In 1988, Brazilian Constitution definedhealth as a universal right and state responsibility. Progress towards universal health coverage (UHC) has been achieved through a Unified Health System (Sistema Único de Saúde, SUS) which was created in 1990. With successes and setbacks in the implementation of health programmes and organization of its health system, Brazil has achieved nearly-universal access to health services for her citizens. The trajectory of the development and expansion of the SUS offers valuable lessons on how to scale UHC in a health system in a highly-unequal country and relatively low resources. The analysis of the 30 years since the inception of SUS shows that innovations in the Brazilian health system extend beyond the development of new models of care and highlights the importance of establishing political, legal, organizational and management-related structures, and the role of the federal and local governments in the governance, planning, financing, and provision of health services. The expansion of SUS has allowed Brazil to rapidly address the changing health needs, with dramatic scaling up health service coverage in just three decades. However, despite its successes, analysis of future scenarios suggests the urgent need to address lingering geographic inequalities, insufficient funding, and the suboptimal private-public collaboration. Recent fiscal policies that ushered austerity measures, environmental, educational and health policies of the new administraion introduced in Brazil could reverse the hard-earned achievements of the SUS and threaten its sustainability and its ability to fulfil its constitutional mandate of providing 'health for all'. 2000 2010 2015 Births attended by skilled health staff (% of total) 87•6 98•6 98•9 99•1 Immunization, BCG (% of one-year-old children) 79 99 99 99 Immunization, measles (% of children ages 12-23 months) 78 99 99 96 Immunization, DPT (% of children ages 12-23 months) 66 98 99 96 Immunization, Hib3 (% of children ages 12-23 months) 90 99 96 Immunization, Pol3 (% of one-year-old children) 58 99 99 98 Immunization, HepB3 (% of one-year-old children) 94 96 96 Antiretroviral therapy coverage (% people living with HIV) 27 38 57

As part of the implementation of the country's Unified Health System (Sistema Unico de Saúde), the Brazilian Government created, in the second half of the 1990s, the Family Health Program (FHP) (Programa de Saúde da Família), based on community-oriented, multidisciplinary care serving people organized into small groups. For this study, we evaluated the implementation of the FHP, based on three criteria: (1) the construction of the program as an entry point for most health needs and for access to specialized care, (2) the program's linkages with a comprehensive network of health services, and (3) the incorporation of new care practices into the health system. We found that the implementation of the FHP was far from uniform. In some municipalities the FHP is a focused program that runs in parallel with other primary care efforts. However, in other municipalities the FHP is viewed as a strategy aimed at changing the primary care model, and it partially or completely replaces preexisting primary care health units. Our research confirms a trend toward incremental change in the primary care model in Brazil. However, the expansion of the FHP in large urban areas faces several obstacles to guaranteeing all individuals access to comprehensive care with adequate clinical and collective health services, including secondary and tertiary care. The positive results that we found with some of the experiences with the FHP indicate that, in addition to increased federal financial incentives, the success of the FHP depends on creative local strategies to deal with Brazil's diversity.

Family health: limits and possibilities for an integral primary healthcare approach in BrazilSaúde da família: limites e possibilidades para uma abordagem integral de atenção primária à saúde no Brasil

Since its creation in 1994, the Family Health Program has become the main strategy for changing care models and increasing access to the first contact service of the Unified Health System (SUS). A little more than ten years later, in 2006 the program was transformed into the Family Health Strategy (FHS) within the National Policy on Primary Care (PNAB). This article evaluates the effects of the implementation of the FHS over the last two decades in Brazil, demonstrating the access provided and the trends in ambulatory care sensitive conditions (ACSC). This is an ecological, time series study with secondary data referring to the number of family health teams that were established and the number of hospital admissions due to ACSC in the SUS from 2001-2016. The results show a 45% reduction of the standardized ACSC rates per 10,000 inhabitants, from 120 to 66 in the period 2001-2016. Although it was not possible to isolate the specific effects of primary care, it is quite plausible that this reduction in ACSC rates is linked to the progress of FHS coverage in Brazil, especially in terms of improved follow-up of chronic conditions, improved diagnosis and easier access to medicines.

Como desconhecer o que é a política de saúde, o que é o Sistema Único de Saúde (SUS), os determinantes sociais, as condições de saúde e as desigualdades do acesso no Brasil? Esta obra consolida o conhecimento crítico sobre o sistema de saúde brasileiro produzido ao longo dos últimos trinta anos. Conhecimento militante na defesa do direito universal à saúde e do acesso aos serviços de um sistema nacional de saúde de qualidade para todos e de políticas de saúde que promovam a redução das desigualdades sociais. Um livro didático e de referência que inclui os eixos de análise individual/coletivo, clínico/epidemiológico e público/privado, além de congregar autores com experiência na gestão de serviços e do próprio sistema, nos três níveis da federação. A construção do SUS há muito deixou de ser obra exclusiva de intelectuais capazes de ler em língua estrangeira. Temos ‘construtores’ que lêem na realidade concreta dos serviços e da gestão, e que participam ativamente do complexo processo de construção cotidiana da saúde.

Primary Health Care; Systems Integration; Health ServicesDiscussões e problemas vinculados à coordenação dos cuidados em saúde, fragmentação da rede assistencial, ausência de comunicação entre prestadores não constituem temas novos nas discussões sobre a organização dos sistemas de saúde. No entanto, mudanças recentes em relação às demandas e necessidades da população com o crescimento da prevalência de doenças crônicas, que exigem maior contato com os serviços de saúde em um contexto de pressão por otimização das relações de custo-eficiência, tornaram premente a busca de soluções 1,2,3 . Na União Européia, desde a década de 1990, reformas pró-coordenação vêm sendo implementadas, sobretudo voltadas ao fortalecimento do primeiro nível de atenção 4,5 .Os ritmos de implantação deste conjunto de reformas têm sido diferenciados entre os países a depender do modelo de proteção social 2,5 . Na região da América Latina ainda são incipientes reformas centradas na coordenação dos cuidados, o que se reflete no reduzido número de estudos que tratam deste tema. Segundo Conill & Fausto 5 , a histórica segmentação e fragmentação que caracterizou a maior parte dos sistemas de saúde latino-americanos, com oferta de Atenção Primária à Saúde seletiva, fragilizaram aspectos como a constituição de redes integradas. Ainda assim, no contexto do recente movimento de valorização e defesa da concepção abrangente de Atenção Primária à Saúde parecem ser promissoras iniciativas pró-coordenação.ARTIGO ARTICLE

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