Established in 1988, the Unified Health System (SUS) unified the public system by transferring social security resources to states and municipalities. Its principles are universal access, fiscal financing, decentralization, and regional organization guided by primary health care. Financing is the responsibility of the three levels of government, with increasing municipal participation. Total health expenditure is 9.8% of GDP, with 44% public, 29% from private insurance, and 22% out-of-pocket spending. Underfunding has been an obstacle since SUS's creation, as public spending being lower than private constitutes a barrier to the principle of universal access. Governance proposes collegial decision-making between government levels and social participation, but in practice management is still fragmented, influenced by political-party interests and high turnover of managers, making it difficult the build of integrated networks. Nevertheless, the expansion of primary health care through the Family Health Strategy in 5570 municipalities, with 53,000 teams and 280,000 community agents, has had positive impacts. The current agenda of regionalization and expansion of specialized care aims to reduce waiting times, strengthen system legitimacy, and could promote its reconstruction from the ground up. Integrated public-private regulation and structural limits on social spending remain persistent challenges.

Primary health care (PHC) is the basis of the Brazilian Unified National Health System (SUS). After a discontinuity in PHC evaluation policies, the Ministry of Health, with the support of the PHC Research Network of the Brazilian Association of Public Health (Abrasco), carried out the Brazilian National Basic Health Unit Census in 2024. The objective of this article is to present its creation and operationalization. The census methodology was based on a participatory approach, involving several actors, including departments of the Brazilian Ministry of Health, the Brazilian National Council of Health, the Brazilian National Council of Municipal Health Departments, academic institutions, and the Brazilian National Health Council. The data collection instrument was built collaboratively and applied online, using the e-Gestor PHC platform to ensure the institutionalization and security of the data. Nationwide, the operationalization received support in all states, mobilizing managers and professionals. All municipalities adhered to the census, with responses from all 44,938 basic health units (BHU) in Brazil. This success, despite the methodological challenges inherent to online surveys, demonstrates the engagement of the actors involved in strengthening the SUS. The process of preparing the 2024 BHU Census encompasses elements that make it an essential tool to the formulation of more effective, equitable public policies aligned with the principles of PHC and SUS, contributing significantly to the institutionalization of PHC evaluation in Brazil.

A atenção primária à saúde (APS) é a base do Sistema Único de Saúde (SUS). Após um período de descontinuidade nas políticas de avaliação da APS, o Ministério da Saúde, com o apoio da Rede de Pesquisa em APS da Associação Brasileira de Saúde Coletiva (Abrasco), realizou o Censo Nacional das Unidades Básicas de Saúde em 2024. O objetivo do presente artigo é apresentar sua concepção e operacionalização. A metodologia do censo foi pautada em uma abordagem participativa, envolvendo diversos atores, incluindo secretarias do Ministério da Saúde, Conselho Nacional de Secretários de Saúde, Conselho Nacional de Secretarias Municipais de Saúde, instituições acadêmicas e Conselho Nacional de Saúde. O instrumento de coleta de dados foi construído de forma colaborativa e aplicado de forma online, utilizando a plataforma e-Gestor APS para garantir a institucionalização e segurança dos dados. A operacionalização contou com uma ampla rede de apoio em todos os estados, com o intuito de mobilizar gestores e profissionais. O censo obteve adesão de 100% dos municípios, com respostas de todas as 44.938 unidades básicas de saúde (UBS) do país. Esse sucesso, apesar dos desafios metodológicos inerentes a inquéritos online, demonstra o engajamento dos atores envolvidos no fortalecimento do SUS. O processo de elaboração do Censo das UBS 2024 engloba elementos que o qualificam para contribuir para a formulação de políticas públicas mais eficazes, equitativas e alinhadas aos princípios da APS e do SUS, contribuindo significativamente para a institucionalização da avaliação da APS no Brasil.

