Abstract

This article presents the results of an analysis of the performance of primary health care in São Paulo state over the last decade against a backdrop of financial crisis and health funding cuts. We conducted a time series analysis (2010-2019) of performance indicators across the following dimensions based on an adapted conceptual framework: health service performance, health system, and determinants of health. Annual percentage change was calculated for each indicator using a log-linear model. Performance across the indicators was generally positive; however, there was a decline in performance across indicators of quality of care (congenital syphilis, cesarean section rate and cervical cancer screening). The findings also show a potential rise in demand for public services (due to population aging and a reduction in the percentage of the population with private health insurance) and increase in health expenditure against a backdrop of falling GDP per capita.

Key words:
Primary health care; Primary care indicators; Time series studies; Brazil

Introduction

Primary health care (PHC) can be defined as a point of care that offers a set of individual and collective actions coordinated via a health system aimed at delivering comprehensive care to the population¹1 Lavras C. Atenção primária à saúde e a organização de redes regionais de atenção à saúde no Brasil. Saude Soc 2011; 20(4):867-874.. In Brazil, significant advances in the organization of PHC services have been made since the implementation of the country’s public health system, the Sistema Único de Saúde (SUS) or Unified Health System. The system adopted a new organizational model called primary care (PC), centered on territorialization, the affiliation of the population to health teams and the delivery of family and community-oriented care through the progressive implementation of the Family Health Strategy (FHS)²2 Luppi CG, Andrade MC, Simões O, Pinho VP. Atenção primária à saúde/Atenção básica. In: Ibañez N, Elias PEM, Seixas PHD, organizadores. Política e gestão pública em saúde. São Paulo: Editora Hucitec; 2011. p. 332-353..

To implement this model at national level, three national primary care policies (PNAB, acronym in Portuguese) have been published since the creation of the SUS (2006, 2012 and 2017)³3 Brasil. Ministério da Saúde (MS). Portaria nº 648, de 28 de março de 2006. Aprova a Política Nacional de Atenção Básica (PNAB), estabelecendo a revisão de diretrizes e normas para a organização da Atenção Básica, para o Programa Saúde da Família (PSF) e o Programa Agentes Comunitários de Saúde (PACS). Diário Oficial da União 2006; 29 mar.

4 Brasil. Ministério da Saúde (MS). Portaria nº 2.488, de 21 de outubro de 2011. Aprova a Política Nacional de Atenção Básica (PNAB), estabelecendo a revisão de diretrizes e normas para a organização da Atenção Básica, para a Estratégia de Saúde da Família (ESF) e o Programa de Agentes Comunitários de Saúde (PACS). Diário Oficial da União 2011; 22 out.^-55 Brasil. Ministério da Saúde (MS). Portaria de Consolidação nº 2, Anexo XXII, de 28 de setembro de 2017. Aprova a Política Nacional de Atenção Básica (PNAB). Diário Oficial da União 2017; 29 set., emphasizing the centrality of the FHS and defining funding rules for the expansion of the strategy. In addition, the “More Doctors” law was created in 2013, aimed at expanding and improving the quality of medical training in the country and promoting a significant increase in the availability of doctors in primary care services⁶6 Girardi SN, Stralen ACS, Cella JN, Maas LWD, Carvalho CL, Faria EO. Impacto do Programa Mais Médicos na redução da escassez de médicos em Atenção Primária à Saúde. Cien Saude Colet 2016; 21(9):2675-2684..

In 2017 there was a shift in policy, with PC losing its centrality and the introduction of changes to the funding model, undermining the capacity of the FHS to reorientate the health system toward PHC⁵5 Brasil. Ministério da Saúde (MS). Portaria de Consolidação nº 2, Anexo XXII, de 28 de setembro de 2017. Aprova a Política Nacional de Atenção Básica (PNAB). Diário Oficial da União 2017; 29 set.

6 Girardi SN, Stralen ACS, Cella JN, Maas LWD, Carvalho CL, Faria EO. Impacto do Programa Mais Médicos na redução da escassez de médicos em Atenção Primária à Saúde. Cien Saude Colet 2016; 21(9):2675-2684.

