHWs able to effectively support the resolution of residents’ problems or needs?	CHWs are not officially integrated into a health team, but they make connections between families’ needs and the local primary care unit which requires good relationships with health workers. Every CHW has a supervisor, who is sometimes a member of the local health team. Lack of resources and health system weaknesses limit CHWs’ impact.	The CHWs are each linked to two GP practices. They are integrated parts of the team, cooperating with other care professionals in the practice and taking part in multi-disciplinary team meetings. We are adopting a learning-by-doing approach to enhance communication, information sharing, and collaboration between CHWs, the GPs and their teams. The RCT is ongoing.	WBPHCOT offer integrated services to households and individuals within their catchment area. More experienced CHWs refer patients to both health and non-health related sectors. WBPHCOTs work with the PHC facility and with non-health services, but there is variability in the level of integration.	CHWWs 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 has been achieved only in some localities. CHWWs are recruited based on their motivation to be problem-solvers for all families, and they generally achieve this well.

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[TFN1] Source: GBD 2019³⁹^,⁵⁰, Global Health Observatory⁵¹.