Abstract

Since 1994, Brazil has been offering Primary Health Care (PHC) services based on the Family Health Strategy. The ESF has achieved important results. During this period, the PHC financing model did not undergo major methodological changes. In this article, the results of the new financing model for PHC approved in a tripartite manner in 2019, Previne Brasil, are laid out, which is composed of (i) weighted capitation, (ii) incentives for specific and strategic actions and, (iii) payment for performance. These first results reveal the increase of more than 50 million people with qualified and unique registration, associated with the record number of more than 52 thousand FH / eAP teams financed by the Ministry of Health, with more than 35 thousand of which (67%) using electronic medical records . In addition, the registration of people and professionals of the Brazilian PHC, together with SISAB, is the largest set of demographic and clinical health data in the world. These advances favor the overcoming of difficulties to achieve greater access, longitudinality and coordination of care, qualifying the Brazilian PHC in search of better health outcomes.

Key words:
Electronic health records; Primary care; Health evaluation; Healthcare financing

Introduction

Brazil, since 1994¹1 Kringos DS, Boerma W, Van der Zee J, Groenewegen P. Europe's strong primary care systems are linked to better population health but also to higher health spending. Health Affairs 2013; 32(4):686-694., has been offering Primary Health Care (PHC) services to the population based on the Family Health Strategy (FHS). Over its 27 years, the FHS has achieved important results: reduction of infant mortality and preventable deaths in adults¹1 Kringos DS, Boerma W, Van der Zee J, Groenewegen P. Europe's strong primary care systems are linked to better population health but also to higher health spending. Health Affairs 2013; 32(4):686-694.

2 Rocha R, Soares R. Evaluating the impact of community-based health interventions: evidence from Brazil's Family Health Program. Health Econnomics 2010; 129(51):126-158.^-33 Bastos ML, Menzies D, Hone T, Dehghani K, Trajman A. Correction: the impact of the Brazilian family health on selected primary care sensitive conditions: a systematic review. PLoS One 2017; 12(12):e0189557.. Despite the advances, it can be observed, especially in the last decade, the difficulty in achieving good indicators in fundamental actions: care provision to frequent clinical conditions⁴4 Chueiri PS, Gonçalves MR, Hauser L, Wollmann L, Mengue SS, Roman R, Rodrigues Agostinho Rech M, Soares MAV, Pertile J, Harzheim E. Reasons for encounter in primary health care in Brazil. Fam Pract 2020; 37(5):648-654.; immunization⁵5 Arroyo LH, Ramos ACV, Yamamura M, Crispim JA, Cartagena-Ramos D, Fuentealba-Torres M, Santos DT, Palha PF, Arcêncio RA. Áreas com queda da cobertura vacinal para BCG, poliomielite e tríplice viral no Brasil (2006-2016): mapas da heterogeneidade regional. Cad Saude Publica 2020; 36(4):e00015619.^,66 Domingues CMAS, Maranhão AGK, Teixeira AM, Fantinato FFS, Domingues RAS. 46 anos do Programa Nacional de Imunizações: uma história repleta de conquistas e desafios a serem superados. Cad Saude Publica 2020; 36(Suppl. 2):e00222919.; control of chronic conditions⁷7 Reis RCP, Duncan BB, Szwarcwald CL, Malta DC, Schmidt MI. Control of glucose, blood pressure, and cholesterol among adults with diabetes: the Brazilian National Health Survey. J Clin Med 2021; 10(15):3428., such as diabetes, hypertension, dyslipidemia, respiratory diseases; cancer screening⁸8 Chueiri PS, Gonçalves MR, Hauser L, Mengue S, Agostinho M, Roman R, Wollmann L, Dilda A, Silva RAM, Harzheim E. Brazilian Survey on Preventive Actions for the Population with Access to Primary Healthcare: inefficient spending in a country in economic crisis. Int J Health Policy Manag 2021. doi: 10.34172/ijhpm.2021.94. Epub ahead of print.
https://doi.org/10.34172/ijhpm.2021.94... ; mental health⁹9 Salum GA, Leite LDS, Santos SJE, Mazzini G, Baeza FLC, Spanemberg L, Evans-Lacko S, Sato JR, Nascimento DM, Frank T, Pfeil J, Katz N, Osório J, Santos PR, Silva E, Nunes C, Soares KN, Machado AMG, Breyer T, Rodrigues M, Galão A, Motta GL, Schuch S, Osório E, Rodrigues C, Sturmer PL, Harzheim E. Prevalence and trends of mental disorders requiring inpatient care in the city of Porto Alegre: a citywide study including all inpatient admissions due to mental disorders in the public system from 2013-2017. Trends Psychiatry Psychother 2020; 42(1):86-91.; decrease in hospitalizations for sensitive conditions and decrease in the search for emergency services for reasons not characterized as urgent¹⁰10 Magalhães FJ, Lima FET, Barbosa LP, Guimarães FJ, Felipe GF, Rolim KMC, Lima EPM. Risk classification of children and adolescents: priority of care in the emergency unit. Rev Bras Enferm 2020; 73(Suppl. 4):e20190679.^,1111 Mendes EV. As redes de atenção à saúde. Brasília: OPAS; 2011.. Added to this scenario is a history of fragility in ensuring access¹²12 Banco Mundial. Um ajuste justo: Análise da eficiência e equidade do gasto público no Brasil. Brasília: Banco Mundial; 2017.

