The 2019 National Health Survey and the importance of ACS in the PHC policy

Bellas, Hugo Cesar; Harris, Matthew; Souza, Jaqueline Tavares Viana de; Minton, Cornelia Junghans

doi:10.1590/1413-81232025306.22322024

Abstract

This article discusses the importance of community health workers (ACS) home visits based on the 2019 National Health Survey, which showed fewer ACS home visits in Brazil. It highlights the possible reasons for this decline and the adoption of the Brazilian ACS model as a parameter in other countries, the option for social organizations in some states, the impact of an extreme right-wing government, and the prospect of expansion with the election of a progressive government. Finally, it emphasizes the importance of home visits for the success of the PHC policy.

Key words:
National Health Survey; National Primary Care Policy; Community health agents; Home visits

Resumo

O artigo traz uma discussão sobre a importância das visitas domiciliares realizadas pelos agentes comunitários de saúde, tendo como base a Pesquisa Nacional de Saúde de 2019, que apontou uma redução no número de visitas domiciliares realizadas pelos agentes comunitários de saúde, no Brasil, além de destacar os possíveis motivos dessa redução. Destaca ainda a adoção do modelo do ACS brasileiro como parâmetro em outros países, a opção pelas organizações sociais em alguns estados, o impacto de um governo de extrema direita e a perspectiva de expansão com a eleição de um governo progressista. Por fim destaca a importância das visitas domiciliares para o sucesso da política de atenção básica.

Palavras-chave:
Pesquisa Nacional de Saúde; Política Nacional de Atenção Básica; Agentes comunitários de saúde; Visitas domiciliares

Resumen

El artículo discute la importancia de las visitas domiciliarias de los agentes comunitarios de salud (ACS), con base en la Encuesta Nacional de Salud de 2019, que mostró una reducción en el número de visitas domiciliarias realizadas por ACS en Brasil, además de destacar las posibles razones de esta reducción. También destaca la adopción del modelo brasileño de los ACS como parámetro en otros países, la opción por organizaciones sociales en algunos estados, el impacto de un gobierno de extrema derecha y la perspectiva de expansión con la elección de un gobierno progresista. Por último, destaca la importancia de las visitas a domicilio para el éxito de la política de atención primaria.

Palabras clave:
Encuesta Nacional de Salud; Política Nacional de Atención Primaria; Agentes de salud comunitarios; Visitas domiciliarias

Introduction

The Community Health Worker (ACS) function was regulated by Law No. 10,507/2002. It is fundamental to the Family Health Strategy as it enables the population’s health needs to reach the team of professionals who will intervene with the community¹. Furthermore, the ACS is also responsible for the counterflow, transmitting health information to their territorially assigned population². This professional is inserted in health systems in different parts of the world³, such as in the United States of America, Kenya, Bangladesh, and the Brazilian model served as a parameter for countries such as the United Kingdom, South Africa, and Belgium⁴^-¹³.

From this perspective, we should underscore that ACS keep close contact with the health system clients through home visits. They are responsible for increasing access to healthcare, adequately using health resources, screening, detecting, and monitoring chronically ill and elderly patients, and preserving healthcare continuity¹⁴^-¹⁶.

In this sense, another point highlighted is that ACS’ interventions create opportunities and expand access, showing their strong performance in actions linked to the gateway and comprehensiveness attributes, especially in rural/inland areas of remote rural municipalities. The intermediation and facilitation of access occur through the strong bond with families and the lack of other assistance resources, ratifying their role as primary mediators of contact with the RAS¹⁷^,¹⁸.

Furthermore, ACS play an important role in health actions that expand health coverage with cost control, receiving the community and identifying, capturing, and resolving health demands¹⁹.

In this context, we underscore their crucial role in health surveillance and care practices. From this perspective, the reduced home visits may also compromise the processing of ACS actions for identifying, notifying, and monitoring diseases, injuries, and health conditions, such as tuberculosis, HIV, AIDS, malnutrition, diarrhea, some cancer types, chronic non-communicable diseases, neglected tropical diseases, mental illnesses, and screening of pregnant women and newborns for maternal and child care²⁰.

