Abstract

This systematic review analyzes the methods and instruments employed to evaluate primary child health care in Brazil and their main findings. The review was conducted in accordance with the recommendations of the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyzes) statement. Searches of articles focusing on children aged between zero and five years published between 1994-2006 were conducted of the following databases: MEDLINE, LILACS, IBECS, BDENF, PubMed, PsycNET, Cochrane, and CINAHL. The searches yielded 3,004 articles. After initial screening and the application of the STROBE and SRQR criteria, 21 articles were included in the review. About 52% of the articles were conducted in the Southeast region and 95.2% were published as of 2010. The most commonly used evaluation tool was the Primary Care Assessment Tool Child Edition, adapted and validated for use in Brazil (52.4%). The quality of primary child care was inadequate. The main limitations included poor access to services, inadequate facilities, and underqualified health staff. There has been a significant increase in the number of evaluation studies conducted in Brazil in recent years. Despite advances in health care across the country, the findings point to the need for a more effective response to the challenges in ensuring comprehensive primary child care in Brazil.

Key words
Primary Health Care; Child Health; Evaluation; Systematic Review

Introduction

Brazil has made significant strides in improving child health in recent decades as a result of improved living conditions, the advancement of children’s rights, and advances in the country’s health policy¹1 Victora CG, Aquino EM, do Carmo Leal M, Monteiro CA, Barros FC, Szwarcwald CL. Maternal and child health in Brazil: progress and challenges. Lancet 2011; 377(9780):1863-1876.^,22 Brasil. Ministério da Saúde (MS). Secretaria de Atenção em Saúde. Departamento de Ações Programáticas. Política Nacional de Atenção Integral à Saúde da Criança: orientações para implementação. Brasília: MS; 2018.. This is illustrated by a sharp fall in infant mortality rates¹1 Victora CG, Aquino EM, do Carmo Leal M, Monteiro CA, Barros FC, Szwarcwald CL. Maternal and child health in Brazil: progress and challenges. Lancet 2011; 377(9780):1863-1876.^,33 Liu L, Oza S, Hogan D, Perin J, Rudan I, Lawn JE, Cousens S, Mathers C, Black RE. Global, regional, and national causes of child mortality in 2000-13, with projections to inform post-2015 priorities: an updated systematic analysis. Lancet 2015; 385(9966):430-440., from 85.6 per 1,000 live births in 1980 to 13.8 in 2015⁴4 Instituto Brasileiro de Geografia e Estatística (IBGE). Taxas de Mortalidade Infantil [Internet]. [acessado 2016 Abr 27]. Disponível em: http://brasilemsintese.ibge.gov.br/populacao/taxas-de-mortalidade-infantil.html
http://brasilemsintese.ibge.gov.br/popul... , when Brazil achieved target 4 of the Millennium Development Goals (Reduce by two-thirds, between 1990 and 2015, the under-five mortality)³3 Liu L, Oza S, Hogan D, Perin J, Rudan I, Lawn JE, Cousens S, Mathers C, Black RE. Global, regional, and national causes of child mortality in 2000-13, with projections to inform post-2015 priorities: an updated systematic analysis. Lancet 2015; 385(9966):430-440..

Brazil began to implement specific interventions targeting child health in the 1960s with the Maternal and Child Health Program. In the 1990s, initiatives began to incorporate policies designed to expand the coverage of public health services, as in the case of the family health and community health agent programs. With the restructuring of primary health care services, it was possible to improve the distribution of health care professionals across underserved areas and widen access to health services, positively impacting child health indicators²2 Brasil. Ministério da Saúde (MS). Secretaria de Atenção em Saúde. Departamento de Ações Programáticas. Política Nacional de Atenção Integral à Saúde da Criança: orientações para implementação. Brasília: MS; 2018.. The creation of the National Policy for Comprehensive Child Health Care (PNAISC, acronym in Portuguese), in 2015, was the culmination of interinstitutional efforts to enhance actions directed at young children and vulnerable groups, based on the principles of the right to life, equality, comprehensive humanized care, and participatory management²2 Brasil. Ministério da Saúde (MS). Secretaria de Atenção em Saúde. Departamento de Ações Programáticas. Política Nacional de Atenção Integral à Saúde da Criança: orientações para implementação. Brasília: MS; 2018..

