1. Primary health care in Brazil: Assessment and recommendations

While Brazil has expanded its cancer care system, population coverage remains low

To tackle the burden of cancer, Brazil has developed its cancer care system incrementally over the past decades. It launched the first National Oncology Care Policy in 2005 and set its Strategic Action Plan for Coping with Chronic Non-Communicable Diseases 2011-22, demonstrating its commitment to reducing the burden of cancer. It introduced the National Policy for the Prevention and Control of Cancer in the Health Care Network of People with Chronic Diseases in 2013 to update the national cancer policy and improve access to cancer care. Brazil has also sought to implement quality improvements in its cancer care system by establishing in 2013 the Cancer Information System (SISCAN), which integrates the Cervical Cancer Information Systems (SISCOLO) and the Breast Cancer Information Systems (SISMAMA). Clinical guidelines for early detection of breast cancer were updated in 2015, and national guidelines for cervical cancer screening in 2016. More importantly, Brazil introduced the PAINEL-Oncology instrument, which helps monitor Law No. 12.732 of 22 November 2012 establishing a 60-day maximum waiting time for the start of treatment for patients with proven malignant neoplasia. While PAINEL-Oncology is key to guarantee access to high-quality cancer care in Brazil, the data presented refer exclusively to users who have a national health card (DATASUS, 2021[8]). Brazil has also developed 17 population-based cancer registries, which provide crucial information about incidence, trends and survival (INCA, 2013[9]).

However, cancer screening in Brazil is opportunistic, managed by each FHT as a result of a recommendation made by a health care provider during a routine medical consultation, or through individual self-referral. Brazil needs to step up its efforts to increase breast cancer screening coverage, notably to improve early diagnosis and reduce mortality. Unlike in many OECD countries, cancer screening does not occur within a population-based programme designed and managed at the central level to reach the bulk of the population at risk. As a result, while coverage for breast cancer screening in Brazil increased from 15.2% in 2014 to 24.2% in 2019 among the target group of women aged 50 to 69 years, it remains very low compared to the OECD average of 58%. Between 2008 and 2019, breast cancer mortality increased by 8.3% in Brazil, whereas it decreased by 10% on average across OECD countries. Breast cancer takes the greatest toll on Brazilian women, with 20.8 deaths per 100 000 females, representing 16.4% of all women’s cancer deaths. Moreover, breast cancer survival dropped by more than two years in Brazil between the 2005-09 and 2010-14 periods, whereas it increased by one year in the OECD region. The lack of availability of mammographs, and their uneven distribution across the country, are major problems contributing to late diagnosis of breast cancer in Brazil (Da Costa Vieira, Formenton and Bertolini, 2017[10]). In 2020, Brazil had 13 mammographs per million people, almost half the OECD average of 24.

In a similar vein, cervical cancer screening in Brazil has substantially risen (from 20.5% in 2014 to 37% in 2019), yet it remains well below the OECD average coverage (57%), and below all OECD countries except Costa Rica and Hungary. Worrying evidence points to large social inequalities: access to cervical cancer screening is particularly low among women living in the North, Northeast and Central-West regions, and those with low socio-economic backgrounds (including poorer, less educated, non-white and younger women) (Costa et al., 2018[11]). Cervical cancer mortality in 2019, for its part, was substantially higher in Brazil than the OECD average (7.4 deaths vs. 3.9 deaths per 100 000 women), and cervical cancer survival in Brazil decreased by 11.3% between 2000-04 and 2010-14.

These worrisome trends suggest large room for improvement in Brazil, including through a national strategy for cancer prevention and screening.

