[I promotori di salute come attori-protagonisti delle cure primarie nel controllo delle malattie comunicabili e non comunicabili e nell' empowerment delle comunità. Esperienza e risultati di lungo periodo in aree marginali in Ecuador dal 1980 al 2018.] / The community health promoters as protagonist actorsof primary health care and community empowerment:a long term field-report from 1980 to 2018.

. INTRODUCTION: Against the increasing recognition of the critical importance of a direct participation of community members to assure effective health care in peripheral areas of Middle and Low Income Countries (MLIC), representative field experiences of their essential role are only occasionally available. AIMS AND METHODS: We report a narrative, factual documentation of a spectrum of projects covering the basic and specific health needs of the disperse communities in Ecuador, a model MLIC, and discuss the broader implications of the role and performance of HPs over a long period, 1980-2018, in the project activation, implementation and monitoring. RESULTS: The role of 60 HPs, with the coordination of a small core group of professionals of the Centro de Epidemiologia Comunitaria y Medicina Tropical (CECOMET) is documented through their main achievements which include: infectious diseases and in particular Neglected Tropical Diseases (eradication of onchocerciasis and yaws; virtual elimination of malaria and of strongyloidiasis; identification and control of a new focus of Chagas Disease; control of tuberculosis), mother and child health, reproductive health, hypertension (as model of the emergence of non-transmissible, chronic diseases). The most effective and sustainable strategies and methods are discussed also in terms of their more general transferability, already partially tested in programs in Bolivia, Burkina Faso, undeserved areas of Argentina. CONCLUSIONS: The systematic availability of non-professional, trained HPs should be recommended as a sustainable and reliable component of health care strategies and interventions targeted to marginalized settings, to assure a concrete accessibility to the fundamental human right to life.

Translating Workforce Development Policy Interventions for Community Health Workers: Application of a Policy Research Continuum.

CONTEXT: There is a need for knowledge translation to advance health equity in the prevention and control of cardiovascular disease and type 2 diabetes. One recommended strategy is engaging community health workers (CHWs) to have a central role in related interventions. Despite strong evidence of effectiveness for CHWs, there is limited information examining the impact of state CHW policy interventions. This article describes the application of a policy research continuum to enhance knowledge translation of CHW workforce development policy in the United States. METHODS: During 2016-2019, a team of public health researchers and practitioners applied the policy research continuum, a multiphased systematic assessment approach that incorporates legal epidemiology to enhance knowledge translation of CHW workforce development policy interventions in the United States. The continuum consists of 5 discrete, yet interconnected, phases including early evidence assessments, policy surveillance, implementation studies, policy ratings, and impact studies. RESULTS: Application of the first 3 phases of the continuum demonstrated (1) how CHW workforce development policy interventions are linked to strong evidence bases, (2) whether existing state CHW laws are evidence-informed, and (3) how different state approaches were implemented. DISCUSSION: As a knowledge translation tool, the continuum enhances dissemination of timely, useful information to inform decision making and supports the effective implementation and scale-up of science-based policy interventions. When fully implemented, it assists public health practitioners in examining the utility of different policy intervention approaches, the effects of adaptation, and the linkages between policy interventions and more distal public health outcomes.

Discretion, power and the reproduction of inequality in health policy implementation: Practices, discursive styles and classifications of Brazil's community health workers.

This article explores the mobilization of power by health workers during policy implementation, showing how in a context of discretion and resource scarcity they can reproduce inequalities in access to health services. The argument innovates theoretically by supplementing the 'street-level bureaucracy' literature, which emphasizes frontline worker discretion, with a conceptualization of power as domination encompassing the shaping of behavior, the constitution of subjects and the reproduction of inequality. Empirically, the article focuses on Brazilian community health workers (agentes comunitários desaúde, CHWs). CHWs are a neglected but highly important segment of the health workforce that traditionally functions as a link between the health system and disadvantaged groups. The article examines how Brazilian CHWs act as street-level bureaucrats mobilizing power in their interactions with users. They operate within a severely under-resourced public health system, the Sistema Único de Saúde, which places constraints upon their action and forces them to make allocation decisions with little training and support. The article highlights the ways in which inequalities in access to health services are reproduced (inadvertently or not) through the practices, discursive styles and classifications of CHWs. Methodologically, the paper is based on ethnography with 24 CHWs and interviews with 77 other CHWs in Brazil.

Community Health Worker (CHW) Movement in Hawai'i: Moving Towards a CHW Association.