13 Mesquita Filho M, Luz BSR, Araújo CS. A Atenção Primária à Saúde e seus atributos: a situação das crianças menores de dois anos segundo suas cuidadoras. Cien Saude Colet 2014; 19(7):2033-2046.

14 Carvalho VCHS, Rossato SL, Fuchs FD, Harzheim E, Fuchs SC. Assessment of primary health care received by the elderly and health related quality of life: a cross-sectional study. BMC Public Health 2013; 13:605.

15 Ibañez N, Rocha JSY, Castro PC, Ribeiro MCSA, Forster AC, Novaes MHD, Viana ALA. Avaliação do desempenho da atenção básica no Estado de São Paulo. Cien Saude Colet 2006; 11(3):683-703.

16 Harzheim E, Hauser L, Pinto LF. Avaliação do grau de orientação para Atenção Primária em Saúde: a experiência dos usuários das Clínicas da Família e Centros Municipais de Saúde na cidade do Rio de Janeiro (relatório final da pesquisa PCATool - Rio-2014). Porto Alegre: UFRGS; 2015.^-1717 Pinto LF, 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. and a limited capacity to incorporate technologies, in addition to the low productivity represented by the reduced number of consultations per doctor/year (1,470 vs. 2,294 in the OECD countries)¹²12 Banco Mundial. Um ajuste justo: Análise da eficiência e equidade do gasto público no Brasil. Brasília: Banco Mundial; 2017..

During this period, the financing model for PHC did not change, being based on criteria of municipal population size, structure and service provision with little focus on achieving results in health or equity, with no guarantee of real monitoring of people enrolled in PHC. There was an evident effort to assess and monitor health outcomes in the National Program for Improving Access and Quality (PMAQ, Programa Nacional de Melhoria do Acesso e da Qualidade) but the observed results indicate that the program helped to improve the physical facilities of the units and brought about a discussion about planning and organization services but did not overcome the difficulties in achieving better health indicators¹⁸18 Sellera PEG, Pedebos LA, Harzheim E, Medeiros OL, Ramos LG, Martins C, D'ávila OP. Monitoramento e avaliação dos atributos da Atenção Primária à Saúde em nível nacional: novos desafios. Cien Saude Colet 2020; 25(4):1401-1412..