Towards population-based screening programmes using a more systematic and personalised approach

In the area of prevention of cervical cancer, the National Immunisation Programme instituted in 2014 the human papillomavirus (HPV) vaccination campaign for girls aged 9 to 13, then expanded to boys aged 11 to 14 in 2017. Following the same trend as in OECD countries, the vaccine is offered under Brazil’s Unified Health System (SUS) in PHC facilities and in the context of school-based vaccination campaigns. Cervical cancer screening is performed through a cytopathological examination (Pap smear), offered to women aged 25 to 64 years and repeated every three years. While the three-year periodicity is aligned with World Health Organization (WHO) recommendations, Brazil could learn from OECD countries and move towards a population-based screening programme while introducing HPV-DNA primary testing. This approach is taken internationally (e.g. in Italy and Finland) and recommended by international guidelines, including the European guidelines and American Cancer Society 2020 guidelines. Its implementation would require use of reliable, validated HPV tests in qualified laboratories, accredited by authorised bodies (such as the National Agency of Sanitary Surveillance [ANVISA]) and complying with international standards. Training for health workers is crucial, along with communication strategies for women in target populations. Such a national strategy should include quality assurance for monitoring cervical cancer screening performance, which the European guidelines define as achieving: (1) an invitation coverage of at least 95% of targeted women; (2) an examination coverage of at least 70% (85% is desirable); and (3) a participation rate of at least 70% (85% is desirable) (von Karsa et al., 2015[12]).

In the area of breast cancer, the Brazilian Ministry of Health recommends a biennial mammogram for women aged 50 to 69 years old as a screening strategy in PHC. Brazil could go beyond this recommendation and develop a population-based breast cancer screening programme, as implemented in several OECD countries (e.g. Australia, France or Portugal). In practice, this would require implementing an effective call-recall structure, devising a screening registry and safeguarding robust quality assurance at all levels. The window of opportunity is large today with the implementation of the Previne Brasil strategy, which will improve patients’ registration with FHTs. Brazil could take advantage of the patient registration system to develop organised screening programmes that allow identifying the eligible target population in each municipality. The establishment of an organised breast cancer screening programme will require building capacity in primary care teams, including providing health professionals with guidelines and protocols on cancer signs and symptoms to improve diagnostic accuracy, giving them sufficient time to evaluate patients, and training practitioners in how to diagnose cancer and develop reliable referral mechanisms. At the same time, the distribution of mammographs across the country will need to be revisited to achieve a balanced supply matching population needs.

Population-based programmes can go hand in hand with personalised invitations. In this regard, Brazil could adopt a more systematic and personalised approach to inviting target populations. A growing number of OECD countries send a personal invitation letter for cancer screening, systematically issued through a registry, to each individual in the target group. Brazil has no such national initiative, and invitations are only issued at some local levels, depending on the initiative of individual municipalities or FHTs. By contrast, Denmark, Germany and Italy send invitation letters with a fixed appointment date for a mammography. Based on the available evidence, the most effective interventions to increase participation in organised screening programmes include postal and telephone reminders, the primary care physician’s signature on the invitation letter and the provision of a scheduled appointment instead of an open appointment (Camilloni et al., 2013[13]). A cost-effectiveness analysis would need to be performed to determine the appropriate interventions in the Brazilian context.

Brazil should develop more systematic monitoring of cancer while using digital health to improve public awareness and health literacy

While Brazil has expanded its cancer information infrastructure (notably with SISCAN, PAINEL-Oncologia and the population-based cancer registry), the main challenges are low coverage, low interconnectedness and lack of feedback. Brazil needs a more comprehensive registry-based information system capable of following each patient individually, to ensure efficient management of screening programmes and cancer care delivery. Such a system is key to identifying target populations and sending personalised invitations and reminders for cancer screening. At the same time, the effectiveness of existing cancer screening protocols in Brazil – such as target groups, screening frequency, methods and cross-population groups – needs to be more systematically assessed. This entails developing integrated information systems to improve the quality of screening programmes, notably through performance benchmarking and feedback to health providers. In fact, provider assessment and feedback have been found to increase coverage for cervical, breast and colorectal cancer screening (Sabatino et al., 2012[14]).