This editorial presents the perspectives of allies - a group of governmental, university and public health organizations that support the creation of a professional association for CHWs in Hawai'i. We support the efforts of CHWs as they organize and move towards establishing a professional association. Hawai'i CHWs have held monthly meetings starting in 2017 to discuss variety of issues around their work and share information and experiences. A group of CHWs and allies developed a strategic plan in 2018 in preparation to establish a professional association. They shared the results with colleagues from across the state. One desirable outcome for many was a professional CHW association. Such an association could be a forum of shared learning, information sharing, networking, and advocating for workforce and professional development issues, such as training, reimbursement for services, credentials, and certifications. Furthermore, allies support CHW-led efforts to develop an association, for instance, by securing diversified funding sources for CHW trainings, networking, and planning activities. Allies also help by informing supervisors, employers, and policymakers about the importance of trainings and other workforce and professional development for CHWs. A professional association for CHWs in Hawai'i could be useful to many. This editorial provides more insights into this topic.

Community Health Workers in Action: Community-Clinical Linkages for Diabetes Prevention and Hypertension Management at 3 Community Health Centers.

In 2014, the Hawai'i State Department of Health (HDOH) received funding from the Centers for Disease Control and Prevention (CDC), via the 1422 Cooperative Agreement, to conduct diabetes prevention and hypertension management. To implement one grant-required strategy-the engagement of community health workers (CHWs) to promote community-clinical linkages-the HDOH partnered with the Hawai'i Primary Care Association and 9 federally qualified health centers (FQHCs). This qualitative evaluation case study sought to understand how 3 of the funded FQHCs engaged CHWs, the types of community-clinical linkages the CHWs promoted, and the facilitators of and barriers to those linkages. Evaluators conducted 2 semi-structured group interviews with 6 administrators/clinicians and 7 CHWs in April 2018. The transcribed interviews were deductively and inductively analyzed to identify major themes. First, CHWs made multiple internal and external linkages using resources provided by the grant as well as other resources. Second, CHWs faced barriers in making community-clinical linkages due to individual patient, geographic, and economic constraints. Third, CHWs have unmet professional needs related to building community-clinical linkages including professional development, networking, and burnout. Reimbursement and payment mechanisms are an all-encompassing challenge to the sustainability of CHW positions, as disease-specific funding and a complete lack of reimbursement structures make CHW positions unstable. Thus, CHWs fulfill a number of grant-specific roles at FQHCs due to this patchwork of funding sources, and this relates to CHWs' experiences of burnout. Policy implications of this study include funding and reimbursement stabilization so FQHCs may consistently engage and support the CHW workforce to meet their patients' complex, diverse needs. More professional development opportunities for CHWs are necessary to build sustainable networks of resources.

Web-based versus in-person methods for training lay community health advisors to implement health promotion workshops: participant outcomes from a cluster-randomized trial.

Project HEAL (Health through Early Awareness and Learning) is an implementation trial that compared two methods of training lay peer community health advisors (CHAs)-in-person ("Traditional") versus web-based ("Technology")-to conduct a series of three evidence-based cancer educational workshops in African American churches. This analysis reports on participant outcomes from Project HEAL. Fifteen churches were randomized to the two CHA training methods and the intervention impact was examined over 24 months. This study was conducted in Prince George's County, MD, and enrolled 375 church members age 40-75. Participants reported on knowledge and screening behaviors for breast, prostate, and colorectal cancer. Overall, cancer knowledge in all areas increased during the study period (p < .001). There were significant increases in digital rectal exam (p < .05), fecal occult blood test (p < .001), and colonoscopy (p < .01) at 24 months; however, this did not differ by study group. Mammography maintenance (56% overall) was evidenced by women reporting multiple mammograms within the study period. Participants attending all three workshops were more likely to report a fecal occult blood test or colonoscopy at 24 months (p < .05) than those who attended only one. These findings suggest that lay individuals can receive web-based training to successfully implement an evidence-based health promotion intervention that results in participant-level outcomes comparable with (a) people trained using the traditional classroom method and (b) previous efficacy trials. Findings have implications for resources and use of technology to increase widespread dissemination of evidence-based health promotion interventions through training lay persons in community settings.

