Impacts of the Family Health Strategy on the health status of the Brazilian population: a literature reviewAbstract
This article is a literature review on the impacts of the Family Health Strategy (FHS) on the health status of the Brazilian population over the past 30 years. The search for studies in the PubMed database identified 882 scientific articles. After having applied both inclusion and exclusion criteria, 43 articles remained for analysis of the findings. The implementation of the FHS was associated with relevant effects on the reduction of infant and under-5 mortality, especially in the postnatal period and for infectious diseases, as well as on mortality and hospitalizations for the general population and specific age groups, with emphasis on preventable causes by PHC actions and services, even though the association of FHS with a decline in hospitalizations and some causes of mortality in the adult population has not been observed in some studies. The effects of FHS were more expressive in vulnerable social groups or in poorer regions and with less structuring of the healthcare network, demonstrating its impacts on reducing health inequities in Brazil. The studies focused on the period prior to 2017, limiting knowledge about the impacts over the 30 years of FHS. Public investment is recommended for the institutionalization of evaluation to support the decision-making process of this relevant health policy in Brazil.
Key words:
Family Health Strategy; Impact Assessment; Primary Health Care
Resumo
Estudo de revisão de literatura sobre impactos da Estratégia Saúde da Família na saúde da população brasileira nos últimos 30 anos. A busca dos estudos na base PubMed identificou 882 artigos científicos. Aplicados critérios de inclusão e exclusão, restaram 43 artigos para análise dos achados. A implementação da ESF foi associada a relevantes efeitos na redução da mortalidade infantil e em menores de 5 anos, especialmente no período pós-natal e por doenças infecciosas, e na mortalidade e hospitalizações para população geral e por grupos etários específicos, com destaque para causas evitáveis por ações e serviços de APS, embora a associação da ESF com a redução de hospitalizações e de algumas causas de mortalidade na população adulta não tenha sido observada em alguns estudos. Os efeitos da ESF foram mais expressivos em grupos sociais vulnerabilizados ou em regiões mais pobres e com menor estruturação da rede de atenção à saúde, demonstrando seus impactos na redução das inequidades em saúde no Brasil. Os estudos se concentraram no período anterior a 2017 limitando o conhecimento sobre os impactos nos 30 anos da ESF. Recomenda-se investimento público para institucionalização da avaliação para apoio ao processo decisório dessa relevante política de saúde do Brasil.
Palavras-chave:
Estratégia Saúde da Família; Avaliação de Impacto; Atenção Primária à Saúde
Resumen
Estudio de revisión bibliográfica sobre impactos de Estrategia Salud de Familia en salud de población brasileña en últimos 30 años. La búsqueda de estudios en base PubMed identificó 882 artículos científicos. Aplicados criterios de inclusión y exclusión, quedaron 43 artículos para análisis de los hallazgos. La implementación de ESF se asoció con efectos relevantes en reducción de la mortalidad infantil y en menores de 5 años, especialmente en período postnatal y por enfermedades infecciosas, en mortalidad y hospitalizaciones para población general y por grupos etarios específicos, destacando causas evitables por acciones y servicios de APS, aunque la asociación de ESF con reducción de hospitalizaciones y de algunas causas de mortalidad en población adulta no ha sido observada en algunos estudios. Efectos de ESF fueron más expresivos en grupos sociales vulnerables o en regiones más pobres y con menor estructuración de red de atención a la salud, demostrando sus impactos en reducción de desigualdades en salud. Los estudios se concentraron en período anterior a 2017 limitando el conocimiento sobre impactos en l 30 años de a ESF. Se recomienda inversión pública para institucionalización de evaluación para apoyo al proceso decisorio de esta relevante política de salud de Brasil.
Palabras clave:
Estrategia de Salud Familiar; Evaluación de Impacto; Atención Primaria de Salud
Introduction
The impacts expected from Primary Health Care (PHC) policies on improving the health status of populations are directly conditioned by the organization characteristics that relate to its implementation in different contexts, especially regarding its role in the reorganization of the national health systems.