Brazil should also develop further digital health strategies to improve public awareness of cancer prevention, cancer screening and health literacy. The Ministry of Health has implemented some actions since 2002, such as the October Pink Campaign aiming to promote prevention and healthy lifestyles, and overcome the fear or stigma associated with cancer. At the local level, municipalities promote screening through campaigns using local media and social networks. Some good initiatives are also implemented at municipal levels through the deployment of units to reach very remote and vulnerable communities, and increase access to screening, diagnosis and treatment.

While all these strategies are valuable and should be maintained, Brazil could also develop more effective communication strategies and education programmes to improve health literacy. Local stakeholders, such as health care providers and civil society representatives, should also be consulted to identify specific barriers to screening and address specific needs, particularly among disadvantaged populations (i.e. remote, poor and less educated people). As systematic sharing of information related to cancer is limited – particularly for cancers that are not subject to screening programmes – Brazil could also develop information-sharing strategies to help patients seek care, including cancer diagnostic services. Brazil could learn from Denmark, England and Estonia, which have developed website or e-health platforms that share evidence-based information on cancer, to promote health literacy and help patients seek appropriate and timely health care, including cancer screening, diagnosis and treatment.

Diabetes and hypertension care are improving

In Brazil, as in many OECD countries, diabetes and hypertension are leading causes of morbidity, associated with significant co-morbidities and expenditures. The total mortality of patients with diabetes and hypertension has been falling in Brazil: diabetes mortality decreased by 9.8% between 2007 and 2019, and hypertension prevalence decreased by 5.3% between 2005 and 2015. Low rates of avoidable admissions for diabetes and hypertension in Brazil also suggest relatively good management of these conditions in PHC: in 2019, the rate of hospital admissions for diabetes was 92 patients per 100 000 people (below the OECD average of 130) and 48 patients per 100 000 people for hypertension (less than half the OECD average).

These are all welcome signs of improved prevention and care for diabetes and hypertension. Nevertheless, the available evidence indicates that the diabetes mortality burden will increase by 144% by 2040, becoming the third leading cause of death (Duncan et al., 2020[15]). Hypertension also became the leading risk factor for deaths in 2017 (Nascimento et al., 2020[16]). Given these trends, more efforts are needed to strengthen diabetes and hypertension prevention in the context of PHC. In Brazil, basic health checks and risk screening for chronic diseases rely on FHTs and are predominantly done through opportunistic screenings during health visits. The Ministry of Health has issued several guidelines relating to chronic non-communicable diseases. Screening for hypertension is recommended for adults without the knowledge that they are hypertensive. It suggests screening every two years for people with blood pressure below 120/80 millimetres of mercury (mmHg) and annual screening if systolic blood pressure is between 120 and 139 mmHg or diastolic blood pressure between 80 and 90 mmHg. For diabetes, the guideline recommends screening for asymptomatic adults with sustained blood pressure greater than 135/80 mmHg, but does not apply to other screening criteria, such as obesity, family history or age range. Specific booklets (Cadernos de atenção básica) for the management of hypertension and a recent protocol for diabetes also provide guidance for PHC practitioners.

Brazil has sought to improve the quality of diabetes and hypertension care, notably through the PMAQ pay-for-performance system, launched in 2011. As part of PMAQ, the evaluation of FHTs included topics such as early detection of hypertension, laboratory exams for diabetes and prescription refills for users on continued care (e.g. for hypertension and diabetes), without the need to make medical appointments. However, the pay-for-performance component of the new Previne Brasil programme only includes two indicators related to hypertension and diabetes; these only cover follow-up of patients who already have the diseases, and do not address prevention in PHC. It will therefore be paramount in the future to monitor how the new programme influences screening activities for hypertension and diabetes in PHC.

Brazil could learn from OECD countries such as Australia, Estonia, Korea and England that have instigated population-based screening programmes targeting high-risk populations. In Australia, for example, PHC physicians can provide a single health assessment for people aged 45-49 who present at least one risk factor (lifestyle habit or family history) for developing a chronic disease, such as type 2 diabetes or heart disease. The WHO Regional Office for Europe also recommends targeting screening in PHC for patients at risk for developing diabetes or hypertension. If Brazil wants to move in this direction, it will be important to ensure that programmes target high-risk population groups, based on the country’s national epidemiology, the characteristics of the health system and a cost-effectiveness analysis.