Brazil’s Family Health Strategy (FHS) has consolidated primary health care, expanding service coverage across the country. However, numerous factors continue to limit coverage, including the coexistence of traditional and family care models in the same service, structural and organizational factors, and staff shortages, driving the institutionalization of evaluation processes to inform strategies to strengthen primary health care⁵5 Figueiredo AM, Kuchenbecker RD, Harzheim E, Vigo Á, Hauser L, Chomatas ER. Análise de concordância entre instrumentos de avaliação da Atenção Primária à Saúde na cidade de Curitiba, Paraná, em 2008. Epidemiol Serv Saúde 2013; 22(1):41-48.

6 Carvalho AL, Souza MD, Shimizu HE, Senra IM, Oliveira KC. A gestão do SUS e as práticas de monitoramento e avaliação: possibilidades e desafios para a construção de uma agenda estratégica. Cien Saúde Colet 2012; 17(4):901-911.^-77 Brousselle A, Champagne F, Contandriopoulos AP, Hartz Z. Avaliação: conceitos e métodos. Rio de Janeiro: Fiocruz; 2011..

Evaluation is a process in which, based on valid and legitimate information, value judgments are made about interventions, processes, and outcomes with a view to enhancing service management performance, facilitating change, decision-making, and the pursuit of quality⁷7 Brousselle A, Champagne F, Contandriopoulos AP, Hartz Z. Avaliação: conceitos e métodos. Rio de Janeiro: Fiocruz; 2011.. The growing recognition of the importance of evaluation has led to the development of a suite of instruments and methods for evaluating the adequacy of public services in Brazil over the last three decades⁸8 Furtado JP, Vieira-da-Silva LM. A avaliação de programas e serviços de saúde no Brasil enquanto espaço de saberes e práticas. Cad Saúde Pública 2014; 30:2643-2655.. This process has been led by the Ministry of Health, with initiatives like the “Sala de Situação” or “Health Situation Room” (2002), the Assessment for Improving the Quality of the Family Health Strategy - AIQ (Avaliação para a Melhoria da Qualidade - AMQ)⁹9 Savassi LC. Qualidade em serviços públicos: os desafios da atenção primária. RBMFC 2012; 7(23):69-74., the Primary Care Assessment Tool¹⁰10 Brasil. Ministério da Saúde (MS). Secretaria de Atenção em Saúde. Manual do instrumento de avaliação da atenção primária à saúde: primary care assessment tool pcatool. Brasília: MS; 2010. (2010), and the National Program for Improving Access and Quality in Primary Care (2011)⁹9 Savassi LC. Qualidade em serviços públicos: os desafios da atenção primária. RBMFC 2012; 7(23):69-74.. In addition, research groups at universities across the country have also developed a number of initiatives⁸8 Furtado JP, Vieira-da-Silva LM. A avaliação de programas e serviços de saúde no Brasil enquanto espaço de saberes e práticas. Cad Saúde Pública 2014; 30:2643-2655..

In view of the need to synthesize the knowledge accumulated in recent years, this review analyzes the methods and instruments employed to evaluate primary child health care in Brazil and their main findings.

Methods

We conducted a systematic review based on the recommendations set out in the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement¹¹11 Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med 2009; 6(7):e1000100.. Searches were conducted of the databases Virtual Health Library, Brazil (MEDLINE, LILACS, IBECS, and BDENF), PubMed, PsycNET, Cochrane, and CINAHL, using the following search terms: “primary health care OR family health strategy AND evaluation AND child health OR child”, based on the DeCS (Health Sciences Descriptors) and MeSH (Medical Subject Headings).

We included studies evaluating primary health care services for children aged 0 to 19 years (focusing on the zero to five-years age group) published in English, Spanish and Portuguese between January 1994 (the year in which the FHS was created) and September 2016. Literature reviews, theses, dissertations, editorials, case study reports, studies with data on non-Brazilian children, and studies that did not meet 80% of the required items of the methodological quality scales used by this study were excluded.