In this sense, reinforcing the importance of ACS actions is timely and necessary as it meets the current challenges regarding the qualification of the Primary Care/Family Health Strategy, implemented for more than two decades in Brazil, which is a model referenced by the World Health Organization as a successful example.

However, according to the 2019 National Health Survey, despite showing an accelerated expansion of the Family Health Strategy’s population coverage from 2013 to 2019 against the 2008-2013 time bracket, we see a declining proportion of the registered population that receives a monthly visit from the ACS, even though this population contingent has expanded in absolute terms²¹.

The research highlights some possible causative factors, such as the sharp expansion of coverage in Rio de Janeiro, especially in the capital and the Federal District, where the care model, somewhat legitimized by the 2017 National Primary Care Policy, prioritized the individual care centrality with a sharp reduction in ACS²²^,²³.

In this context, the research also points out that although the proportion of registered households increased from 56.1% to 62.6% between 2013 and 2019 (p=0.0001), the proportion of households that received monthly visits (as prescribed in the ACS role) decreased from 47.2% to 38.4% between the same period (p<0.0001). Of all the states, Alagoas was the only state to increase the proportion of households that received monthly visits, and in Rio, the proportion of monthly visits fell by half. This situation occurred mainly due to the administration of Mayor Marcelo Crivella, who produced a dismantling of the municipality’s PHC policy, closing several family health units, and shrinking the number of community health workers. During Mayor Eduardo Paes’ administration, coverage returned to the 80% range, per data from the PHC e-manager²⁴. This pattern is consistent across income quintiles²²^,²³.

On the other hand, in states that already had greater coverage, the expansion occurred to middle-class housing areas, which have distinct difficulties in conducting home visits, such as residents’ absence due to work outside the home, buildings, and condominiums that hinder ACS entry and residents’ resistance to home visits.

The research also highlights other possible factors associated with the declining home visits, such as changes observed in the ACS responsibilities with the escalated activities within the PHC Units in receiving, completing the Bolsa Família forms and information systems, or even outside the UBS, such as the delivery of references for tests and scheduled specialist appointments. These factors need to be ratified with other quantitative and qualitative research.

Some authors also highlight that these activities may be reflected in a scope of practices with greater dedication to administrative, support, and bureaucratic activities, to the detriment of time for home visits and activity in the territory, which may contribute to declining home visits²⁵^,²⁶.

In this sense, some authors warn of the gradual change in the meaning of the ACS work in the territory, from a complex scope and community action in producing the community diagnosis to operational tasks such as simply registering, keeping the records updated, and delivering documents to residents²⁵^,²⁶. These administrative actions as a factor that hampers visits are also mentioned in other studies²⁷^-²⁹.

Furthermore, some authors raise the real possibilities of privatization and pricing of PHC actions based on the creation of the Agency for Developing PHC (ADAPS), later transformed into a SUS agency³⁰, and the portfolio of services, which could be another element to weaken the community dimension of the Family Health Strategy, as is already observed in some management privatization contexts via Social Health Organizations (OSS)²³^,³¹.

Regarding Social Health Organizations, several studies have portrayed the advancement of this management model in Brazilian states and municipalities, pointing out advantages and disadvantages³²^-³⁸. However, this dichotomy between having a more agile hiring model for managers and greater precariousness for workers remains without a consensus. In this sense, we should underscore the need for a national and integrated policy and health personnel management, which ensures labor rights, health responsibility, and humanized care. However, the progress made by municipalities that have implemented OSS models, such as Rio de Janeiro and São Paulo³⁹^,⁴⁰, which have expanded services and improved the quality of care provided to the population, is undeniable.

Another relevant point highlighted by the research, which may have contributed to the declining home visits, is that the 2017 PNAB allowed the establishment of Family Health teams with only one ACS and PHC teams without ACS, while Ordinance No. 2,979, of 2019, equated the funding of primary care teams and Family Health teams, abolishing the priority for the ESF and weakening the community and collective dimension of PHC in the SUS. The continuity of these policies may represent an even more significant decline in ACS home visits over time⁴¹.

The results of the 2019 PNS confirm that the ESF remains the primary PHC model in the SUS. However, the possible absence of ACS in the team affects one of the pillars of the care model that characterizes the ESF in its community and health promotion component, guided by the conception of the social determination of the health-disease process and the expanded clinic³¹.