Resumo: A proposta de universalização da atenção primária à saúde (APS) tornou-se a principal estratégia do governo chileno (2022-2026) de Reforma do Sistema de Saúde, sob os valores da equidade no acesso, qualidade dos cuidados e proteção financeira. O artigo identifica e analisa estratégias relacionadas à “universalização da APS” no que se refere à operacionalização, condução da reforma e medidas para ampliação e qualificação do acesso à APS. Foi realizado estudo de caso, com abordagem qualitativa, com base em entrevistas semiestruturadas com atores-chave, visitas in loco, complementadas por análise documental. A implementação da universalização da APS é apoiada por um Conselho Assessor e Comissões, nas quais se busca garantir o pluralismo político com vistas à governabilidade. Foi iniciada por meio de projetos pilotos, atualmente em 21 “Comunas Pioneiras”, cuja inscrição nos serviços de APS independe do tipo de asseguramento. Entre as estratégias para ampliar e qualificar o acesso à APS destacam-se: horário estendido de funcionamento dos centros de saúde; sistema de gestão remota da demanda; diretrizes para o manejo integral e integrado de condições crônicas com “atenção por duplas” e o “plano de cuidados consensuados”; “diálogos cidadãos” e cartografia dos ativos comunitários para fortalecer a participação social. No Chile, pós-derrota da proposta de Constituição em 2022 e em um contexto condicionado por conflitos políticos, baixa governabilidade, direcionalidade neoliberal das políticas públicas prévias, a universalização da APS emergiu como possível, consensual e sem resistências importantes, ganhando destaque frente à impossibilidade de reformas estruturais no sistema de saúde, que permanece dual.

Ensaio sobre a trajetória e desafios persistentes da Estratégia Saúde da Família (ESF) no Brasil, a partir de inquietações quanto às perspectivas para plena implementação desta abordagem de atenção primária à saúde de base territorial e orientação comunitária no Sistema Único de Saúde (SUS). Examina a trajetória de expansão e revisita criticamente os principais marcos institucionais da ESF nestes 30 anos, destacando a indução financeira federal associada ao processo de municipalização; ampliação da mutiprofissionalidade no trabalho desenvolvido nas unidades básicas de saúde (UBS) e territórios; indução da qualidade articulada à avaliação da estrutura e processo das equipes e transferências financeiras associadas ao desempenho; e provimento emergencial de médicos em áreas desassistidas, associado à formação profissional. Sintetiza repercussões da expansão da cobertura da ESF e da adoção de práticas centradas em pessoas, famílias e comunidades sobre a saúde e o acesso. Retrocessos, entre 2016 e 2022, com restrições à multiprofissionalidade abordagem comunitária e ameaças à universalidade e integralidade são abordados criticamente, bem como a retomada, pelo Governo Federal, da prioridade para a ESF a partir de 2023. Dados do Censo Nacional das UBS 2024 ilustram a situação atual resultante desta trajetória. Na análise dos desafios para a efetiva mudança no modelo assistencial e universalização da ESF, destaca-se suficiência do financiamento; estabilidade funcional, formação e trabalho colaborativo interprofissional; os riscos de mercantilização na atenção primária à saúde (APS); coordenação do cuidado e rol da APS na regulação assistencial e; as desigualdades geográficas, sociais e étnico-raciais no acesso.

The proposal for the universalization of primary health care (PHC) has become the main strategy of the Chilean government (2022-2026) for reform of the healthcare system under the values of equity in access, quality of care, and financial protection. The article identifies and analyzes strategies related to the universalization of PHC with regards to operationalization, reform, and measures to expand and qualify access to PHC. A case study was carried out with a qualitative approach based on interviews with key actors during on-site visits complemented by documental analysis. The implementation of the universalization of PHC is supported by an advisory council and commissions that seek to ensure political pluralism with a view to governability. It was initiated through pilot projects currently in 21 "pioneer communes". The following strategies to expand and qualify access to PHC stand out: extended office hours at health centers; remote demand management system; guidelines for the comprehensive management of chronic conditions with "care by pairs" and a "consensual care plan"; "citizen dialogues" and mapping of community assets to strengthen social participation. After the defeat of the proposed Constitution in 2022 and in a context conditioned by political conflicts, low governability, and the neoliberal directives of previous public policies in Chile, the universalization of PHC emerged as possible, consensual, and without substantial resistance, gaining prominence in the face of the impossibility of structural reforms in the healthcare system, which remains polarized.