The methodological quality of observational studies was assessed in accordance with the STROBE¹²12 Vandenbroucke JP, Von Elm E, Altman DG, Gotzsche PC, Mulrow CD, Pocock SJ, Poole C, Schlesselman JJ, Egger M, Strobe Initiative. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration. PLoS Med 2007; 4(10):e297. (Strengthening the reporting of observational studies in epidemiology) statement, consisting of a checklist of 22 items that should be addressed in articles. The version translated and validated for use in Brazil in 2008¹³13 Malta M, Cardoso LO, Bastos FI, Magnanini MM, Silva CM. STROBE initiative: guidelines on reporting observational studies. Rev Saúde Pública 2010; 44(3):559-565. establishes article quality categories. Articles that meet at least 80% of the items are classified as category “A”¹²12 Vandenbroucke JP, Von Elm E, Altman DG, Gotzsche PC, Mulrow CD, Pocock SJ, Poole C, Schlesselman JJ, Egger M, Strobe Initiative. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration. PLoS Med 2007; 4(10):e297.^,1313 Malta M, Cardoso LO, Bastos FI, Magnanini MM, Silva CM. STROBE initiative: guidelines on reporting observational studies. Rev Saúde Pública 2010; 44(3):559-565.. Qualitative studies were assessed using the Standards for Reporting Qualitative Research (SRQR)¹⁴14 O'Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Academic Med 2014; 89(9):1245-1251.. Studies that used both quantitative and qualitative methodologies were assessed using both instruments and included if they met at least 80% or higher of the items of one of the instruments. One independent reviewer assessed methodological quality and two reviewers evaluated thematic eligibility.

Results

The searches yielded 3,004 articles, 538 of which were excluded because they were duplicates. A total of 2,333 articles were excluded after the analysis of the titles and abstracts because they failed to meet the study eligibility criteria. The full texts of the remaining citations were then examined, resulting in the exclusion of 99 articles because they failed to meet the study inclusion criteria. The remaining articles were then assessed against the STROBE and SRQR checklists. A total of 13 publications were excluded because they failed to meet at least 80% of the items, resulting in a final sample of 21 articles. The article selection process is shown in Figure 1.

Table 1 presents the general characteristics of the selected studies. Around 95% of the articles where published after 2009. All the studies used quantitative methodologies and two used a combination of quantitative and qualitative methodologies. We did not find any qualitative studies that met the inclusion criteria. The most commonly used evaluation instrument was the Primary Care Assessment Tool Child Edition (PCAT-CE) adapted and validated for use in Brazil (52.4%). The other studies used instruments developed by the researchers, except for a study conducted in Maceió in 2003¹⁵15 Sales ML, Ponnet L, Campos CE, Demarzo MM, de Miranda CT. Qualidade da atenção à saúde da criança na estratégia saúde da família. J Human Growth Dev 2013; 23(2):151-156., which used the AIQ.

Only two studies¹⁶16 Perez LG, Sheridan JD, Nicholls AY, Mues KE, Saleme PS, Resende JC, Ferreira JA, Leon JS. Professional and community satisfaction with the Brazilian family health strategy. Rev Saúde Públ 2013; 47(2):403-413.^,1717 Costa GD, Cotta RM, Reis JR, Ferreira MD, Reis RS, Franceschini SD. Avaliação da atenção à saúde da criança no contexto da Saúde da Família no município de Teixeiras, Minas Gerais, Brasil. Cien Saúde Colet 2011; 1:3229-3240. included both health care professionals and service users. In 85.7% of the studies, only parents and/or guardians evaluated services, in the majority of cases the children’s mothers. In the other studies, doctors and nurses evaluated services. The studies evaluated children’s and young people’s services, with 61.9% of studies focusing specifically on the zero to five-year age group. Some studies focused on specific groups, such as children living with HIV¹⁸18 Silva CB, Paula CC, Lopes LFD, Harzheim E, Magnago TSBS, Schimith MD. Atenção à saúde de criança e adolescente com HIV: comparação entre serviços. Rev Bras Enferm 2016; 69(3):522-531., quilombolas¹⁹19 Marques AS, Freitas DA, Alves Leão CD, Oliveira M, Ketllin S, Pereira MM, Caldeira AP. Atenção Primária e saúde materno-infantil: a percepção de cuidadores em uma comunidade rural quilombola. Cien Saúde Colet 2014; 19(2):365-371., and children hospitalized for ambulatory care sensitive conditions²⁰20 Ferrer AP, Brentani AV, Sucupira AC, Navega AC, Cerqueira ES, Grisi SJ. The effects of a people-centred model on longitudinality of care and utilization pattern of healthcare services-Brazilian evidence. Health Policy Planning 2014; 29(2):107-113..

