Abstract

This study analyzes the spatial pattern of implementation of Primary Health Care (PHC) teams in Northern and Northeastern Brazil. This is an ecological study on the rates of Community Health Workers (ACS), Family Health Team (eSF), Oral Health Team (eSB), and Family Health Extended Center (NASF) based on data from the Ministry of Health (MoH). The analysis of the area data identified patterns of spatial dependence of the municipalities for the rates, using Moran indices and scatterplots to visualize critical areas’ clusters (95% confidence). Municipalities of the North (n=450) and Northeast (n=1,794) had 132,174 ACS, 18,405 eSF, 13,017 eSB, and 2,205 NASF. The proportion of municipalities with rates within the recommended by the MoH were: ACS (>1.33), 96% in the North and 98.5% in the Northeast; eSF (>2.9/1,000), 54% and 80% in the respective regions; eSB (>2.9/10,000) 28% and 59% in these respective regions. NASF teams were deployed in 70% of the North and 89% of the Northeast. Except for ACS, the North was a critical team area, mainly in Pará, Rondônia, Amazonas, and Amapá. In the Northeast, these areas were smaller and concentrated mainly in western Bahia and eastern Maranhão. The Northeast showed a better composition of teams and a smaller extent of critical areas.

Key words:
Primary Health Care; Health workforce; Space analysis

Introduction

The development of public policies for universal health coverage, expressed in the millennium goals and the 2030 Agenda, has been encouraged by international organizations since 2005¹1 World Health Organization (WHO). Department of Health Systems Governance and Financing. Health Systems Governance for Universal Health Coverage: action plan [Internet]. Washington, D.C.: WHO [cited 2019 jul 19]. Available from: https://www.who.int/universal_health_coverage/plan_action-hsgov_uhc.pdf.
https://www.who.int/universal_health_cov... ^,22 Organização das Nações Unidas-Brasil (ONU-BR). Documentos temáticos: objetivos de desenvolvimento sustentável 1, 2,3 5, 9 e 14 [Internet]. Brasília: ONU-BR; 2017 [acessado 2019 jul 19]. Disponível em: http://www.br.undp.org/content/brazil/pt/home/library/ods/documentos-tematicos--ods-1--2--3--5--9--14.html.. The concept of universality in health in Brazil refers to the assumptions of a universal public system, the Unified Health System (SUS). It is reaffirmed by the national PHC policy, which seeks to structure comprehensive services and universal access to comprehensive care with inter and multidisciplinary work³3 Brasil. Ministério da Saúde (MS). Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Ofical da União; 2017..

Primary care is essential for being the preferred gateway and communication center of the health care network (RAS), with excellent resolving potential when introduced in a self-regulated and user-centered health system. The primary strategy for expanding and consolidating the PHC, the Family Health is the primary care coordinating and regulatory base for the RAS, restructuring the SUS care model, although there are several models and heterogeneous territories⁴4 Viana ALA, Bousquat A, Melo GA, Negri Filho A, Medina MG. Regionalização e Redes de Saúde. Cien Saude Colet 2018; 23(6):1791-1798..

Population-based data showed an increase in the Family Health Strategy (ESF) coverage from 50.9% in 2008 to 53.4% in 2013 in Brazil⁵5 Malta DC, Santos MAS, Stopa SR, Vieira JEB, Melo EA, Reis Ademar AC. A Cobertura da Estratégia de Saúde da Família (ESF) no Brasil, segundo a Pesquisa Nacional de Saúde, 2013. Cien Saude Colet 2016; 21(2):327-338.. This trend is similar to that observed in the Ministry of Health’s administrative data, which identified a more significant increase for the North. In 2013, the most extensive coverage was in the Northeast (65%), states of Tocantins, Paraíba, and Piauí (>80%) and their capitals (>69%). Half of the capitals in these regions ranked below the national average (40%)⁶6 Neves RG, Flores TR, Duro SMS, Nunes BP, Tomasi E. Tendência temporal da cobertura da Estratégia Saúde da Família no Brasil, regiões e Unidades da Federação, 2006-2016. Epidemiol Serv Saude 2018; 27(3):e2017170.. Advancing ESF coverage in these regions means, in part, offsetting PHC setbacks⁴4 Viana ALA, Bousquat A, Melo GA, Negri Filho A, Medina MG. Regionalização e Redes de Saúde. Cien Saude Colet 2018; 23(6):1791-1798..

