Primary Health Care Portfolio: Assuring of integrality in the Family Health and Oral Health Teams in Brazil

Carlo Roberto Hackmann da Cunha Erno Harzheim Olivia Lucena de Medeiros Otávio Pereira D’Avila Caroline Martins Lucas Wollmann Lívia de Almeida Faller About the authors

Abstract

More than 30 years into the anniversary of the Unified Health System (SUS), 40 years after Alma-Ata, and soon after the Astana Conference, the Brazilian Ministry of Health proposes several strategies to strengthen PHC with the creation of the Primary Health Care Secretariat (SAPS). This paper presents the process of developing the national PHC service portfolio, one of the strategies developed by SAPS to strengthen the PHC clinic, and the challenges for the expansion of comprehensive care in the actions developed by the Family Health and Oral Health teams. After the public consultation, from a total of 209 initially listed actions and procedures, including incorporations and exclusions, 210 items were defined, including the actions planned for the integration between primary care and health surveillance. We emphasize that the national portfolio model can be adapted to the reality and municipal context in each of the federation units, including considering the availability of the local care network.

Key words
Primary health care; Comprehensiveness; Family health; Oral health; Brazil

Introduction

In August 2007, the Pan American Health Organization (PAHO) announced that the first approach to producing sustainable and equitable improvements in the health of the populations of the Americas is developing health systems firmly based on Primary Health Care (PHC)11 Organização Pan-Americana da Saúde (OPAS). Renovação da Atenção Primária em Saúde nas Américas: documento de posicionamento da Organização Pan-Americana da Saúde/Organização Mundial da Saúde (OPAS/OMS). Washington: OPAS; 2007.. In 2008, in its World Health Report, WHO reinforced this guideline with the statement that gives name to that publication Primary Health Care Now More Than Ever!22 Organização Mundial da Saúde (OMS). Relatório Mundial de Saúde 2008. Cuidados de Saúde Primários: agora mais do que nunca. Lisboa: OMS; 2008. More recently, in October 2018, when Alma-Ata completed 40 years, the Global Conference on PHC produced the document entitled the Astana Declaration, which stresses that PHC is the most effective, efficient and equitable approach to improving health, making it a necessary foundation for achieving universal health coverage33 Organização Mundial da Saúde (OMS). Declaração de Astana. Genebra: OMS; 2019..

Upon completing 30 years of the SUS, 40 years after Alma-Ata44 Organização Mundial da Saúde (OMS). Declaração de Alma-Ata. Genebra: OMS; 1978. and shortly after the Astana Conference33 Organização Mundial da Saúde (OMS). Declaração de Astana. Genebra: OMS; 2019., the Brazilian Ministry of Health proposes several strategies to strengthen PHC with the creation of the Primary Health Care Secretariat (SAPS)55 Reis JG, Harzheim E, Nachif MCA, Freitas JC, D'Avila OP, Hauser L, Marins CJ, Pedebos LA, Pinto LF. Criação da Secretaria de Atenção Primária à Saúde e suas implicações para o SUS. Cien Saude Colet 2019; 24(9):3457-3462.. As SAPS competences and commitments, defined by the decree above, worth highlighting are expanding the population’s access to family health units, defining a new financing model based on health and efficiency results, defining a new model of supply and training doctors for remote areas, strengthening the PHC clinic and teamwork, and expanding the computerization of the units and the use of electronic medical records.

The strengthening of the clinic and teamwork in the Family Health Strategy (ESF) requires the recognition of federated entities of the importance of PHC for the organization of services. Thus, besides the physical infrastructure of the Family Health Units (USF), one must have working conditions and a clear division and subsidiary attributions of each of the professionals from the actions and procedures provided to the population, without prejudice to the shared care processes among professionals. In this sense, the creation of a “primary health care portfolio” may define the individual roles, besides fundamentally presenting the procedures and services offered in this care environment, reducing the heterogeneity of existing practices in the national PHC between municipalities, but also between facilities in the same municipality, so that the Brazilian population can recognize what is expected from actions and services in a Family Health Unit.

