The UK’s National Health Service (NHS) is now adopting a model inspired by Brazil’s community health worker system. As reported by The Telegraph, the British Community Health Workers and Wellbeing program draws directly from Brazil’s Family Health Strategy, created by the Ministry of Health in the 1990s and still active today. The pilot project was launched in the London neighborhood of Pimlico, with plans to expand to 25 additional regions across England.

The news highlights the complex — and often ambivalent — international perception of Brazil’s public health system (Sistema Único de Saúde [SUS]). Foreign physicians who arrive to work in Brazil frequently view SUS as an impressive model of universal healthcare. Meanwhile, Brazilian doctors who leave the country in search of better opportunities abroad often reflect on SUS’s strengths after experiencing other systems.

“The SUS model is extraordinary, even though it has flaws in practice,” said Dennis Kirii, a Kenyan physician who has worked for a year as a generalist in hospitals in the metropolitan region of Rio de Janeiro, Brazil.

“The Family Health Strategy is the best I’ve ever seen,” added Thiago Funk, a Brazilian physician who previously worked as a family doctor and has spent the past 2 years practicing emergency medicine in Italy.

“I had already worked in several health systems around the world, and I can say that SUS is one of the most complete and well-designed I’ve encountered,” said Luis Sauchay Romero, a Cuban doctor who arrived in Brazil in 2014 under the More Doctors program after working in Guatemala, Namibia, Sri Lanka, and Bolivia.

Despite coming from different backgrounds, all three doctors share two experiences:

• They have seen Brazil’s public health system from the inside.
• They are expatriate physicians, practicing medicine far from their home countries.

Their stories raise central questions: What are their professional and personal experiences working abroad? And what challenges do they face as foreign-trained physicians in Brazil?

From Kenya to Brazil: Dennis Kirii

Kirii, now 30, first came to Brazil in 2017 through the federal government’s Undergraduate Student Exchange Program (PEC-G). Created in 1965, PEC-G offers free undergraduate seats at Brazilian public universities to students from 73 countries — 29 in Africa, 27 in Latin America and the Caribbean, 10 in Asia, and 7 in Europe.

To enter PEC-G, foreign students must demonstrate proficiency in Portuguese. One way to do this is by passing Celpe-Bras, Brazil’s official Portuguese-language proficiency exam, administered both in Brazil and at international testing centers. The exam evaluates oral and written comprehension, text production, and conversation skills.

If students cannot take Celpe-Bras in their home country, they may enroll in the PEC-PLE, a 1-year preparatory track focused on Portuguese as a foreign language. In this route, the student spends a full year studying Portuguese in Brazil before sitting for the Celpe-Bras exam. Only after passing can they begin an undergraduate degree at one of more than 100 participating higher-education institutions.

Kirii chose the PEC-PLE path and spent a year studying Portuguese in the northern state of Amapá. After passing Celpe-Bras in 2018, he began medical school at the Federal University of Rio de Janeiro — one of Brazil’s largest and most prestigious public universities. He graduated in 2024.

“Medical school really helped with the language,” he told Medscape’s Portuguese edition. “After a year, you can communicate and understand most conversations. But fluency took time.”

After completing his degree, he obtained his medical license through the Regional Council of Medicine (Conselho Regional de Medicina [CRM]) of the State of Rio de Janeiro, following the same registration steps as Brazilian graduates.

Networking, he said, was critical for finding work. Near the end of his internship, while rotating through a hospital, he learned of an opening in the ICU of the public health network in São Gonçalo, a municipality of about 1 million people in the Rio de Janeiro metropolitan region.

“You have to know colleagues who are already working and build a network,” he said. “Join WhatsApp groups that post shift openings. I covered many shifts before getting a fixed position.”

The public sector, he added, tended to have more openings. “Private hospitals fill their needs quickly because most physicians prefer to work privately. In the public system, there’s more work, fewer resources, worse conditions, and lower pay — so many doctors avoid it.”

Today, Kirii works 96 hours a week, splitting his time between São Gonçalo’s municipal hospitals and the city’s urgent care units. He does so under a temporary visa tied to a 1-year renewable work contract that does not extend residency rights to his family.

When he first arrived, he had limited knowledge of SUS. “The model is incredible, but in practice there are failures,” he said. “I see patients waiting for tests or critical surgeries that should be done the same day, but they wait far too long. Last month, I lost a young patient — only 35 — who waited for an oral and maxillofacial surgeon and died in the ICU.”

Even so, he believes SUS is stronger than the system in his home country. Despite Kenya’s history as a former British colony, he noted, the country did not inherit the NHS model. Instead, the health system varies greatly depending on the administrative region, creating unequal access. “Some counties have good systems; others don’t,” he said.