Access to health is provided by heterogeneous locoregional Brazilian realities, with differences in the structuring of the RAS, marked by socioeconomic and developmental inequalities of SUS guidelines in different areas of the country, especially evident in the least favored territories, isolated from urban centers, such as rural and riverside communities in the Amazon region⁷7 Garnelo L, Lima JG, Rocha ESC, Herkrath FJ. Acesso e cobertura da Atenção Primária à Saúde para populações rurais e urbanas na região Norte do Brasil. Saude Debate 2018; 42(Supl. 1):81-99.. These are settings for the regular lack of services, which exacerbate the insufficient integration of PHC in the RAS⁴4 Viana ALA, Bousquat A, Melo GA, Negri Filho A, Medina MG. Regionalização e Redes de Saúde. Cien Saude Colet 2018; 23(6):1791-1798.

5 Malta DC, Santos MAS, Stopa SR, Vieira JEB, Melo EA, Reis Ademar AC. A Cobertura da Estratégia de Saúde da Família (ESF) no Brasil, segundo a Pesquisa Nacional de Saúde, 2013. Cien Saude Colet 2016; 21(2):327-338.^-66 Neves RG, Flores TR, Duro SMS, Nunes BP, Tomasi E. Tendência temporal da cobertura da Estratégia Saúde da Família no Brasil, regiões e Unidades da Federação, 2006-2016. Epidemiol Serv Saude 2018; 27(3):e2017170..

Shortage and high turnover of human resources in primary care is a challenge for some Brazilian territories. Incentive programs, such as the Mais Médicos (“More Doctors”) Program⁸8 Pinto HA, Andreazza R, Ribeiro RJ, Loula MR, Reis AAC. O Programa Mais Médicos e a mudança do papel do Estado na regulação e ordenação da formação médica. Interface (Botucatu) 2019; 23(Supl. 1):e170960., were adopted in response to the most critical component - doctors -, which, along with the NASF, joined to strengthen PHC, increasing the scope and development of PHC⁹9 Machado MH, Ximenes Neto FRG. Gestão da Educação e do Trabalho em Saúde no SUS: trinta anos de avanços e desafios. Cien Saude Colet 2018; 23(6):1971-1979.^,1010 Herval AM, Rodrigues ET. Ampliação do acesso e mudança de modelo: experiência a partir do Programa Mais Médicos. Interface (Botucatu) 2017; 21(Supl. 1):1325-1332..

In this context, it is imperative to think in spatial terms to understand better the local and regional adequacy of deployed PHC teams. The approach allows visualizing the distribution patterns in similar and critical areas¹¹11 Nucci LB, Souccar PT, Castilho SD. Spatial data analysis and the use of maps in scientific health articles. Rev Assoc Med Bras 2016; 62(4):336-341.. Analyses of spatial data in public health can contribute to finding insufficient and unequal structuring of primary care and, thus, support the design of PHC extension actions towards health integrity. This work aims to analyze the spatial pattern of implementing PHC teams in the North and Northeast of Brazil in 2017.

Methods

This is an ecological study based on secondary data of the spatial pattern of the geographic distribution of PHC teams deployed in the cities of the North and Northeast. An exploratory description of the magnitude of the rates in the municipalities was carried out as a preliminary step.

The number of primary care teams in the municipalities was the monthly average for 2017, obtained from the eGestor data reported by the Family Health Department (DESF) of SAPS/MS¹²12 Brasil. Ministério da Saúde (MS). Departamento de Atenção Básica (DAB) [internet]. [acessado 2018 jan. 29]. Disponível em: https://egestorab.saude.gov.br/paginas/acessoPublico/relatorios/relHistoricoCoberturaAB.xhtml.
https://egestorab.saude.gov.br/paginas/a... . The source of the population estimates was the DataSUS website (http://tabnet.datasus.gov.br/cgi/deftohtm.exe?popsvs/cnv/popbr.def). Data from administrative records of the DESF/MS were consistent and timely in analyses on the ESF⁵5 Malta DC, Santos MAS, Stopa SR, Vieira JEB, Melo EA, Reis Ademar AC. A Cobertura da Estratégia de Saúde da Família (ESF) no Brasil, segundo a Pesquisa Nacional de Saúde, 2013. Cien Saude Colet 2016; 21(2):327-338.^,1313 Aquino R, Barreto ML. Programa Saúde da Família: acerca da adequação do uso do seu indicador de cobertura. Cad Saude Publica 2008; 24(4):905-914..