Despite Law No. 14,536 of January 20, 2023, which recognized community health workers as health professionals and allowed accumulating positions provided there are compatible schedules, maintaining this professional, who has served as an example for several countries worldwide as an activity that increases access to health services for the most vulnerable population, improves communication between the community and PHC units and reduces the harm suffered by chronically ill patients, and is under threat in its composition⁴².

Another ACS challenge is digital health tools, which have escalated in PHC and the ACS practice. Some research indicates that digital health re-edits old challenges surrounding ACS work, such as greater bureaucracy, control, social and technical division, new challenges around the use of the Internet, maintenance and quality of equipment, and digital literacy³^,⁴³.

We should also underscore that the Brazilian ESF and ACS model inspires other health systems, including those in G20 countries, which have much higher health investments than the Brazilian model and structured health systems. In these countries, the ACS role is characterized by proactive monthly home visits, universally in small geographic areas, detecting the care needs of these populations, acting in prevention and health promotion that directly impacts budget savings, and preventing the deterioration of the population’s health conditions.

Reducing the number of ACS and home visits could jeopardize all the progress made in the Family Health Strategy over the last thirty years in Brazil. In this context, public policymakers are warned to pay attention to the results of the National Health Survey so that ACS is not dragged into excessively bureaucratic tasks that distract them from their unique and important role in the Brazilian health system.

Furthermore, the country emerges from a period of an extreme right-wing government that promoted a proper dismantling of public policies. However, the election of a progressive government renews hopes of moving towards an expanded primary care policy and an increase in the number of teams and population coverage, following the precepts of the Alma-Ata and Astana declarations⁴⁴^,⁴⁵.

Therefore, we should reinforce the strategic role of Community Health Workers and home visits. They link the community and health services and provide improved access to health systems for the economically vulnerable population, positively impacting their quality of life through health promotion and prevention actions.

Acknowledgments

This work was conducted with the support of the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPQ).

This report is an independent investigation supported by the National Institute for Health and Care Research Applied Research Collaboration Northwest London. The views expressed in this publication are those of the author(s) and not necessarily those of the National Institute for Health Research or the Department of Health and Social Care.