The aim of this article is to describe and comment on the results of the new financing model for PHC, Prevent Brasil (Previne Brasil) approved in a tripartite manner in 2019¹⁹19 Brasil. Portaria nº 2.979, de 12 de novembro de 2019. Institui o Programa Previne Brasil, que estabelece novo modelo de financiamento de custeio da Atenção Primária à Saúde no âmbito do Sistema Único de Saúde, por meio da alteração da Portaria de Consolidação nº 6/GM/MS, de 28 de setembro de 2017.^,2020 Harzheim E, D'ávila OP, Ribeiro DC, Ramos LG, Silva LE, Santos CMJ, Costa LGM, Cunha CRH, Pedebos LA. Novo financiamento para uma nova Atenção Primária à Saúde no Brasil. Cien Saude Colet 2020; 25(4):1361-1374.. Data related to the PHC federal budget, the immediate effects of adopting Weighted Capitation, Incentives for Specific and Strategic Actions and Payment for Performance are presented.

Primary health care budget

Graph 1 shows the evolution of the federal budget for PHC related to the budgetary actions of new the financing model in the period between 2018 and 2021²¹21 Brasil. SIOP Consulta Livre. [acessado 2021 Out 18]. Disponível em: https://www1.siop.planejamento.gov.br/QvAJAXZfc/opendoc.htm?document=IAS%2F Execucao_Orcamentaria.qvw&host=QVS%40pqlk 04&anonymous=true&sheet=SH06
https://www1.siop.planejamento.gov.br/Qv... and Graph 2 shows the proportion of the variation in the transferred amounts.

It can be observed that the budget resources of budgetary actions 219A and 217U followed the loss of power of the Brazilian currency for the years 2018 and 2019 and in 2020 it exceeded this inflationary loss, that is, it obtained real gains in its budget composition. According to data from the Extended Consumer Price Index (IPCA - Índice de Preços ao Consumidor Amplo)²²22 Instituto Brasileiro de Geografia e Estatística. IPCA - Índice Nacional de Preços ao Consumidor Amplo. [acessado 2021 Out 18]. Disponível em: https://www.ibge.gov.br/estatisticas/economicas/precos-e-custos/9256-indice-nacional-de-precos-ao-consumidor-amplo.html?=&t=series-historicas
https://www.ibge.gov.br/estatisticas/eco... , inflation for the fiscal year 2019 was 4.3%, while the growth of budget resources of the new financing was 8.4%.

On the other hand, in the 2021 budget year to date, the PHC budget loses relevance. Despite the fact that the 2021 budget execution is still in progress, in the Annual Budget Law Project (Projeto de Lei Orçamentária Anual) related to the 2022 fiscal year, the budget resources do not replace the inflation for the period. Expectations regarding the inflation projection for the year 2021 are around 8.5%²2 Rocha R, Soares R. Evaluating the impact of community-based health interventions: evidence from Brazil's Family Health Program. Health Econnomics 2010; 129(51):126-158. ⁸8 Chueiri PS, Gonçalves MR, Hauser L, Mengue S, Agostinho M, Roman R, Wollmann L, Dilda A, Silva RAM, Harzheim E. Brazilian Survey on Preventive Actions for the Population with Access to Primary Healthcare: inefficient spending in a country in economic crisis. Int J Health Policy Manag 2021. doi: 10.34172/ijhpm.2021.94. Epub ahead of print.
https://doi.org/10.34172/ijhpm.2021.94... , while the budget increase has been 3.2% so far. In relation to fiscal year 2022, the inflationary expectation of the financial market predicts a restitution of 4.1%, while the budget proposal indicates an increase of 6.1%²³23 Banco Central do Brasil. Focus - Relatório de Mercado de 27/09/2021. [acessado 2021 Out 18]. Disponível em: https://www.bcb.gov.br/content/focus/focus/R20210924.pdf
https://www.bcb.gov.br/content/focus/foc... .

Weighted capitation - accountability for people and expanded access

One of the aims of Prevent Brazil is to put people at the center of the system. The new model encouraged municipalities to identify the citizens served through better qualified registers, providing the structural conditions for greater accountability of the FHS teams in relation to the people. This, together with an informatization strategy, allowed a rapid growth of the base of adequately identified citizens and with effective assistance by the Family Health teams (FHT).