Categories of PHC workers considered are ACS, eSF, eSB 1 and 2, and NASF teams 1, 2, and 3, per the definition and composition of the national primary care policy-PNAB that establishes guidelines for their organization within the SUS. ACS rates were calculated per one thousand inhabitants, eSF and eSB per 10 thousand inhabitants, and NASF per 100,000 inhabitants. The denominator was the population residing in the municipalities in 2017.

The magnitude of the rates of teams deployed in the municipalities was typified by their medians and interquartile ranges (first=Q1 and third=Q3) as they better represent the set of indicators for the variables under study, i.e., they are not sensitive to extreme values. The variables explaining the rates of deployed teams were the North and Northeast; capital and not capital; metropolitan and non-metropolitan area; and population size (up to 20 thousand, 20 to 50 thousand, 50 to 100 thousand, 100 to 200 thousand, and 200 thousand and over).

The adequacy parameters recommended by the PNAB for the types of teams investigated in this study were adopted. A maximum number of 750 people monitored by ACS, or an appropriate rate above 1.33 per thousand inhabitants. The population enrolled by eSF from 2,000 to 3,500 people, which corresponds to a rate of 2.9 to 5.0 per 10,000 inhabitants, considered adequate rates above 2.9/10 thousand. The same parameter was applied for eSB. As the policy does not define parameters for the NASF, it establishes that the criterion of inadequacy is defined by the lack this type of team in place in the municipality.

The spatial analysis was based on the area data analysis technique to identify spatial dependence patterns of the municipalities for the rates of ACS, eSF, eSB, and NASF implemented in 2017. The indicators were normalized and subsequently submitted to the (I) Moran Global and Local (Local Indicator of Spatial Association - LISA) Indices.

Moran’s Global Index (I) provides a single spatial association value for the entire dataset. Values close to zero indicate the absence of spatial autocorrelation or spatial randomness. Values close to +1 refer to positive spatial autocorrelation and those close to -1, negative spatial autocorrelation¹⁴14 Bailey T, Gattrel A. Spatial Data Analysis by Example. London: Longman; 1995..

Moran’s Local Index (I) (LISA), using first-order neighborhood criteria (adjacent local neighbors), allows checking the spatial dependence and identifying the spatial patterns of each location¹⁵15 Anselin L. Local indicators of spatial association-LISA. Geograph Anal 1995; 27(2):93-115.. Moran’s scatterplot was generated to visualize the results.

According to the results (95% confidence level of significance), the municipalities were classified in values from 0 to 4: 0 (not significant); 1 corresponds to the values of Q1 (high-high) - high values of the indicator with the neighborhood with also high mean; 2 (Q2) (low-low) - low values of the indicator with neighbors with also low values. These areas are homogeneous and with a positive spatial association. While the areas of quadrants 3 (Q3) high-low and 4 (Q4) low-high, with high values of the indicator close to neighbors with low values and vice versa, are areas with a negative spatial or heterogeneous association¹⁴14 Bailey T, Gattrel A. Spatial Data Analysis by Example. London: Longman; 1995.^,1515 Anselin L. Local indicators of spatial association-LISA. Geograph Anal 1995; 27(2):93-115.. We considered a critical area, which was classified in the Moran scatterplot as Q2 (low-low), i.e., places where the PHC structuring is insufficient.

