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Impact of primary health care on mortality from heart and cerebrovascular diseases in Brazil: a nationwide analysis of longitudinal data

BMJ 2014; 349 doi: (Published 03 July 2014) Cite this as: BMJ 2014;349:g4014

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Rasella et al's conclusion that elements of the Family Health Strategy are conceivably transportable to other low and middle income countries is overly modest. An intervention that, at scale, reduces mortality for cerebrovascular and cardiovascular disease, to the extent that has been shown in the Family Health Strategy is one that ought to be considered in all countries - not just resource-poor ones. The impact of this model on mortality, morbidity and secondary care use, that has now been quite extensively described (1-3), should be welcome as much in high income contexts as in low income ones.

In the UK, we have been painfully slow to admit that Brazil and other Low and Middle Income Countries such as Pakistan and Ethiopia have got it right. To anyone familiar with these programmes, Rasella et al's findings will come as no surprise. They draw on lay Community Health Workers to proactively identify health needs, support healthy lifestyle choices, and improve access to health services. But these programmes are nothing like our Health Trainer model, which provides only ad hoc health advice. Instead, they are deployed systematically, at scale and each Community Health Worker operates across all health domains - not just the disease areas that Rasella et al have included in their analysis. The WHO have recommended the scaled use of lay Community Health Workers for all member states since 2012 (4). Rasella et al have missed an opportunity to promote Brazil's exceptional Family Health Strategy and call for even developed health systems to learn from its approach.


1. Macinko j and Lima-Costa M. Horizontal equity in health care utilization in Brazil, 1998–2008. International Journal for Equity in Health 2012, 11:33

2. Macinko et al (2010) - Major Expansion Of Primary Care In Brazil Linked To Decline In Unnecessary Hospitalization. Health Affairs, 29, no.12 (2010):2149-2160

3. Rocha A and Soares R (2010) - Evaluating the impact of community-based health interventions: evidence from Brazil’s Family Health Program. Health Economics 19: 126 – 158 (2010)

4. WHO (2012) - Optimizing health worker roles to improve access to key maternal and newborn health interventions through task shifting. Available from:

Competing interests: No competing interests

08 July 2014
Matthew J Harris
Academic Clinical Lecturer in Public Health
Imperial College London
Department of Primary Care and Public Health, Reynolds Building, St Dunstans Road, Hammersmith, London, W6 8RP