In November 2019, at the launch of Prevent Brazil, data from the previous four-month period (2019 Q2) showed that by August of that year, 98.2 million people were duly registered in the PHC database (SISAB - Primary Care Information System)²⁴24 Brasil. Sistema de Informação em Saúde para a Atenção Básica. [acessado 2021 Out 18]. Disponível em: https://sisab.saude.gov.br/paginas/acessoRestrito/relatorio/federal/saude/RelSauProducao.xhtml
https://sisab.saude.gov.br/paginas/acess... . To verify growth, compared to the two previous quarters of 2019, with the discussion of Prevent Brazil already taking place in all states of the federation, the average growth of the registration base was between 6.4% and 6.7% per four-month period. The latest available data, for August 2021 (2021 Q2) shows 151.8 million people duly registered, without duplicates, representing an increase of 55% compared to the time of launch of the new financing model, a proportion of four-month growth of more of 9%²⁴24 Brasil. Sistema de Informação em Saúde para a Atenção Básica. [acessado 2021 Out 18]. Disponível em: https://sisab.saude.gov.br/paginas/acessoRestrito/relatorio/federal/saude/RelSauProducao.xhtml
https://sisab.saude.gov.br/paginas/acess... .

The capitation model also allowed people to have the freedom to enroll in any team without the need to be bound exclusively by geographic criteria. If the citizen is registered by an FHT, but is not effectively assisted, the FHT that actually assisted them ends up with the effective registration at the federal government, even in cases where this effectuation involves FHT from different municipalities. This approach corrects distortions caused by the per capita payment model of the total population since this criterion did not allocate resources to where the citizen was effectively served.

In recent decades, the paradigm of person-centered care has been consolidated as a fundamental element of quality in health, both from a structural perspective of health systems²⁵25 Committee on Quality Health Care in America, Institute of Medicine. Crossing the Quality Chasm: a New Health System for the 21st Century. Washington, D.C.: National Academy Press; 2001. and in the development of professional skills in clinical care²⁶26 Stewart M, Welston W, Mcwillian C. Medicina centrada na pessoa: transformando o método clínico. Porto Alegre: Artmed, 2017.. Longitudinality is one of the main strategies to achieve the Triple Aim²⁷27 Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood) 2008; 27(3):759-69. of health care, as it promotes better health outcomes, with greater satisfaction, at a lower cost²⁸28 Starfield Bárbara. Atenção primária: equilíbrio entre necessidade de saúde, serviços e tecnologia. Brasília: UNESCO, Ministério da Saúde; 2004.. The longitudinality effect is mediated by the relationship of trust between people and professionals, established over time. How is it possible to build a relationship of trust from a vertical designation of care reference, based on territory and not on the autonomy of choice?

Community guidance, an attribute derived from PHC, does not mean care allocation by territories, but rather “a PHC approach that uses epidemiological and clinical skills in a complementary way to adjust programs to meet the specific health needs of a defined population”²⁸28 Starfield Bárbara. Atenção primária: equilíbrio entre necessidade de saúde, serviços e tecnologia. Brasília: UNESCO, Ministério da Saúde; 2004. The supposed benefit of territory-oriented care is the synergy between assistance and surveillance actions²⁹29 Teixeira CF, Paim JS, Vilasbôas AL. SUS, modelos assistenciais e vigilância da saúde. Inf Epidemiol 1998; 7(2):7-28.. However, there is a fragmentation in SUS (Brazilian Unified Health System) between these two actions. The integration between care and surveillance depends on the quality of people’s clinical information management, rather than on territorial orientation. It is the strengthening of informatization and the integration of clinical and epidemiological information on the population that will allow the teams to work together on assistance and surveillance, incorporating contextual information into individual care. The need to overcome territory-oriented ascription has already been pointed out by different PHC specialists in Brazil³⁰30 Tasca R, Massuda A, Carvalho WM, Buchweitz C, Harzheim E. Recomendações para o fortalecimento da atenção primária à saúde no Brasil. Rev Panam Salud Publica 2020; 44:e4. and even by ABRASCO³¹31 Associação Brasileira de Saúde Coletiva (ABRASCO). Fortalecer o SUS, em defesa da democracia e da vida [Internet]. 2020. [acesso 2021 Out 3]. Disponível em: https://www.abrasco.org.br/site/wp-content/uploads/2020/10/Abrasco_Fortalecer-o-SUS.pdf
https://www.abrasco.org.br/site/wp-conte... . If care is to be people-centered, offered through trust relationships over time, the bond must necessarily be made with people, freely, and not with their homes.