The studies were conducted in areas with varying population characteristics, ranging from state capitals to rural communities. Eleven of the 21 studies were conducted in the Southeast region, nine of which in the State of Minas Gerais (Figure 2).

Table 2 shows a synthesis of the methods and main conclusions of the selected articles. All the studies assessed the performance of family health teams, 52.4% investigated traditional health centers or a mixture of traditional and FHS centers, and 14.3% addressed other types of models. Almost all of the studies investigated service structure and work processes. The main aspects of care investigated were: primary care attributes (47.7%); specific actions developed by primary health care services, such as immunization programs, acolhimento or “receptiveness”, and child health surveillance (33.3%); care structure (9.5%); and health care professional training and development (9.5%).

Only one study, conducted in the State of Paraná in 2015²¹21 Oliveira VB, Veríssimo MD. Assistência à saúde da criança segundo suas famílias: comparação entre modelos de Atenção Primária. Rev Esc EnfermUSP 2015; 49(1):30-36. using the PCAT-CE, showed that children’s health care services provided under the FHS achieved the minimum cut-off score for service quality. In the studies that used this evaluation tool, the lowest-scoring primary care attributes were “first contact accessibility”, “family centeredness”, and “community orientation”, while the highest-scoring attributes were “first contact utilization”, “longitudinality”, and “coordination-information system”. The FHS obtained higher scores in four of the six studies that compared the performance of FHS centers and traditional health centers²⁰20 Ferrer AP, Brentani AV, Sucupira AC, Navega AC, Cerqueira ES, Grisi SJ. The effects of a people-centred model on longitudinality of care and utilization pattern of healthcare services-Brazilian evidence. Health Policy Planning 2014; 29(2):107-113.

21 Oliveira VB, Veríssimo MD. Assistência à saúde da criança segundo suas famílias: comparação entre modelos de Atenção Primária. Rev Esc EnfermUSP 2015; 49(1):30-36.

22 Leão CD, Caldeira AP, Oliveira MM. Atributos da atenção primária na assistência à saúde da criança: avaliação dos cuidadores. Rev Bras Saúde Matern Infant 2011: 11(3):323-334.^-2323 Caldeira AP, Oliveira RM, Rodrigues OA. Qualidade da assistência materno-infantil em diferentes modelos de Atenção Primária. Cien Saúde Colet 2010; 15(Supl. 2):3139-3147.. Furthermore, the findings of these studies also showed that the FHS was the preferred service among service users.