“We have a lot to learn from SUS, especially universal care,” he added. “In Kenya, medical distribution is unequal — doctors want to work only in Nairobi or major cities with wealthier populations.”

This inequity mirrors trends in Brazil, as shown in the Medical Demographics in Brazil 2025 study. For Kirii, this is one of the major systemic weaknesses.

Although he originally planned to practice in Brazil’s north region — where he learned Portuguese and expected higher demand — job leads in his professional network never appeared there. “It’s strange. I thought there would be a need for doctors. If there is, it’s not publicized. All the openings I found were in Rio, so I stayed.”

Among the challenges he cites is prejudice — especially stereotypes about Africans. “Some assumed I had grown up hungry or fled a war. But when I chose to come, I was already in my second year of medical school in Kenya. I had to explain that we have universities, airports, major highways.”

His next goals include sitting for a residency exam in orthopedics and obtaining his Specialist Qualification Registration. Eventually, he hopes to bring his experience with SUS back to Kenya. “Maybe one day I can propose a similar model there,” he said.

Revalidation for Foreign-Trained Doctors

Foreign physicians who earn their medical degree in Brazil, like Kirii, do not need to revalidate their diploma. But anyone who studied medicine outside the country must undergo the official revalidation process.

(Click here for details on practicing medicine in Brazil as a foreign doctor.)

Created in 2011, the National Examination for the Revalidation of Medical Diplomas Issued by a Foreign Higher Education Institution, known as Revalida, is administered twice a year. Each edition includes a theoretical exam and a clinical-skills (practical) exam.

Only candidates who pass both stages may move forward with diploma revalidation and then seek registration with the CRM in the state where they plan to practice.

The theoretical test consists of 100 multiple-choice questions to be answered in 5 hours. Some questions require identifying the correct diagnosis and appropriate management — for example, recognizing and treating meningococcal meningitis. Others test knowledge of the SUS.

The clinical exam is divided into 10 stations simulating real patient-care scenarios in the five major areas of medicine: internal medicine, general surgery, gynecology and obstetrics, pediatrics, and family and community medicine. Candidates must perform core clinical tasks: diagnosing conditions, conducting physical examinations, and carrying out clinical procedures. Communication skills with patients and relatives are also evaluated.

(See previous exams and answer keys here.)

Foreign physicians must also present a Celpe-Bras certificate when applying for CRM registration, except for doctors from Portuguese-speaking countries and those who completed medical school in Brazil.

The proficiency level required for diploma validation is typically advanced, and the threshold is set by the Federal Council of Medicine — Brazil’s national medical regulatory authority.

Revalida is widely known for being complex and time-consuming, with historically low pass rates. Since the first exam in 2011, some editions have had pass rates below 20%. In 2013, more than 90% of candidates failed the first stage. In 2024, fewer than 30% passed both rounds.

“It’s an unnecessarily long and exhausting exam,” said Romero. “In the first phase, we sat for 9 hours. That much time isn’t necessary to prove you’re a doctor,” said the Cuban physician, who passed the 2022 exam after failing the previous year.

He added that the exam includes highly specialized questions, more suitable for experts than for general practitioners, making it even harder for nonspecialists to pass.

Still, the process is mandatory for foreign doctors who want to practice in Brazil. Access to medical societies also usually requires a revalidated diploma, CRM registration, and a residency in internal medicine (or another required specialty).

In 2025, Brazil’s Federal Regional Court of the 1st Region reaffirmed that only foreign-trained doctors with a revalidated diploma may legally practice in Brazil, except under government programs such as More Doctors.

Bringing Doctors to Remote Areas

The More Doctors program was created to bring primary care physicians to remote, underserved, and vulnerable areas across Brazil. The initiative was implemented nationwide through Law No. 12.871/2013.

In its first public call, 3511 of Brazil’s 5570 municipalities applied to participate, collectively requesting 15,460 physicians. Through a cooperation agreement with the Pan American Health Organization, the Brazilian government reached an arrangement with Cuba to receive experienced primary care clinicians.

Cuban doctors were sent to priority municipalities — remote regions that Brazilian physicians typically did not choose. The Ministry of Health authorized foreign doctors participating in the program to practice medicine for 3 years in their assigned locations.

It was during this period that Romero, a graduate of the University of Medical Sciences of Havana, arrived in Brazil with a group of 500 Cuban physicians. He was assigned to the municipal health department in Miguel Alves, a town of 33,000 residents located about 110 km from Teresina, the capital of the state of Piauí.

“Integration into SUS was easy,” he said. “I gained a lot of experience and learned a great deal about primary care in Miguel Alves.”