7 Almeida ER, Sousa ANA, Brandão CC, Carvalho FFB, Tavares G, Silva KC. Política Nacional de Atenção Básica no Brasil: uma análise do processo de revisão (2015-2017). Rev Panam Salud Publica 2018; 42:e180.

8 Melo EA, Mendonça MHM, Oliveira JR, Andrade GCL. Mudanças na Política Nacional de Atenção Básica: entre retrocessos e desafios. Saude Debate 2018; 42(Esp.1):38-51.^-99 Brasil. Ministério da Saúde (MS). 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. Diário Oficial da União 2019; 13 nov.. In addition, constitutional amendment 95/2016 - ‘the spending cap amendment’ - which freezes health spending for 20 years, has adversely affected already inadequate funding of the SUS and consequently PC¹⁰10 Morosini MVGC, Fonseca AF, Lima LD. Política Nacional de Atenção Básica 2017: retrocessos e riscos para o Sistema Único de Saúde. Saude Debate 2018; 42:11-24..

PHC monitoring and evaluation is key to effective public health management¹¹11 Castanheira ERL, Nemes MIB, Almeida MAS, Puttini RF, Soares ID, Patrício KP, Nasser MA, Machado DF, Caldas Júnior AL, Vasconcelos Rd'A, Pissato SB, Carrapato JFL, Bizelli SSK. QualiAB: desenvolvimento e validação de uma metodologia de avaliação de serviços de atenção básica. Saude Soc 2011; 20(4):935-947.

12 Tanaka OY, Tamaki EM. O papel da avaliação para a tomada de decisão na gestão de serviços de saúde. Cien Saude Colet 2012; 17(4):821-828.

13 Hernández-Rubio MSI, Armesto SG. Indicadores em atención primaria: la realidade o el deseo. Gac Sanit 2012; 26(Supl. 1):27-35.^-1414 Kringos DS, Boerma WG, Bourgueil Y, Cartier T, Hasvold T, Hutchinson A, Lember M, Oleszczyk M, Pavlic DR, Svab I, Tedeschi P, Wilson A, Windak A, Dedeu T, Wilm S. The european primary care monitor: structure, process and outcome indicators. BMC Family Practice 2010; 11:81.. Given the above changes to public policy and the political and economic context in the country over the last two decades, there is a pressing need to better understand the effectiveness of the implementation of PC in Brazil.

This study therefore sought to analyze the development of PHC actions over the last decade in São Paulo state (SPS) using a set of performance indicators. While SPS is the country’s most populated and wealthy state¹⁵15 Instituto Brasileiro de Geografia e Estatística (IBGE). Produto Interno Bruto dos Municípios [Internet]. [acessado 2021 maio 13]. Disponível em: https://www.ibge.gov.br/estatisticas/economicas/contas-nacionais/9088-produto-interno-bruto-dos-municipios.html?=&t=o-que-e
https://www.ibge.gov.br/estatisticas/eco... , it had the lowest FHS coverage rate in 2009, partly due to its program-based care model, characterized by the existence of a broad network of health centers prior to the implementation of the SUS¹⁶16 Sala A, Mendes JDV. Perfil de Indicadores da Atenção Primária à Saúde no Estado de São Paulo: retrospectiva de 10 anos. Saude Soc. 2011; 20(4): 912-926.. In 2019, SPS had an estimated population of 45,919,049 inhabitants (22% of the national population) distributed across 645 municipalities, with 76% of the population living in 81 municipalities with over 100,000 inhabitants¹⁵15 Instituto Brasileiro de Geografia e Estatística (IBGE). Produto Interno Bruto dos Municípios [Internet]. [acessado 2021 maio 13]. Disponível em: https://www.ibge.gov.br/estatisticas/economicas/contas-nacionais/9088-produto-interno-bruto-dos-municipios.html?=&t=o-que-e
https://www.ibge.gov.br/estatisticas/eco... ^,1717 Instituto Brasileiro de Geografia e Estatística (IBGE). Estimativas da população [Internet]. [acessado 2021 maio 13]. Disponível em: https://www.ibge.gov.br/estatisticas/sociais/populacao/9103-estimativas-de-populacao.html?edicao=25272&t=resultados
https://www.ibge.gov.br/estatisticas/soc... .