Universal health systems are sustainable if they have strong PHC66 Macinko J, Starfield B, Shi L. The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, 1970-1998. Health Serv Res 2003; 38(3):831-865.,77 Kringos SD, Boerma WGW, Hutchinson A, Saltman RB. Building primary care in a changing Europe. Copenhagen: European Observatory on Health Systems and Policies, World Health Organization (WHO); 2015.. PHC aims at a better individual and population health with equity, which is only achieved if the PHC services work correctly, that is, they combine high clinical resolution with accountability for the health of the population under care, and the adequate communication of the facts and events that characterize people’s clinical path. PHC must be organized with the maximum presence and extent of its operational characteristics and attributes to achieve the above objectives and function properly. The essential attributes of Primary Care (first contact access, longitudinality, coordination, and comprehensiveness) are operational and measurable characteristics of PHC services88 Starfield B. Atenção primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: UNESCO, Ministério da Saúde (MS); 2002.. The stronger the presence and extent of these attributes, the more robust the PHC will be. Different and complementary organizational tools are required to strengthen each attribute.

In Brazil, the PHC portfolio is one of the most important organizational tools. It is already used in Rio de Janeiro, Curitiba and Florianópolis, among other places99 Rio de Janeiro. Secretaria Municipal de Saúde e Defesa Civil (SMSDC). Guia de Referência Rápida. Carteira de Serviços: Relação de serviços prestados na Atenção Primária à Saúde. Rio de Janeiro: SMSDC; 2011.

10 Curitiba. Secretaria Municipal de Saúde (SMS). Carteira de Serviços - Guia para profissionais de saúde - Relação de serviços e condições abordadas na Atenção Primária à Saúde. Curitiba: SMS; 2014.
-1111 Secretaria Municipal de Saúde de Florianópolis. Carteira de Serviços Atenção Primária à Saúde. Florianópolis: Prefeitura Municipal de Florianópolis; 2014.. It is a vital instrument to ensure comprehensiveness. PHC must be organized in such a way to provide citizens with all the necessary health services, identifying and providing preventive services, as well as services that enable the diagnosis and treatment of diseases, also establishing the appropriate way to solve organic, functional, or social problems.

By defining a transparent list of actions and services aimed at the most frequent health problems and conditions, we have the necessary ‘leverage’ to move the ‘world’ of comprehensiveness and bring it into the daily lives of people and PHC teams. The PHC portfolio makes it clear to people what services and actions they can find in the PHC facilities, and allows professionals to organize themselves in the service routine, as well as seek knowledge and skills to offer the actions and services with competence. Moreover, the portfolio becomes an instrument for monitoring management, which must provide the structural conditions (equipment, inputs, human resources, financing) and the work process – people deployment, continuous personal development strategies, monitoring, and evaluation – enough to make their actions and services a reality in the day-to-day life of PHC.

Intended for professionals in the Health Care Network (RAS), it contains the definition of PHC responsibilities to ensure, primarily, the care comprehensiveness attribute. It seeks to establish general organizational guidelines and define actions and procedures provided in each service based on virtually structural criteria. PHC must be responsible for the most common and frequent health problems of the population and resolve 80% to 90% of their demands. From a clinical viewpoint, the PHC Portfolio does not aim to list or exhaust all the most prevalent signs/symptoms or pathologies that must be managed and monitored by PHC, especially since the epidemiology and people’s needs are dynamic and varying, mainly when referring to a country with continental dimensions like Brazil. Yet it is worth mentioning that the procedures and actions to be carried out must respect the specific regulations of the professional councils, as well as individual skills, and are the motto for the organization and the identification of additional necessary training. The central objective of the PHC portfolio is guiding professionals concerning services that are expected to be provided in PHC units (especially in the context of the SAPS and MoH guidelines and goals), and whether any particular condition for this service to occur (table of actions/programs and materials) is in place. Furthermore, it serves to reinforce which criteria are indicative of handling common conditions or complaints at a higher level of complexity in the municipality’s network, on an elective basis (not including emergencies). It is a document that is not intended to be exclusive. Therefore, the absence of mention of a sign, symptom, or disease does not mean that you should not be attended at the PHC.

This paper aims to show the development of the national PHC portfolio of services and the challenges for strengthening comprehensive care in the actions developed by the Family Health and Oral Health teams.

