Importing What Works: A Territory-Based Community Health Worker Framework from Brazil's ESF for U.S. Federally Qualified Health Centers Serving Underserved Populations

  1. Ivone de Almeida Paradela

Reviewed by

Read the full article

Discuss this preprint

Start a discussion What are Sciety discussions?

Listed in

Log in to save this article

Abstract

<p><span><span>Background: Approximately 92 million Americans reside in primary care Health Professional Shortage Areas, and preventable hospitalizations generate substantial avoidable inpatient costs. Federally Qualified Health Centers (FQHCs) serve as the federal safety-net response, yet their community health worker (CHW) integration models remain reactive, heterogeneous, and underfunded.</span></span><span><br><br><span>Objectives: This policy analysis examines Brazil's Estrategia Saude da Familia (ESF) and its CHW component, the Agente Comunitario de Saude (ACS), as an evidence-based operational model with adaptation potential for U.S. FQHCs. It identifies structural analogues between the two systems, discusses the financial logic of territory-based CHW deployment, and proposes a three-component adaptation framework.</span><br><br><span>Findings: Peer-reviewed evidence consistently links ESF expansion to reductions in hospitalizations for ambulatory care-sensitive conditions (Macinko et al., 2010; Bastos et al., 2017). The most rigorously evaluated U.S. CHW program documents a Medicaid return of USD 2.47 per dollar invested (Kangovi et al., 2020). Illustrative scenario projections for FQHC territory-based deployment are calibrated against the CDC-funded systematic review of U.S. CHW programs (Rashid et al., The Lancet Regional Health Americas, 2026), which reports a national median ROI of USD 2.12 (IQR 1.64-4.03). The structural parallel between ESF teams and U.S. FQHC care teams appears closer than commonly recognized in the implementation science literature; the operational difference most amenable to adaptation is deployment logic rather than organizational design.</span><br><br><span>Conclusions: FQHCs in Texas and Florida, serving large Hispanic and immigrant populations in documented shortage areas, represent strategically plausible early implementation contexts. The author proposes a pilot design and invites collaboration from U.S.-based health organizations.</span><br><br><span>Version 1.0 - May 2026. This is a working paper that has not been peer reviewed.</span></span><span></span></p> <p><span>Also available at Zenodo:&nbsp;</span><span>https://doi.org/10.5281/zenodo.20278817</span></p>

Article activity feed

  1. PREreview

    This Zenodo record is a permanently preserved version of a Structured PREreview. You can view the complete PREreview at https://prereview.org/reviews/20632025.

    A introdução explica o objetivo da pesquisa apresentada no preprint? Sim
    Os métodos são adequados para esta pesquisa? Altamente adequados
    As conclusões são sustentadas pelos dados? Altamente sustentadas
    As apresentações de dados, incluindo visualizações, são adequadas para representar os dados? Altamente adequadas e claras
    Quão claramente os autores discutem, explicam e interpretam seus achados e possíveis próximos passos da pesquisa? Muito claramente
    É provável que o preprint contribua para o avanço do conhecimento acadêmico? Altamente provável
    Seria benéfico passar por uma revisão de linguagem? Não
    Você recomendaria este preprint a outras pessoas? Sim, é de alta qualidade
    Está pronto para receber atenção de um editor, de editoras ou de um público mais amplo? Sim, tal como está

    Conflitos de interesse

    O autor declara que não possui conflitos de interesse.

    Uso de Inteligência Artificial (IA)

    The author declares that they did not use generative AI to come up with new ideas for their review.

  2. Version published to 10.2139/ssrn.6792158