Complexidade e potencialidade do trabalho dos agentes comunitários de saúde no Brasil contemporâneo / Complexity and potentiality of the community health workers' labor in contemporary Brazil

RESUMO O objetivo deste artigo foi analisar o escopo de práticas dos Agentes Comunitários de Saúde (ACS) relacionando-o à situação social e de saúde, bem como os elementos facilitadores e os limitantes. Trata-se de um estudo transversal de abordagem mista, e estratégia explanatória sequencial, realizado em quatro municípios do Ceará. No estudo quantitativo, a amostra de 160 ACS foi aleatória com instrumento estruturado. No qualitativo, realizou-se seis grupos focais e entrevistas. Prevaleceram, na amostra, mulheres (139; 86,9%), casadas (111; 69,4%), com renda familiar maior ou igual a 2 salários mínimos (102; 63,7%), nível técnico incompleto (68; 42,5%), da zona urbana (114; 71,3%), atuando como ACS há menos de 10 anos (93; 58,2%). As principais atividades foram visitação domiciliar de grupos prioritários e cadastramento de famílias. Evidenciou-se a complexidade do trabalho, que inclui ações de promoção e vigilância à saúde como pré-natal, imunizações, hipertensão, diabetes, cuidado com idosos, entre outros. Como limitantes das práticas, identificaram-se: deficiência da formação técnica, suporte reduzido no trabalho e violência. Como potencializadores: educação permanente e gestão participativa. O escopo de práticas dos ACS é complexo e abrangente, incluindo a articulação de políticas públicas no território, o que se constitui em uma potencialidade para promoção da saúde de comunidades vulneráveis.(AU)

ABSTRACT The aim of this article was to analyze the Community Health Worker' (CHW) scope of practices, relating it to the social and health situation faced, as well as with facilitating and limiting elements of their practice. This is a cross-sectional study utilizing a mixed approach, including sequential explanatory strategy, carried out in four municipalities of Ceará. In the quantitative study, the sample of 160 CHW was randomized, and a structured instrument was used to collect data. In the qualitative study, six focal groups and interviews were carried out. We mainly found women (139; 86.9%), married (111; 69.4%), with a family income greater than or equal to 2 minumm wages (102; 63.7%), incomplete professional trainning (68; 42.5 %), from the urban area (114, 71.3%), acting as CHW for less than 10 years (93, 58.2%). The main activities were home visitation of priority groups and families registration. The complexity of the work was evidenced, which includes actions of health promotion and surveillance, such as prenatal care, immunizations, hypertension, diabetes, care for the elderly, among others. As limitations of their practices, we identified: deficiency of technical/professional training, reduced work support, and violence. As facilitators, we observed: permanent education and participatory management practices. The scope of CHW practices is complex and broad, including the articulation of public policies in the territory, which constitutes a potential for health promotion of vulnerable communities.(AU)

Os agentes comunitários na atenção primária à saúde no Brasil: inventário de conquistas e desafios / Community workers in primary health care in Brazil: an inventory of achievements and challenges

O artigo analisou a construção do perfil de atuação profissional dos Agentes Comunitários de Saúde - conhecidos internacionalmente como Community Health Workers -, apoiado na discussão sobre as disputas em torno do seu trabalho. Foram examinados documentos das políticas de saúde, com destaque para as inflexões produzidas sobre suas atribuições e formação profissional. Buscou-se compreender a racionalidade e os argumentos que sustentam as alterações induzidas pelas políticas e seus possíveis resultados sobre as práticas. Identificou-se que esse trabalho tem assumido conformações crescentemente próximas da educação para a saúde em uma vertente biomédica, agravada por mecanismos de gestão que promovem sua fragmentação e simplificação. Não houve avanço na implementação do Curso Técnico de Agente Comunitário de Saúde e, em paralelo, vêm se instituindo qualificações breves e impulsionadas por demandas pontuais. Entende-se que as políticas dirigidas a esse trabalhador se orientam por uma perspectiva de curto prazo e expressam, no contexto brasileiro atual, o próprio enfraquecimento do Sistema Único de Saúde. Observa-se a redução do papel do Agente Comunitário de Saúde na consolidação de estratégias que poderiam contribuir para concretizar a Atenção Primária à Saúde como espaço de fortalecimento da universalidade e da integralidade.(AU)

The article analyzed the construction of the profile of professionals internationally known as Community Health Workers, supported in the discussion about the disputes surrounding their work. Health policy documents were examined, with emphasis on the inflections produced on their attributions and professional training. It was sought to comprehend the rationality and the arguments that sustain the changes induced by the policies and their possible results on the practices. It was identified that this work has assumed conformations increasingly close to health education in a biomedical aspect, aggravated by management mechanisms that promote its fragmentation and simplification. There was no progress in the implementation of the Technical Course of Community Health Worker and, in parallel, short qualifications have been introduced and driven by specific demands. It is understood that the policies directed to this worker are guided by a short-term perspective and express, in the current Brazilian context, the very weakening of the Unified Health System. It is observed the reduction of the role of the Community Health Worker in the consolidation of strategies that could contribute to implement Primary Health Care as a space for strengthening universality and integrality.(AU)

Community Health Workers: Addressing Client Objectives Among Frequent Emergency Department Users.