After revalidating his diploma in 2022, Romero worked as an on-call physician in a hospital and at a family health clinic. He later became a specialist in traffic medicine and now works as a medical examiner in a clinic operated by the State Transport Department (Detran).

His residency status was regularized through an indefinite residence authorization granted after the 2019 interministerial ordinance that extended permanent residency rights to Cuban doctors who participated in More Doctors.

Romero said his biggest challenges were learning Portuguese and adapting to Brazilian culture — and, importantly, understanding how SUS operates.

“SUS has updated protocols and high-quality technologies, and primary care offers treatments you wouldn’t expect in a country like Brazil,” he explained. “But every municipality has its own rules, influenced by local politics, and this weakens the system. Many problems stem not from SUS itself, but from local administration.”

For foreign physicians, he emphasized, it is crucial to thoroughly understand SUS policies — including national health strategies for children, women, and older adults. “Each program specifies exactly what to do, and when,” he said.

Brazilian Doctors Abroad

Many Brazilian doctors take the opposite route, moving to wealthier countries for better career prospects. Common destinations include the United States and European nations, where they also need to revalidate their diplomas.

Among them is Funk, 35, a graduate of the Federal University of Santa Catarina, who has lived in Europe since 2017. For the past 2 years, he has worked in the emergency departments of Italian hospitals, sometimes up to 70 hours per week.

Italy has an exam similar to Revalida, with a pass rate of around 60%. “It’s not easy, but it’s also not an impossible barrier,” he said.

Revalidating his Brazilian diploma took 1.5 years, involving document collection — reviewed by both the Brazilian Consulate and Italy’s Ministry of Health in Rome — and a licensure exam covering surgery, gynecology, pediatrics, and forensic medicine.

“Forensic medicine was the hardest part for me,” he explained. “It’s not something we study extensively in Brazil.”

He did not need a visa because he holds Italian citizenship.

Revalidation also requires intermediate to advanced proficiency in Italian. After validating his diploma in 2024, Funk worked in several facilities, including the emergency departments at Ospedale Giovanni Paolo II in Sardinia and Ospedale S. Giacomo - Novi Ligure in Piedmont.

One of his greatest challenges, he said, was local prejudice. “Italians are not as welcoming as South Americans, especially toward people who look different from them,” he noted. “I have colleagues from other South American countries, and patients often don’t treat them well — likely due to ethnic bias.”

Communication barriers were most common with specialist physicians. “It’s difficult when you need to contact specialists for referrals during emergency care,” he said.

Immigration is a contentious issue in Italy. Funk recalled a newspaper article in Sardinia featuring a governor’s promise to end the hiring of foreign doctors — a move that prompted backlash from the medical community and was ultimately abandoned.

“He was speaking to a population frustrated with the region’s healthcare system,” Funk said. “He blamed foreign doctors, but the real issue is staffing shortages. During summer, the population doubles, and the number of physicians is not enough.”

Despite challenges, he views working conditions in Italy as generally better than those in Brazil. Italy’s public health system, like SUS, is universal and tax-funded, but includes small copayments.

“For medium- or high-severity care, there’s no charge. But for minor issues treated in the emergency department, patients pay a small fee to discourage overuse,” he said.

Inspired by the NHS — much like SUS — the Italian system provides universal coverage to European Union citizens.

Funk said his training in SUS was invaluable. “The Family Health Strategy is the best I’ve seen. In Italy, they have general practitioners, but no community health agents.”

His advice to those considering Italy: “Learn the language well before arriving. Our training in Brazil is strong — better than here. Financially, it’s worthwhile, and it’s a safe country. You just need to adapt to the small challenges of Italian life.”

International Attraction to SUS

In contrast to Italy’s health system, SUS appears more welcoming to foreign health professionals. The public system attracts doctors from across Latin America — especially Paraguay, Bolivia, Argentina, and Cuba — as well as from African nations such as Angola, Nigeria, Kenya, and Benin.

SUS is structured into three levels of care, organized by increasing complexity:

• Primary care serves as the main entry point and resolves the majority of health needs.
• Secondary care provides specialized services, including outpatient clinics, urgent care units, and general hospitals.
• Tertiary care handles high-complexity interventions that require advanced technology. 

Today, SUS includes 53,356 Family Health Teams and 281,425 Community Health Agents cofunded by the Ministry of Health and present in every Brazilian state.

Washington Castilhos has been a science and health journalist for more than 20 years. He holds a master’s degree in science, health, and technology communication from the Oswaldo Cruz Foundation in Rio de Janeiro, Brazil, and a doctorate in education and biosciences communication from the Federal University of Rio de Janeiro, which included a doctoral internship at Paris 8 University, Saint-Denis, France.

This story was translated from Medscape’s Portuguese edition.