References

¹ Brasil. Lei no 10.507, de 10 de julho de 2002. Cria a profissão de Agente Comunitário de Saúde e dá outras providências. Diário Oficial da União; 2002.
² Nunes MDO, Trad LB, Almeida BDA, Homem CR, Melo MCIDC. O agente comunitário de saúde: construção da identidade desse personagem híbrido e polifônico. Cad Saude Publica 2002; 18(6):1639-1646.
³ Méllo LMBDDE, Santos RCD, Albuquerque PCD. Agentes Comunitárias de Saúde: o que dizem os estudos internacionais? Cien Saude Colet 2023; 28(2):501-520.
⁴ Witmer A, Seifer SD, Finocchio L, Leslie J, O'Neil EH. Community health workers: integral members of the health care work force. Am J Public Health 1995; 85(8_Pt_1):1055-1058.
⁵ Livingston A, Tomedi A, Campbell A, Morales C, Mwanthi MA. A Community Health Worker Home Visitation Project to Prevent Neonatal Deaths in Kenya. J Tropical Pediatr 2013; 59(1):64-66.
⁶ Chowdhury AMR, Chowdhury S, Islam MN, Islam A, Vaughan JP. Control of tuberculosis by community health workers in Bangladesh. Lancet 1997; 350(9072):169-172.
⁷ Harris MJ, Haines A. The potential contribution of community health workers to improving health outcomes in UK primary care. J R Soc Med 2012; 105(8):330-335.
⁸ Junghans C, Antonacci G, Williams A, Harris M. Learning from the universal, proactive outreach of the Brazilian Community Health Worker model: impact of a Community Health and Wellbeing Worker initiative on vaccination, cancer screening and NHS health check uptake in a deprived community in the UK. BMC Health Serv Res 2023; 23(1):1092.
⁹ Haines A, Barros EF, Berlin A, Heymann DL, Harris MJ. National UK programme of community health workers for COVID-19 response. Lancet 2020; 395(10231):1173-1175.
¹⁰ Hayhoe B, Cowling TE, Pillutla V, Garg P, Majeed A, Harris M. Integrating a nationally scaled workforce of community health workers in primary care: a modelling study. J R Soc Med 2018; 111(12):453-461.
¹¹ Schneider H, Hlophe H, Van Rensburg D. Community health workers and the response to HIV/AIDS in South Africa: tensions and prospects. Health Policy Plan 2008; 23(3):179-187.
¹² Vanden Bossche D, Lagaert S, Willems S, Decat P. Community Health Workers as a Strategy to Tackle Psychosocial Suffering Due to Physical Distancing: A Randomized Controlled Trial. IJERPH 2021; 18(6):3097.
¹³ Vanden Bossche D, Willems S, Decat P. Understanding Trustful Relationships between Community Health Workers and Vulnerable Citizens during the COVID-19 Pandemic: A Realist Evaluation. IJERPH 2022; 19(5):2496.
¹⁴ Chagas AAP, Barçante JMDP, Costa JO, Ferreira RA. Ações de combate à Covid-19 conduzidas por agentes comunitários de saúde em um município brasileiro. Physis 2024; 34:e34074.
¹⁵ Gutiérrez Murillo RS. A visita domiciliar a pessoas idosas na ótica do agente comunitário de saúde e a noção de território sanitário. Trab Educ Saude 2024; 22:e02463247.
¹⁶ Malinverni C, Brigagão JIM, Gervasio MDG, Lucena FS. O papel dos agentes comunitários de saúde no enfrentamento à pandemia de COVID-19: o caso de Peruíbe, São Paulo, Brasil. Cien Saude Colet 2023; 28(12):3543-3552.
¹⁷ Lima JG, Giovanella L, Fausto MCR, Almeida PFD. O processo de trabalho dos agentes comunitários de saúde: contribuições para o cuidado em territórios rurais remotos na Amazônia, Brasil. Cad Saude Publica 2021; 37(8):e00247820.
¹⁸ Sousa JDO, Almeida PFD. Atuação do agente comunitário de saúde em municípios rurais remotos do Semiárido: um olhar a partir dos atributos da Atenção Primária à Saúde. Physis 2023; 33:e33044.
¹⁹ Costa SDM, Araújo FF, Martins LV, Nobre LLR, Araújo FM, Rodrigues CAQ. Agente Comunitário de Saúde: elemento nuclear das ações em saúde. Cien Saude Colet 2013; 18(7):2147-2156.
²⁰ Prefeitura do Rio de Janeiro. Carteira de serviços da atenção primária: abrangência do cuidado. Rio de Janeiro: Secretaria Municipal de Saúde; 2021.
²¹ Giovanella L, Bousquat A, Schenkman S, Almeida PFD, Sardinha LMV, Vieira MLFP. Cobertura da Estratégia Saúde da Família no Brasil: o que nos mostram as Pesquisas Nacionais de Saúde 2013 e 2019. Cien Saude Colet 2021; 26(Supl. 1):2543-2556.
²² Bousquat A, Barros NF, Gomes L. Brasília saudável: a estratégia de saúde da família e a conversão do modelo assistencial [relatório de pesquisa]. Brasilia: Rede de Pesquisa em APS, OPAS; 2019.
²³ Melo EA, Mendonça MHMD, Teixeira M. A crise econômica e a atenção primária à saúde no SUS da cidade do Rio de Janeiro, Brasil. Cien Saude Colet 2019; 24(12):4593-4598.
