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

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.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.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.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.Version 1.0 - May 2026. This is a working paper that has not been peer reviewed.