Material and methods

This is a study with a documentary analysis that aims to produce technical guidance to assist PHC teams and management at the state and municipal level in defining the provision of actions and services in family health units. The so-called “Primary Health Care Portfolio” (CASAPS) is a document that aims to guide health actions in Brazilian PHC with recognition of the multi-professional clinic. It is a guiding document for all Brazilian PHC services and is, thus, an instrument that aims to contribute to the strengthening of PHC’s care supply. It is an essential care management tool that will be regularly reviewed by the SAPS, and is intended for all professionals, managers, and Brazilian citizens to take ownership and have knowledge of the health services offered in PHC. One of its versions is specifically aimed at professionals and managers and contains the list of services and necessary supplies and equipment (Table 1).

Table 1
Level of agreement with the inclusion of the services proposed in the public consultation for the construction of a national portfolio of services for PHC.

We considered the following materials for its preparation: (i) review of national and international documents with PHCportfolios. Initially, a comprehensive review of PHC portfolios published in Brazil and abroad was carried out. As it is a tool rarely used in our country, we reviewed portfolios in Rio de Janeiro, Florianópolis, Curitiba (Services Portfolio and Access Booklet), Belo Horizonte, Natal, and Porto Alegre. The portfolios of services in Portugal, Spain, and the city of Madrid were also revised; (ii) revision of the Primary Care Assessment Tool Manual (PCATool) published in 2010 by the Ministry of Health1212 Brasil. Ministério da Saúde (MS). Manual do instrumento de avaliação da atenção primária à saúde: primary care assessment tool pcatool - Brasil. Brasília: MS; 2010..

All the services described in the portfolios of the municipalities mentioned above were listed, and a comparison was made between them, building a table with the list of terms and verification of the cities where the service was present in the portfolio. The services were divided and shown as follows: adult and older adult health care, child and adolescent health care, and PHC and oral health procedures. Moreover, we elaborated a guiding text regarding the work process of health teams in PHC, and PHC’s essential attributes were the principal axes.

The stages of the public consultation were: (i) interaction with external evaluators to contribute to the elaboration of the portfolio’s content; (ii) provision of the draft service portfolio during the public consultation period on the Ministry of Health Portal, along with a form on the Google Forms Platform in August 2019. At this point, participants expressed their opinion for inclusion or exclusion and could suggest changes for each item of the list of actions and procedures1313 Brasil. Ministério da Saúde (MS). Carteira de serviços da Atenção Primária à Saúde Brasileira: avaliação por convidados externos e consulta pública. [acessado 2019 Out 29]. Disponível em: http://189.28.128.100/dab/docs/portaldab/documentos/carteira_servico_da_APS_consulta_SAPS.pdf
http://189.28.128.100/dab/docs/portaldab...
(iii) review after public consultation by SAPS of the introductory text and the list of actions and services presented.

The contribution of Professional Associations, the National Council of State Health Secretaries (CONASS) and the National Council of Municipal Health Secretaries (CONASEMS)

Besides other Secretariats of the Ministry of Health, the proposal was sent to CONASS, CONASEMS, and the Professional Associations of the Brazilian Society of Family and Community Medicine (SBMFC), the Brazilian Association of Family and Community Nursing (ABEFACO) and the Brazilian Association of Dentistry (ABO), which were called external evaluators. Such entities were approached both during the public consultation period and later, on the final version of the portfolio resulting from the public consultation. At this stage, these bodies also gave their opinion on the classification in essential and expanded PHC standards provided for in the PNAB.

Results of the final version of the portfolio of services

A quantitative and qualitative analysis of the responses sent by electronic forms was conducted after the public consultation. In all, 1,855 forms were answered, distributed from the respondent’s profile as follows: 1,415 (76.3%) health professionals, 86 (4.6%) SUS users, 81 (4.4%) students, 121 (6.5%) municipal managers, 28 (1.5%) state managers, 17 (0.9%) Ministry of Health managers, 44 (2.4%) researchers and 63 (3.4%) identified in the “others” category.

The level of agreement (people who marked “I agree with the inclusion” or “I agree with the inclusion, with changes”) was high (Table 1). The item with the lowest percentage of agreement (46.7%) was: “Identification regarding the possession of a firearm by adults and guidance on how to store it safely”. A low agreement was also observed with the PHC procedures, among which the following stand out: “infiltration of substances in the synovial cavity (joint, tendon sheath) (70.8%)”, “biopsy/puncture of superficial skin tumors and sending the material for anatomopathological analysis” (73.9%) and “manual removal of fecaloma” (74.1%).