Instituido en 1988, el Sistema Único de Salud (SUS) unificó el sistema público mediante la transferencia de recursos del seguro social a los Estados y los municipios. Sus principios son acceso universal, financiación fiscal, descentralización y organización regional orientada por la atención primaria de salud. La financiación es responsabilidad de los tres niveles de gobierno, con creciente participación municipal. El gasto total en salud es del 9,8% del producto interior bruto, siendo el 44% público, el 29% de seguros privados y el 22% gasto directo. La infrafinanciación ha sido un obstáculo desde la creación del SUS, pues el gasto público menor que el privado constituye una barrera al principio de acceso universal. La gobernanza propone decisiones colegiadas entre niveles de gobierno y participación social, pero en la práctica la gestión es aún fragmentada, con influencias político-partidistas y alta rotación de gestores, lo que dificulta construir redes integradas. No obstante, la expansión de la atención primaria de salud mediante la Estrategia Salud de la Familia en 5570 municipios, con 53.000 equipos y 280.000 agentes comunitarios, ha generado impactos positivos. La actual agenda de regionalización y expansión de la atención especializada busca reducir los tiempos de espera y reforzar la legitimidad del sistema, y podría llegar a favorecer su reconstrucción desde la base. Una regulación público-privada integrada y unos límites estructurales al gasto social son desafíos persistentes.

This essay examines the trajectory and persistent challenges faced by Brazil’s Family Health Strategy (FHS), stemming from concerns regarding the prospects for the full implementation this territory-based community-oriented approach to the delivery of primary health care within the Brazilian Unified National Health System. We look at the development of the strategy and provide a critical overview of the main institutional milestones over the last 30 years, focusing on the following: federal funding associated with the process of the municipalization of care; the expansion of multidisciplinarity in the work of health professionals in basic health units (BHU) and the local community; improvements in quality associated with the evaluation of team structure and work processes and performance-based funding; and emergency medical staffing in underserved areas and professional training. We outline how the expansion of FHS coverage and the adoption of practices centered on individuals, families and communities has impacted population health and access to care. Setbacks between 2016 and 2022 are critically addressed, including the undermining of the multidisciplinary community-based approach and threats to universality and comprehensiveness. We then go on to discuss the reprioritization of the FHS by the Federal Government in 2023. Data from the 2024 national BHU Census are used to illustrate the current status of the FHS. Challenges to implementing effective change in the care model and achieving universal FHS coverage include the following: ensuring adequate funding, employment stability, professional training and interprofessional collaboration; addressing the risks of commodification in primary health care (PHC); improving coordination of care and the strengthening the role of PHC in patient access management; and reducing geographical, social and racial inequalities in access to care.

The structural typology of PHC units was drawn up based on the results of the 2024 National Census of PHC units, and the results were compared with those of 2012. Types of teams, diversity of professionals, shifts, available services, and facilities and supplies were used as the sub-dimension categories. A reference standard was set for each sub-dimension and a standardized score was calculated, with 1 being the best. Of the 44,938 PHC units that took part in the Census, 43,209 presented complete information on the variables and were analyzed. The final average score was 0.878, which proved to be 20% higher than in 2012. The sub-dimension with the worst score was "types of teams", and the best was "shifts". The units were grouped according to their final score from best to worst: A, B, C, D, E. All regions increased the percentage of PHC units in groups A and B, especially the North and Northeast. Type A was observed in 21.3% of the PHC units, a 4.4-fold increase, when compared to 2012. Advances in infrastructure conditions, shifts, and the increased presence of doctors indicate the effects of policies aimed at expanding access to PHC. However, essential components for comprehensive PHC still deserve attention, such as the presence of a sufficient number of Community Health Workers (CHWs), universal dispensing of medicines, and equalization between oral health teams and family health strategy (FHS) teams.