²⁴ Brasil. Ministério da Saúde (MS). E-gestor atenção básica [Internet]. 2021 [acessado 2024 jun 10]. Disponível em: https://egestorab.saude.gov.br/paginas/acessoPublico/relatorios/relCoberturaAPSCadastroParamPnab.xhtml;jsessionid=5cJsPxxCjTYRauqn+0PlLvIe
» https://egestorab.saude.gov.br/paginas/acessoPublico/relatorios/relCoberturaAPSCadastroParamPnab.xhtml;jsessionid=5cJsPxxCjTYRauqn+0PlLvIe
²⁵ Nogueira ML. Expressões da precarização no trabalho do agente comunitário de saúde: burocratização e estranhamento do trabalho. Saude Soc 2019; 28(3):309-323.
²⁶ Morosini MV, Fonseca AF. Os agentes comunitários na Atenção Primária à Saúde no Brasil: inventário de conquistas e desafios. Saude Debate 2018; 42(n. esp. 1):261-274.
²⁷ Bellas HC, Jatobá A, Bulhões B, Koster I, Arcuri R, Burns C, Grindrod K, Carvalho PVR. Effects of Urban Violence on Primary Healthcare: The Challenges of Community Health Workers in Performing House Calls in Dangerous Areas. J Community Health 2019; 44(3):569-576.
²⁸ Costa NR, Bellas H, Silva PRF, Carvalho PVR, Uhr D, Vieira C, Jatobá A. Community health workers' attitudes, practices and perceptions towards the COVID-19 pandemic in brazilian low-income communities. Work 2021; 68(1):3-11.
²⁹ Jatobá A, Bellas HC, Bulhões B, Koster I, Arcuri R, Carvalho PVR. Assessing community health workers' conditions for delivering care to patients in low-income communities. Applied Ergonomics 2020; 82:102944.
³⁰ Cunha CRHD, Harzheim E, Medeiros OLD, D'Avila OP, Martins C, Wollmann L, Faller LA. Carteira de Serviços da Atenção Primária à Saúde: garantia de integralidade nas Equipes de Saúde da Família e Saúde Bucal no Brasil. Cien Saude Colet 2020; 25(4):1313-1326.
³¹ Giovanella L, Franco CM, Almeida PFD. Política Nacional de Atenção Básica: para onde vamos? Cien Saude Colet 2020; 25(4):1475-1482.
³² Costa NDR, Silva IDM, Lima PTD, Silva TSD, Costa ICMD, Figueiredo IVO. A implantação em larga escala da Estratégia de Saúde da Família na cidade do Rio de Janeiro, Brasil: evidências e desafios. Cien Saude Colet 2021; 26(6):2075-2082.
³³ Krüger TR, Reis C. Organizações sociais e a gestão dos serviços do SUS. Serv Soc Soc 2019; 135:271-289.
³⁴ Martins LDJ, Olivieri C. Contratualização de resultados: fragilidades na transparência e baixa accountability das organizações sociais. Rev Adm Publica 2019; 53(6):1189-1202.
³⁵ Morais HMMD, Albuquerque MDSVD, Oliveira RSD, Cazuzu AKI, Silva NAFD. Organizações Sociais da Saúde: uma expressão fenomênica da privatização da saúde no Brasil. Cad Saude Publica 2018; 34(1):e00194916.
³⁶ Shimizu HE, Carvalho ALBD, Brêtas Júnior N, Capucci RR. Regionalização da saúde no Brasil na perspectiva dos gestores municipais: avanços e desafios. Cien Saude Colet 2021; 26(Supl. 2):3385-3396.
³⁷ Silva VCE, Barbosa PR, Hortale VA. Parcerias na saúde: as Organizações Sociais como limites e possibilidades na gerência da Estratégia Saúde da Família. Cien Saude Colet 2016; 21(5):1365-1376.
³⁸ Travagin LB. O avanço do capital na saúde: um olhar crítico às Organizações Sociais de Saúde. Saude Debate 2017; 41(115):995-1006.
³⁹ Campos GWDS. Reforma sanitária e o Sistema Único de Saúde (SUS). Cien Saude Colet 2022; 27(7):2516.
⁴⁰ Coelho VSP, Greve J. As Organizações Sociais de Saúde e o Desempenho do SUS: Um Estudo sobre a Atenção Básica em São Paulo. Dados 2016; 59(3):867-901.
⁴¹ Brasil. Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União; 2017.
⁴² Brasil. Lei no 14.536, de 20 de janeiro de 2023. Altera a Lei nº 11.350, de 5 de outubro de 2006, a fim de considerar os Agentes Comunitários de Saúde e os Agentes de Combate às Endemias como profissionais de saúde, com profissões regulamentadas, para a finalidade que especifica. Diário Oficial da União; 2023.
⁴³ Santos RCD, Ribeiro LF, Amado CF, Méllo LMBDDE, Santos L. Condições de trabalho dos agentes comunitários de saúde em um contexto de saúde digital: velhos e novos desafios. Interface (Botucatu) 2024; 28:e230548.
⁴⁴ Organização Mundial da Saúde (OMS). Declaração de Alma-Ata. Genebra: OMS; 1978.
⁴⁵ Giovanella L, Mendonça MHMD, Buss PM, Fleury S, Gadelha CAG, Galvão LAC, Santos RFD. De Alma-Ata a Astana. Atenção primária à saúde e sistemas universais de saúde: compromisso indissociável e direito humano fundamental. Cad Saude Publica 2019; 35(3):e00012219.