In the same sense, the need for continuous expansion in the number of PHC services led to the inclusion of teams with flexible hours in a work model based on the development of PHC attributes. The financing of Primary Health Care Teams (PHCT) with workloads of 20h and 30h resulted in a growth of financed teams, increasing the number of registered people and access to health services³²32 Brasil. Portaria nº 2.539, de 26 de setembro de 2019. Altera as Portarias de Consolidação nº 2/GM/MS, de 28 de setembro de 2017, e nº 6, de 28 de setembro de 2017, para instituir a equipe de Atenção Primária - eAP e dispor sobre o financiamento de equipe de Saúde Bucal - eSB com carga horária diferenciada.. In December 2018, 43,026 PHC teams were financed, in December 2019 there were 43,755 and for the September 2021 period, 52,829 teams were identified, being 48,611 FHT and 4,218 PHCT (National Register of Health Establishments CNES - Cadastro Nacional de Estabelecimentos de Saúde - September/2021reference)³³33 Brasil. Cadastro Nacional de Estabelecimentos em Saúde. [acesso 3 Ago 2020]. Disponível em: http://cnes.datasus.gov.br/
http://cnes.datasus.gov.br... .

Informatiza APS - the valorization of health records

The informatization of PHC services is also part of Prevent Brazil strategy. In 2019, the SAPS (Primary Health Care Secretariat - Secretaria de Atenção Primária a Saúde) of the Ministry of Health) launched the Informatiza APS³⁴34 Brasil. Portaria nº 2.983, de 11 de novembro de 2019. Institui o Programa de Apoio à Informatização e Qualificação dos Dados da Atenção Primária à Saúde - Informatiza APS, por meio da alteração das Portarias de Consolidação nº 5/GM/MS e nº 6/GM/MS, de 28 de setembro de 2017., a program to encourage municipalities to informatize their units. Resources were transferred directly to the municipalities, with the clear and specific objective of qualification of the data sent to the Ministry of Health, with the consequent promotion of the development of companies in the sector through free competition. Through this incentive, municipalities started to choose the solution that was best adapted to their own local reality.

This element is intrinsic and fundamental for Prevent Brazil, since both the population payment per capitation (per capita) and the payment for performance based on indicators calculated directly in the federal database (SISAB), require quality data to be correctly collected, processed and sent. Specifically regarding the calculation of indicators for payment for performance, they no longer have a quantitative basis (population aggregate) and are now based on an individual basis for each citizen for calculation. This change allowed the adoption of several clinical management tools, such as active search, case monitoring and outcome measurement.

At the time of the implementation of the Informatiza APS, the MH more conservatively adopted a standard to define whether teams were informatized and included all teams that sent any data collected through an informatized solution, whether eSUS PEC (Prontuário Eletrônico do Cidadão - Citizen’s Electronic Record) or a proprietary/outsourced solution. In this scenario, there were 27,514 (62.40%) teams with some degree of informatization of the 44,072 FHTs in operation at that time²⁴24 Brasil. Sistema de Informação em Saúde para a Atenção Básica. [acessado 2021 Out 18]. Disponível em: https://sisab.saude.gov.br/paginas/acessoRestrito/relatorio/federal/saude/RelSauProducao.xhtml
https://sisab.saude.gov.br/paginas/acess... . Currently, according to data from Informatiza APS, 41,117 (78.25%) teams have some degree of informatization, being able to request the program’s incentive. When disregarding teams with a more irregular pattern of data sending, there are still 35,365 (69.20%) teams that have already been approved or accepted²⁴24 Brasil. Sistema de Informação em Saúde para a Atenção Básica. [acessado 2021 Out 18]. Disponível em: https://sisab.saude.gov.br/paginas/acessoRestrito/relatorio/federal/saude/RelSauProducao.xhtml
https://sisab.saude.gov.br/paginas/acess... , which represent an increase of 24% in the number of fully informatized teams in a period of less than two years.

