Thirty years of the Family Health Strategy in the Brazilian Unified National Health System: milestones, advances, setbacks and challenges

Giovanella, Ligia; Mendonça, Maria Helena Magalhães de; Campos, Estela Márcia Saraiva; Vilasbôas, Ana Luiza Queiroz; Aquino, Rosana; Facchini, Luiz Augusto

doi:10.1590/0102-311XEN206025

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DEBATE • Cad. Saúde Pública 42 • 2026 • https://doi.org/10.1590/0102-311XEN206025 linkcopy

Thirty years of the Family Health Strategy in the Brazilian Unified National Health System: milestones, advances, setbacks and challenges

30 años de la Estrategia de Salud Familiar en el Sistema Único de Salud brasileño: hitos, avances, retrocesos y retos

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

This essay examines the trajectory and persistent challenges faced by Brazil’s Family Health Strategy (FHS), stemming from concerns regarding the prospects for the full implementation this territory-based community-oriented approach to the delivery of primary health care within the Brazilian Unified National Health System. We look at the development of the strategy and provide a critical overview of the main institutional milestones over the last 30 years, focusing on the following: federal funding associated with the process of the municipalization of care; the expansion of multidisciplinarity in the work of health professionals in basic health units (BHU) and the local community; improvements in quality associated with the evaluation of team structure and work processes and performance-based funding; and emergency medical staffing in underserved areas and professional training. We outline how the expansion of FHS coverage and the adoption of practices centered on individuals, families and communities has impacted population health and access to care. Setbacks between 2016 and 2022 are critically addressed, including the undermining of the multidisciplinary community-based approach and threats to universality and comprehensiveness. We then go on to discuss the reprioritization of the FHS by the Federal Government in 2023. Data from the 2024 national BHU Census are used to illustrate the current status of the FHS. Challenges to implementing effective change in the care model and achieving universal FHS coverage include the following: ensuring adequate funding, employment stability, professional training and interprofessional collaboration; addressing the risks of commodification in primary health care (PHC); improving coordination of care and the strengthening the role of PHC in patient access management; and reducing geographical, social and racial inequalities in access to care.

Keywords:
Family Health Strategy; Primary Health Care; Unified Health System

Year	FHT (n)	PHCT (n)	Estimated population coverage by the FHS teams (%)	PHC population coverage (%)	OHT (n)	Estimated population coverage by OHT linked to FHT (%)	Estimated population coverage by oral health in PHC (%)	NASF (n)	CHW (n)
1998	3,062	-	6.6	-	0	-	-	0	-
1999	4,114	-	8.8	-	0	-	-	0	-
2000	8,503	-	17.6	-	0	-	-	0	-
2001	13,155	-	25.6	-	2,248	-	-	0	-
2002	16,698	-	32.1	-	4,261	-	-	0	-
2003	19,068	-	35.7	-	6,170	-	-	0	-
2004	21,232	-	39.9	-	8,951	-	-	0	-
2005	24,564	-	42.8	-	12,603	-	-	0	-
2006	26,729	-	46.2	-	15,086	-	-	0	-
2007	28,195	-	48.0	60.3	17,508	29.9	46.2	0	245,663
2008	29,769	-	51.0	64.3	19,280	33.3	49.5	0	257,578
2009	30,898	-	51.4	65.0	20,626	34.6	49.8	0	261,839
2010	32,243	-	53.0	66.2	21,999	36.5	50.8	1,317	270,775
2011	33,135	-	54.6	67.1	23,076	38.4	52.7	1,564	275,246
2012	33,899	-	55.5	68.3	23,586	38.9	53.0	1,929	283,404
2013	35,567	-	57.5	70.6	24,131	39.4	52.9	2,767	284,136
2014	39,426	-	61.1	73.1	25,327	39.8	52.5	3,898	288,335
2015	40,765	-	62.5	73.7	25,891	40.3	52.1	4,288	285,736
2016	41,061	-	62.6	74.1	25,827	39.9	51.7	4,406	286,556
2017	42,513	-	63.9	74.6	27,082	41.2	51.9	4,886	284,867
2018	43,016	-	64.2	74.6	28,050	42.1	52.7	5,517	285,570
2019	43,755	-	64.5	74.8	28,991	43.1	53.0	5,487	284,196
2020	43,286	-	63.6	76.1	30,606	45.0	56.1	-	287,064
2021	47,501	3,869	-	69.5	29,816	46.1	56.6	-	288,771
2022	48,817	3,712	-	75.1	28,054	-	40.4	-	291,378
2023	51,369	5,708	-	79.7	31,035	-	44.8	-	295,406
2024	54,629	6,355	-	100.0	34,591	-	45.9	4,567 **	300,104

