Health system reforms are characterized by a set of substantive changes at the various levels and functions of the health sector in order to increase equity in service delivery, efficiency in management and effectiveness of their actions to meet the health needs of the population11. Organización Panamericana de la Salud (OPS). La cooperación de la Organización Panamericana de la Salud ante los procesos de reforma sectorial. Washington: OPAS; 1997.. Indeed, the most significant incremental reform in the history of the Brazilian Unified Health System was the creation of the Variable Minimum Primary Care Package (PAB-Variable), established by the NOB-96 and created by Ordinance GM/MS Nº 1882, dated 18/12/1997, in force as of February 1998, which paved the way for the inclusion of more than 140 million Brazilians in the Family Health Strategy22. Organização Pan-Americana da Saúde (OPAS). Relatório 30 anos de SUS, que SUS para 2030? Brasilia: OPAS; 2018..
In less than ten years, small municipalities responded quickly to financial induction and expanded their primary care coverage to close to 100%. Later and surrounded by class struggles, large municipalities were slow to adhere to this change of model. The early 21st century featured no shortage of national and international evidence on the advantages of health team care under the aegis of PHC attributes and the family health model with other types of health service delivery.
Among the Brazilian capitals, Teresina, João Pessoa, Aracajú, Vitória, Florianópolis and Belo Horizonte were the first to reach coverage levels above 70%. At the same time, Salvador, Rio de Janeiro, and Brasília were characterized by low coverage and constant crises in the local SUS, fragmentation of the system and the lack of structured primary care, which generated dissatisfaction and overload throughout the network making the system increasingly unsustainable.
From 2009 to 2017, Rio de Janeiro increased its coverage to 70%, leaving Salvador and the Federal District at the bottom of the list, in almost isolated positions.
Analyzing the model of primary health care in the Federal District underpinned by the Health at Home (1997 and 1998), Family Health Program (1999 to 2003) and Healthy Family Program (2004-2006), Hildebrand33. Hildebrand SM. O modelo político-tecnológico da atenção à saúde da família no Distrito Federal: 1997 a 2006 [tese]. Brasília: Universidade de Brasília; 2008. identified a low adherence to the national policy and the wrong choice of a model parallel to the health network, focused on some programmatic actions and a very small population group, which was reinforced by Kashiwakura et al.44. Kashiwakura HK, Gonçalves AO, Silva RMP. Atenção Primária à Saúde: elementos de continuidade e mudanças na saúde do Distrito Federal. Saúde Debate 2016; 40(111):49-62. in their paper analyzing the budget priorities from 2005 to 2014 of the Federal District. These authors emphasized the contradictions between the discourse in favor of PHC and the maintenance of the goals of building new hospitals submitted to each new management, classifying as “discontinuous and disarticulated” the initiatives to strengthen PHC until then.
In 2017, SES-DF Ordinances Nº 77 and 78 enunciated the concepts and attributes of the PHC and the ESF for the primary care facilities, twenty years after the regulation of the variable PAB, and for the first time in its history, the GDF Government adhered to the National Primary Care Policy (PNAB), providing increased real access to almost 70% of the population of the country’s capital.
It is also essential to highlight the increased coordinating role of the care of the family health teams, with the creation of the regulation by the family physicians that begin to be at the fore of the system. These reforms are classified by Gérvas and Fernándes (2019) as pro-coordination reforms, but more than others, these reforms require a great political commitment from those who commit them, since most of them face resistance from the Brazilian hegemonic model.
Indeed, the expanded access and organization of the network through the PHC attributes will have a very positive impact on DF health indicators; these gains are already felt in the satisfaction of users and teams. However, a set of structured research and evaluations are required to show the results achieved and streamline the network with necessary fine adjustments, besides strengthening and expanding family medicine and family nursing residency.
Brasilia has shown to the Country that it is possible to use the best scientific evidence in the implementation of health policies, seeking a more equitable and integrated health system.
- 1Organización Panamericana de la Salud (OPS). La cooperación de la Organización Panamericana de la Salud ante los procesos de reforma sectorial Washington: OPAS; 1997.
- 2Organização Pan-Americana da Saúde (OPAS). Relatório 30 anos de SUS, que SUS para 2030? Brasilia: OPAS; 2018.
- 3Hildebrand SM. O modelo político-tecnológico da atenção à saúde da família no Distrito Federal: 1997 a 2006 [tese]. Brasília: Universidade de Brasília; 2008.
- 4Kashiwakura HK, Gonçalves AO, Silva RMP. Atenção Primária à Saúde: elementos de continuidade e mudanças na saúde do Distrito Federal. Saúde Debate 2016; 40(111):49-62.
- 5Gérvas J, Fernándes MP. Organização da Atenção Primária à Saúde. In: Gusso G, Lopes JMC, organizadores. Tratado da Medicina da Família e Comunidade 2ª ed. Porto Alegre: Artmed: 2019. p. 42-51.