Simplified PHC models, implemented as a basic set of actions and services focused on specific diseases and grievances, as well as on the most vulnerable social groups, have only a limited impact on health status. Meanwhile, impacts on a wide array of health problems and their unequal distribution in the population can be addressed by broad PHC strategies, with multiple interconnected structuring components of universal healthcare systems, such as being the main entry into the system, being the coordinator of care, and being the locus of intersectoral articulation with social policies1.
Besides the organizational design, implementing the evaluation of studies regarding the effects of interventions requires one to consider other contextual characteristics of their implementation2, such as socioeconomic, demographic, political and cultural factors, and other structured interventions, such as health care and social policies, which act simultaneously, in a synergetic manner, or independently, in the definition of health issues.
Brazilian PHC differentiates itself from designs of selective PHC from several countries due to its considerable capillarity in Brazil, mainly due to the implementation of the Family Health Strategy (FHS), which is one of the greatest achievements of the Unified Health System (SUS)3. Over the past 30 years, the FHS, which is far reaching, resolutive, with a territorial basis, family guided and communitarian, has been consolidated as the main organizational model of PHC, as it has been structured through technological innovation, and includes Community Health Agents (CHAs), who are responsible for a wide variety of actions, including health promotion, prevention, and care at the PHC units and throughout the country; the implementation of democratic spaces for population involvement; the articulation of intersectoral policies; and a potential role in coordinating regional networks of integral healthcare. This last one is still in its initial stages, given its dependency on mechanisms of access and communication with the network of specialized services, which is crucial for more resolve in PHC.
The evolution of FHS has not been linear; there have been both advances and setbacks from its origin in 1994 as the Family Health Program (FHP) to the present day. From 1998 to 2015, with the significant expansion of population coverage and strengthened by the implementation of multiple actions and interventions, FHS has been consolidated as a national strategy of PHC reorganization, although with local and regional diversity, given the inequalities present in Brazil.
From 2016 to 2022, after the impeachment of the elected president and the later rise of an extreme right wing, neoliberal government, the FHS suffered severe setbacks, which reconfigured its organizational bases and reversed its growth tendency, due to a set of fiscal austerity measures, worsening the state of chronic underfunding of healthcare and of the dismantling of the Brazilian State, impacting SUS and other national social security policies4.
Since 2023, government measures have pointed out the need for an overhaul of the FHS, with a return of its priority status in terms of federal co-funding, created in April 20245, highlighting the resizing of the number of professionals per team, the return of funding for multidisciplinary teams and the increase of federal resources transferred to municipalities, investments for the construction and supplying new Basic Health Units (BHUs) through the new Growth Increase Plan (GIP), increases in the number of oral health teams, and the resumption and expansion of More Doctors for Brazil Project (Projeto Mais Médicos para o Brasil)6.
The PHC network has highlighted that government policies aimed at universalizing the broad and resolutive FHS model must be followed by evaluation processes that consider the lingering challenges. Specifically, regarding the impacts of FHS on the health status of the Brazilian population, the systematization of the knowledge produced in recent decades may subsidize decision-making, potentially revealing possible consequences of current changes and of the contextual diversity of the places of implementation, in terms of conforming to and of reconfiguring the model7.
One systematic literature review, conducted in 2017, regarding the impacts of FHS on conditions that are sensitive to PHC, concluded that there was reasonable evidence of association between an increase in FHS coverage and a decrease in child mortality, especially in terms of postnatal deaths, as well as a reduction in mortality of children younger than 5 years of age. However, although seen in many studies, the association between FHS and the decline in hospitalizations for PHC-sensitive conditions was less consistent. In relation to other health outcomes, the authors considered that the reduced number of articles and the higher risk of bias in the studies did not allow for a generalization of the findings8.
No other reviews that referred to studies after 2017 were found. Therefore, this article aims to conduct a literature review concerning the impacts of FHS on the health status of the Brazilian population, over the past 30 years, thus covering the entire period of its implementation in Brazil.