Improved disease-management pathways and increased workforce capacity in primary health care are essential to better screening and disease management

Chronic disease-management pathways are critical to delivering seamless co-ordinated care for chronic patients. Widely used in some OECD countries to improve care integration and co-ordination, they are associated with cost reductions and better quality of care. In Brazil, the development of two clinical guidelines with explicit pathways of care to guide health professionals in PHC are the only attempts to promote care co-ordination. However, these guidelines do not integrate other care providers or stakeholders (e.g. specialists or patient-support groups) and are not produced in a patient-friendly format.

Brazil should promote disease-management pathways with a people-centred perspective to clearly establish the responsibilities of health professionals at different stages of disease, set quality expectations for chronic diseases such as diabetes and cardiovascular disease, and standardise the quality of care across Brazil. As seen in OECD countries, co-ordinated management approaches enable PHC teams and individual patients to take appropriate actions to manage diabetes and hypertension. Brazil should also ensure that pathways integrate all health care providers across different sectors.

PHC professionals should have the tools and capacities to undertake these responsibilities and tasks. There is scope in Brazil to build capacity for screening and management of hypertension and diabetes through task-shifting or expanding the role of other health workers, including nurses, nutritionists and pharmacists. Nurses could have the capacity and training to conduct an initial patient assessment, including blood-sugar testing in all practices, and collaborating with doctors and other team members in follow-up activities. The benefit of nurse-led-care has already been demonstrated (Maier, Aiken and Busse, 2017[17]; Martínez-González et al., 2015[18]).

Last but not least, integrated patient pathways require adequate payment systems to incentivise multiple health professionals to work together. Brazil could consider experimenting the use of bundled payments for chronic conditions. As implemented in several OECD countries (i.e. the Netherlands, Australia and Canada), bundled payments consist of one payment per patient with a chronic illness to cover the cost of all health care services extended by the full range of providers during a specific time period. Such a system has the potential to incentivise co-ordination of care between providers and ensure a broader range of care. While Brazil has already taken steps to improve PHC funding through weighted capitation, that payment model is not likely to spur care co-ordination and integration for diabetes and hypertension.

Improving the data infrastructure underpinning diabetic and hypertension care should be a priority

Brazil has developed Hiperdia, a specific registration and monitoring system for hypertensive and diabetic patients, which is managed by the Ministry of Health in conjunction with the State and Municipal Health Secretariats. Through Hiperdia, municipalities that are members of the National Pharmaceutical Assistance Programme for Hypertension and Diabetes Mellitus send information on the registration and monitoring of patients with these diseases. Remarkably, all this information is processed and made available by DATASUS, the health data infrastructure and information system of the Ministry of Health. However, Hiperdia does not collect information on screening, nor is it capable of capturing the pathway of care for each patient (referrals, waiting times, consultations with specialists, laboratory tests and medications). It is also difficult for FHTs to review and act on this information as they do not receive regular feedback, and patients do not have access to their personal health data. There are also some problems linking data with other databases, such as hospitalisation and death registries.

Improving the data infrastructure by linking different data sources should therefore be a priority in Brazil, to help patients and health professionals identify shortcomings and further fine-tune prevention strategies. Health information systems should be expanded so that they provide more and better information to both PHC teams and patients, thereby improving clinical management decisions in primary care and empowering patients to take a leading role in their own prevention and control actions. Data should be systematically fed back to practitioners, and should be used to identify risks or shortcomings. Brazil could learn from OECD countries in developing a strong health information system within a data-governance framework that protects the privacy of patients’ health information, as laid out in OECD (2019[19]). A stronger information system would also be crucial to streamlining efforts to identify and invite target populations for hypertension and diabetes screening.