The free software TerraView 4.2.2, developed by the National Institute for Space Research (INPE), was used for spatial data analysis. The study worked with secondary data records with non-nominal basis, under Decree No. 7,724, of May 16, 2012¹⁶16 Brasil. Decreto nº 7.721, de 16 de maio de 2012. Regulamenta a Lei nº 12.527, de 18 de novembro de 2011, que dispõe sobre o acesso a informações previsto no inciso XXXIII do caput do art. 5º , no inciso II do § 3º do art. 37 e no § 2º do art. 216 da Constituição. Diário Oficial da União 2012; 16 maio., and Resolution No. 510, of April 7, 2016¹⁷17 Brasil. Resolução nº 510, de 07 de abril de 2016. dispõe sobre as normas aplicáveis a pesquisas em Ciências Humanas e Sociais cujos procedimentos metodológicos envolvam a utilização de dados diretamente obtidos com os participantes ou de informações identificáveis ou que possam acarretar riscos maiores do que os existentes na vida cotidiana. Diário Oficial da União 2016; 24 maio..

Results

The municipalities of the North (n=450) and Northeast (n=1,794) had 132,174 ACS, 18,405 eSF, 13,017 eSB and 2,205 NASF teams. Municipalities without eSB and NASF were 4.4% and 30% in the North and 1.1% and 11% in the Northeast, mainly in municipalities with less than 100,000 inhabitants.

The median of ACS rates in the North was 2.5/thousand inhabitants, remaining within the recommended parameter (≥1.33/thousand inhabitants) in inland municipalities and with up to 200,000 inhabitants. This pattern was similarly reproduced in the Northeast, with slightly lower values (Table 1). The UFs reached medians above 1.33/thousand (Table 2). However, only four capitals reached this value (Table 3). Municipalities with inadequate rates were 4% (n=18) in the North and 1.5% (n=27) in the Northeast.

The median of eSF rates in the Northeast was 3.8/10 thousand inhabitants, with inland municipalities up to 50 thousand inhabitants within the parameter (≥2.9/10 thousand inhabitants). The North followed an equivalent profile but with lower values (Table 1). The medians of the UFs were above 2.9/10 thousand (Table 2), but only one capital had an adequate rate (Table 3). Rates below recommended in municipalities were 20% (n=359) in the Northeast and 46% (n=207) in the North.

The distribution pattern of eSB implanted in the Northeast is similar to that of eSF in the region but with lower values. The eSB median was within the recommended range (≥2.9/10 thousand inhabitants) for the total number of municipalities in the region (3.2/10 thousand inhabitants), inland municipalities, and up to 20 thousand inhabitants. In the North, the median eSB rate was below that recommended for all variables analyzed, mainly larger cities (Table 1). Among UFs, the median was above 2.9/10 thousand in eight units in the Northeast and three in the North (Table 2). The number of eSB was below the parameter in 41% (n=736) of the municipalities in the Northeast and 72% (n=324) in the North, including all capitals (Table 3).

The median rate of NASF teams was 5.6/100 thousand inhabitants (17,857 people per team) in the Northeast and 2.9/100 thousand inhabitants (34,883 people per team) in the North. In both regions, the rates were higher in inland municipalities, metropolitan areas, and cities with less than 20,000 inhabitants. The median of NASF teams ranged from zero to 14.4/100 in the states (Table 2), while rates ranged from 0.1 to 4.1/100 thousand in the capitals (Table 3).

Team distribution maps illustrate how most locations have adequate numbers of ACS in both regions. The Northeast also has a larger area with adequate rates of eSF, eSB, and NASF teams. The states of Piauí, Rio Grande do Norte, and Paraíba stood out as the most prominent areas with the recommended number of eSF and eSB. On the other hand, most of the other states had shortcomings, mainly in the implementation of eSB (Figure 1).

Spatial autocorrelation was observed for all teams When analyzing the spatial pattern of the distribution of deployment of PHC teams, using the (I) Global Moran Index with p=0.01 (I_ACS=0.286; I_eSF= 0.348; I_eSB=0.436; and I_NASF=0.32). By applying LISA and obtaining the Moran scatterplot (Figure 2), we visualized clusters of homogeneous, statistically significant areas whose locations have more pronounced spatial dependence, establishing priority areas. The North was a critical area in almost all its extension, mainly in Pará, Rondônia, Amazonas, and Amapá for all teams, except for ACS. While the critical areas reached a lower proportion in the Northeast, concentrating by teams in ACS (Coast of Ceará, South of Sergipe, and dispersed territories of Bahia and Pernambuco); eSF (Central region of Ceará and metropolitan region of Fortaleza, North and West of Bahia, and Central and West regions of Pernambuco, and metropolitan region of Recife); eSB (West of Maranhão, west coast of Ceará, metropolitan region of Recife and North of Bahia, mainly); NASF (North and West of Maranhão, Ceará, Pernambuco, south of Sergipe, and North and West of Bahia). Tocantins displayed a behavior more similar to the states of the Northeast.