Chief editors:
Maria Cecília de Souza Minayo, Romeu Gomes, Antônio Augusto Moura da Silva

Publication Dates

Publication in this collection
20 June 2025
Date of issue
June 2025

History

Received
11 Sept 2024
Accepted
19 Feb 2025
Published
21 Feb 2025

Este é um artigo publicado em acesso aberto sob uma licença Creative Commons

[1] ¹ Brasil. Lei no 10.507, de 10 de julho de 2002. Cria a profissão de Agente Comunitário de Saúde e dá outras providências. Diário Oficial da União; 2002.

[2] ² Nunes MDO, Trad LB, Almeida BDA, Homem CR, Melo MCIDC. O agente comunitário de saúde: construção da identidade desse personagem híbrido e polifônico. Cad Saude Publica 2002; 18(6):1639-1646.

[3] ³ Méllo LMBDDE, Santos RCD, Albuquerque PCD. Agentes Comunitárias de Saúde: o que dizem os estudos internacionais? Cien Saude Colet 2023; 28(2):501-520.

[4] ⁴ Witmer A, Seifer SD, Finocchio L, Leslie J, O'Neil EH. Community health workers: integral members of the health care work force. Am J Public Health 1995; 85(8_Pt_1):1055-1058.

[5] ⁵ Livingston A, Tomedi A, Campbell A, Morales C, Mwanthi MA. A Community Health Worker Home Visitation Project to Prevent Neonatal Deaths in Kenya. J Tropical Pediatr 2013; 59(1):64-66.

[6] ⁶ Chowdhury AMR, Chowdhury S, Islam MN, Islam A, Vaughan JP. Control of tuberculosis by community health workers in Bangladesh. Lancet 1997; 350(9072):169-172.

[7] ⁷ Harris MJ, Haines A. The potential contribution of community health workers to improving health outcomes in UK primary care. J R Soc Med 2012; 105(8):330-335.

[8] ⁸ Junghans C, Antonacci G, Williams A, Harris M. Learning from the universal, proactive outreach of the Brazilian Community Health Worker model: impact of a Community Health and Wellbeing Worker initiative on vaccination, cancer screening and NHS health check uptake in a deprived community in the UK. BMC Health Serv Res 2023; 23(1):1092.

[9] ⁹ Haines A, Barros EF, Berlin A, Heymann DL, Harris MJ. National UK programme of community health workers for COVID-19 response. Lancet 2020; 395(10231):1173-1175.

[10] ¹⁰ Hayhoe B, Cowling TE, Pillutla V, Garg P, Majeed A, Harris M. Integrating a nationally scaled workforce of community health workers in primary care: a modelling study. J R Soc Med 2018; 111(12):453-461.

[11] ¹¹ Schneider H, Hlophe H, Van Rensburg D. Community health workers and the response to HIV/AIDS in South Africa: tensions and prospects. Health Policy Plan 2008; 23(3):179-187.

[12] ¹² Vanden Bossche D, Lagaert S, Willems S, Decat P. Community Health Workers as a Strategy to Tackle Psychosocial Suffering Due to Physical Distancing: A Randomized Controlled Trial. IJERPH 2021; 18(6):3097.

[13] ¹³ Vanden Bossche D, Willems S, Decat P. Understanding Trustful Relationships between Community Health Workers and Vulnerable Citizens during the COVID-19 Pandemic: A Realist Evaluation. IJERPH 2022; 19(5):2496.

