By Clara Rosa Guimarães, CSP journalist
The new Debate published in Cadernos de Saúde Pública (CSP) brings together public health researchers and managers to discuss the 30-year history of the Family Health Strategy (ESF), considered one of the key public policies for strengthening primary health care in Brazil. Comprising a main essay, expert commentaries, and a final rejoinder from the authors, the Debate revisits the ESF’s historical trajectory, its advances, persistent challenges, and prospects for the future of the Unified Health System (SUS).
In the main article, “30 Years of the Family Health Strategy in the Unified Health System: milestones, advances, setbacks, and challenges,” researchers Lígia Giovanella and Maria Helena Magalhães de Mendonça—leading the CEE-Fiocruz Integrated Project on Primary Care within the SUS Network—along with Estela Márcia Saraiva Campos, Ana Luiza Queiroz Vilasbôas, Rosana Aquino, and Luiz Augusto Facchini, critically analyze the trajectory of the Family Health Strategy (ESF) since its implementation in 1994. The text highlights initiatives that marked its expansion, such as the incorporation of oral health services, the Family Health Support Centers (NASF), the Mais Médicos Program, and policies to improve the quality of primary care. The authors also discuss the impact of expanded ESF coverage on access to health services and the living conditions of the Brazilian population, while addressing setbacks observed between 2016 and 2022 and current challenges regarding the model’s consolidation. According to the researchers, there is an urgent need to “fill gaps in care provision, incorporate technology to enhance the problem-solving capacity of quality primary care, improve network organization and integration, and ensure adequate, sustainable funding.”
The commentaries accompanying the debate delve into various dimensions of the ESF’s trajectory. Dirceu Klitzke highlights the institutional capacity built over three decades, stating that preserving the core family health team was a key factor in the policy’s continuity, despite changes in government and disparities among municipalities. For the author, strengthening primary care depends on expanding support structures, integrating care across levels, and addressing social, racial, and territorial inequalities.
Meanwhile, James Macinko emphasizes the collective and historical nature of the ESF’s development, attributing its endurance to the ongoing efforts of professionals, managers, researchers, and advocates of the SUS. In his commentary, he states that “the vision of the ESF remained deeply rooted in the humanitarian and egalitarian spirit of Alma-Ata,” even amidst political, economic, and health crises. The researcher also draws attention to persistent challenges, such as underfunding, the unequal distribution of professionals, and health inequities.
In another contribution, Luciano Bezerra Gomes offers a critical reflection on the very foundations of the Family Health Strategy (ESF). The author questions the extent to which the ESF has actually succeeded in shifting the Brazilian care model, or whether it remains a contested project within the field of collective health. In his view, understanding the strategy’s limitations and challenges requires examining not only its implementation but also the political and conceptual conflicts that have shaped its formulation over the past three decades.
Commentaries by Natalia Houghton and Ernesto Bascolo, as well as by Claunara Schilling Mendonça and Ana Luiza Ferreira Rodrigues Caldas, broaden the debate regarding care coordination, the integration of care networks, and the institutional sustainability of the ESF. The authors highlight the need to strengthen governance, financing, and regulatory mechanisms that ensure the continuity of principles such as territory-based primary care, equity, and community-based care. They also point to the importance of telehealth, reducing team workloads, and providing technical support to small municipalities and remote areas.
In the final rejoinder, the authors of the original essay engage with the discussants and reinforce that the consolidation of the Family Health Strategy depends on strengthening its core principles: social participation, a territorial and community-based approach, network integration, professional valuation, and the reduction of social and ethno-racial inequalities. While acknowledging the commentators’ contributions, the authors state that the ESF’s 30-year history reveals a process marked simultaneously by progress, contention, and heterogeneity; however, they reiterate the need to “persevere in the implementation and universalization of the ESF care model” as a central strategy for guaranteeing the right to health within the Unified Health System (SUS).