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Community health workers (CHWs) are framed as the link between communities and the formal health system. CHWs must establish trusting relationships with the community and with the broader health service. How to find the optimal balance between the various strands of work for CHWs, and how to formalise this, has been the focus of different studies. We performed an extensive documentary analysis of federal legislation in Brazil to understand the institutionalisation of the CHW workforce in Brazil over the last 3 decades. The paper offers three contributions to the literature: the development and application of an analytical framework to consider the institutionalisation process of CHWs; a historical analysis of the professional institutionalisation of CHW in Brazil; and the identification of the paradoxes that such institutionalisation faces: firstly, institutionalisation focused on improving CHW remuneration created difficulties in hiring and paying these professionals; when CHW are incorporated within state bureaucracy they start to lose their autonomy as community agents; and that the effectiveness of CHW programmes depends on the improvement of clinical services in the most deprived areas. [ABSTRACT FROM AUTHOR]

This paper analyzes the conduct of the federal primary health care politics in Brazil in the 2000's, seeking to identify elements of continuity and change in the previous period. The research was based on the theoretical framework of historical institutionalism and the concept of path dependence. The methodology included a variety of strategies: literature review, document analysis, analysis of secondary databases, budget analysis and interviews with key stakeholders of the policy. It was possible to identify continuities and changes in the conduct of national policy for federal primary care during the study period. The predominance of continuities, emphasizing the persistence of the Family Health Program as a hegemonic strategy for reorientation of primary care in the country, creates a condition of path-dependence. There were also incremental changes, such as initiatives to strengthen inter-sectoral coordination and important innovations, notably the creation of the Centers for Family Health Support. There are, however, structural problems within primary care, and it is important to overcome them to enable the effective change in the health care model in the country. [ABSTRACT FROM AUTHOR]