Primary Health Care Reform in the city of Rio de Janeiro began in 2009 with the approval of the legal framework for the implementation of a new administrative model governance and management support from their municipal units. It has been developed in some axes involving changes in management model and health care. The coverage of the Family Health Strategy (FHS) by December 2008 was around 3.5%. From this year, a radical change in health management at the local level was initiated. Strong emphasis was given to primary health care, through the encouragement of the Family Health Strategy, coming to the end of the year 2015 at a coverage of about 50% of Rio, exceeding three million people registered and monitored by the Family Health Teams (FHT). .
This impressive program was built on firm founding principles, which many countries and states can learn from. It required political will (evident from the time of the relevant constitutional reforms of 1988); a clear commitment to reducing sociodemographic health inequalities, by prioritizing services for the more deprived communities; emphasizing the need to make partners of the individuals, families, and leaders of communities where the clinics are based; taking seriously the principles of preventive care and health literacy, by going beyond vaccination and family planning programs into educational and social interventions; and aiming to reduce hospital use by early diagnosis and referral management. All these mean that Rio has moved much closer to universal health coverage, and – like other parts of Brazil since the FHS reforms - have seen significant falls in morbidity and mortality, especially among the under 5s.
The Family Clinics have also taken an important step to raise standards of health care, and to strengthen the skills and attitudes of the medical workforce. They provide centers for training health care staff, and particularly encourage residents and students to become more aware of how primary health care is both an enjoyable and worthwhile setting in which to work. The training of family medicine specialists in Rio is becoming one of the many strengths of the municipality’s reforms – encouraging and enabling bright young doctors to take up a post in clinics which are attractive to work in, and well supported and protected by the presence of other staff and the support of the local community. Although not all doctors working in the FHS are as yet fully qualified as family medicine specialists, this new cadre of staff will in turn inspire others to follow their example, and ensure that the people can get good medical services in one setting, without unnecessary expenditure or delay.
The challenges to Rio in continuing its success are likely to be the same as those in other states and countries – first, ensuring continuing political commitment to the community and primary health sector, which translates into sustained investment and development. This needs knowledge about effective models for health systems financing; clear and unbiased decision making around public-private partnerships; and accountability and governance structures which avoid the risk of corruption and minimize unsafe practice. Also, making services of sufficiently high quality and consistency that the people have faith in them and use them appropriately is important – otherwise cost effectiveness is reduced and outputs deteriorate. This requires the training, resourcing, and retention of a well qualified and motivated workforce, who value their practice scope as generalists, and who advocate both for any unmet health needs of their communities and for the status of the work they carry out. Both these are easy to say, but hard to achieve. As we have found in the U.K., a new government can reverse the principles which have carried a service forward. Rio and Brazil will need to retain a full commitment to the FHS to continue their progress over the next period – but the world will be watching and learning!
- Publication in this collection