Analisam-se as práticas desenvolvidas por enfermeiras em equipes de saúde da família (EqSF) de municípios rurais remotos. Trata-se de um estudo de casos múltiplos, com abordagem qualitativa, realizado por meio de 52 entrevistas semiestruturadas com enfermeiras de 27 municípios rurais remotos distribuídas entre 10 estados. De acordo com os resultados, as enfermeiras destacaram-se, com poucas especificidades entre os municípios rurais remotos, por desenvolverem um escopo variado de competências em atividades gerenciais, práticas assistenciais individuais e ações no território. Independentemente dos obstáculos impostos ao atendimento das EqSF em todos os municípios rurais remotos, sobressaiu-se a articulação das enfermeiras na busca por contornar as adversidades, restabelecer fluxos para os usuários e minimizar ao máximo a desassistência. As enfermeiras, em todos os municípios rurais remotos, buscavam restabelecer o vínculo comunicacional e viabilizar a continuidade do cuidado das pessoas que necessitavam de alguma assistência fora da atenção primária à saúde (APS). De forma unânime, nenhuma enfermeira estabelecia uma interlocução entre o saber popular e as ações biomédicas das práticas consolidadas na APS, ainda que reconhecessem a diversidade cultural e étnica que povoava os territórios. Em síntese, as enfermeiras nos municípios rurais remotos buscavam driblar as adversidades comunicacionais e forjavam, ainda que limitadas, práticas sensíveis às demandas das pessoas e da comunidade.

Objective: To explore the opportunities and challenges of shared care in primary healthcare from the perspectives of physicians, nurses, and key stakeholders, with the aim of reflecting on the implementation of Advanced Nursing Practice. Methods: This is an exploratory study with a qualitative approach carried out with primary care physicians and nurses (working in the states of Paran & aacute; and Rio de Janeiro) and representatives of associative entities of both professional categories (at regional and national levels). Three online focus groups and one in-person focus group were held in 2022, with a total of 29 participants. Content analysis was performed according to Bardin. Results: Professionals report that they already provide shared care, alternating consultations between physicians and nurses in the areas of childcare and prenatal care and chronic conditions and elderly care, thereby enhancing the overall quality of care. They identified that shared care is more harmonious in units with multiprofessional medical or nursing residences. They reflected that restrictions on shared care are promoted by power asymmetries between physicians and nurses, which can be deconstructed over time. They also emphasized the importance of better understanding each professional's role, naming work overload as a particular challenge. Conclusion: The activities currently shared between nurses and physicians in primary healthcare lay the groundwork for the implementation of Advanced Nursing Practice. However, it is essential to deepen the understanding of this practice among these professionals and optimize the conditions for its effective execution.

Practices developed by nurses of family health teams (FHTs) in remote rural municipalities were analyzed. A multiple case study with a qualitative approach was conducted through 52 interviews with nurses from 27 remote rural municipalities distributed across 10 states. With few specificities among the remote rural municipalities, nurses stood out for developing a broad range of skills related to management activities, individual care practices, and actions in the local community. Irrespective of the obstacles to care faced by FHTs, the work of nurses stood out in all remote rural municipalities to overcome adversities, reestablish patient flow, and minimize the lack of care as much as possible. In all remote rural municipalities, nurses sought to reestablish the communication link and enable the continuity of care for individuals who required assistance outside primary care. None of the nurses established dialogue between folk knowledge and the biomedical actions of the practices established in primary care but recognized the cultural and ethnic diversity in the local communities. In summary, nurses in the remote rural municipalities sought to overcome communication difficulties and forged - although in a limited way - practices sensitive to the needs of individuals and the community.