Discussion

Only the ACS coverage reached the adequacy parameter defined in the PNAB for the regions analyzed among the types of teams in the PHC. The Northeast of Brazil denoted even better composition and distribution of eSF, eSB, and NASF. The smaller the size of the municipality, the greater the adequacy of teams in the PHC and inland cities. The frequency of municipalities without NASF was not negligible, while the North had a more significant number of places with insufficient PHC structuring (critical areas). In the Northeast, the state of Bahia stood out for the persistent critical areas. Conversely, Piauí, Rio Grande do Norte, and Paraíba stood out with their adequate coverage.

The previous analyses⁵5 Malta DC, Santos MAS, Stopa SR, Vieira JEB, Melo EA, Reis Ademar AC. A Cobertura da Estratégia de Saúde da Família (ESF) no Brasil, segundo a Pesquisa Nacional de Saúde, 2013. Cien Saude Colet 2016; 21(2):327-338.

6 Neves RG, Flores TR, Duro SMS, Nunes BP, Tomasi E. Tendência temporal da cobertura da Estratégia Saúde da Família no Brasil, regiões e Unidades da Federação, 2006-2016. Epidemiol Serv Saude 2018; 27(3):e2017170.^-77 Garnelo L, Lima JG, Rocha ESC, Herkrath FJ. Acesso e cobertura da Atenção Primária à Saúde para populações rurais e urbanas na região Norte do Brasil. Saude Debate 2018; 42(Supl. 1):81-99. found settings compatible with the results found in this study. Better ESF structuring was identified in the Northeast and rural areas, with an increasing coverage inversely proportional to the size of the municipality, and higher coverage in Tocantins, Paraíba, Piauí, and its capitals. Some level of correspondence between this PHC coverage profile and the quality of primary care for the regions under analysis is observed. Municipalities with adequate team parameters meant better care coordination³3 Brasil. Ministério da Saúde (MS). Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Ofical da União; 2017. and increased access for the population¹⁸18 Corrêa GT, Celeste RK. Associação entre a cobertura de equipes de saúde bucal na saúde da família e o aumento na produção ambulatorial dos municípios brasileiros, 1999 e 2011. Cad Saude Publica 2015; 31(12):2588-2598..

The unfavorable structuring of the PHC in the North may be very critical due to the deployment of teams outside their coverage areas. This arrangement, teams to serve rural communities located in urban spaces, and the accumulation of service provision in the municipal seats hinder the entry to the health unit⁷7 Garnelo L, Lima JG, Rocha ESC, Herkrath FJ. Acesso e cobertura da Atenção Primária à Saúde para populações rurais e urbanas na região Norte do Brasil. Saude Debate 2018; 42(Supl. 1):81-99.^,1919 Poças KC, Freitas LRS, Duarte EC. Censo de estrutura da Atenção Primária à Saúde no Brasil (2012): estimativas de coberturas potenciais. Epidemiol Serv Saude 2017; 26(2):275-284.. The service away from the households still hampers the professional-user bond in this type of territory, which is commonly extensive and with a high population density. This spatial reality is exceptionally pronounced in the Amazon region. Thus, isolated results of medium coverage should be considered, as they may not necessarily translate into greater geographic or organizational accessibility for everyone.

ESF increased coverage often translates into an impact on the health of the population²⁰20 Abreu DMX, Pinheiro PC, Queiroz BL, Lopes EAS, Machado ATGM, Lima AMLD, Santos AF, Rocha HA. Análise espacial da qualidade da Atenção Básica em Saúde no Brasil. Saude Debate 2018; 42(n. esp. 1):67-80., but without representing changes in the care model²¹21 Lentsck MH, Mathias TAF. Internações por doenças cardiovasculares e a cobertura da estratégia saúde da família. Rev Latino-Am Enferm 2015; 23(4):611-619.. The high level of PHC adequacy is accompanied by significant differences between states, incipient care provision on weekends, and weak reception of user demands¹⁹19 Poças KC, Freitas LRS, Duarte EC. Censo de estrutura da Atenção Primária à Saúde no Brasil (2012): estimativas de coberturas potenciais. Epidemiol Serv Saude 2017; 26(2):275-284..

