ABSTRACT

Objective:

To describe positive evaluations of Primary Health Care (PHC) in Brazil from the perspective of users and their association with sociodemographic characteristics and comorbidities.

Methods:

Analysis of the 2019 National Health Survey, in which 9,562 adults responded to the Primary Care Assessment Tool (PCATool). The association between positive PHC assessment (overall score ≥6.6) and individual characteristics was tested using Prevalence Ratios (PR) calculated by Poisson Regression.

Results:

Less than 40% of Brazilians rated PHC with a high score. Regarding the association of sociodemographic variables with high PHC assessment, adjusted for sex and age, the best PHC assessments were made by women [PR_aj 1.10 (95%CI 1.00–1.21)]; elderly (60 years and over) [PR_aj 1.27 (95%CI 1.09–1.48); people with a per capita income of 1 to 3 minimum wages (MW) PRaj 1.14 (95%CI 1.03–1.27) and ≥5 MW PRaj 1.75 (95%CI 1.39–2.21) when comparing with income up to 1 MW; residents of the South, Southeast and Midwest regions, compared to the North Region. Considering comorbidities, individuals with hypertension PRaj1,29 (95%CI 1.17–1.43); diabetes PRaj 1.21 (95%CI 1.08–1.36); heart disease PRaj 1.23 (95%CI 1.07–1.41); musculoskeletal disorders PRaj 1.36 (95%CI 1.10–1.69); lung disease PRaj 1.48 (95%CI 1.13–1.95) and obesity PRaj 1.15 (95%CI 1.03–1.28) rated PHC better when compared to normal weight people.

Conclusion:

Users who evaluate PHC well are usually women, elderly, with high prevalence of chronic non-communicable diseases. A positive evaluation of PHC, in general, results from greater use of health services.

Keywords:
Primary health care; Evaluation; health services; Health surveys; Noncommunicable diseases

INTRODUCTION

Primary health care (PHC), composed of multidisciplinary teams, is responsible for the coverage of specific territories with defined populations and acts as first contact with the health system¹1. Brasil. Ministério da Saúde. Gabinete do Ministro. 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). Brasília: Ministério da Saúde; 2017. [acessado em 14 out. 2021]. Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/prt2436_22_09_2017.html
https://bvsms.saude.gov.br/bvs/saudelegi... ,²2. Starfield B. Atenção primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: UNESCO, Ministério da Saúde; 2002.. These teams should be dedicated to solving the vast majority of the population’s health problems¹1. Brasil. Ministério da Saúde. Gabinete do Ministro. 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). Brasília: Ministério da Saúde; 2017. [acessado em 14 out. 2021]. Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/prt2436_22_09_2017.html
https://bvsms.saude.gov.br/bvs/saudelegi... ,²2. Starfield B. Atenção primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: UNESCO, Ministério da Saúde; 2002. and establishing a strategic role in the health care network (RCN), functioning as a basis for its organization and effective integrality¹1. Brasil. Ministério da Saúde. Gabinete do Ministro. 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). Brasília: Ministério da Saúde; 2017. [acessado em 14 out. 2021]. Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/prt2436_22_09_2017.html
https://bvsms.saude.gov.br/bvs/saudelegi... .

Despite the consensus that PHC is a priority public policy and extensive evidence that demonstrates that national systems based on PHC are more effective and equitable, scientific production in this field of knowledge is still low compared to related areas. From the existing studies, we can see an increase in number of PHC studies in Brazil from 2005 onwards, which may be associated with the expansion of population coverage from this period on. However, when analyzing the objects of investigation of the Brazilian PHC, research with scope limited to local investigations, of low cost, and with a small number of subjects is found to be very common³3. Medina MG, Aquino R, Vilasbôas ALQ, Nunes CA. A pesquisa em atenção primária à saúde no Brasil. In: Mendonça MHM, Matta GC, Gondim R, Giovanella L, orgs. Atenção primária à saúde no Brasil: conceitos, práticas e pesquisa. Rio de Janeiro: FIOCRUZ; 2018. https://doi.org/10.7476/9788575416297
https://doi.org/10.7476/9788575416297... .