Methodology
This article is a scientific literature review, conducted in March 2025, guided by the research question: What are the impacts of the Family Health Strategy on the health status of the Brazilian population over the past 30 years?
The search was restricted to studies published in scientific article format in the PubMed database, with no timeframe or language restrictions. For the identification of the articles, the following search routine was followed: (Brazil[Title/Abstract]) AND (Family Health Program [Title/Abstract] OR Family Health Program[Title/Abstract]) OR Family Health Strategy[Title/Abstract]). The search was intentionally broad in order to identify every article that dealt with any aspect of the FHS, using the official terms that designated the intervention. Afterwards, by reading the articles, abstracts, and full texts, studies evaluating the impact of FHS on the health status of the Brazilian population were selected, with no restriction as to the kind of health problem or grievance.
A total of 882 articles were identified. After the exclusion of duplicates, using Rayyan®, a bibliographical reference manager software, 874 articles remained, published from 1998 to 2025.
The following inclusion criteria was followed: Brazilian population as the study population, regardless of territorial coverage; FHS as an intervention, evaluated as one of the main independent variables; morbimortality results from all causes or specific causes, as independent variables, measured by indicators of incidence, prevalence, mortality, and hospitalization, with the exception of oral health; the use of some type of comparison (different levels of population coverage, time of implementation, or other PHC models); observational or experimental study designs; multivariate analyses, considering potential confounding factors (socioeconomic and organizational characteristics of the local healthcare systems) and of interaction (other interventions).
Studies on the effects of the FHS only upon access, use, or coverage of actions and services, such as prenatal care, vaccines and treatments, were excluded, as were exploratory studies or studies on spatial or temporal trends in health problems, which included FHS in the group of determining factors; systematic or literature review studies; opinion articles, editorials, letters or comments.
Two reviewers (RA and ALQV) applied the inclusion and exclusion criteria independently, in two phases: reading of the titles and abstracts, followed by reading of the complete text of the articles selected in the first phase. In the case of disagreement, the reviewers defined, by consensus, the situation of the articles in each phase. After reading the titles and abstracts, 767 articles were excluded, leaving 107 articles for complete text reading, which then resulted in the exclusion of 64 articles. In the end, 43 articles were selected.
Results
The findings of the 43 articles used in this literature review (Chart 1) were grouped in three thematic categories: studies on mortality, on hospitalization for conditions sensitive to PHC, and on other morbidity themes.
Infant and child mortality
The impacts of the FHS on infant and child mortality were evaluated in 13 articles9-21 (Chart 2). Most of the studies followed an ecological design, with nationwide coverage, having municipalities as the main unit of analysis11-15,17,18,21, and including a simulation study at the aggregate level18. Regarding the remaining five studies, two ecological studies, with a nationwide coverage, used the units of federation9 and microregions10 as the main unit of analysis; one ecological study covered municipalities in the Semi-Arid region16; one was a cohort study about live births from mothers residing in the municipality of Rio de Janeiro and registered in the Single Registry20 (Cadastro Único); and one was a simulation study on individual data related to the 15 largest Brazilian cities19.
Nearly all of the studies analyzed data referring to the period leading up to 2014, covering the creation and consolidation of the FHS in Brazil. The evaluation of its impacts on infant and child mortality, after 2017, was only considered in two studies of data micro-simulation18,19 to predict the effects of FHS for the period until 2030.
The seven studies analyzing the effects of FHS on infant mortality9-11,14,16,17,19 found a decline in infant mortality rates associated with the implementation of the FHS. Decreases of up to 4.5% were observed, associated with a 10% increase in FHS coverage9,10, reaching 22% in towns that are in the high coverage strata in comparison with towns without FHS coverage11. Additionally, increasing effects were observed with an increase in time of FHS implementation, with a decline of up to 20% in mortality in towns that had eight years of FHS implementation, considering the average rate during the period14. A lesser probability of death was also associated with maternal use of FHS services during the first trimesters of pregnancy, with no association observed regarding maternal use before pregnancy20.