The aim of this study was to examine temporal trends in PHC performance indicators in SPS during the period 2010-2019.

Materials and methods

This ecological time series study of PHC indicators is part of a research project titled “Participation of Social Organizations in the Management of Primary Health Care in Municipalities in São Paulo State” (FAPSPS-PPSUS, Nº 2019/03961-8). The study period is 2010-2019.

Indicators and data sources

The selected indicators make up a conceptual framework for monitoring PC adapted from criteria proposed by the Health System Performance Assessment Project (PROADESS)¹⁸18 Viacava F, Ugá MAD, Porto S, Laguardia J, Moreira RS. Avaliação de Desempenho de Sistemas de Saúde: um modelo de análise. Cien Saude Colet 2021; 17(4):921-934.. The framework consists of the following dimensions: health service performance, health system, and determinants of health. For each dimension we considered the following subdimensions: health service performance (access, effectiveness and adequacy of PHC); health system (funding); determinants of health (socioeconomic and demographic determinants).

The indicators were selected based on the data available in official open access databases linked to the SUS, adopting relevant validity, reliability and sensitivity criteria¹⁹19 McGlynn EA. Selecting Common measures of quality and system performance. Medical Care 2003; 41(1):139-147.. The indicators, data sources and calculation methods are presented in Chart 1.

The indicators were obtained from the following health information systems: the Mortality Information System (SIM); the Live Birth Information System (SINASC); the National Health Facility Registry (CNES); the National Notifiable Diseases Information System (SINAN); the National Immunization Program Information System (SI-PNI); and the Public Health Budget Information System (SIOPS). They were extracted from the following platforms: Primary Care Information and Management (e-Gestor AB); São Paulo Department of Health (SES-SP); the SUS’s Department of Informatics (DATASUS); and the State Data Foundation (SEADE). Annual GDP per capita and health expenditure per capita were inflation adjusted based the national consumer price index (IPCA) using the IPCA calculator. The databases used in this study are online and open access and provide annual indicator rates.

Statistical analysis

Indicator trends were analyzed using a log-linear model, where the independent variable was the year and the dependent variables were the indicator rates. The annual percent change (APC) in rates was calculated using the Joinpoint Regression Program 4.8.0.0. Joinpoints in the trend curves were detected to identify statistically significant changes in the APC over the study period.

When joinpoints were detected, we calculated the APC corresponding to each segment of the curve. In addition, we calculated the average annual percent change (AAPC) over the study period. We also calculated 95% confidence intervals (95%CI).

Ethical considerations

The study protocol was approved by the Santa Casa de Misericórdia hospital’s research ethics committee (reference code no. 4.007.368).

Results

The annual rates for each of the 23 indicators are shown in Table 1. The following trends were observed in the dimension service performance: an increase in PHC coverage from 51.03% to 60.33%; a reduction in hospitalization rates (for asthma among children aged under 10; strokes among people aged 30-59, and ARI among children aged under 5); a slight reduction in the rate of infant mortality and its components; a reduction in babies born to teenage mothers (< 20 years) and with low birth weight; a reduction in the percentage of hospitalizations for ambulatory care sensitive conditions. Rates of congenital syphilis and syphilis detection in pregnant women increased. In addition, there was an increase in the cesarian section rate among SUS deliveries and a decrease in Pap testing rates in the 25-64 year age group.

In the dimension determinants of health, there was an increase in the proportion of older people in the overall population throughout the study period.

As regards the dimension health system, the findings reveal an increase in total health expenditure per capita between 2010 and 2014, and a reduction between 2015 and 2018 followed by a slight increase in 2019.

The results of the temporal trend analysis are presented in Table 2. The AAPC for PHC coverage was 1.9% (95%CI 1.4; 2.5), while estimated oral health team population coverage showed a constant reduction over the study period (APC = -0.4; 95%CI: -0.8; -0.1) (service performance dimension).