Payment for performance

Prevent Brazil also proposed seven performance indicators for the year 2020²¹21 Brasil. SIOP Consulta Livre. [acessado 2021 Out 18]. Disponível em: https://www1.siop.planejamento.gov.br/QvAJAXZfc/opendoc.htm?document=IAS%2F Execucao_Orcamentaria.qvw&host=QVS%40pqlk 04&anonymous=true&sheet=SH06
https://www1.siop.planejamento.gov.br/Qv... ^,2222 Instituto Brasileiro de Geografia e Estatística. IPCA - Índice Nacional de Preços ao Consumidor Amplo. [acessado 2021 Out 18]. Disponível em: https://www.ibge.gov.br/estatisticas/economicas/precos-e-custos/9256-indice-nacional-de-precos-ao-consumidor-amplo.html?=&t=series-historicas
https://www.ibge.gov.br/estatisticas/eco... . It was planned to increase seven more indicators for the year 2021, and another seven indicators for the year 2022, including PHC global quality indicators such as Net Promoter Score, the PCATool-Brasil³⁵35 Brasil. Ministério da Saúde (MS). Secretaria de Atenção Primária à Saúde. Departamento de Saúde da Família. Manual do Instrumento de Avaliação da Atenção Primária à Saúde: PCATool-Brasil - 2020. Brasília: MS; 2020. scores and PDRQ9³⁶36 Wollmann L, Hauser L, Mengue SS, Agostinho MR, Roman R, Feltz-Cornelis CMV, Harzheim E. Cross-cultural adaptation of the Patient-Doctor Relationship Questionnaire (PDRQ-9) in Brazil. Rev Saude Publica 2018; 52:71. scores. However, due to the COVID-19 pandemic, payment for performance has not been considering the actual results obtained. This situation delayed the advance of PHC in Brazil, accumulating for the next few years the need to measure and pay according to the result of a broad care agenda, especially for chronic conditions in health and maternal and child health. However, it is possible to observe a positive impact of the use of performance indicators for the monitoring of PHC based on the initial results (Table 1).

Unfortunately, the indicator “inactivated poliomyelitis and pentavalent vaccination coverage” does not have updated public data for the observed period. It is important to highlight that the worsening or improvement of these indicators can be easily identified from the availability of information in an easy and simple way through the SAPS, which allows the individual evaluation of the indicator up to the level of the FHT. This four-month feedback on the quality of care will allow teams to improve the service offered based on information from their own work, in addition to ensuring transparency with the population, two important advances in relation to the PMAQ.

Encouragement to specific and strategic actions of Prevent Brazil

Health on Time (Saúde na Hora)

The Health on Time program, launched in 2019, aimed to finance teams with extended opening hours³⁷37 Brasil. Portaria nº 930, de 15 de maio de 2019. Institui o Programa "Saúde na Hora", que dispõe sobre o horário estendido de funcionamento das Unidades de Saúde da Família, altera a Portaria nº 2.436/GM/MS, de 2017, a Portaria de Consolidação nº 2/GM/MS, de 2017, a Portaria de Consolidação nº 6/GM/MS, de 2017, e dá outras providências.. Currently, there are 2,600 Basic Health Units working with extended hours (until 8 PM or 10 PM), distributed in 595 Brazilian municipalities, involving 8,238 FHT, 217 PHCT and 2,397 Oral Health Teams (OHT)³³33 Brasil. Cadastro Nacional de Estabelecimentos em Saúde. [acesso 3 Ago 2020]. Disponível em: http://cnes.datasus.gov.br/
http://cnes.datasus.gov.br... .

