Universalization of the access to the Unified Health System in Brazil: challenges

Introduction: Twenty-five years after the promulgation of the 1988 Federal Constitution in Brazil, whichdefined a “Sistema único de Saúde” (‘SUS’, or “Unified Health System” - UHS) for the country, many advanceshave occurred, but many challenges still remain. Objective: To present the theoretical and practical bases of the“Aten o Primária à Saúde” (‘APS’, or “Primary Health Care” - PHC), in the Brazilian and Sao Paulo Stateexperiences; to discuss the service “access” category, entrances to UHS and challenges for the universalizationof the access based on PHC. Methodology: Results analysis of the researches that have investigated the differentBrazilian and Sao Paulo State situations. Results: Different organization models coexist in PHC: the “A esProgramáticas” (or “Programmatic Actions” - 1970) and the “Saúde da Família” (or “Family Health” - 1996).Results that are slightly more positive appear in the “Family Health” strategy: health indicators, staff, completenessof approach, and quality of assistance and access. Difficulties: different degrees in the deployment of the programand staff in different municipalities; home visits only by CHA (community health agent); constant human resources (HR) shifts; difficulties in the follow-up to other levels of assistance; inequality among municipalities;fragmentation and different development levels of the local systems and health regions; under-financing of the system, especially at out-patient level and diagnosis support. Conclusion: Strategic importance of Human Resource matters: relation between services and education institutions, amount of professionals and workers,distribution, labor market, formation, profile, expectations and resistance.