OBJECTIVES: To evaluate effectiveness of a community health worker (CHW) program designed to address client objectives among frequent emergency department (ED) users. DESIGN: Program evaluation using secondary analysis of client objectives from program records. Client objectives were characterized according to the World Health Organization's social determinants of health framework. Hierarchical generalized linear modeling was used to assess factors associated with objective achievement. SETTING: An ED and the surrounding community in an economically disadvantaged area of Buffalo, New York. PARTICIPANTS: A total of 1600 adults over age 18 eligible for Medicaid and/or Medicare and who had at least 2 ED visits in the prior year. INTERVENTION: Clients worked with CHWs in the community to identify diverse needs and objectives. Community health workers provided individualized services to help achieve objectives. MAIN OUTCOME MEASURE: Achievement of client-focused objectives. RESULTS: Most objectives pertained to linkage to community resources and health care navigation, emphasizing chronic medical conditions and connection to primary care. Clients and CHWs together achieved 43% of total objectives. Objective achievement was positively associated with greater client engagement in CHW services. CONCLUSIONS: Low objective achievement may stem from system- and policy-level barriers, such as lack of affordable housing and access to primary care. Strategies for improving client engagement in CHW services are needed. Community health workers and their clients were most successful in areas in which public health policies and systems made resources easy to access or where the program had formalized relationships with resources, such as primary care.

The added value of a mobile application of Community Case Management on referral, re-consultation and hospitalization rates of children aged under 5 years in two districts in Northern Malawi: study protocol for a pragmatic, stepped-wedge cluster-randomized controlled trial.

BACKGROUND: There is evidence to suggest that frontline community health workers in Malawi are under-referring children to higher-level facilities. Integrating a digitized version of paper-based methods of Community Case Management (CCM) could strengthen delivery, increasing urgent referral rates and preventing unnecessary re-consultations and hospital admissions. This trial aims to evaluate the added value of the Supporting LIFE electronic Community Case Management Application (SL eCCM App) compared to paper-based CCM on urgent referral, re-consultation and hospitalization rates, in two districts in Northern Malawi. METHODS/DESIGN: This is a pragmatic, stepped-wedge cluster-randomized trial assessing the added value of the SL eCCM App on urgent referral, re-consultation and hospitalization rates of children aged 2 months and older to up to 5 years, within 7 days of the index visit. One hundred and two health surveillance assistants (HSAs) were stratified into six clusters based on geographical location, and clusters randomized to the timing of crossover to the intervention using simple, computer-generated randomization. Training workshops were conducted prior to the control (paper-CCM) and intervention (paper-CCM + SL eCCM App) in assigned clusters. Neither participants nor study personnel were blinded to allocation. Outcome measures were determined by abstraction of clinical data from patient records 2 weeks after recruitment. A nested qualitative study explored perceptions of adherence to urgent referral recommendations and a cost evaluation determined the financial and time-related costs to caregivers of subsequent health care utilization. The trial was conducted between July 2016 and February 2017. DISCUSSION: This is the first large-scale trial evaluating the value of adding a mobile application of CCM to the assessment of children aged under 5 years. The trial will generate evidence on the potential use of mobile health for CCM in Malawi, and more widely in other low- and middle-income countries. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT02763345 . Registered on 3 May 2016.

Reducing resistance to polio immunisation with free health camps and Bluetooth messaging: An update from Kaduna, Northern, Nigeria.

Since 1997, the Global Polio Eradication Initiative has sponsored regular door-to-door polio immunisation campaigns in northern Nigeria. On 30 July 2015, the country was finally declared poliofree, a hard won success. At various times, polio eradication has been threatened by rumours and community tensions. For example, in 2003, local Imams, traditional leaders and politicians declared a polio campaign boycott, due to the concerns about the safety of the polio vaccine. Although the campaigns resumed in 2004, many parents continued to refuse vaccination because of the persistence of rumours of vaccine contamination, and anger about the poor state of health services for conditions other than polio. To address this, UNICEF and Nigerian Government partners piloted two interventions: (1) mobile 'health camps' to provide ambulatory care for conditions other than polio and (2) an audiovisual clip about vaccine safety and other health issues, shareable on multimedia mobile phones via Bluetooth pairing. The mobile phone survey found that Bluetooth compatible messages could rapidly spread behavioural health messages in low-literacy communities. The health camps roughly doubled polio vaccine uptake in the urban ward where it was piloted. This suggests that polio eradication would have been accelerated by improving primary health care services.