Of the 11 indicators in the subdimension effectiveness, nine showed a downward trend during the study period (Table 2), including percentage of hospitalizations for ambulatory care sensitive conditions, which declined over the study period (APC = -1.4; 95%CI: -1.5; -1.3).

In the same subdimension, rate of congenital syphilis showed an APC of 25.0% (95%CI: 20.6; 29.6) between 2010 and 2015. During the period 2015-2019 the APC was not statistically significant. However, the AAPC over the period for this indicator was high (AAPC = 14.3; 95%CI: 11.7; 17.0). The rate of syphilis detection in pregnant women increased considerably between 2010 and 2017 (APC = 24.1; 95%CI: 19.5; 28.9), stabilizing thereafter. The AAPC for this indicator was 19.3% (95%CI: 19.3; 25.8).

In the subdimension adequacy, while the overall cesarian section rate in both public and private sector health services showed a statistically significant reduction during the period 2013-2019, the rate among deliveries performed on the SUS showed an upward trend over the study period (AAPC = 1.1%; 95%CI: 0.3; 1.8). Pap testing rates showed a constant reduction over the study period (APC = -3.3%; 95%CI: -4.1; -2.5). There were no statistically significant trends in the screening mammography rate among women (Table 2).

Joinpoints were detected in the indicators of the dimension determinants of health, revealing differing trends. The proportion of older people in the overall population showed an upward trend throughout the study period (AAPC = 2.8%; 95%CI: 2.8; 2.8). The percentage of the population with private health insurance showed a downward trend during the period 2013-2019, with an APC of -2.3% (95%CI: -3;3; -1.4). GDP per capita showed an upward trend up to 2014 (APC = 2.1%; 95% CI: 0.9; 3.,3), followed by a downward trend thereafter up to the end of the study period (APC = -3,8%; 95%CI: -4.9; -2.7).

In the dimension health system, joinpoints were detected in the indicators total health expenditure per capita and expenditure on health as a percentage of total government expenditure, with an initial statistically significant upward trend in both indicators followed by a period of stabilization in total health expenditure and decline in expenditure on health as a percentage of total expenditure, from 2014 and 2016, respectively.

Chart 2 presents a synthesis of the results by dimension, highlighting trends over the entire study period and joinpoints.

Discussion

Our findings clearly show that, despite an improvement in access to PHC in SPS during the study period, performance across care quality indicators was poor, revealing that SPS faces major challenges in improving the quality of PC. It was observed that most of the performance indicators in the access and effectiveness subdimensions showed a favorable trend, with only the congenital syphilis incidence rate showing a downward trend. Performance across indicators of adequacy was poor or stable over the study period, indicating that while access to care in the state has improved, care quality remains a challenge.

With regard to access, PHC coverage increased up to 2016. This may be related to the introduction of the More Doctors Program²⁰20 Brasil. Ministério da Saúde (MS). Lei nº 12.871, de 22 de outubro de 2013. Institui o Programa Mais Médicos, altera as Leis nº 8.745, de 9 de dezembro de 1993, e nº 6.932, de 7 de julho de 1981, e dá outras providências. Diário Oficial da União 2013; 23 out., which allocated 14,256 professionals to family health teams across the country during the first two years of the initiative⁶6 Girardi SN, Stralen ACS, Cella JN, Maas LWD, Carvalho CL, Faria EO. Impacto do Programa Mais Médicos na redução da escassez de médicos em Atenção Primária à Saúde. Cien Saude Colet 2016; 21(9):2675-2684.. The stabilization of coverage rates in the following period may be due to several factors, including the effects of financial constraints on health actions, the reorientation of the PNAB and a reduction in the number of PHC doctors, especially after 2018¹⁰10 Morosini MVGC, Fonseca AF, Lima LD. Política Nacional de Atenção Básica 2017: retrocessos e riscos para o Sistema Único de Saúde. Saude Debate 2018; 42:11-24.^,2121 Gomes CBS, Gutiérrez AC, Soranz D. Política Nacional de Atenção Básica de 2017: análise da composição das equipes e cobertura nacional da Saúde da Família. Cien Saude Colet 2020; 25(4):1327-1337.. There was a downward trend in estimated oral health team population coverage over the study period. In this respect, a study using national data reported an increase in oral health team population coverage between 2008 and 2015, followed by a slight reduction in 2016 and stabilization thereafter. In the same study, the authors found an upward trend in the transfer of resources for oral health up to 2010, followed by stabilization²²22 Rossi TRA, Lorena-Sobrinho JE, Chaves SCL, Martelli PJL. Crise econômica, austeridade e seus efeitos sobre o financiamento e acesso a serviços públicos e privados de saúde bucal. Cien Saude Colet 2019; 24(12):4427-4436.. Another study investigating oral health care coverage across Brazil’s regions showed that expansion of coverage during the period 2001-2013 was lowest in the Southeast²³23 Pinho JRO, Souza TC, Bôas MDV, Marques CPC, Neves PAM. Evolução da cobertura das equipes de saúde bucal nas macrorregiões brasileiras. Rev Assoc Paul Cir Dent 2015; 69(1):80-85..