Variables	Brazil (%)	North (%)	Northeast (%)	Southeast (%)	South (%)	Central-West (%)
BHU and teams
Number of BHU (n)	44,938	4,096	17,735	13,375	6,607	3,123
BHU in urban areas	67	55	52	82	79	84
BHU in rural areas or riverine	33	46	48	18	21	16
BHU facilities belonging to the Municipal Health Department	85	91	85	82	90	88
BHU with one FHT	67	54	79	59	61	67
BHU three or more FHT	10	12	7	14	10	14
BHU with OHT	75	63	80	71	70	79
BHU with multidisciplinary PHC support team	42	32	47	46	31	32
BHU with Family and Community Medicine specialist	29	27	25	33	32	28
BHU with doctors from the PMM	43	56	43	38	46	38
BHU with at least one permanently contracted doctor	33	24	23	41	49	33
BHU with private human resource outsourcers *	20	6	19	25	21	20
Provision of PHC services
BHU that provide medical and nurse consultation	99	94	99	99	99	99
BHU that provide dental consultation	89	79	92	86	88	89
BHU that perform vaccination	85	81	93	80	76	80
BHU that dispense medicines	70	79	83	54	71	56
Community orientation and public participation
BHU with defined catchment area	85	77	84	89	89	83
BHU that perform community appraisals	66	59	68	68	67	62
BHU that perform annual community appraisals	49	56	51	48	41	43
BHU with an active local health council	36	37	30	42	40	39
Coordination and integration across the regional network
Use of electronic health records in BHU	87	65	84	92	98	95
Electronic health records shared with other BHU	70	42	64	76	85	83
Electronic health records shared with specialist public services	19	6	8	29	36	20
Frequent communication between teams and specialists	41	42	37	46	43	41
BHU receives the hospital discharge summary always or almost always	28	20	21	42	27	19
BHU schedules the specialist appointments/examinations using the scheduling system and communicates the date to patients	59	52	46	73	71	53
BHU maintains a record/list of patients referred to other services within the health network	57	52	51	68	58	46
BHU tracks referred patient wait times	34	31	30	43	36	25
BHU provides specialist care for acute coronary syndrome	57	44	49	66	71	58
BHU provides specialist stroke care services	61	50	54	68	72	62

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Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz Rua Leopoldo Bulhões, 1480 , 21041-210 Rio de Janeiro RJ Brazil, Tel.:+55 21 2598-2511, Fax: +55 21 2598-2737 / +55 21 2598-2514 - Rio de Janeiro - RJ - Brazil
E-mail: cadernos@ensp.fiocruz.br

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[TFN1] FHT: family health teams; PHC: primary health care.

[TFN2] Source: Brazilian Ministry of Health e-Gestor (https://egestoraps.saude.gov.br/) primary care information system, considering public reports including time series data on number of funded teams and services, PHC coverage, oral health coverage, PHC funding and CHW coverage, based on the availability of indicators and methodology used for each period (1998-2024).

[TFN3] * The “FHS team population coverage” indicator was discontinued in 2020. In 2021, the “PHC coverage” indicator began to be used, calculated based on the estimated population registered by FHT and PHCT funded by the Brazilian Ministry of Health. In 2024, the “Potential PHC coverage” indicator was adopted, which includes all types of teams co-funded by the Brazilian Ministry of Health, as well as teams funded by state and municipal governments. In 2024, a new method was adopted for the “Estimated oral health in PHC population coverage” indicator, based on the oral health strategy population coverage linked exclusively to the FHS, including street clinic teams (SCT), family health teams for riverine communities (RFHT) and prison primary health care teams (PPHCT);

[TFN4] ** Includes resumption of federal funding for multidisciplinary teams in PHC under the multidisciplinary teams model.