Effectiveness of Two Community Health Worker Models of Tobacco Dependence Treatment Among Community Residents of Ohio Appalachia.

INTRODUCTION: Community health workers (CHW) may be effective in the delivery of tobacco dependence treatment with underserved groups. This study evaluated two evidence-based CHW models of treatment. It was hypothesized that smokers assigned to a CHW face-to-face condition would have higher abstinence at 12-month posttreatment than smokers enrolled in CHW referral to a state-sponsored quitline condition. Intrapersonal and treatment-related factors associated with abstinence at 12 months were determined. METHODS: A group-randomized trial was conducted with residents of 12 Ohio Appalachian counties with counties (n = 6) randomized to either a CHW face-to-face (F2F) or CHW quitline (QL) condition. Both conditions included behavioral counseling and free nicotine replacement therapy for 8 weeks. Follow-up data were collected at 3-, 6-, and 12-month posttreatment. Biochemically validated abstinence at 12 months served as the primary outcome. RESULTS: Seven hundred and seven participants were enrolled (n = 353 CHWF2F; n = 354 CHWQL). Baseline sample characteristics did not differ by condition. Using an intent-to-treat analysis (85.4% retention at 12 months), 13.3% of CHWF2F participants were abstinent at 12 months, compared to 10.7% of CHWQL members (OR = 1.28; 95% confidence interval [CI] = 0.810, 2.014; p = .292). No differences in abstinence were noted at 3 or 6 months by condition. Age, marital status, and baseline levels of cigarette consumption, depressive symptoms, and self-efficacy for quitting in positive settings were associated with abstinence, as was counseling dose during treatment. CONCLUSIONS: This research adds to the body of science evaluating the effectiveness of CHW models of tobacco dependence treatment. Both approaches may offer promise in low-resource settings and underserved regions. IMPLICATIONS: This 12-county community-based group-randomized trial in Ohio Appalachia adds to the body of science evaluating the effectiveness of CHW models of tobacco dependence treatment. Both CHW approaches may offer promise in low-resource settings and underserved regions. These findings are useful to national, state, and local tobacco control agencies, as they expand delivery of preventive health care services postadoption of the Affordable Care Act in the United States.

Training of Community Health Agents in health hearing children: current perspectives.

PURPOSE: To characterize the training of Community Health Workers in the field of child hearing health. RESEARCH STRATEGY: A systematic literature review on Biblioteca Virtual em Saúde (BVS) and Biblioteca Digital de Teses e Dissertações of USP databases was performed. SELECTION CRITERIA: The search strategy was oriented by the specific question: "How have the Community Health Workers been trained to work in the field of child hearing health?" The study selection criteria involved consistency with the proposed theme, belonging to the category of scientific papers, dissertation or thesis, and publication in Brazilian Portuguese. DATA ANALYSIS: A total of 2,687 studies were found. After analyzing the title and abstract, eight studies were chosen for full reading, however, only four of them met the proposed criteria and were included in the review. RESULTS: The studies indicated live and virtual classes with the use of video conferencing or CD-ROM as training strategies for Community Health Workers. Trainings were effective. Only one questionnaire about hearing and language monitoring was described. Different possibilities for the activities of Community Health Workers were identified. CONCLUSION: Different learning methodologies have been used for training the Community Health Worker in the field of child hearing health, and all of have proven effective for knowledge acquisition. Community Health Workers play an important role in promoting and monitoring child hearing health.