All indicators in the effectiveness subdimension except for congenital syphilis showed favorable APC, with the highest reductions being found in rates of hospitalization for asthma, stroke and ARI. Hospitalization rates for these conditions, which are on Brazilian List of Hospitalizations due to Ambulatory Care Sensitive Conditions²⁴24 Brasil. Ministério da Saúde (MS). Portaria nº 221, de 17 de abril de 2008. Publica, na forma do Anexo desta Portaria, a Lista Brasileira de Internações por Condições Sensíveis à Atenção Primária. Diário Oficial da União 2008; 18 abr., have been shown to decrease with improving PHC quality. The percentage of hospitalizations for ambulatory care sensitive conditions decreased throughout the study period. This may be explained by increased coverage of PHC and the FHS. In this respect, ecological studies have reported an association between increased FHS coverage and a decrease in hospitalizations and mortality due to ambulatory care sensitive conditions²⁵25 Ceccon RF, Meneghel SN, Viecili PRN. Internações por condições sensíveis à atenção primária e ampliação da Saúde da Família no Brasil: um estudo ecológico. Rev Bras Epidemiol 2014; 17(4):968-977.

26 Boing AF, Vicenzi RB, Magajewski F, Boing AC, Pires ROM, Peres KG, Lindner SR, Peres MA. Redução das internações por condições sensíveis à atenção primária no Brasil entre 1998-2009. Rev Saude Publica. 2012; 46(2):359-366.

27 Macinko J, Mendonça CS. Estratégia Saúde da Família, um forte modelo de Atenção Primária à Saúde que traz resultados. Saude Debate 2018. 42(Esp. 1):18-37.^-2828 Rasella D, Harhay MO, Pamponet ML, Aquino R, Mauricio L Barreto ML. Impact of primary health care on mortality from heart and cerebrovascular diseases in Brazil: a nationwide analysis of longitudinal data. BMJ 2014. 349:g4014..

Although the considerable increase in syphilis detection in pregnant women indicates adequate screening among pregnant women, the upward trend in the rate of congenital syphilis, with an APC of 25% between 2010 and 2015, is worrying²⁹29 Domingues RMS, Saracen V, Hartz ZMDA, Leal MDC. Sífilis congênita: evento sentinela da qualidade da assistência pré-natal. Rev Saude Publica 2013; 47(1):147-157., indicating persistent flaws in antenatal care and treatment of the disease during pregnancy. A study investigating trends in mean congenital syphilis rates in Brazil between 2010 and 2015 observed rising rates over the period and a correlation between congenital syphilis and screening for maternal syphilis and infant death, miscarriage and stillbirth rates, suggesting gaps in basic health care for pregnant women³⁰30 Bezerra MLMB, Fernandes FECV, Oliveira JPN, Araújo SLSMB, Randau KP. Congenital syphilis as a measure of maternal and child healthcare, Brazil. Emerg Infect Dis 2019; 25(8):1469-1476..

