Medicina de Família e Comunidade na saúde suplementar do Brasil: implicações para o Sistema Único de Saúde e para os médicos

Abstract

This article aims to problematize the interaction between Family and Community Medicine and the supplementary health system (private healthcare services and private health plans) in Brazil's current scenario. The point of departure is a historical contextualization, proceeding to some central aspects in this movement. In the history of health policies in Brazil before and after the creation of the Unified National Health System (SUS), one of the greatest challenges has been public-private relations. This process shaped a field of interests, actors, and disputes that weaken the possibilities for achieving health as a civil right and the SUS as a social policy of the State 1. While arguments indicate that inclusion of the private sector in health was a condition for the approval of the chapter on health in the 1988 Federal Constitution 2 , different forms of incentives have been granted by the state to the private sector, while major underfunding still exists in the SUS 3. Added to this is the symbolic and imaginary construction in Brazilian society, positively valuing the private health sector to the detriment of the public sector. Primary healthcare (PHC) has been one of the key strategies in the implementation of the SUS, considering the guarantee of universal access. The principal model instituted in 1994 was the Family Health Program, later reconceptualized as the Family Health Strategy (ESF in Portuguese). The ESF was expanded and improved in the subsequent decades and currently has 42,000 teams (with general medical practitioners, nurses, nurse technicians, and community health agents), covering 63% of Brazil's territory 4. In addition to internationally acknowledged attributes such as access and first contact, comprehensiveness, continuity over time, and coordination of care 5 , Brazil's PHC also features multidisciplinary teamwork and a strong territorial approach. This is seen in the population's modes of enrollment in the system, in the approach to collective health problems and risks, and in the community health agents 6. The main challenges in the history of the implementation of the ESF have been training, distribution, hiring, pay scales, and development of health professionals, especially physicians 7. In this sense, although Family and Community Medicine has existed in Brazil since the 1970s 8 , more intensely since 2011 9 , national policies were formulated that targeted the physician workforce in PHC. The More Doctors Program (PMM in Portuguese), with its components of emergency provision and training (undergraduate medical education and residency) was quite emblematic, with a central focus on Family and Community Medicine in national law and on the government agenda 7,10 .

Organization of primary health care in pandemics

“…This review suggests that perhaps FHS is the more effective PHC model in Brazil to provide effective, comprehensive health care during the pandemic, because of its community orientation, multi-professional teamwork, deep territorial connection, and intersectoral integration 28 . PHC models restricted to small doctor-focused services, which in Brazil are more common in supplementary health 29 , may be more fragile in these situations due to the high risk of contagion of their professionals and less integration with the structure public health. It is also worth reflecting on the extent to which the PNAB adopted in recent years leads to a more powerful PHC in a context of profound social inequalities, underfunding of the health system and high epidemiological complexity 28,30 .…”

Fragilidades que afastam e desafios para fixação dos médicos da Estratégia de Saúde da Família

“…Representam postos de trabalho alternativos que podem atrair tanto trabalhadores, quanto a população. Porém, podem fragilizar ainda mais os vínculos que a ESF necessita 29 .…”

Organization of Primary Health Care in pandemics: a rapid systematic review of the literature in times of COVID-19

“…Specifically addressing the Brazilian context, the most appropriate PHC model to provide effective, comprehensive health care during the pandemic might be the Family Health Strategy (FHS), because of its community orientation, multiprofessional teamwork, deep territorial connection and intersectoral integration 24 . PHC models restricted to small doctor-focused services, which in Brazil are more common in supplementary health 25 , may be more fragile in these situations due to the high risk of contagion of their professionals and less integration with the structure public health. Some aspects addressed in the articles could be better studied and implemented in the context of the FHS, in order to enhance their results.…”