The MDP has been successful in strengthening the provision of PHC services in underserved communities

Established in 2013, the MDP is a large-scale health system intervention aiming to strengthen the provision of PHC services in underserved communities. The MDP was designed by the Ministry of Health as a supply-side intervention featuring three objectives: 1) transferring funds to municipalities to strengthen the PHC infrastructure; 2) improving access to and the quality of medical school training; and 3) recruiting Brazilian and foreign physicians to municipalities struggling to recruit and retain doctors. Based on the available evidence, the programme has been successful. Good progress has been made with regard to investing in and renovating the PHC infrastructure, expanding the number of new medical undergraduate vacancies in PHC, and recruiting more than 16 000 physicians from both Brazil and abroad to work exclusively within FHTs. By its fifth year of implementation, the MDP was associated with a 12.2% increase in the number of PHC physicians, with more pronounced effects in municipalities featuring lower levels of physician availability at the start of the programme (Hone et al., 2020[2]). The evidence also mostly suggests that the MDP led to improved access to care and quality of care, as measured by reductions in avoidable hospitalisations for some chronic conditions (Fontes, Conceição and Jacinto, 2018[20]).

While these results are remarkable, the implementation of the MDP has not been without drawbacks. First, there is evidence that the MDP led to the substitution of Brazilian physicians who were already working in communities. Second, only three-quarters of priority municipalities have at least one MDP physician, meaning that community-targeting methods were insufficient to recruit physicians for all priority municipalities. Third, MDP physicians did not have to undergo recertification or revalidation to practise medicine in Brazil. It is also fair to note that despite these positive results, unfilled PHC positions are still the norm in Brazil, with persisting geographic disparities in access to medical training. The North and Northeast regions offer the lowest levels of per capita medical undergraduate positions in the country.

The new Programa Médicos pelo Brasil, initiated in 2020 by the federal government to replace the MDP, will continue to increase the provision of medical services in remote or highly vulnerable municipalities as well as promote the training of doctors specialising in FCM. To avoid repeating mistakes, the experience of the MDP can inform the design and implementation of the Programa Médicos pelo Brasil. The federal government should focus on community-targeting methods to maximise the recruitment of physicians for all priority municipalities. It should also ensure that the new programme does not lead to a substitution of Brazilian physicians. The introduction of a compulsory revalidation process for all medical licences and the establishment of a two-year specialty programme in FCM as part of the Programa Médicos pelo Brasil are certainly positive steps for strengthening PHC.

Complementary solutions to recruit and retain the workforce would make the Programa Médicos pelo Brasil more effective

While Brazil already has many complementary solutions to recruit and retain the PHC workforce, it could learn from international experience on health workforce policies:

• First, as part of the new Programa Médicos pelo Brasil, there is scope to train more rural doctors in order to boost numbers and improve retention over the longer term. Extensive international evidence shows that establishing medical education in rural locations leads to increases in the number of medical graduates who will work in rural places over the long term (McGirr, Barnard and Cheek, 2019[21]). Learning from the experiences of OECD countries such as Australia, Canada, England and Norway, Brazil could establish medical education programmes in rural localities. At the same time, it could encourage medical students to gain experience in rural areas, for example, by including a compulsory rural rotation in any medical internship.

• Second, Brazil could make financial and non-financial incentives for medical doctors contingent on practising for a time in underserved communities. As part of the Programa Médicos pelo Brasil, physicians in underserved areas will receive financial incentives ranging from BRL 3 000 to BRL 6 000, depending on the location. As implemented in Chile, Germany and Canada, these incentives could be contingent on a return-of-service obligation of two to four years. The federal government will also need to ensure that the various types of financial incentives are received directly by the medical doctors, and not distributed at the discretion of the municipalities. In Chile, the programme combining financial and non-financial incentives with a return-of-service obligation of three to six years has been successful, with the number of applicants exceeding the number of available positions, high satisfaction rates among applicants and high retention rates among the hired doctors (Pena et al., 2010[22]).