When we analyzed the contributions and changes made from a qualitative viewpoint, after the public consultation, we highlighted six relevant points: (i) addressing what belongs to PHC, and the need for protocols, articulating with the network; (ii) the inclusion of an item that considered the promotion of integrative and complementary practices; (iii) mentioning that some items in the portfolio will be challenging to execute concerning exams and procedures, considering the infrastructure of some facilities; (iv) the inclusion of items that measure the assessment of frailty and multidimensional assessment in older adults; (v) in the text that precedes the list, it would be necessary to mention the need for the PHC team to be supported by other services in the care network; (vi) the need for reinforcement and the possibility of adapting the portfolio to the local reality.

The reorganization of portfolio items

The assignments for higher education professionals were considered in the construction of the final version of the portfolio, keeping the essential attributes in the “Child/Adolescent”, “Adult and Older Adult”, “PHC Actions/Procedures”, and “Oral Health” groups, thus considering the work process of doctors, nurses and dentists. From a total of 209 actions and procedures initially listed in the public consultation, including inclusions and exclusions, at the end of its creation, 210 items were defined, including the set of actions planned for the integration between primary care and health surveillance. The vital contribution from the public consultation with the change and qualification in the text of 109 items in total is also cited: 44 items changed to “Adult/Older Adult”, 27 to “Child/Adolescent”, 17 to “PHC Procedures”, and 21 to “Oral Health”. Moreover, the details of supplies, equipment, and even the technical references necessary for the performance of each action/procedure by the team were included. We emphasize that the model of the national portfolio can be adapted to the reality and municipal context in each of the federative units, also considering the availability of the local care network.

Chart 1
List of services of the Portfolio of Primary Health Care Services in Brazil - CASAPS.

Discussion

The service portfolio is a document that aims to guide health actions and presents itself as the regulator of PHC in the places where it was implemented. Its content covers the set of care and clinical, health surveillance, promotion, and prevention activities offered as services that aim to improve the quality of care in PHC. For the current management of the Ministry of Health and SAPS, it is part of the PHC clinic strengthening process, establishing itself as a guide for users of health services, for PHC professionals and other levels of care and health care, and managers. The starting point for the elaboration of this document was the review and evaluation of service portfolios implemented in important Brazilian cities. As a managerial innovation strategy, the municipality of Rio de Janeiro adopted the service portfolio in PHC in 201099 Rio de Janeiro. Secretaria Municipal de Saúde e Defesa Civil (SMSDC). Guia de Referência Rápida. Carteira de Serviços: Relação de serviços prestados na Atenção Primária à Saúde. Rio de Janeiro: SMSDC; 2011.. Similarly, after this movement started in the capital of Rio de Janeiro, important Brazilian cities followed in the same line, with the development of their municipal document. This occurred in Curitiba, Florianópolis, Natal, Belo Horizonte, and, more recently, in Porto Alegre1010 Curitiba. Secretaria Municipal de Saúde (SMS). Carteira de Serviços - Guia para profissionais de saúde - Relação de serviços e condições abordadas na Atenção Primária à Saúde. Curitiba: SMS; 2014.,1111 Secretaria Municipal de Saúde de Florianópolis. Carteira de Serviços Atenção Primária à Saúde. Florianópolis: Prefeitura Municipal de Florianópolis; 2014.,1414 Belo Horizonte. Secretaria Municipal de Saúde (SMS). Carteira Orientadora de Serviços do SUS - BH. Relação de serviços prestados na atenção primária à saúde. Belo Horizonte: SMS; 2018.

15 Natal. Secretaria Municipal de Saúde (SMS). Carteira de Serviços da Atenção Básica de Natal. Natal: SMS; 2014.
-1616 Porto Alegre. Secretaria Municipal de Saúde (SMS). Carteira de Serviços da Atenção Primária à Saúde de Porto Alegre. Porto Alegre: SMS; 2019.. The initiative to develop PHC portfolios at the municipal level was encouraged by some Brazilian state health secretariats. Even so, nine years into the first publication of the document in Rio de Janeiro, considering all the 5,570 Brazilian municipalities, we can observe that a very minimal number of cities are equipped with their document, failing to supply and describe with transparency for its population the clinical, health surveillance and preventive spectrum offered by its PHC/ESF teams. In this sense, the national portfolio prepared by the Ministry of Health aims to assist municipal managers in the implementation of a list of PHC actions and services. It is a document that is not intended to be exclusive since the failure to mention a symptom, sign, diagnosis, action, or care does not mean that it should not be performed in PHC. This tool must be revised periodically, given the natural change in the health maintenance and illness process.