In Brazil, PHC expanded its population coverage significantly between 2000 and 2020, going from 42% in 2007 to 76% in 2020⁴. The expansion of PHC, however, was not always accompanied by an improvement in its quality. Quality means wider reach with better health outcomes⁵5. Facchini LA, Tomasi E, Dilélio AS. Qualidade da atenção primária à saúde no Brasil: avanços, desafios e perspectivas. Saúde Debate 2018; 42(1): 208-23. https://doi.org/10.1590/0103-11042018S114
https://doi.org/10.1590/0103-11042018S11... . There is evidence of strong and effective PHC when associated with greater user satisfaction with the system². Therefore, it is essential to assess the quality and breadth of the services offered so we can provide information for society and managers to rely on in decision-making in the pursuit of improving the population’s health with equity⁶6. Prates ML, Machado JC, Silva LS, Avelar PS, Prates LL, Mendonça ET, et al. Desempenho da atenção primária à saúde segundo o instrumento PCATool: uma revisão sistemática. Ciên Saúde Colet 2017; 22(6): 1881-93. https://doi.org/10.1590/1413-81232017226.14282016
https://doi.org/10.1590/1413-81232017226... ,⁷7. Silva GS, Alves CRL. Avaliação do grau de implantação dos atributos da atenção primária à saúde como indicador da qualidade da assistência prestada às crianças. Cad Saúde Pública 2019; 35(2): e00095418. https://doi.org/10.1590/0102-311X00095418
https://doi.org/10.1590/0102-311X0009541... .

The primary care assessment tool (PCATool), developed by Starfield et al.⁸8. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q 2005; 83(3): 457-502. https://doi.org/10.1111/j.1468-0009.2005.00409.x
https://doi.org/10.1111/j.1468-0009.2005... , had the health service quality assessment proposed by Donabedian⁹9. Donabedian A. Evaluating the quality of medical care. Milbank Q 2005; 83(4): 691-729. https://doi.org/10.1111/j.1468-0009.2005.00397.x
https://doi.org/10.1111/j.1468-0009.2005... as model, which is based on the triad “structure, processes and results”. It allows measuring the quality of PHC from the users’ point of view, evaluating service structure and process⁸8. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q 2005; 83(3): 457-502. https://doi.org/10.1111/j.1468-0009.2005.00409.x
https://doi.org/10.1111/j.1468-0009.2005... through essential attributes (individual’s first contact with the health system, longitudinality, care comprehensiveness and coordination) and derivatives (cultural competence, family and community guidance) of PHC⁸8. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q 2005; 83(3): 457-502. https://doi.org/10.1111/j.1468-0009.2005.00409.x
https://doi.org/10.1111/j.1468-0009.2005... ,¹⁰10. Harzheim E, Starfield B, Rajmil L, Álvarez-Dardet C, Steins AT. Consistência interna e confiabilidade da versão em português do instrumento de avaliação da atenção primária (PCATool-Brasil) para serviços de saúde infantil. Cad Saúde Pública 2006; 22(8): 1649-59. https://doi.org/10.1590/S0102-311X2006000800013
https://doi.org/10.1590/S0102-311X200600... ,¹¹11. Harzheim E, Oliveira MMC, Agostinho MR, Hauser L, Stein AT, Gonçalves MR, et al. Validação do instrumento de avaliação da atenção primária à saúde: PCATool-Brasil adultos. Rev Bras Med Fam Comunidade 2013; 8(29): 274-8. https://doi.org/10.5712/rbmfc8(29)829
https://doi.org/10.5712/rbmfc8(29)829... . There is an understanding that, when the health service is oriented towards the achievement of these attributes, it is able to provide comprehensive care from a biopsychosocial point of view to the community¹²12. Harzheim E, Gonçalves MR, D’Avila P, Hauser L, Pinto, LF. Estudos de PCATool no Brasil. In: Mendonça MHM, Matta GC, Gondim R, Giovanella L, orgs. Atenção primária à saúde no Brasil: conceitos, práticas e pesquisa. Rio de Janeiro: FIOCRUZ; 2018. https://doi.org/10.7476/9788575416297
https://doi.org/10.7476/9788575416297... . The PCATool has been one of the most used instruments to assess the quality of PHC¹³13. Fracolli LA, Gomes MFP, Nabão FRZ, Santos MS, Cappellini VK, Almeida ACC. Instrumentos de avaliação da atenção primária à saúde: revisão de literatura e metassíntese. Ciênc Saúde Coletiva 2014; 19(12): 4851-60. https://doi.org/10.1590/1413-812320141912.00572014
https://doi.org/10.1590/1413-81232014191... , even though it had never been applied on a national scale.