The lower rate of ESF teams in capitals, a finding corroborated by a previous study⁵5 Malta DC, Santos MAS, Stopa SR, Vieira JEB, Melo EA, Reis Ademar AC. A Cobertura da Estratégia de Saúde da Família (ESF) no Brasil, segundo a Pesquisa Nacional de Saúde, 2013. Cien Saude Colet 2016; 21(2):327-338., may mean an extended PHC coverage in urban centers, and the introduction of family health units to the preexisting structure of traditional units is not uncommon. When integrated into an organizational and systemic structure, the composition of varying PHC access models has been perceived as a unique experience of comprehensive and robust systems. An adaptive variety of care strategies for the SUS united by general principles is relevant⁴4 Viana ALA, Bousquat A, Melo GA, Negri Filho A, Medina MG. Regionalização e Redes de Saúde. Cien Saude Colet 2018; 23(6):1791-1798. given the heterogeneous health realities in different parts of the country.

Despite the obstacles, good PHC practices are confirmed, in particular prevention and health promotion activities aimed at specific groups, such as rural children in the North and Northeast.²²22 Santos AMA, Jacinto PA. O Impacto do Programa Saúde da Família Sobre a Saúde das Crianças da Área Rural do Brasil. Rev Econ Soc Rural 2017; 55(2):227-246. Continuity of care in the ESF was a powerful equitable policy²³23 Martins MMF, Aquino R, Pamponet ML, Pinto Junior EP, Amorim LDAF. Acesso aos serviços de atenção primária à saúde por adolescentes e jovens em um município do Estado da Bahia, Brasil. Cad Saude Publica 2019; 35(1):e00044718.

24 Andrade MV, Noronha K, Barbosa ACQ, Rocha TAH, Silva NC, Calazans JA, Souza MN, Carvalho LR, Souza A. A equidade na cobertura da Estratégia Saúde da Família em Minas Gerais, Brasil. Cad Saude Publica 2015; 31(6):1175-1187.^-2525 Kessler M, Lima SBS, Weiller TH, Lopes LFD, Ferraz L, Thumé E. A longitudinalidade na Atenção Primária à Saúde: comparação entre modelos assistenciais. Rev Bras Enferm 2018; 71(3):1063-1071. when prioritizing the most vulnerable. On the other hand, the low availability of this strategy was related to failures in the prevention of diseases relevant to public health²⁶26 Nunes PS, Zara ALSA, Rocha DFNC, Marinho TA, Mandacarú PMP, Turchi MD. Sífilis gestacional e congênita e sua relação com a cobertura da Estratégia Saúde da Família, Goiás, 2007-2014: um estudo ecológico. Epidemiol Serv Saude 2018; 27(4):e2018127..

The PHC workforce in Brazil has been an example for innovating in teams that involve mid-level professionals and ACS with users and their families to provide health services, a people-centered scale quality condition²⁷27 Schwarz D, Duong D, Adam C, Awoonor-Williams JK, Back D, Bang A, Bang R, Beebe M, Bhatt S, Campbell J, Conteh M, Dimitrova D, Dimovska D, Dossou J-P, Evans T, Gadir M, Islam K, Kasyaba R, Kumar P, Levy C, Oanh TM, Monsef N, Oh J, Otoo N, Palazuelos D, Poh A, Sinha S, Smith C, Stewart B, Thomas C, Tritter B, Varnum P, Weilnau T, Ellner A. Primary Care 2030: Creating an Enabling Ecosystem for Disruptive Primary Care Models to Achieve Universal Health Coverage in Low- and Middle-Income Countries. Annals Glob Health 2020; 86(1):9.. However, the low regulation of human resources in health is a decisive condition for the expansion and development of PHC in Brazil. Although without solving this trajectory of regulatory deficit, the Mais Médicos Program expanded coverage and equity in PHC with the allocation of doctors in places with a more critical situation for the presence of this professional¹⁰10 Herval AM, Rodrigues ET. Ampliação do acesso e mudança de modelo: experiência a partir do Programa Mais Médicos. Interface (Botucatu) 2017; 21(Supl. 1):1325-1332.^,2828 Campos GWS, Pereira Júnior N. A Atenção Primária e o Programa Mais Médicos do Sistema Único de Saúde: conquistas e limites. Cien Saude Colet 2016; 21(9):2655-2663.^,2929 Pinto HA, Oliveira FP, Santana JSS, Santos FOS, Araujo SQ, Figueiredo AM, Araújo GD. Programa Mais Médicos: avaliando a implantação do Eixo Provimento de 2013 a 2015. Interface (Botucatu) 2017; 21(Supl. 1):1087-1101..