The studies that employed other instruments used different aspects of primary care to evaluate care quality. One of the highest-scoring aspects was the patient-health care professional relationship¹⁶16 Perez LG, Sheridan JD, Nicholls AY, Mues KE, Saleme PS, Resende JC, Ferreira JA, Leon JS. Professional and community satisfaction with the Brazilian family health strategy. Rev Saúde Públ 2013; 47(2):403-413.^,2424 Machado MM, Bezerra Filho JG, Machado MD, Lindsay AC, Magalhães FB, Gama ID, Cunha AJ. Características dos atendimentos e satisfação das mães com a assistência prestada na atenção básica a menores de 5 anos em Fortaleza, Ceará. Cien Saúde Colet 2012; 17(11):3125-3133.^,2525 Luhm KR, Cardoso MR, Waldman EA. Cobertura vacinal em menores de dois anos a partir de registro informatizado de imunização em Curitiba, PR. Rev Saúde Publ 2011; 45(1):90-98.. However, these studies also highlighted a number of problems, including: difficulties in accessing services, underqualified professional staff¹⁶16 Perez LG, Sheridan JD, Nicholls AY, Mues KE, Saleme PS, Resende JC, Ferreira JA, Leon JS. Professional and community satisfaction with the Brazilian family health strategy. Rev Saúde Públ 2013; 47(2):403-413.^,1717 Costa GD, Cotta RM, Reis JR, Ferreira MD, Reis RS, Franceschini SD. Avaliação da atenção à saúde da criança no contexto da Saúde da Família no município de Teixeiras, Minas Gerais, Brasil. Cien Saúde Colet 2011; 1:3229-3240.^,2626 Rocha AC, Pedraza DF. Acompanhamento do crescimento infantil em unidades básicas de saúde da família do município de Queimadas, Paraíba, Brasil. Texto Contexto-Enferm 2013; 22(4):1169-1178.^,2727 Figueiras ACM, Puccini RF, Silva EM, Pedromônico MR. Avaliação das práticas e conhecimentos de profissionais da atenção primária à saúde sobre vigilância do desenvolvimento infantil. Cad Saúde Públ 2003; 19(6):1691-1699., staff shortages¹⁶16 Perez LG, Sheridan JD, Nicholls AY, Mues KE, Saleme PS, Resende JC, Ferreira JA, Leon JS. Professional and community satisfaction with the Brazilian family health strategy. Rev Saúde Públ 2013; 47(2):403-413.^,2626 Rocha AC, Pedraza DF. Acompanhamento do crescimento infantil em unidades básicas de saúde da família do município de Queimadas, Paraíba, Brasil. Texto Contexto-Enferm 2013; 22(4):1169-1178., poor structure and shortage of materials²⁶26 Rocha AC, Pedraza DF. Acompanhamento do crescimento infantil em unidades básicas de saúde da família do município de Queimadas, Paraíba, Brasil. Texto Contexto-Enferm 2013; 22(4):1169-1178., and an emphasis on disease-based curative care over health promotion and disease prevention¹⁶16 Perez LG, Sheridan JD, Nicholls AY, Mues KE, Saleme PS, Resende JC, Ferreira JA, Leon JS. Professional and community satisfaction with the Brazilian family health strategy. Rev Saúde Públ 2013; 47(2):403-413.^,1717 Costa GD, Cotta RM, Reis JR, Ferreira MD, Reis RS, Franceschini SD. Avaliação da atenção à saúde da criança no contexto da Saúde da Família no município de Teixeiras, Minas Gerais, Brasil. Cien Saúde Colet 2011; 1:3229-3240.^,2424 Machado MM, Bezerra Filho JG, Machado MD, Lindsay AC, Magalhães FB, Gama ID, Cunha AJ. Características dos atendimentos e satisfação das mães com a assistência prestada na atenção básica a menores de 5 anos em Fortaleza, Ceará. Cien Saúde Colet 2012; 17(11):3125-3133.^,2525 Luhm KR, Cardoso MR, Waldman EA. Cobertura vacinal em menores de dois anos a partir de registro informatizado de imunização em Curitiba, PR. Rev Saúde Publ 2011; 45(1):90-98..

Discussion

The findings show that the most commonly used tool for evaluating primary child care in Brazil was the PCAT-CE. Furthermore, the studies mainly used quantitative methodologies, involved parents/guardians and health care professionals, covered all regions of Brazil, and concluded that care quality was inadequate.

The fact that the large majority of articles where published after 2009 reflects the trend in national scientific output in recent years²⁸28 Gonçalves E, Santos MI, Maia BT, Brandão RC, Oliveira EA, Martelli Júnior H. Scientific research in pediatrics produced at the CNPq. Rev Bras Educ Med 2014; 38(3):349-355.