[14] ¹⁴ Chagas AAP, Barçante JMDP, Costa JO, Ferreira RA. Ações de combate à Covid-19 conduzidas por agentes comunitários de saúde em um município brasileiro. Physis 2024; 34:e34074.

[15] ¹⁵ Gutiérrez Murillo RS. A visita domiciliar a pessoas idosas na ótica do agente comunitário de saúde e a noção de território sanitário. Trab Educ Saude 2024; 22:e02463247.

[16] ¹⁶ Malinverni C, Brigagão JIM, Gervasio MDG, Lucena FS. O papel dos agentes comunitários de saúde no enfrentamento à pandemia de COVID-19: o caso de Peruíbe, São Paulo, Brasil. Cien Saude Colet 2023; 28(12):3543-3552.

[17] ¹⁷ Lima JG, Giovanella L, Fausto MCR, Almeida PFD. O processo de trabalho dos agentes comunitários de saúde: contribuições para o cuidado em territórios rurais remotos na Amazônia, Brasil. Cad Saude Publica 2021; 37(8):e00247820.

[18] ¹⁸ Sousa JDO, Almeida PFD. Atuação do agente comunitário de saúde em municípios rurais remotos do Semiárido: um olhar a partir dos atributos da Atenção Primária à Saúde. Physis 2023; 33:e33044.

[19] ¹⁹ Costa SDM, Araújo FF, Martins LV, Nobre LLR, Araújo FM, Rodrigues CAQ. Agente Comunitário de Saúde: elemento nuclear das ações em saúde. Cien Saude Colet 2013; 18(7):2147-2156.

[20] ²⁰ Prefeitura do Rio de Janeiro. Carteira de serviços da atenção primária: abrangência do cuidado. Rio de Janeiro: Secretaria Municipal de Saúde; 2021.

[21] ²¹ Giovanella L, Bousquat A, Schenkman S, Almeida PFD, Sardinha LMV, Vieira MLFP. Cobertura da Estratégia Saúde da Família no Brasil: o que nos mostram as Pesquisas Nacionais de Saúde 2013 e 2019. Cien Saude Colet 2021; 26(Supl. 1):2543-2556.

[22] ²² Bousquat A, Barros NF, Gomes L. Brasília saudável: a estratégia de saúde da família e a conversão do modelo assistencial [relatório de pesquisa]. Brasilia: Rede de Pesquisa em APS, OPAS; 2019.

[23] ²³ Melo EA, Mendonça MHMD, Teixeira M. A crise econômica e a atenção primária à saúde no SUS da cidade do Rio de Janeiro, Brasil. Cien Saude Colet 2019; 24(12):4593-4598.

[24] ²⁴ Brasil. Ministério da Saúde (MS). E-gestor atenção básica [Internet]. 2021 [acessado 2024 jun 10]. Disponível em: https://egestorab.saude.gov.br/paginas/acessoPublico/relatorios/relCoberturaAPSCadastroParamPnab.xhtml;jsessionid=5cJsPxxCjTYRauqn+0PlLvIe
» https://egestorab.saude.gov.br/paginas/acessoPublico/relatorios/relCoberturaAPSCadastroParamPnab.xhtml;jsessionid=5cJsPxxCjTYRauqn+0PlLvIe

[25] ²⁵ Nogueira ML. Expressões da precarização no trabalho do agente comunitário de saúde: burocratização e estranhamento do trabalho. Saude Soc 2019; 28(3):309-323.

[26] ²⁶ Morosini MV, Fonseca AF. Os agentes comunitários na Atenção Primária à Saúde no Brasil: inventário de conquistas e desafios. Saude Debate 2018; 42(n. esp. 1):261-274.

[27] ²⁷ Bellas HC, Jatobá A, Bulhões B, Koster I, Arcuri R, Burns C, Grindrod K, Carvalho PVR. Effects of Urban Violence on Primary Healthcare: The Challenges of Community Health Workers in Performing House Calls in Dangerous Areas. J Community Health 2019; 44(3):569-576.

[28] ²⁸ Costa NR, Bellas H, Silva PRF, Carvalho PVR, Uhr D, Vieira C, Jatobá A. Community health workers' attitudes, practices and perceptions towards the COVID-19 pandemic in brazilian low-income communities. Work 2021; 68(1):3-11.