Studies which analyzed the two components of infant mortality rate (IMR) observed that FHS had no effect10 or that the effects were of a low magnitude11,13,20 in reducing neonatal mortality rates (NNMR). For post-natal infant mortality (PNIMR), expressive effects were noticed10,11,13.
The five studies that analyzed the effects of the FHS on infant mortality under 5 years of age (IM-U5)12-14,18,21 observed an inverse association between FHS coverage and mortality in infancy. Reductions of up to 24% in IMR of children 1 to 4 years of age were observed in municipalities with six years of FHS implementation, with greater impact upon mortality from infectious and respiratory diseases14. Studies using strata of municipal FHS coverage, when compared to towns without coverage, observed, in the higher coverage stratus, a 13% reduction in IM-U5, more expressive in IM-U5 by diarrhea and by pneumonia13; and reductions of 50% and 60%, respectively, in IM-U5 due to ill-defined causes and IM-U5 without medical care12.
Some studies have analyzed the heterogeneity of the effects of the FHS in specific subgroups. Greater declines in infant mortality were observed according to coverage strata in towns with higher IMR values, in the beginning of the study period and in towns with lower HDI11; there was more reduction of IM-U5 by deaths without medical care in towns with lower HDI12; and more expressive effects were observed in the North and Northeast regions of the country, of years of FHS coverage in infant mortality and mortality of children between 1 and 4 years of age14.
The studies estimating the effects of the coverage of the FHS and the Bolsa Família Program (BFP) found associations of the two programs with reductions in IMR16,27, PNCMR15 and IM-U521. The increase in FHS coverage, from 0% to 100% was associated with a decrease of 5.24 to 3.54 neonatal deaths per 1000 live births in towns with 25% BFP coverage, and a decline from 4.65 to 1.38 deaths when the coverage was 60%15; meanwhile, a decline in infant and post-neonatal mortality was more pronounced in towns with higher FHS coverage21. The analysis of the interaction between the FHS and the BFP showed a significant association with the decrease in IM-U5, and an independent effect of the FHS and the BFP on reductions in IM-U5 in general, as well as from undernourishment, diarrhea, and respiratory infections, with the greater declines in associations between the BFP and decreases in mortality, due to undernourishment, and in the FHS, due to infectious causes21.
With the establishment of alternative scenarios of declines in FHS coverage in Brazil, following the implementation of financial austerity measures by the Federal Government, beginning in 2017, increases were predicted in municipal averages of IM-U5 due to causes sensitive to PHC, of up to 13.2%, in a more restrictive scenario (reduction of federal spending in health and interruption of the More Doctors for Brazil Program), when compared to maintaining the coverage of the FHS stable, from 2017 to 203018. Considering the 15 largest Brazilian cities, the increase in FHS coverage from 2020 to 2030 was associated with estimated decreases in infant and child mortality for 203019.
Overall mortality, among adults and from a variety of causes
Fourteen studies evaluated the effects of the FHS on overall and cause-specific mortality in the young and adult population14,18,19,22-32 (Chart 2). Nine were longitudinal ecological studies, using municipalities as the unit of analysis14,18,23-26,29,30,32, four were cohort studies22,27,28,31, of which two used data from the Single Registry (Cadastro Único)27,28 and one was a simulation study of individual data19.
Most of the studies were national in scope, with the exception of four studies that were municipal, whose studies were conducted in the municipalities of Joinville22; Bajé28; Rio de Janeiro27 and the 15 largest Brazilian cities19. The studies analyzed data from different time periods, with eleven of the studies up to 2018, and one study from 2016 to 202232. Two simulation studies18,19 estimated results until 2030.
Studies that analyzed mortality from all causes14,27,28,19 and from PHC-sensitive conditions18,24,25,29,30 observed impacts of the FHS on the reduction of those outcomes, and in some of the studies, on the decrease in inequalities in mortality in specific groups.