Oral health

Among the actions of Prevent Brazil that strengthened oral health in PHC, we can mention the expansion of oral health teams, the prioritization of strategic audiences to achieve universal access to oral health in PHC (e.g., pregnant women) and the qualification of care, in addition to the expansion of the amount of resources that finance oral health in PHC. In order to bring about the expansion of oral health teams, Prevent Brazil predicted for 2020 the adjustment of the federal financing resources of oral health teams, increasing it by 10%³⁸38 Brasil. Portaria nº 2.305, de 28 de agosto de 2020. Altera a Portaria de Consolidação nº 6/GM/MS, de 28 de setembro de 2017, para reajustar os valores dos incentivos financeiros de custeio das Equipes de Saúde Bucal, nas modalidades 1 e 2, segundo critérios estabelecidos pela Política Nacional de Atenção Básica. which, added to the payment for performance, resulted in an increase in the financing of 32% for the oral health teams²¹21 Brasil. SIOP Consulta Livre. [acessado 2021 Out 18]. Disponível em: https://www1.siop.planejamento.gov.br/QvAJAXZfc/opendoc.htm?document=IAS%2F Execucao_Orcamentaria.qvw&host=QVS%40pqlk 04&anonymous=true&sheet=SH06
https://www1.siop.planejamento.gov.br/Qv... ^,3939 Brasil. Lei nº 13.978, de 17 de janeiro de 2020 (http://www.planalto.gov.br/ccivil_03/_ato2019-2022/2020/lei/l13978.htm).
http://www.planalto.gov.br/ccivil_03/_at... . In addition to this action, the oral health teams that work with different monthly workloads were also recognized. The measure sought to recognize the oral health teams that were already in operation and that did not benefit from federal resources because they worked 30 or 20 hours a week⁴⁰40 Brasil. Portaria nº 2.918, de 21 de outubro de 2020. Credencia municípios a receberem incentivos financeiros referentes às Equipes de Saúde Bucal com carga horária diferenciada.. Currently, there are 30,117 oral health teams with a workload of 40 hours a week and 1,060 with a workload of 30/20 hours a week, approved and financed by the MH²⁴24 Brasil. Sistema de Informação em Saúde para a Atenção Básica. [acessado 2021 Out 18]. Disponível em: https://sisab.saude.gov.br/paginas/acessoRestrito/relatorio/federal/saude/RelSauProducao.xhtml
https://sisab.saude.gov.br/paginas/acess... .

Create teams based on local health needs

Another relevant aspect was the end of specific financing for the Family Health Support Centers (FHSC, Núcleos de Apoio à Saúde da Família). In September 2019, there were 96,525 higher education health professionals eligible to join the FHSC teams working in the PHC⁴⁰40 Brasil. Portaria nº 2.918, de 21 de outubro de 2020. Credencia municípios a receberem incentivos financeiros referentes às Equipes de Saúde Bucal com carga horária diferenciada.. Of this total, only 35% were linked to specific FHSC financing. With the flexibilization of the financing, allowing the municipality to establish the most appropriate multidisciplinary team according to local health needs, there was an increase in the presence of these professionals in PHC. According to CNES data from September 2021³³33 Brasil. Cadastro Nacional de Estabelecimentos em Saúde. [acesso 3 Ago 2020]. Disponível em: http://cnes.datasus.gov.br/
http://cnes.datasus.gov.br... , there are currently 111,813 higher education health professionals of the same type that was mentioned above working in PHC, an increase of 16% in the number of higher education professionals who comprise the work teams in PHC with the advent of Prevent Brazil.