The indicators of adequacy of care reveal little progress and that some backward steps were taken. The high cesarean section rate in the SUS and deliveries performed in the private sector reveal a care model that favors the interests of professionals and parturient women, often resulting in unnecessary interventions during labor and child birth³¹31 Patah LEM, Malik, AM. Modelos de assistência ao parto e taxa de cesárea em diferentes países. Rev Saude Publica 2011; 45(1):185-194.. Despite the measures proposed by the Rede Cegonha (Stork Network)³²32 Brasil. Ministério da Saúde (MS). Portaria nº 1.459, de 24 de junho de 2011. Institui, no âmbito do Sistema Único de Saúde (SUS), a Rede Cegonha. Diário Oficial da União 2011; 25 jun. to improve labor and childbirth care on the SUS, the results obtained were unsatisfactory, suggesting gaps in the quality of PHC services.

Also regarding indicators of adequacy, the percentage of newborns whose mothers made at least seven antenatal visits oscillated between 75% and 80%, showing a slight increase during the period 2013-2019. However, this result was not statistically significant throughout the whole period. In a nationwide study conducted with PHC patients in 2012 and 2013, 89% of respondents reported having made at least six antenatal visits, with only 69% having access to all recommended tests, 60% receiving all recommended guidance, and 24% undertaking all physical examinations, thus raising questions about the quality of antenatal care³³33 Tomasi E, Fernandes PAA, Fischer T, Siqueira FCV, Silveira DS, Thumé E, Duro SM, Saes MO, Nunes BP, Fassa AG, Facchini LA. Qualidade da atenção pré-natal na rede básica de saúde do Brasil: indicadores e desigualdades sociais. Cad Saude Publica 2017; 33(3):e00195815.. A literature review of articles on antenatal care in Brazil reported an increase in coverage between 2005 and 2015, with variability in care quality, including not only the number of antenatal visits but also routine tests, health guidance and basic technical procedures³⁴34 Nunes JT, Gomes KRO, Rodrigues MTP, Mascarenhas MDM. Qualidade da assistência pré-natal no Brasil: revisão de artigos publicados de 2005 a 2015. Cad Saude Colet 2016; 24(2):252-261..

Cervical and breast cancer screening are key prevention strategies aimed at reducing mortality due to these diseases. The related indicators in this study suggest low screening coverage, with a downward trend for cervical screening and stationary breast cancer screening rates. However, studies reveal a reduction in mortality from breast and cervical cancer in state capitals in the Southeast, due mainly to early diagnosis and treatment. This reduction was more pronounced for cervical cancer³⁵35 Silva GAE, Jardim BC, Ferreira VM, Junger WL, Girianelli VR. Cancer mortality in the Capitals and in the interior of Brazil: a four-decade analysis. Rev Saude Publica 2020; 54:126.^,3636 Girianelli VR, Gamarra CJ, Azevedo, Silva G. Disparities in cervical and breast cancer mortality in Brazil. Rev Saude Publica 2014; 48(3):459-467.. A study evaluating cervical and breast cancer screening in Brazil using data from the Surveillance of Risk and Protection Factors for Chronic Diseases by Telephone Survey (VIGITEL) for the period 2007-2017 found an upward trend in breast cancer screening rates and stabilization in cervical screening rates. Coverage of cervical and breast cancer screening in SPS was above 90% and 80%, respectively, in 2018³⁷37 Malta DC, Prates EJS, Silva AG, Santos FM, Oliveira GC, Vasconcelos NM, Cristo EB. Inequalities in mammography and Papanicolaou test coverage: a time-series study. Sao Paulo M J 2020; 38(6):475-482.. It is important to note that the VIGITEL methodology consisted of phone interviews conducted with people living in state capitals. The difference in indicator values between the VIGITEL study and our study may be partially due to variations in calculation methodology - with the present study considering only screening performed on the SUS - and bias arising from phone interviews.

Our findings suggest the need to step up cervical cancer screening efforts in PHC services to increase the coverage of testing, which is generally performed in health centers. With regard to breast cancer, efforts need to be intensified to increase the referral of women to services that perform mammograms. In this respect, PHC services need to develop strategies to promote mammography screening among target women affiliated to family health teams and other PHC teams.