• The final option to redress the geographical imbalance of doctors would be to restrict the choice of practice location for PHC doctors. In this respect, Brazil could learn from Turkey, Germany, Norway or some Canadian provinces (e.g. New Brunswick and Quebec), which restrict the choice of location for newly qualified medical doctors. Such a regulatory approach requires careful and coherent workforce planning, which is far from being the case today. In Brazil, unlike in many OECD countries, there is a lack of knowledge of present and future needs for doctors and other health care professionals (Oliveira et al., 2017[23]). Health care workforce planning is not based on an objective assessment of professionals’ characteristics, work processes, the characteristics of the health system in place and the population’s health needs.

Boosting the local workforce, changing its scope of practice and making greater use of technology are key levers to cope with health workforce shortages

In many low, middle and high-income countries, task-shifting is a key lever to fill the gap in PHC provision stemming from a lack of PHC doctors (Afobali et al., 2019[24]). While extensive international evidence supports the transfer of roles traditionally performed by doctors to nurses and other allied health professionals, Brazil has not yet experimented with changing the scope of practice and task-shifting among health workers such as nurses and community health workers. As implemented internationally (e.g. in Australia and France), Brazil should capitalise on its large existing nurse training network to expand and recognise the role of advanced practice nurses, who could help manage the care of patients with mild acute diseases and chronic disorders, complementing the practising PHC doctors. Alternatively, advanced practice nurses can be deployed in remote and underserved areas to enhance access to qualified health professionals. Such a policy would require a thorough analysis of current nursing curriculums to further invest in core competencies, including team practice, care co-ordination between and across health sectors, clinical and professional leadership, and quality and safety management (Cassiani et al., 2018[25]). In a similar vein, community health workers – who already play a crucial role in PHC provision in Brazil – could play a bigger role, notably by taking a patient’s medical history, conducting basic physical exams, ordering tests and providing counselling on preventive care. This would certainly require investments in training, as well as improved communication between community health workers and other FHT staff.

Improved use of alternatives to face-to-face consultations could be another avenue for coping with PHC doctor shortages and geographical imbalances in Brazil. While telehealth has been used for quite some time, its development and use are patchy. For example, just under 3.5 million telehealth services across all levels of care were registered in Brazil between 2016 and 2019. Of these, 50% occurred in the Southeast, 36% in the South and only 1% in the North, the most deprived region in terms of workforce shortages. A lack of funding, training and equipment for FHTs are factors impeding the use of telehealth services to deliver safe, fast and seamless health care services in Brazil. Scaling up telemedicine in Brazil without compounding existing social divides will require new investment and funding to ensure the effective and equal use of digital technologies in PHC. Brazil will also need to establish a governance structure that better supports municipalities with insufficient resources.

Increasing the credibility and recognition of the primary care specialty is a huge challenge in Brazil

While the Family Health Strategy has made access to PHC a priority, the country has not invested sufficiently in enhancing the credibility and recognition of FCM. Several worrying indicators suggest that the FCM specialty is undervalued and is the last option chosen by physicians: in 2018, only 1.5% of recent graduates chose the FCM speciality among the 55 specialities available. The low degree of academic incorporation and low funding in this research area are factors impeding recognition of the specialty (Wenceslau, Sarti and Trindade, 2020[26]; Fontenelle et al., 2020[27]). And yet they are critical to promoting FCM and encouraging students to choose this specialty as their future career, notably by proving that PHC is not a profession that does not require many qualifications. If Brazil wishes to fill the gap in the PHC workforce, it needs to create academic FCM departments in all medical schools, promote interdisciplinary collaboration with other specialists and encourage mutual respect.

At the same time, making specialty training in FCM compulsory for all medical doctors wishing to practise PHC would be paramount to promote excellence in Brazil, and deliver more effective and patient-centred primary care. The benefits of specialised PHC have already been demonstrated elsewhere (OECD, 2020[28]), notably to address the bulk of patient needs, and provide a stronger focus on prevention and early management of health conditions. Post-training requirements to practise PHC are currently implemented in 22 OECD countries; there is no doubt that such a professionalisation would bring benefits to Brazil.