Experience has shown that universal health models based on PHC principles have achieved better results³⁰30 Facchini LA, Tomasi E, Dilélio AS. Qualidade da Atenção Primária à Saúde no Brasil: avanços, desafios e perspectivas. Saude Debate 2018; 42(n. esp. 1):208-223.^,3131 Uchôa SAC, Arcêncio RA, Fronteira I, Coêlho AA, Martiniano CS, Brandão ICA, Yamamura M, Maroto RM, Silva AKF. Acesso potencial à Atenção Primária à Saúde: o que mostram os dados do Programa de Melhoria do Acesso e da Qualidade do Brasil? Rev Latino-Am Enferm 2016; 24:e2672.. For a broader reach, the renewed commitment to PHC in the Astana Declaration³²32 World Health Organization (WHO). Global Conference on Primary Health Care. Declaration of Astana [Internet] Astana; 2018 [cited 2020 out 16]. Available from: https://www.who.int/docs/default-source/primary-health/declaration/gcphc-declaration.pdf.
https://www.who.int/docs/default-source/... demands country leadership for user-centered technology innovation and models coordinated by multidisciplinary teams, powerful to overcome episodic and poorly equipped care networks²⁷27 Schwarz D, Duong D, Adam C, Awoonor-Williams JK, Back D, Bang A, Bang R, Beebe M, Bhatt S, Campbell J, Conteh M, Dimitrova D, Dimovska D, Dossou J-P, Evans T, Gadir M, Islam K, Kasyaba R, Kumar P, Levy C, Oanh TM, Monsef N, Oh J, Otoo N, Palazuelos D, Poh A, Sinha S, Smith C, Stewart B, Thomas C, Tritter B, Varnum P, Weilnau T, Ellner A. Primary Care 2030: Creating an Enabling Ecosystem for Disruptive Primary Care Models to Achieve Universal Health Coverage in Low- and Middle-Income Countries. Annals Glob Health 2020; 86(1):9.^,3333 Friebel R, Molloy A, Leatherman S, Dixon J, Bauhoff S, Chalkidou K. Achieving high-quality universal health coverage: a perspective from the National health service in England. BMJ Glob Health 2018;3:e000944.^,3434 Tao W, Zeng Z, Dang H, Lu B, Chuong L, Yue D, Wen J, Zhao R, Li W, Kominski GF. Towards universal health coverage: lessons from 10 years of healthcare reform in China. BMJ Global Health 2020; 5(3):e002086.. While still a distant reality, the adoption of these technologies is seen as a possibility to scale the provision of quality primary care even in areas with a shortage of professionals and other access barriers²⁷27 Schwarz D, Duong D, Adam C, Awoonor-Williams JK, Back D, Bang A, Bang R, Beebe M, Bhatt S, Campbell J, Conteh M, Dimitrova D, Dimovska D, Dossou J-P, Evans T, Gadir M, Islam K, Kasyaba R, Kumar P, Levy C, Oanh TM, Monsef N, Oh J, Otoo N, Palazuelos D, Poh A, Sinha S, Smith C, Stewart B, Thomas C, Tritter B, Varnum P, Weilnau T, Ellner A. Primary Care 2030: Creating an Enabling Ecosystem for Disruptive Primary Care Models to Achieve Universal Health Coverage in Low- and Middle-Income Countries. Annals Glob Health 2020; 86(1):9., innovations allowing the world to address the determinants and the growing burden of accidents and diseases³⁵35 Kluge H, Barkley S, Theodorakis PN, Yamamoto N, Tsoy A, Aiypkhanova A, Ganesh V, Hipgrave DB, Peterson SS, Valderas JM, Mossialos E. How primary health care can make universal health coverage a reality, ensure healthy lives, and promote wellbeing for all. Lancet 2018; 392(10156):1372-1374..