29 Petherick A. High hopes for Brazilian science. Nature 2010; 465:674-675.^-3030 Strehl L, Calabró L, Souza DO, Amaral L. Brazilian Science between National and Foreign Journals: Methodology for Analyzing the Production and Impact in Emerging Scientific Communities. Bornmann L. PLoS ONE 2016; 11(5):e0155148.. In this respect, the quality of national publications has been the target for criticism, particularly due to the lack visibility of Brazilian research in international journals²⁸28 Gonçalves E, Santos MI, Maia BT, Brandão RC, Oliveira EA, Martelli Júnior H. Scientific research in pediatrics produced at the CNPq. Rev Bras Educ Med 2014; 38(3):349-355.^,3030 Strehl L, Calabró L, Souza DO, Amaral L. Brazilian Science between National and Foreign Journals: Methodology for Analyzing the Production and Impact in Emerging Scientific Communities. Bornmann L. PLoS ONE 2016; 11(5):e0155148.. The large number of articles excluded from this review in the screening for methodological quality stage is a reflection of this situation. The rise in the number of publications in the field of health care evaluation is linked to the expansion of postgraduation programs and an increase in research funding in the country¹1 Victora CG, Aquino EM, do Carmo Leal M, Monteiro CA, Barros FC, Szwarcwald CL. Maternal and child health in Brazil: progress and challenges. Lancet 2011; 377(9780):1863-1876.^,88 Furtado JP, Vieira-da-Silva LM. A avaliação de programas e serviços de saúde no Brasil enquanto espaço de saberes e práticas. Cad Saúde Pública 2014; 30:2643-2655.. Over the last two decades, studies conducted by research groups in partnership with the Ministry of Health have driven the development of conceptual and methodological frameworks and the application of evaluation as management tool⁸8 Furtado JP, Vieira-da-Silva LM. A avaliação de programas e serviços de saúde no Brasil enquanto espaço de saberes e práticas. Cad Saúde Pública 2014; 30:2643-2655..

The predominance of quantitative methods was also found by a review of evaluation studies conducted between 2000 and 2006³¹31 Almeida PF, Giovanella L. Assessment of Primary Health care in Brazil: mapping and analysis of research conducted and/or financed by the Ministry of Health from 2000 to 2006. Cad Saúde Pública 2008; 24(8):1727-1742.. In this respect, until recently, qualitative approaches were seen to have less methodological rigor, thus hindering their publication in high-impact journals³²32 Taquette SR, Minayo MCS, Rodrigues AO. Percepção de pesquisadores médicos sobre metodologias qualitativas. Cad. Saúde Pública 2015; 31(4):722-732.. The combination of different methodological approaches provides a broader and deeper understanding of the phenomena and processes of concern³³33 Tanaka OY. Avaliação da atenção básica em saúde: uma nova proposta. Saúde Soc 2011; 20:927-934.. The fact that none of the articles used only qualitative methods suggests that the understanding of the underlying factors influencing the evaluations provided by service users and professionals may be limited.

The review shows that the majority of studies were conducted in the Southeast and South regions, which is consistent with the findings of a review of Brazilian literature in the field of pediatrics conducted by Gonçalves et al.²⁸28 Gonçalves E, Santos MI, Maia BT, Brandão RC, Oliveira EA, Martelli Júnior H. Scientific research in pediatrics produced at the CNPq. Rev Bras Educ Med 2014; 38(3):349-355.. In this regard, the majority of Brazil’s higher education and research institutions are concentrated in these regions, facilitating their integration with services and the development of evaluation studies. The integration of education institutions with health services results in training and technical collaboration, fruits of joint research based on health service needs¹⁸18 Silva CB, Paula CC, Lopes LFD, Harzheim E, Magnago TSBS, Schimith MD. Atenção à saúde de criança e adolescente com HIV: comparação entre serviços. Rev Bras Enferm 2016; 69(3):522-531..