In terms of overall mortality, towns in which the FHS had been implemented for 3 and 8 years showed declines of 3.2% and 11.2%, respectively, in mortality of individuals, aged 15 to 59 years, as well as less robust effects on the mortality of individuals above 59 years of age14. One study with CadÚnico participants residing in the city of Rio de Janeiro revealed that FHS users, when compared to non-users, showed a lower risk of death by all-causes, with more expressive decreases found among black and brown individuals; among those with a lower level of education, and among participants of the BFP27. In a study conducted in the town of Bagé-RS, lower risks of mortality were observed among FHS users in the middle-income and low-income strata, as compared to the wealthier groups28.
Expansion of the FHS (from 0% to 100%) was associated with a 6.8% reduction in preventable deaths among individuals under 75 years of age, more pronounced in municipalities with higher scores of municipal governance in the area of health, when compared to towns with lower scores24. Our study identified an association between an increase in FHC coverage and a decrease in the mortality rate for conditions sensitive to outpatient care among individuals under 70 years of age, related to race/skin color, with more significant decreases found for the black and brown populations when compared to the white population25. More time of exposure to FHS was associated with decreases in preventable mortality rates of individuals 0 to 65 years of age, of 22% and 61%, respectively, in towns covered by the FHS for 10 and for 20 years30, as well as of individuals 25 to 64 years of age, of 30.2% and 64%, respectively, in towns covered by the FHS for 14 and 20 years29.
Two data simulation studies estimated effects, in 2030, of possible changes in the FHS coverage on overall mortality in the 15 largest Brazilian cities19 and from PHC-sensitive causes in Brazil18, which are in line with the results of the aforementioned studies. Declines in FHS coverage, from 2020 to 2030, contributed to an increase in mortality and in inequalities between cities, while increases in coverage had more expressive impacts on a decrease in mortality among vulnerable groups, such as BFP beneficiaries, and racial/ethnic minorities19. Increases of up to 8.6% in the municipal average of mortality rates from sensitive causes of individuals under 70 years of age were observed when declines in FHS coverage occurred, as compared to a scenario in which the levels of coverage remained stable from 2017 to 203018.
Eleven studies evaluated the effects of the FHS on selected causes of mortality18,19,22,23,25-27,29-32. The results were: (1) declines in mortality rates of individuals, aged 20 to 79 years, due to cerebrovascular diseases, ischemic diseases and other types of cardiac diseases, associated with wider coverage with a dose-response effect with increased time of FHS implementation23; (2) decreases in mortality rates of individuals, aged 25 to 64 years, due to infectious gastroenteritis, immunizable diseases, asthma, cerebral vascular diseases and diabetes, associated with a longer time of FHS implementation29; (3) higher decreases in the risk of deaths that can be prevented by health care (tuberculosis, intestinal infections, diabetes, cardiovascular diseases, and alcohol and drug use disorders) when compared to causes that are less accessible to health care (cancer of the cervix, mouth, and throat; nervous system diseases; and external causes)) among FHS users when compared to non-users27; (4) reduction in mortality due to tuberculosis in municipalities with a wider FHS coverage, adjusted by coverage of the BFP26; (5) reduction in mortality due to AIDS among the CadÚnico population, which is more expressive among men and among people, aged 35 years and over32; and (6) decline in mortality rates due to COVID-19 and cardiorespiratory causes in towns with high FHS coverage32. One cohort study with patients that had their first stroke indicated that those who had at least two appointments per year in FHS units and received prescriptions for secondary prevention did not present a lower risk of death by cardiovascular diseases, although a decrease was observed in the risk of death due to all causes22.
In the data micro-simulation study conducted in the 15 largest Brazilian cities, the specific causes of mortality that were most sensitive to changes in PHC coverage by the FHS were deaths by Noncommunicable Diseases (cardiac diseases and cerebrovascular accident) and deaths by external causes, while the lowest alterations were for deaths caused by nervous system diseases, tuberculosis, malaria, neglected tropical diseases, and maternal causes19.