The universalization of PHC will not be possible without the integration and unity of the most varied care models found in practice and the adjustment of inadequacies in applying the PNAB principles and guidelines⁴4 Viana ALA, Bousquat A, Melo GA, Negri Filho A, Medina MG. Regionalização e Redes de Saúde. Cien Saude Colet 2018; 23(6):1791-1798.^,3030 Facchini LA, Tomasi E, Dilélio AS. Qualidade da Atenção Primária à Saúde no Brasil: avanços, desafios e perspectivas. Saude Debate 2018; 42(n. esp. 1):208-223.^,3131 Uchôa SAC, Arcêncio RA, Fronteira I, Coêlho AA, Martiniano CS, Brandão ICA, Yamamura M, Maroto RM, Silva AKF. Acesso potencial à Atenção Primária à Saúde: o que mostram os dados do Programa de Melhoria do Acesso e da Qualidade do Brasil? Rev Latino-Am Enferm 2016; 24:e2672.. However, the changes introduced in this policy point in another direction, by promoting the relativization of universal coverage, the segmentation of access, and the recomposition of teams. In a country with such different realities and a decentralization process lacking betterments, it is a risk for the State to renounce its attribution of inducing national bases and unity for PHC³⁶36 Morosini MVGC, Fonseca AF, Lima Luciana Dias de. Política Nacional de Atenção Básica 2017: retrocessos e riscos para o Sistema Único de Saúde. Saude Debate 2018; 42(116):11-24..

In recent years, SUS has been subject to tensions resulting from fiscal austerity policies. The deteriorated health indicators signaled the effects of lower investments in health³⁷37 Paes-Sousa R, Rasella D, Carepa-Sousa J. Política econômica e saúde pública: equilíbrio fiscal e bem-estar da população. Saude Debate 2018; 42(n. esp. 3):172-182.^,3838 Castro MC, Massuda A, Almeida G, Menezes-Filho NA, Andrade MV, Noronha QVMS, Rocha R, Macinko J, Hone T, Tasca R, Giovanella L, Malik AM, Werneck H, Fachini LA, Atun R. Brazil's unified health system: the first 30 years and prospects for the future. Lancet 2019; 394(10195):345-356.. The recent COVID-19 epidemic escalated the pressure on health and revealed the obstructive capacity of political agents of the State when forming narratives of conflict with the good public health practices. Brazil’s experience with other health emergencies, materialized in the response of the care and surveillance networks of the SUS, has prevented worse harm from uncertainties along the way³⁹39 Campos GWS. O pesadelo macabro da Covid-19 no Brasil: entre negacionismos e desvarios. Trab Educ Saude 2020; 18(3):e00279111.^,4040 Croda J, Oliveira WK, Frutuoso RL, Mandetta LH, Baia-da-Silva DC, Brito-Sousa JD, Monteiro WM, Lacerda MVG. COVID-19 in Brazil: advantages of a socialized unified health system and preparation to contain cases. Rev Soc Bras Med Trop 2020; 53:e20200167..

The main limitation of this study is related to the nature of administrative data on teams deployed in the city. This information varies throughout the year due to the monthly update of the number of registered teams. To deal with this limitation, we calculated the monthly average for the studied year, as stated in the methods. Furthermore, some degree of data incompleteness and underreporting can affect the quality of secondary data. Finally, the spatial analysis unit can conceal differentials arising from aggregated data (ecological bias).

This study indicated a pattern in the composition and extent of PHC in the North and Northeast of the country. The level of adequacy and distribution of the different types of teams affects the different territories unevenly. The data suggest different structures and realities of primary health care, with an evident condition of inferiority for the North. Identifying critical coverage areas provides evidence to establish priority areas and plan specific primary health adequacy policies. From the perspective of universal health, it can guide the expansion of articulated PHC structures and strategies adjusted to the multiple Brazilian realities and inserted in a structured health care network to affect people’s health.

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