In 2019, the National Health Survey, the largest national health survey, was innovated with the implementation of the PCATool module, allowing to explore the evaluation of PHC and characteristics associated on a national scale, from the users’perspective¹⁴14. Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde: 2019: atenção primária à saúde e informações antropométricas: Brasil. Rio de Janeiro: IBGE; 2020..

This study is pioneer in seeking to describe positive evaluations of PHC in Brazil from the perspective of users and their association with sociodemographic characteristics and comorbidities.

METHODS

STUDY DESIGN

This cross-sectional study analyzed data from the National Health Survey (PNS) 2019, a home-based health survey. The PNS 2019 was carried out by the Brazilian Institute of Geography and Statistics (IBGE) between August 2019 and March 2020 and included in the PHC module (module H)¹⁴14. Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde: 2019: atenção primária à saúde e informações antropométricas: Brasil. Rio de Janeiro: IBGE; 2020.,¹⁵15. Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, et al. National Health Survey 2019: history, methods and perspectives. Epidemiol Serv Saúde 2020; 29(5): e2020315. http://doi.org/10.1590/S1679-49742020000500004
http://doi.org/10.1590/S1679-49742020000... the adapted and shortened version of PCATool-Brazil¹⁴14. Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde: 2019: atenção primária à saúde e informações antropométricas: Brasil. Rio de Janeiro: IBGE; 2020.,¹⁶16. Brasil. Ministério da Saúde. 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: Ministério da Saúde; 2020. [acessado em 03 out. 2021]. Disponível em: http://189.28.128.100/dab/docs/portaldab/documentos/12052020_Pcatool.pdf
http://189.28.128.100/dab/docs/portaldab... ,¹⁷17. Oliveira MMC, Harzheim E, Riboldi J, Duncan BB. PCATool-ADULTO-BRASIL: uma versão reduzida. Rev Bras Med Fam Comunidade 2013; 8(29): 256-63. https://doi.org/10.5712/rbmfc8(29)823
https://doi.org/10.5712/rbmfc8(29)823... .

SAMPLE

The PCATool module was applied to 9,562 individuals aged 18 years or older, and only those individuals who had consulted with the same doctor at least twice when using PHC services in the six months before the interview¹⁴14. Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde: 2019: atenção primária à saúde e informações antropométricas: Brasil. Rio de Janeiro: IBGE; 2020. responded. By using this filter, the PNS assumes that individuals were familiar with the health service provided¹⁴14. Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde: 2019: atenção primária à saúde e informações antropométricas: Brasil. Rio de Janeiro: IBGE; 2020..

OUTCOME: PCATOOL DESCRIPTION AND CALCULATION

The questionnaire applied during the interview had 26 questions assessing PHC attributes, distributed across ten components¹⁴14. Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde: 2019: atenção primária à saúde e informações antropométricas: Brasil. Rio de Janeiro: IBGE; 2020.. The questions of the original PCATool instrument were adapted by replacing the terms professional or physician/nurse with physician.

The instrument used Likert-type responses, assigning scores from 1 to 4 for each attribute (1=definitely no; to 4=certainly, yes). Based on the average of responses of the items that make up the attribute, a general PHC score is obtained¹⁰10. Harzheim E, Starfield B, Rajmil L, Álvarez-Dardet C, Steins AT. Consistência interna e confiabilidade da versão em português do instrumento de avaliação da atenção primária (PCATool-Brasil) para serviços de saúde infantil. Cad Saúde Pública 2006; 22(8): 1649-59. https://doi.org/10.1590/S0102-311X2006000800013
https://doi.org/10.1590/S0102-311X200600... ,¹¹11. Harzheim E, Oliveira MMC, Agostinho MR, Hauser L, Stein AT, Gonçalves MR, et al. Validação do instrumento de avaliação da atenção primária à saúde: PCATool-Brasil adultos. Rev Bras Med Fam Comunidade 2013; 8(29): 274-8. https://doi.org/10.5712/rbmfc8(29)829
https://doi.org/10.5712/rbmfc8(29)829... ,¹⁴14. Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde: 2019: atenção primária à saúde e informações antropométricas: Brasil. Rio de Janeiro: IBGE; 2020.,¹⁶16. Brasil. Ministério da Saúde. 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: Ministério da Saúde; 2020. [acessado em 03 out. 2021]. Disponível em: http://189.28.128.100/dab/docs/portaldab/documentos/12052020_Pcatool.pdf
http://189.28.128.100/dab/docs/portaldab... .