In the dimension determinants of health, the selected indicators reveal a trend towards population aging and consequently growing demand for related services and actions, such as the treatment of neoplastic and circulatory system diseases and neurological complications resulting from strokes. The so-called “demographic transition” and population aging give rise to changes in the morbidity and mortality profile³⁸38 Oliveira AS. Transição demográfica, transição epidemiológica e envelhecimento populacional no brasil. Hygeia 2019; 15(31):69-79. that need to be recognized to adapt public health policy to address the challenges of population aging³⁹39 Miranda GMD, Mendes ACG, Silva ALA. O envelhecimento populacional brasileiro: desafios e consequências sociais atuais e futuras. Rev Bras Geriatr Gerontol 2016; 19(3):507-519..

In addition to population aging, declining GDP per capita and the reduction in the percentage of the population with private health insurance put increasing pressure on the SUS, and consequently PHC services.

It is important to highlight that there was an initial upward trend in both health expenditure per capita and expenditure on health as a percentage of total government expenditure. However, the joinpoints observed reveal a decline in funding in recent years against a backdrop of falling GDP per capita and increased demand for public health services, pointing to a potentially unfavorable scenario for the SUS and PHC. This is probably due to the influence of changes made during the same period, including the reorientation of primary care policy (review of the PNAB in 2017) and recent modifications to funding rules, especially Constitutional Amendment 95/2016.

In the dimension health system, the funding indicators were certainly impacted by the financial crisis that emerged in 2015. This inflection in health funding adds to the strain on the SUS and PHC services⁴⁰40 Mendes A, Carnut L. Capitalismo contemporâneo em crise e sua forma política: o subfinanciamento e o gerencialismo na saúde pública brasileira. Saude Soc 2018; 27(4):1105-1119..

One of the limitations of this study is the fact that the data were not disaggregated by region or municipal characteristics, meaning that it was not possible to capture more pronounced trends in PHC performance in more homogeneous groups of municipalities.

Conclusion

In the last decade, national primary health care policy⁴4 Brasil. Ministério da Saúde (MS). Portaria nº 2.488, de 21 de outubro de 2011. Aprova a Política Nacional de Atenção Básica (PNAB), estabelecendo a revisão de diretrizes e normas para a organização da Atenção Básica, para a Estratégia de Saúde da Família (ESF) e o Programa de Agentes Comunitários de Saúde (PACS). Diário Oficial da União 2011; 22 out.

5 Brasil. Ministério da Saúde (MS). Portaria de Consolidação nº 2, Anexo XXII, de 28 de setembro de 2017. Aprova a Política Nacional de Atenção Básica (PNAB). Diário Oficial da União 2017; 29 set.^-66 Girardi SN, Stralen ACS, Cella JN, Maas LWD, Carvalho CL, Faria EO. Impacto do Programa Mais Médicos na redução da escassez de médicos em Atenção Primária à Saúde. Cien Saude Colet 2016; 21(9):2675-2684. has expanded coverage and improved access to health services. However, recent years have seen a reorientation of this policy⁸8 Melo EA, Mendonça MHM, Oliveira JR, Andrade GCL. Mudanças na Política Nacional de Atenção Básica: entre retrocessos e desafios. Saude Debate 2018; 42(Esp.1):38-51.^,1010 Morosini MVGC, Fonseca AF, Lima LD. Política Nacional de Atenção Básica 2017: retrocessos e riscos para o Sistema Único de Saúde. Saude Debate 2018; 42:11-24.. In SPS, the expansion of PHC coverage up to 2016, followed by a period of stabilization reflect this shift in policy.

The indicators in the dimensions health system and determinants of health reveal important changes to the structure of the health system and health demands in the second half of the decade. The decline in health funding and economic slowdown (fall in GDP per capita) have potentially weakened the response of PHC to the challenges posed by population aging and the growing proportion of the population who depend exclusively on SUS.

Finally, the negative or stationary trends in indicators of adequacy of PHC and mother-to-child transmission of syphilis are worrying, pointing to persistent gaps in care quality. These gaps need to be addressed by the state’s public health managers.

References

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