A study conducted by Fracolli et al.³⁴34 Fracolli LA, Gomes MF, Nabão FR, Santos MS, Cappellini VK, Almeida AC. Primary health care assessment tools: a literature review and metasynthesis. Cien Saúde Colet 2014; 19(12):4851-4860. concluded that the PCAT is the most adequate tool for evaluating the quality of care services provided under the FHS and allows researchers to assess the extent to which primary care attributes are operationalized¹⁰10 Brasil. Ministério da Saúde (MS). Secretaria de Atenção em Saúde. Manual do instrumento de avaliação da atenção primária à saúde: primary care assessment tool pcatool. Brasília: MS; 2010.. The Essential Score is made up of the attributes Strength of affiliation, First contact accessibility/utilization, Longitudinality, Coordination-integration of care and information systems, and Comprehensiveness of services available and provided. The Derived Score is made up of the attributes Family centeredness and Community orientation¹⁰10 Brasil. Ministério da Saúde (MS). Secretaria de Atenção em Saúde. Manual do instrumento de avaliação da atenção primária à saúde: primary care assessment tool pcatool. Brasília: MS; 2010.. The analysis of each of these attributes enables health managers to tailor actions to the determinants of care quality in each service/setting. One of the advantages of the PCAT is that the instrument has been validated and applied in other countries¹⁹19 Marques AS, Freitas DA, Alves Leão CD, Oliveira M, Ketllin S, Pereira MM, Caldeira AP. Atenção Primária e saúde materno-infantil: a percepção de cuidadores em uma comunidade rural quilombola. Cien Saúde Colet 2014; 19(2):365-371.^,3434 Fracolli LA, Gomes MF, Nabão FR, Santos MS, Cappellini VK, Almeida AC. Primary health care assessment tools: a literature review and metasynthesis. Cien Saúde Colet 2014; 19(12):4851-4860.^,3535 Malouin RA, Starfield B, Sepulveda MJ. Evaluating the tools used to assess medical home. Manag Care 2009; 18(6):44-48.. The tool has three editions (adult, child, and professional), which enables comparisons between different actors and types of primary care organizations¹⁰10 Brasil. Ministério da Saúde (MS). Secretaria de Atenção em Saúde. Manual do instrumento de avaliação da atenção primária à saúde: primary care assessment tool pcatool. Brasília: MS; 2010.^,1515 Sales ML, Ponnet L, Campos CE, Demarzo MM, de Miranda CT. Qualidade da atenção à saúde da criança na estratégia saúde da família. J Human Growth Dev 2013; 23(2):151-156..

Evaluation instruments should be able to identify service strengths and weaknesses and be recognized by the scientific community³⁴34 Fracolli LA, Gomes MF, Nabão FR, Santos MS, Cappellini VK, Almeida AC. Primary health care assessment tools: a literature review and metasynthesis. Cien Saúde Colet 2014; 19(12):4851-4860.. The only evaluation instrument used in more than one study was the PCAT-CE. The other instruments used in the studies were mainly elaborated and validated by the researchers according to the specific objectives of each study. Although this might allow researchers to investigate the specific aspects of given services and settings, the use of individual tools limits comparison and the extrapolation of results. In this respect, cross-cultural adaptation and validation may not always be sufficient to allow the evaluation of different contexts and the peculiarities of different types of services.

Besides the evaluation of service performance, some of the studies compared different primary care models. Although it recognizes different models, the National Primary Health Care Policy¹⁰10 Brasil. Ministério da Saúde (MS). Secretaria de Atenção em Saúde. Manual do instrumento de avaliação da atenção primária à saúde: primary care assessment tool pcatool. Brasília: MS; 2010. states that the FHS is the basic care model underpinning primary care services in Brazil. The FHS differs from other models insofar as multiprofessional health teams are responsible for delivering a suite of integrated services to a specific number of families in a specific geographical area¹⁰10 Brasil. Ministério da Saúde (MS). Secretaria de Atenção em Saúde. Manual do instrumento de avaliação da atenção primária à saúde: primary care assessment tool pcatool. Brasília: MS; 2010., while traditional primary care centers emphasize clinical and health interventions¹⁰10 Brasil. Ministério da Saúde (MS). Secretaria de Atenção em Saúde. Manual do instrumento de avaliação da atenção primária à saúde: primary care assessment tool pcatool. Brasília: MS; 2010..

Although evidence shows that the FHS performs better in comparison to traditional care models, the review shows that this model has a number of limitations. In this respect, accessibility, understood as people’s ability to get care easily and conveniently³⁶36 Donabedian A. An introduction to quality assurance in health care. Oxford University: Press; 2002., was one of the lowest-scoring attributes.

Although studies frequently highlighted the strength of affiliation with the FHS, geographic barriers, lack of adequate service structure, staff shortages, underprovision of care, appointment scheduling problems, and long wait times were shown to be major obstacles to improving access to high quality health services³⁷37 Silva SA, Fracolli LA. Avaliação da assistência à criança na Estratégia de Saúde da Família. Rev Bras Enf 2016; 69(1):47-53.. These obstacles also affect child health indicators, highlighted as one of the main challenges of the PNAISC²2 Brasil. Ministério da Saúde (MS). Secretaria de Atenção em Saúde. Departamento de Ações Programáticas. Política Nacional de Atenção Integral à Saúde da Criança: orientações para implementação. Brasília: MS; 2018..

