ABSTRACT:
The Family Health Strategy has become consolidated as the main model of Primary Health Care in the Brazilian public health system, with positive effects on access and health indicators. From 2017 onward, regulatory changes and modifications to federal financing mechanisms introduced significant risks to the continuity of the model. This study aimed to analyze the repercussions of the changes introduced by the 2017 National Primary Care Policy and the federal financing program implemented in 2019 on the primary health care model in two health regions, taking into account contextual and institutional factors, as well as decisions made by local managers. This was a multicenter, comparative, mixed-methods study conducted in fourteen municipalities across two contrasting regions: a metropolitan region in the state of Rio de Janeiro and the northern macro-region of the state of Paraná, composed predominantly of small-population municipalities. The analytical framework was based on federative interactions and the roles of local actors in implementing national policies, while accounting for institutional capacities and contextual influences. Forty-four interviews were conducted with municipal and state primary health care managers, along with a descriptive analysis of secondary data organized into three axes: institutional conceptions and profiles; organizational decisions; and coverage and composition of primary health care teams from 2017 to 2022. In both regions, an expansion of Family Health teams and a reduction in the number of community health workers per team were observed, with unequal impacts on the organization of primary care. The results show that the implementation of federal guidelines depends strongly on local institutional capacities, intergovernmental relations, and the role of state governments, posing challenges to the comprehensiveness and quality of care. These findings reinforce the relevance of federative coordination within Brazil’s public health system.