Capacitação do Agente Comunitário de Saúde na saúde auditiva infantil: perspectivas atuais / Training of Community Health Agents in health hearing children: current perspectives

RESUMO Objetivo: Caracterizar a capacitação dos Agentes Comunitários de Saúde (ACS) na área da saúde auditiva infantil. Estratégia de pesquisa Foi realizada uma revisão sistemática da literatura no Portal de Pesquisa da Biblioteca Virtual em Saúde (BVS) e na Biblioteca Digital de Teses e Dissertações da USP. Critérios de seleção: A estratégia de busca foi direcionada por uma questão específica "Como tem sido realizada a capacitação do Agente Comunitário de Saúde na área de saúde auditiva infantil?". Os critérios de seleção dos estudos envolveram a coerência com o tema proposto, pertencer à categoria artigo, dissertação ou tese e ser publicado na língua portuguesa. Análise dos dados: Foram localizados 2.687 estudos. Após análise do título e resumo, 8 estudos foram selecionados para leitura completa. Destes, apenas 4 atenderam aos critérios propostos e foram incluídos na revisão. Resultados: Os estudos apontaram como estratégias de capacitação dos ACS a aula presencial e as aulas a distância com o uso de videoconferência ou de CD-ROM. As capacitações foram consideradas efetivas. Foi apontado apenas um questionário de monitoramento sobre a audição e linguagem. Distintas possibilidades de atuação dos ACS foram identificadas. Conclusão: Atualmente, diferentes modalidades de ensino têm sido utilizadas para a capacitação do ACS na área de saúde auditiva infantil, todas se mostrando efetivas quanto à retenção do conhecimento. O ACS desempenha um papel importante na promoção e vigilância da saúde auditiva infantil.

ABSTRACT Purpose To characterize the training of Community Health Workers in the field of child hearing health. Research strategy A systematic literature review on Biblioteca Virtual em Saúde (BVS) and Biblioteca Digital de Teses e Dissertações of USP databases was performed. Selection criteria The search strategy was oriented by the specific question: "How have the Community Health Workers been trained to work in the field of child hearing health?" The study selection criteria involved consistency with the proposed theme, belonging to the category of scientific papers, dissertation or thesis, and publication in Brazilian Portuguese. Data analysis : A total of 2,687 studies were found. After analyzing the title and abstract, eight studies were chosen for full reading, however, only four of them met the proposed criteria and were included in the review. Results The studies indicated live and virtual classes with the use of video conferencing or CD-ROM as training strategies for Community Health Workers. Trainings were effective. Only one questionnaire about hearing and language monitoring was described. Different possibilities for the activities of Community Health Workers were identified. Conclusion Different learning methodologies have been used for training the Community Health Worker in the field of child hearing health, and all of have proven effective for knowledge acquisition. Community Health Workers play an important role in promoting and monitoring child hearing health.

Promotores As Advocates for Community Improvement: Experiences of the Western States REACH Su Comunidad Consortium.

The REACH Su Comunidad Consortium worked with 10 communities to address disparities in access to healthy food and physical activity opportunities among Hispanic populations through policy, systems, and environmental (PSE) strategies. Community health workers took leadership roles in the implementation of PSE strategies in partnership with local multisector coalitions. This article describes the role of community health workers in PSE change, the technical and professional development support provided to the REACH Su Comunidad Communities, and highlights professional development needs of community health workers engaging in PSE strategies.

Redesigning primary care to tackle the global epidemic of noncommunicable disease.

Noncommunicable diseases (NCDs) have become the major contributors to death and disability worldwide. Nearly 80% of the deaths in 2010 occurred in low- and middle-income countries, which have experienced rapid population aging, urbanization, rise in smoking, and changes in diet and activity. Yet the health systems of low- and middle-income countries, historically oriented to infectious disease and often severely underfunded, are poorly prepared for the challenge of caring for people with cardiovascular disease, diabetes, cancer, and chronic respiratory disease. We have discussed how primary care can be redesigned to tackle the challenge of NCDs in resource-constrained countries. We suggest that four changes will be required: integration of services, innovative service delivery, a focus on patients and communities, and adoption of new technologies for communication.

[Professional education and work of indigenous health agents in the Brazilian health system]. / La formación y el trabajo del agente indígena de salud en el Subsistema de Salud Indígena en Brasil.

OBJECTIVE: To discuss the role of indigenous health agents in the implementation of the model of differentiated attention or intercultural health in Brazil. MATERIALS AND METHODS: We revised the scientific literature about the work and professional education of indigenous health agents in the Brazilian indigenous health system. RESULTS: There is a subordination of the agents to the hegemonic medical model. With regards to professional education, we observe the absence and irregularity of these processes, with a general emphasis the biomedicine. There are conflicts with the health team and community, with devaluation of the agents. The agent does not plays the role of mediator between the different health knowledge and practices. CONCLUSIONS: We suggest that the discussion of the model of differentiated attention should strengthen the relationship between the health system and the selfcare.