It is structured with an emphasis on the essential attribute, namely, Comprehensiveness and divided into Attention and Care Centered on the Adult and Older Adult, Child and Adolescent, PHC Procedures, and Oral Health Attention and Care. Among the problems it seeks to solve, worth mentioning is the concentration of patients at the secondary and tertiary levels of health care seeking PHC procedures, such as removing cerumen and treating the ingrown nail, for example. However, the challenge of strengthening the clinic transcends performing more complex procedures or interventions in the PHC environment. It also involves monitoring and resolute care for highly prevalent and relatively low-complexity clinical problems such as Systemic Arterial Hypertension and Type 2 Diabetes Mellitus. And this is becoming increasingly more important over the years, and with the consequent more significant number of older adults in our population: caring, addressing, managing and working with the prevention of chronic non-communicable diseases, at the individual, family and community level, is one of the relevant PHC roles listed in the Brazilian portfolio. When describing 210 actions and services typical of the PHC environment, distributed by the PHC clinic, health surveillance, health promotion, and prevention activities and a family and community approach, the service portfolio proposes a quality challenge in healthcare, which also involves the challenge of training and qualifying the scope of PHC professional practice, stimulating the clinical training of doctors, nurses, and dentists, and regulating the need for training through Family and Community Medicine, Family and Community Nursing, and Dentistry residency programs in PHC.

PHC is the organizer of health systems, but it still has to improve its efficiency1717 Mendes EV. As redes de atenção à saúde. Brasília: Organização Pan-Americana da Saúde; 2011. to perform this function knowledgeably. Studies that set out to investigate the presence and extent of PHC attributes in Brazil indicated that the services have low PHC orientation, especially when the essential attributes are observed1818 Ferrer APS. Avaliação da atenção primária à saúde prestada a crianças e adolescentes na região oeste do município de São Paulo [tese]. São Paulo: Universidade de São Paulo; 2013.

19 Elias PE, Ferreira CW, Alves MCG, Cohn A, Kishima V, Escrivão JA, Gomes A, Bousquat A. Atenção Básica em Saúde: comparação entre PSF e UBS por estrato de exclusão social no município de São Paulo. Cien Saude Colet 2006; 11(3):633-641.

20 Silva AS. Avaliação dos atributos da atenção primária à saúde na estratégia saúde da família em municípios do sul de Minas Gerais [tese]. São Paulo: Universidade de São Paulo; 2014.

21 Van Stralen CJ, Belisário SA, van Stralen TBS, Lima AMD, Massote AW, Oliveira CL. Percepção dos usuários e profissionais de saúde sobre atenção básica: comparação entre unidades com e sem saúde da família na Região Centro-Oeste do Brasil. Cad Saude Publica 2008; 24(Supl. 1):s148-s158.
-2222 Pinto LP, Harzheim E, Hauser L, D'Avila OP, Gonçalves MR, Travassos P, Pessanha R. A qualidade da Atenção Primária à Saúde na Rocinha - Rio de Janeiro, Brasil, na perspectiva dos cuidadores de crianças e dos usuários adultos. Cien Saude Colet 2017; 22(3):771-781.. Comprehensiveness still seems to be one of the most consistent challenges among the essential attributes. The low performance of this attribute may be related to the organizational incapacity of PHC teams to provide services, and their heterogeneity thereof. From this perspective, it is essential to note that a set of structured actions to strengthen PHC is essential to gain efficiency. This involves an organized health care network with established flows, continuous improvement of access, investments in family and community medicine and multi-professional residencies, and the definition of a portfolio of services that meets the needs of the population.

Another important managerial function provided by the service portfolio is to assist with the production of the list of supplies and physical structures necessary for the execution of the procedures and services by the professionals of the PHC teams. In this sense, in its complete version for professionals and managers, the Brazilian PHC Portfolio presents the list of necessary supplies in its description structure for each service, as well as a brief excerpt of guidelines related to the topic, followed at the end by the “Learn more” section, where the service of the item under evaluation is referenced to the clinical contents elaborated and present in the Ministry of Health materials (Primary Care Notebooks, Protocols, and other).