[29] ²⁹ Jatobá A, Bellas HC, Bulhões B, Koster I, Arcuri R, Carvalho PVR. Assessing community health workers' conditions for delivering care to patients in low-income communities. Applied Ergonomics 2020; 82:102944.

[30] ³⁰ Cunha CRHD, Harzheim E, Medeiros OLD, D'Avila OP, Martins C, Wollmann L, Faller LA. Carteira de Serviços da Atenção Primária à Saúde: garantia de integralidade nas Equipes de Saúde da Família e Saúde Bucal no Brasil. Cien Saude Colet 2020; 25(4):1313-1326.

[31] ³¹ Giovanella L, Franco CM, Almeida PFD. Política Nacional de Atenção Básica: para onde vamos? Cien Saude Colet 2020; 25(4):1475-1482.

[32] ³² Costa NDR, Silva IDM, Lima PTD, Silva TSD, Costa ICMD, Figueiredo IVO. A implantação em larga escala da Estratégia de Saúde da Família na cidade do Rio de Janeiro, Brasil: evidências e desafios. Cien Saude Colet 2021; 26(6):2075-2082.

[33] ³³ Krüger TR, Reis C. Organizações sociais e a gestão dos serviços do SUS. Serv Soc Soc 2019; 135:271-289.

[34] ³⁴ Martins LDJ, Olivieri C. Contratualização de resultados: fragilidades na transparência e baixa accountability das organizações sociais. Rev Adm Publica 2019; 53(6):1189-1202.

[35] ³⁵ Morais HMMD, Albuquerque MDSVD, Oliveira RSD, Cazuzu AKI, Silva NAFD. Organizações Sociais da Saúde: uma expressão fenomênica da privatização da saúde no Brasil. Cad Saude Publica 2018; 34(1):e00194916.

[36] ³⁶ Shimizu HE, Carvalho ALBD, Brêtas Júnior N, Capucci RR. Regionalização da saúde no Brasil na perspectiva dos gestores municipais: avanços e desafios. Cien Saude Colet 2021; 26(Supl. 2):3385-3396.

[37] ³⁷ Silva VCE, Barbosa PR, Hortale VA. Parcerias na saúde: as Organizações Sociais como limites e possibilidades na gerência da Estratégia Saúde da Família. Cien Saude Colet 2016; 21(5):1365-1376.

[38] ³⁸ Travagin LB. O avanço do capital na saúde: um olhar crítico às Organizações Sociais de Saúde. Saude Debate 2017; 41(115):995-1006.

[39] ³⁹ Campos GWDS. Reforma sanitária e o Sistema Único de Saúde (SUS). Cien Saude Colet 2022; 27(7):2516.

[40] ⁴⁰ Coelho VSP, Greve J. As Organizações Sociais de Saúde e o Desempenho do SUS: Um Estudo sobre a Atenção Básica em São Paulo. Dados 2016; 59(3):867-901.

[41] ⁴¹ Brasil. Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União; 2017.

[42] ⁴² Brasil. Lei no 14.536, de 20 de janeiro de 2023. Altera a Lei nº 11.350, de 5 de outubro de 2006, a fim de considerar os Agentes Comunitários de Saúde e os Agentes de Combate às Endemias como profissionais de saúde, com profissões regulamentadas, para a finalidade que especifica. Diário Oficial da União; 2023.

[43] ⁴³ Santos RCD, Ribeiro LF, Amado CF, Méllo LMBDDE, Santos L. Condições de trabalho dos agentes comunitários de saúde em um contexto de saúde digital: velhos e novos desafios. Interface (Botucatu) 2024; 28:e230548.

[44] ⁴⁴ Organização Mundial da Saúde (OMS). Declaração de Alma-Ata. Genebra: OMS; 1978.

[45] ⁴⁵ Giovanella L, Mendonça MHMD, Buss PM, Fleury S, Gadelha CAG, Galvão LAC, Santos RFD. De Alma-Ata a Astana. Atenção primária à saúde e sistemas universais de saúde: compromisso indissociável e direito humano fundamental. Cad Saude Publica 2019; 35(3):e00012219.