Incentive to qualified training

The encouragement of professional training in PHC aims to qualify the care of people by supporting specialized professional training for Primary Care, through financial transfer to municipalities that have professionals in Medicine, Nursing or Dentistry performing professional residency in Family Health teams (FHT) or Oral Health teams (OHT)⁴¹41 Brasil. Portaria nº 3.510, de 18 de dezembro de 2019. Altera a Portaria de Consolidação nº 6/GM/MS, de 28 de setembro de 2017, para instituir incentivo financeiro de custeio adicional mensal para municípios com equipes de saúde integradas a programas de formação profissional no âmbito da Atenção Primária à Saúde.. The incentive is already being transferred to 2,151 vacancies in residency programs, of which 1,331 vacancies in Medicine, 571 vacancies in Nursing and 249 vacancies in Dentistry, distributed in 120 municipalities. This corresponds to an annual transfer of R$ 86,634,000.00 to municipalities that have been authorized²¹21 Brasil. SIOP Consulta Livre. [acessado 2021 Out 18]. Disponível em: https://www1.siop.planejamento.gov.br/QvAJAXZfc/opendoc.htm?document=IAS%2F Execucao_Orcamentaria.qvw&host=QVS%40pqlk 04&anonymous=true&sheet=SH06
https://www1.siop.planejamento.gov.br/Qv... to receive support for consolidation of residency in PHC.

Final considerations

The description of the first results of Prevent Brazil demonstrates the benefit to the population produced by the reform of the PHC financing. The increase of more than 50 million people with qualified and single registration, associated with the record number of more than 52,000 HFS/PHCT teams financed by the MH, with more than 35,000 of these with constant use of electronic medical records, greatly favors the overcoming of difficulties in achieving a greater presence of first-contact access, longitudinality and coordination of care, both very dependent on the continuity of clinical information. Moreover, the registration of people and professionals of the Brazilian PHC in the SISAB, has shown to be the largest set of demographic and clinical health data in the world. If the actions started in 2019/2020 for the qualification of the eSUS-PEC are maintained, with the inclusion of reliable and measurable clinical variables, in addition to the control of duplicates of the records and the incorporation of contact information such as cell phones and addresses through the crossing-over of federal databases, the possibility of conducting large interventions through information technology will be unprecedented. It will be possible to have a list of patients/people per team or health unit, produce active search reports - as already performed in the measles vaccination at the end of 2019, monitor patients with chronic diseases, engage people with chronic diseases in actions that increase adherence to instituted therapies, among other very relevant clinical actions considering the epidemiological scenario of triple disease burden.

In addition to the benefits perceived through the capitation component, the incentive component produced a considerable increase in the number of Units and teams that work until 8 pm or 10 pm at night, expanding people’s access to PHC. There was also a strong expansion of the oral health teams, the presence of health professionals and residency vacancies for doctors, nurses and dentists.

These benefits, together with the definition of the PHC Service Portfolio⁴²42 Brasil. Ministério da Saúde (MS). Secretaria de Atenção Primária à Saúde. Departamento de Saúde da Família. Carteira de serviços da Atenção Primária à Saúde (CaSAPS): versão profissionais de saúde e gestores. Brasília: MS; 2020. and the ongoing project to define lines of care, open up great possibilities for qualifying clinical practice in PHC, creating the structural conditions to face the challenges mentioned at the beginning of the text, mainly the qualification of care for chronic conditions, aging and mental health.

It should be noted that the increase in the number of people under the actual responsibility of the PHC, the number of FH/PHCT teams, the use of electronic medical records, oral health teams, the multidisciplinary composition of Health Units, and residency vacancies have occurred within 20 months, 18 of which were under the pressure and challenge of facing the COVID-19 pandemic.

The changes and achievements described herein were much more the result of the change in the financing method than from the also significant increase in the value of federal transfers in the period. And, without a doubt, its protagonists are the municipal health managers of the 5,570 Brazilian municipalities, who, with the support of CONASEMS and CONASS, actively participated in the construction of Prevent Brazil and its successful implementation. Even in the shadow of the pandemic, the use of management methods based on evidence and supported by successful experiences in an international context⁴³43 Chasing C, Chi Y-L, Smith P, Borowitz M, Thomson S. Paying for performance in health care - implications for health system performance and accountability. Genebra: European Observatory on Health Systems and Policies; 2014, representing innovation for the SUS, brought new light to the Brazilian PHC. This light can be a hope that the tripartite management, by privileging scientifically based methods and techniques, can bring to SUS increased access and quality, with financial sustainability, which the Brazilian population needs.

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