Hospitalizations for PHC-sensitive conditions (PHCSC)
This study identified 15 articles that evaluated the effects of the FHS on hospitalizations due to PHC-sensitive conditions (Chart 3). Eleven of those were ecological longitudinal studies30,33-42, the rest which were of ecological cross-sectional design43, cohort22,44, and mixed methods45. Six studies had nationwide coverage, with units of analysis including municipalities30,33,34,39, microregions36, and federated units35. Four studies had a statewide scope, with municipalities as units of analysis38,40-42, and one covered a state-level health microregion45. In the four studies with municipal scope, the units of analysis were census sectors37, areas of coverage of the PHC units, with or without FHS teams22,43, and users registered in the CadÚnico44. The study period ranged from 4 to 20 years, with data referring to 1988 and 2018.
Twelve studies revealed that greater FHS coverage contributed for the decline in hospitalization rates for the PHC-sensitive conditions30,33,35,36,42 for selected causes, such as cardiovascular disease, strokes, and asthma34, among women residing in areas of high social vulnerability37; among children under 5 years of age38; among children under 1 year of age40; and among children under 5 years of age for acute gastroenteritis45.
One cohort study conducted with individuals, aged 15 to 84 years, registered in the CadÚnico and residing in the municipality of Rio de Janeiro, demonstrated a decrease in hospitalization rates for emergencies caused by PHCSC and by readmissions among FHS users, with a greater effect among individuals with a higher per-capita income, an older age, especially above 70 years of age, who are less educated and unemployed44.
Between 1998 and 2018, in municipalities covered by the FHS for 20 years, there was an average reduction of 2.97 hospitalizations per 10,000 inhabitants. The estimated effect of two years of exposure to the FHS corresponded to 2.37% of the hospitalization rates observed in 1998. However, that effect did not continue after three years of implementation of the program30.
Associations were observed between availability of a family doctor and annual reductions of 1.1 hospitalizations of individuals per 10,000 inhabitants, aged 65 years and over, due to heart failure43, associated with an increased FHS coverage with a decrease in HPCSC rates for heart failure (HF) and strokes, even though the magnitude of these effects was minimal41.
In a cohort study with a municipal scope, with individuals followed up after a first stoke episode, covered or not covered by an FHS PHC unit, no associations were observed between hospitalizations for acute myocardial infarction or recurring stroke, and being FHS users22. Another study - after multivariate adjustment for having trash collection, sanitation and treated water - found no significant associations between an increase in FHS coverage and a decline in the hospitalization rate for gastroenteritis among children under 5 years of age45.
Silva and Powell-Jackson39 found no associations between FHS coverage and the decline of PHCSC rates. These authors indicated that the FHS led to a major increase in the number of PHC appointments per 1,000 inhabitants, which may have facilitated user access to hospitals by referrals and by an increase in the detection of diseases and grievances.
Other issues
Seven studies, classified as other issues (Chart 4), evaluated FHS coverage on morbidity outcomes, measured by indicators of incidence and prevalence of PHC-sensitive conditions46 and other morbidity indicators. Three studies were identified, concerning infectious and parasitic diseases (IPD)47,48,31; three, which studied Noncommunicable Diseases (NCDs)49-51; and one study that used measures of health self-evaluation, limitations in routine activities for health reasons, being bedridden, and hospitalizations52. Six studies used information available up to 201731,47,48,50-52.
Regarding the methodologies used, four were cross-sectional studies that used municipalities49,50, metropolitan regions52 and a nationwide sample51 as units of analysis. Three studies were ecological with a national scope, with the totality of the municipalities32,47, while another had 1,358 municipalities with a high risk of Hansen’s disease detection48.
Among the studies that analyzed IPD as an outcome, associations were observed between FHS coverage and a decline in AIDS incidence among individuals, aged 13 years of age and over31; an absence of association with the incidence of congenital syphilis47; and an increase in new cases of Hansen’s disease in municipalities with a wider coverage of FHS; however, there was reduction in new cases in municipalities with greater BFP coverage48.