It is important to note that the service portfolio plays a vital role in inducing a more significant offer of actions and procedures by PHC teams. This characteristic was shown in a study that identified the offer of actions and procedures by the Family Health teams, based on the Services Portfolio of the Municipality of Rio de Janeiro99 Rio de Janeiro. Secretaria Municipal de Saúde e Defesa Civil (SMSDC). Guia de Referência Rápida. Carteira de Serviços: Relação de serviços prestados na Atenção Primária à Saúde. Rio de Janeiro: SMSDC; 2011., and that compared the city of Rio de Janeiro with other places divided by population strata2323 Salazar BA, Campos MR, Luiza VL. A Carteira de Serviços de Saúde do Município do Rio de Janeiro e as ações em saúde na Atenção Primária no Brasil. Cien Saude Colet 2017; 22(3):783-796.. This study concluded that the city of Rio de Janeiro showed a better performance when compared to the average of large cities concerning the provision of health actions and services.

When comparing the Brazilian portfolio with that of other countries, mainly the Portuguese and Spanish portfolios2424 Portugal. Portaria nº 1368/2007, de 18 de outubro de 2007. Diário da República 2007; 18 out.,2525 España. Ministerio de Sanidad y Politica Social. Cartera de servicios de atención primaria - Desarollo, organización, usos y contenido. Madrid: Gobierno de España; 2010., we see that the list established for the Brazilian scenario includes the implementation of a strong and comprehensive PHC in all its aspects. Following the model and example used mainly in the Spanish PHC portfolio, in a next review, we will be able to incorporate the description and definition of the indicators used for monitoring and evaluating PHC in the country into the Brazilian portfolio, thus further emphasizing the principle of transparency in SAPS’ actions.

The most important principle of the current management of SAPS is to put people first, that is, to strengthen the SUS so that it is factually a health system that places people at the center, consolidating itself as a person-centered health system. This system is manifested by a strong and clinically resolute PHC, with transparency, monitoring, evaluation, and providing autonomy and flexibility for the management process carried out in each Brazilian city. The service portfolio does this by placing people at the center of the process and contributing to the strengthening of PHC’s care offer. In the same way, it provides transparency when describing the list of PHC actions and services for the whole society, contributing to the monitoring, evaluation, and management processes by allowing the construction of some monitoring indicators for the implementation of the health services listed in the portfolio.

References

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    Organização Pan-Americana da Saúde (OPAS). Renovação da Atenção Primária em Saúde nas Américas: documento de posicionamento da Organização Pan-Americana da Saúde/Organização Mundial da Saúde (OPAS/OMS). Washington: OPAS; 2007.
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    » http://189.28.128.100/dab/docs/portaldab/documentos/carteira_servico_da_APS_consulta_SAPS.pdf
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    Elias PE, Ferreira CW, Alves MCG, Cohn A, Kishima V, Escrivão JA, Gomes A, Bousquat A. Atenção Básica em Saúde: comparação entre PSF e UBS por estrato de exclusão social no município de São Paulo. Cien Saude Colet 2006; 11(3):633-641.
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    Silva AS. Avaliação dos atributos da atenção primária à saúde na estratégia saúde da família em municípios do sul de Minas Gerais [tese]. São Paulo: Universidade de São Paulo; 2014.
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    Pinto LP, Harzheim E, Hauser L, D'Avila OP, Gonçalves MR, Travassos P, Pessanha R. A qualidade da Atenção Primária à Saúde na Rocinha - Rio de Janeiro, Brasil, na perspectiva dos cuidadores de crianças e dos usuários adultos. Cien Saude Colet 2017; 22(3):771-781.
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    Salazar BA, Campos MR, Luiza VL. A Carteira de Serviços de Saúde do Município do Rio de Janeiro e as ações em saúde na Atenção Primária no Brasil. Cien Saude Colet 2017; 22(3):783-796.
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Publication Dates

  • Publication in this collection
    06 Apr 2020
  • Date of issue
    Mar 2020

History

  • Received
    30 Oct 2019
  • Accepted
    17 Dec 2019
  • Published
    19 Dec 2019
ABRASCO - Associação Brasileira de Saúde Coletiva Rio de Janeiro - RJ - Brazil
E-mail: revscol@fiocruz.br