Lack of family and community centeredness was one of the most common limitations cited by the literature²²22 Leão CD, Caldeira AP, Oliveira MM. Atributos da atenção primária na assistência à saúde da criança: avaliação dos cuidadores. Rev Bras Saúde Matern Infant 2011: 11(3):323-334.^,3838 Araújo JP, Viera CS, Toso BR, Collet N, Nassar PO. Avaliação dos atributos de orientação familiar e comunitária na saúde da criança. Acta Paul Enferm 2014; 27(5):440-446., suggesting that care is centered on the individual, with little emphasis on patient contextual factors. Social disadvantage, poor hygiene habits, unhealthy environments, and family violence are just some factors that adversely affect child health and therefore increase the demand for care services. The lack of health promotion and disease prevention actions culminates in not only increased demand for health services, but also a reduction in quality of care delivery³⁹39 Mesquita Filho M, Luz BS, Araújo CS. A Atenção Primária à Saúde e seus atributos: a situação das crianças menores de dois anos segundo suas cuidadoras. Cien Saúde Colet 2014; 19(7):2033-2046.^,4040 Modes PS, Gaiva MA. Satisfação das usuárias quanto à atenção prestada à criança pela rede básica de saúde. Esc Anna Nery Rev Enferm 2013; 17(3):455-465.. In this respect, training of care professionals is a decisive factor in tackling determinants of child health such as the domestic environment, family life, and antenatal care and care throughout labor and birth²2 Brasil. Ministério da Saúde (MS). Secretaria de Atenção em Saúde. Departamento de Ações Programáticas. Política Nacional de Atenção Integral à Saúde da Criança: orientações para implementação. Brasília: MS; 2018..

The quality of the patient-health care professional relationship, which encompasses access to health workers and information, the fact that patients know the professionals, receptiveness, and forming bonds with patients, was highlighted as a positive point¹⁶16 Perez LG, Sheridan JD, Nicholls AY, Mues KE, Saleme PS, Resende JC, Ferreira JA, Leon JS. Professional and community satisfaction with the Brazilian family health strategy. Rev Saúde Públ 2013; 47(2):403-413.^,2323 Caldeira AP, Oliveira RM, Rodrigues OA. Qualidade da assistência materno-infantil em diferentes modelos de Atenção Primária. Cien Saúde Colet 2010; 15(Supl. 2):3139-3147.^,4141 Ribeiro LD, Rocha RL, Ramos-Jorge ML. Acolhimento às crianças na atenção primária à saúde: um estudo sobre a postura dos profissionais das equipes de saúde da família. Cad Saúde Pública 2010; 26(12):2316-2322.. Improving the quality of the patient-health care professional relationship is one of the pillars of quality primary health care and one of the guidelines of the PNAISC²2 Brasil. Ministério da Saúde (MS). Secretaria de Atenção em Saúde. Departamento de Ações Programáticas. Política Nacional de Atenção Integral à Saúde da Criança: orientações para implementação. Brasília: MS; 2018.^,2323 Caldeira AP, Oliveira RM, Rodrigues OA. Qualidade da assistência materno-infantil em diferentes modelos de Atenção Primária. Cien Saúde Colet 2010; 15(Supl. 2):3139-3147. and, despite the organizational and structural challenges faced by the FHS, important strides have been taken in this direction.

One of the limitations of this study is the fact that screening for methodological quality was performed by only one reviewer; however, we adopted a rigorous study methodology, following the PRISMA statement for reporting systematic reviews and the STROBE and SRQR guidelines.

Conclusion

The findings show that the highest-scoring primary care attributes were strength of affiliation and the patient-health care professional relationship. Furthermore, despite the expansion of the FHS, accessibility remains a major obstacle to securing the necessary improvements in care quality. The lack of family centeredness and community orientation underscores the need for adequate staff training, extending the challenge beyond policy makers to include education institutions. In this respect, the latter need to prioritize the training of health professionals who have the necessary knowledge, practical skills, and commitment to strengthen primary health care.

Future research should investigate contexts outside the South and Southeast regions, focusing on vulnerable populations and more economically disadvantaged areas where it is difficult to attract and retain health workers, in order to help identify and respond to the challenges in improving primary child health care in Brazil.

References

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