Studies which used measures of user perception regarding their own state of health, indicated a greater prevalence of arterial hypertension, diabetes, and ischemic heart disease49, most likely due to improved access to diagnoses at the PHC level, as well as a higher proportion of individuals with a positive self-evaluation in areas covered by the FHS44. Household coverage of the FHS was associated with a higher probability of abnormal results for biomarkers related to anemia, renal failure, and arterial hypertension51.
Discussion
The results of this review show that the implementation of the FHS was associated with relevant impacts on the health status of the population. Studies demonstrated that the FHS brought about a reduction in infant mortality and in children under 5 years of age, especially in the postnatal period and for infectious diseases. Results also showed a decrease in mortality rates and hospitalizations for the overall population and by specific age groups, with a focus on causes that are preventable through PHC actions and services, although some studies found no association between the FHS and decreases in preventable hospitalizations and some causes of mortality among the adult population. Some studies highlighted that the effects of the FHS were more expressive in vulnerable social groups or in poorer areas with a less well-structured healthcare network, thus demonstrating impacts of the FHS in reducing inequalities in Brazil.
The vast majority of the studies analyzed data referring to years before 2017. Only two data simulation studies aimed at predicting the effects of possible changes in levels of FHS coverage on mortality18,19, and one study about mortality due to COVID-1932, referred to more recent periods.
The results were consistent in the majority of the studies regardless of the use of different methodological strategies or methods of measuring the intervention. Some studies highlighted the importance of analyzing not only the levels of coverage, but also the use of services in FHS units, in studies with individual data, as well as the time taken to implement the FHS, since impacts in the reduction of some health conditions demand a certain time to implement of FHS actions and services in order to be achieved, and may vary considerably with time.
Consistency and plausibility was found in the findings of the studies regarding the association of FHS with the decline in infant mortality and in the mortality of children under 5 years of age; minor or no associations with neonatal mortality; and more significant associations with post-neonatal mortality and a set of PHC-sensitive conditions. Such effects on mortality in infancy were expected, considering that the actions and services offered by the FHS potentially affect this age group, mainly through the decrease in infectious diseases, meanwhile the causes of neonatal mortality include conditions that are not preventable by PHC, such as congenital problems and conditions related to quality of care during delivery. Macinko et al.53 found similar results regarding the effect of PHC on child mortality in low and middle-income countries.
The use of FHS services reinforces the plausibility of the findings regarding mortality in childhood. Municipalities with higher levels of FHS coverage had a higher annual number of medical appointments per inhabitant11,13 and educational activities; a higher prenatal and vaccination coverage of children under 1 year of age11; and of household visits per family13. The use of FHS services by mothers, before or during pregnancy, was associated with an increase in probability of having 7 or more prenatal consultations; a lesser probability of premature delivery; with low birth weight and with hospitalization of children 4 to 12 months after birth20.
Studies have shown an association of the FHS with a decrease in mortality rates for all causes in the general population, standardized by age or by specific age groups of young people and adults. Most of the studies found an association of the FHS with a decline in mortality from PHC-sensitive causes, either in groups or in isolation, however, some studies found no association with specific mortality causes, especially causes that are not preventable by PHC actions. Even though unplanned or unexpected effects can eventually be observed, the absence of association with such effects is not surprising, and if it had been found, it would demand efforts to specify which resources or processes were mobilized in order to produce such effects, and whether or not they could be attributed to the implementation of the FHS.
Nationwide studies indicated a decline in hospitalization rates for PHC-sensitive conditions due to all causes, in time periods coinciding with the expansion of the FHS. Studies that did not find effects on PHCSC showed a more limited geographic scope and focused on selected causes or age groups.
Access to medical appointments and specialized exams for PHC users with chronic diseases and acute conditions in childhood, which is essential for increasing PHC resolve and avoiding complications that may require hospital care, is conditioned by the existence of secondary care services and regulating mechanisms, which still present weaknesses nowadays, given that these are more incipient in the initial periods of expansion of the FHS. That is something to be considered when interpreting the results. Moreover, FHS effects must be adjusted by the local-regional availability of hospital beds, restricting or expanding the possibilities of hospitalizations for all causes, including PHCSC.