Resumo Objetivo Compreender as possibilidades e obstáculos ao cuidado compartilhado na atenção primária à saúde sob a perspectiva de médicos, enfermeiros e pessoas chave com vistas a reflexão sobre a implementação da prática avançada de enfermagem. Métodos Estudo exploratório de abordagem qualitativa realizado com médicos e enfermeiros da atenção primária (atuando nos estados do Paraná e Rio de Janeiro) e representantes de entidades associativas de ambas categorias profissionais (em nível regional e nacional). Foram realizados três grupos focais online e um grupo focal presencial, em 2022, com um total de 29 participantes. A análise de conteúdo foi realizada segundo Bardin. Resultados Os profissionais mencionaram já realizar cuidado compartilhado, intercalando consultas entre médicos e enfermeiros nas áreas de puericultura e pré-natal e nas condições crônicas e atenção aos idosos, potencializando o cuidado. Eles identificaram que esse cuidado é mais harmônico em unidades com residências multiprofissionais médica ou de enfermagem. Refletiram que as restrições a essa expansão são condicionadas por assimetrias de poder entre médicos e enfermeiros que poderão ser desconstruídas ao longo do tempo. Eles também destacaram a importância de melhor conhecer as funções de cada profissional referindo a sobrecarga de trabalho como um desafio. Conclusão As atividades atualmente desenvolvidas e compartilhadas entre enfermeiros e médicos na Atenção Primária à Saúde possibilitarão implementar a prática avançada de enfermagem. Porém, é necessário ampliar o entendimento sobre essa prática entre esses profissionais e otimizar as condições para seu exercício efetivo.

Aim To explore the enablers of and barriers to implementing advanced practice nursing in primary health care in Germany and Brazil.Design A qualitative cross-country comparative study.Methods Nine focus groups were conducted: 4 in Brazil and 5 in Germany with 48 participants (23 primary health care policy stakeholders and 25 nurses practicing in primary health care and general practitioners) between May 2022 and June 2023. The data were analysed by content analysis using a deductive-inductive approach.Results Our findings reveal a need for clarity around the concept, specific roles and responsibilities of advanced practice nurses in primary health care. Although there is still no regulation in place for practising advanced practice nursing in either country, clear drivers can be observed, with Germany strengthening community health nursing and Brazil following clinical protocols in nursing practice. Dialogue among stakeholders-at both the policy and practitioner levels-is essential to bridge communication gaps. Additionally, involving patients in the implementation process is crucial for the holistic integration of advanced nursing roles.Conclusions Political, organisational and financial barriers persist, such as the need to establish both legal foundations and regulatory frameworks, enhance political participation within the nursing profession, and involve stakeholders in dialogue and consensus-building efforts. Giving advanced practice nursing a higher priority on political and research agendas-with policy adjustments and input from practitioners-can help integrate advanced practice nursing into primary health care.Implications for the Profession and/or Patient Care Our findings highlight that actively involving nursing as an equal partner in political discourse is seen by stakeholders as crucial to drive the implementation process forward sustainably.Impact This study addresses the lack of data on the enablers and barriers to implementing advanced practice nursing in primary health care in Germany and Brazil. It underscores the need for clearer definitions of advanced practice nursing in primary health care, as well as sufficient regulation and funding. Dialogue is essential to bridge gaps and foster mutual understanding. The findings support future practice development and research, especially in countries that have introduced advanced nursing practice roles in primary health care.Reporting Method The COnsolidated criteria for REporting Qualitative research (COREQ).Patient or Public Contribution No involvement of patient and public contribution.What Does This Paper Contribute to the Wider Global Clinical Community? Our study highlights the growing adoption of expanded nursing responsibilities even in countries that have not yet formally implemented advanced practice nursing roles.