Last but not least, standardising the contractual arrangements for primary care workers is key to improve the attractiveness of PHC as a profession. Since each municipality defines the level of salaries, bonuses and other payment mechanisms, these arrangements are widely heterogenous across municipalities. Stronger oversight and regulation by the federal government is warranted to ensure consistent salary scales across the country, and it could be important to ensure that smaller municipalities offer similar contracts as larger municipalities. The new Agency for the Development of Primary Health Care could play a role in this regard. Key examples for learning are available internationally. In Turkey, for example, the implementation of the Health Transformation Programme led to family physicians being paid according to national terms and conditions, with more generous salaries and improved working conditions.

Quality measures for medical education should be introduced without delay

While Brazil’s Ministry of Health (in partnership with Ministry of Education) regulates medical education nationwide, more could be done to standardise the medical curriculum. The inadequate academic programme, and the gap in the quality of medical education among medical schools, are areas of concern. To achieve greater standardisation of the medical curriculum and teaching, Brazil could introduce a national test at the end of the university period. The national licensing examination would complement the accreditation performed by the National Institute of Educational Studies and Research Anísio Teixeira (INEP) or the Federal Council of Medicine. The national examination has been increasingly used across OECD countries. The United Kingdom is introducing a nationwide Medical Licensing Assessment, which is overseen and regulated by the General Medical Council and will test the core knowledge, skills and behaviours needed to practise medicine. Brazil could learn from the United Kingdom’s example.

At the same time, Brazil could take further step to promote workforce quality through stronger requirements for CME. Unlike in many OECD countries, CME is voluntary in Brazil. Not only is this insufficient to guarantee a high standard of competencies for PHC doctors, but it also does not ensure their fitness to practise throughout their career. More needs to be done to help medical doctors maintain their competency and acquire new skills. While a number of bodies, such as CONASS, CONASEM, the Brazilian Medical Association or the Brazilian Society of Family and Community Medicine organise trainings to maintain and update competencies, it is impossible to know whether – and how many – PHC medical doctors have undertaken CME. A stronger regulatory approach is required, for example through a formal CME framework that clarifies the expectations placed on PHC doctors and helps them meet these expectations. Brazil could learn from the United Kingdom and the Netherlands, where CME for PHC doctors is compulsory and linked to recertification: PHC physicians need to demonstrate they have regularly participated in CME activities, and undergo peer evaluation of their professional skills. At the federal level, the Agency for the Development of Primary Health Care could set such requirements and monitor providers’ CME compliance. Municipalities could also use the contracting arrangement to actively push PHC doctors to comply with CME requirements and encourage quality improvement. CME requirements should be directed towards the key challenges of the health care system, such as the prevention of risk factors for health (e.g. obesity) and management of chronic conditions (including diabetes).

Focus on fundamental enablers to increase the digitalisation of PHC

While pockets of excellence exist, progress towards effective use of digital technologies in PHC has been slow and fundamentally unequal: 3 600 PHC units across the nation currently have no computers, and 7 200 have no Internet access. Only 17% of PHC units have Internet speeds over 10 megabytes per second (Mbps), limiting simultaneous use of EHR systems and high-quality video consultations, not to mention remote patient monitoring. Additionally, around 18 000 health care facilities (18% of all facilities) do not have an EHR system, with large regional differences in adoption: in 2019, one in four PHC units still maintained clinical records and patient data in paper format only (CGI.br, 2020[34]). Only 40% of primary care managers consider their ICT equipment to be new and up-to-date, and only 32% believe their Internet connection suits their needs. Around one-third of nurses and physicians reported having completed capacity-building courses in health informatics. COVID-19 has likely accelerated digitalisation, but its true impact remains unclear.

A real digital transformation of PHC in Brazil will not happen without setting two foundations. First, the country must ensure a reliable energy supply and fast connectivity for all PHC units, tackling one of the main barriers to digitalisation reported by municipalities during the recent pilot project in Alagoas. Although previous programmes (e.g. Connected Brazil) have been instrumental in expanding broadband connectivity, it is crucial that these initiatives set ambitious and clear targets for both the reliability and speed of connections in PHC units. It is also important to improve co-operation among governmental entities and across the different levels of government (federal, state and municipal) in implementing broadband connectivity initiatives, building on good practices in OECD countries and beyond.