Results of studies on morbidity looked into the incidence or prevalence of IPD, given that actions for its prevention and surveillance are part of the scope of FHS actions; however, these results must be interpreted with caution. The increase in new cases of neglected diseases may indicate a better quality of surveillance actions in the territories covered by FH teams.
Finally, it is important to highlight the findings regarding the effects of the FHS and the BFP, which is one of the most important social policies in the country. Such findings were demonstrated by some of the studies, with strong evidence that these policies act in an articulate manner, based on synergistic mechanisms geared toward the reduction of poverty and the expansion of access to healthcare services, a decrease in infant mortality15-17,21, in new cases of Hansen’s disease48, and in mortality caused by tuberculosis26.
The majority of the studies had an ecological design, using data that is accessible to the public in the SUS information system. Few studies used primary data, since that implies higher costs, which is not feasible given the lack of public financing for scientific research in Brazil. However, some cohort studies, with extensive coverage, used individual data from the Single Registry (Cadastro Único), linked with different health databases and accessible to research institutions, especially after the regulamentation of access and of the protection of personal data.
The possibilities of conducting major studies with individual data referring to the clinical conditions of the users and to actions performed by FHS professionals, may improve even further with public access, through a process of integration with the National Health Data Network from SUS, while maintaining the ethical principles of data protection.
This literature review had two important limitations that require caution when interpreting the results. First, it was limited to one database, which considered only published scientific articles, even though it was guided by a broad search strategy. Second, this study did not conduct a quality analysis of articles used, which may have compromised interpretation of variability of the effects observed in the studies, especially regarding some specific outcomes. The heterogeneity of effects across review studies may result from methodological differences in those studies, such as in terms of design, coverage, forms of measuring interventions, and statistical analyses, as well as characteristics of the participants and analyzed outcomes. Considering such implications, a synthesis of methodological aspects was presented in a summary chart, and the methodological differences between the studies were considered in the discussion of the findings. It is also important to emphasize that the eligibility criteria guaranteed that only studies investigating effects or associations of the FHS were included, using multivariate analysis methods, adjusting for other determinants of the investigated health problems. In the case of studies that evaluated the effects of the FHS and the BFP, only those that considered FHS as first or second main independent variables were considered in such a ways as to evaluate independent effects and combined effects of two interventions.
The results found and the gaps identified in this review may support the conducting of new studies that can help to expand knowledge regarding FHS impacts and investigate new hypotheses regarding the mechanisms involved in the production or the absence of these effects on the population’s health.
Research conducted with a nationwide scope with longer periods of study is necessary to investigate possible heterogeneity in the magnitude of the effects of the FHS, taking into consideration the conjunctural changes in the national policy and in PHC funding over the past 30 years. Since most studies analyzed periods corresponding to the establishment and consolidation of the FHS in Brazil, we were not able to investigate the possible effects of the measures of FHS setbacks and dismantling, implemented between 2017 and 2022.
FHS resolve primarily depends on structural conditions of the Basic Healthcare Units; on the universalization of an expanded array of actions of promotion, prevention and care by qualified healthcare professionals; on the integration of PHC with the healthcare network; and of intersectoral articulation with social policies. Some of these aspects were incorporated into the studies, through the use of indicators of service use, characteristics of the local governance, or the articulation with social policies like the BFP. Nonetheless, interpretation of results observed in impact evaluations will always require evidence from other studies evaluating the implementation of the intervention.
In Brazil, from 2003 to 2018, robust national quality initiatives contributed to a growing institutionalization of PHC evaluation, which was discontinued during the period of setbacks in FHS implementation. The National Census of BHUs, conducted in 2024, may represent a milestone in the resumption of a national evaluation policy, supported by a broad research agenda, as defended by the PHC Research Network, through improvements in quality and availability of data in the health information systems and by increasing public financing for scientific research, thereby contributing to the expansion of knowledge regarding the impacts of the FHS on the health status of the population, and considering the diversities in FHS implementation within various local and regional contexts.
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The data sources adopted in the research are indicated in the article’s body.