Second, financial payments included in the Connect SUS pilot project in Alagoas should be consolidated and expanded to the entire Brazilian territory. To ensure the funds are used for their intended purpose, receipt of financial support should be tied to participation by municipal and state officials in capacity-building workshops, especially targeting senior executives. Funding should be linked to explicit targets for the adoption and use of EHR systems (like e-SUS AB), including effective electronic drug prescribing and exchange of clinical and administrative data across units. As PHC units go digital, it will be vital to safeguard operational dependence on digital systems by enforcing appropriate cybersecurity.

Ensuring digital uptake and effective use among the most vulnerable and digitally excluded

Even if Brazil were to break down all barriers to the connectivity and digitalisation of PHC units, significant inequalities among citizens in the use of digital technologies and tools would persist. Nearly 47 million Brazilians did not use the Internet in 2019 (more than 20% of the population). Digital divides are clearly associated with social inequalities, with older Brazilians, those from rural areas, those with lower incomes and those with lower education levels less likely to use the Internet, and more likely to use mobile phones only. As a result, there exists a serious risk that a digital transformation of PHC will compound existing social divides.

An effective digital PHC that reaches all Brazilians is only possible if every citizen is not only connected, but also considered in the design of digital PHC services. Brazil should focus on eliminating digital divides as a foundation for effective digital PHC, strengthening the role of telecentres as providers of training – especially in rural and remote areas – and ensuring appropriate funding and technical assistance at all levels of government. Given the importance of mobile phones as a means of accessing the Internet, it should prioritise a multichannel approach focusing on mobile access among vulnerable groups. Although digital PHC content, services and applications should meet the needs of both health workers and patients, they should specifically target citizens with low digital uptake, with continued efforts to expand patients’ access to their personal health information.

Moving from digital PHC strategies to implementation and monitoring

Brazil’s decentralised government creates challenges to digitalising PHC. The country’s single federal district, 26 states, well over 5 000 municipalities (around 44% of which have under 10 000 inhabitants) and 438 health regions have highly heterogeneous demographics, socio-economic indicators and governance structures. With only around 800 inhabitants, the municipality of Serra da Saudade has the same responsibilities in managing the digitalisation of PHC as the municipality of São Paulo, which numbers over 12 million inhabitants. Decentralisation has many benefits, but it is also creating barriers to the digital transformation of PHC in Brazil to meet the targets set in ESD28.

A major barrier to digital PHC in Brazil is human and technical capacity in municipalities. Setting responsibilities for the digitalisation of PHC at the municipal level across Brazil is likely leading to diseconomies of scale and creating challenges for small municipalities. Brazil could look to examples from New Zealand, England and Portugal for a new model of shared services and responsibilities related to the digitalisation of PHC at less decentralised levels. Building on existing institutions (e.g. Co-ordenação-Geral de Tecnologia da Informação e Comunicações/General Co-ordination of Information and Communications Technology) and experiences, Brazil could explore setting up dynamic purchasing systems at the federal level, with appropriately funded agencies at the state or regional levels providing municipalities with specialised human resources, purchasing and management services for digital PHC.

Brazil has invested significantly in connectivity (e.g. through Governo Eletrônico – Serviço de Atendimento ao Cidadão) and software (e.g. e-SUS AB), as well as provided municipalities with support for hardware and training (e.g. Informatiza APS). Yet the ambitious vision set out in ESD28 will likely require both larger and smarter investments, tying financial support to effective and equitable use. Taking into account the magnitude of investments made in more digitally advanced countries, Brazil could review its current investments and consider providing more funding for change management, capacity-building, and monitoring and evaluation. Financial support could be tied to specific milestones in the adoption and use of digital PHC functionalities, starting with key functionalities like ePrescribing, referral management, appointment scheduling and patient access to EHR.