As an outcome, the general score obtained by the average between the components of essential and derived attributes and the degree of connection of the user with the service was initially calculated. The score values were standardized for a scale from 0 to 10, where values equal to or greater than 6.6 were considered as high score, with strong orientation to the attributes of PHC, which corresponds to responses to options 3 or 4 on the instrument’s original scale¹⁰10. Harzheim E, Starfield B, Rajmil L, Álvarez-Dardet C, Steins AT. Consistência interna e confiabilidade da versão em português do instrumento de avaliação da atenção primária (PCATool-Brasil) para serviços de saúde infantil. Cad Saúde Pública 2006; 22(8): 1649-59. https://doi.org/10.1590/S0102-311X2006000800013
https://doi.org/10.1590/S0102-311X200600... ,¹¹11. Harzheim E, Oliveira MMC, Agostinho MR, Hauser L, Stein AT, Gonçalves MR, et al. Validação do instrumento de avaliação da atenção primária à saúde: PCATool-Brasil adultos. Rev Bras Med Fam Comunidade 2013; 8(29): 274-8. https://doi.org/10.5712/rbmfc8(29)829
https://doi.org/10.5712/rbmfc8(29)829... ,¹⁴14. Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde: 2019: atenção primária à saúde e informações antropométricas: Brasil. Rio de Janeiro: IBGE; 2020.,¹⁶16. Brasil. Ministério da Saúde. 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: Ministério da Saúde; 2020. [acessado em 03 out. 2021]. Disponível em: http://189.28.128.100/dab/docs/portaldab/documentos/12052020_Pcatool.pdf
http://189.28.128.100/dab/docs/portaldab... . The overall mean PCATool score, the high score ≥6.6 and respective 95% confidence intervals (95%CI) were calculated for each of the 27 Federation Units (FU).

EXPLANATORY VARIABLES

This study followed the theoretical model of Perillo et al.¹⁸18. Perillo RD, Poças KC, Bernal RTI, Duarte EC, Malta DC. Fatores associados à avaliação da atenção primária à saúde na perspectiva do usuário: resultados do inquérito telefônico Vigitel, 2015. Ciênc Saúde Coletiva 2021; 26(3): 961-74. https://doi.org/10.1590/1413-81232021263.45722020
https://doi.org/10.1590/1413-81232021263... , which considers that users assigning a general score ≥6.6 to the system use services more often, as they have more comorbidities, and, consequently, a positive assessment of quality of care is provided. Taking into account the aptitude of PHC to assist and monitor individuals with chronic diseases, we sought to verify the associations between positive evaluation of PHC, sociodemographic variables and morbidities¹⁸18. Perillo RD, Poças KC, Bernal RTI, Duarte EC, Malta DC. Fatores associados à avaliação da atenção primária à saúde na perspectiva do usuário: resultados do inquérito telefônico Vigitel, 2015. Ciênc Saúde Coletiva 2021; 26(3): 961-74. https://doi.org/10.1590/1413-81232021263.45722020
https://doi.org/10.1590/1413-81232021263... .

Covariates studied

STATISTICAL ANALYSIS

Models were calculated using Poisson regression to estimate crude and age-adjusted prevalence ratios (PR) and respective 95%CIs. All analyses were performed using the Survey module available in Data Analysis and Statistical Softwares (STATA), version 14, using the PNS weights.

ETHICAL ASPECTS

The 2019 PNS was approved by the National Research Ethics Committee of the National Health Council, under opinion number 3,529,376. The adults participated in the research voluntarily and the confidentiality of information was guaranteed.

RESULTS

Table 1 shows that the average overall PHC score in Brazil for adults was 5.9 (95%CI 5.8–5.9), ranging from 5.2 in Roraima (95%CI 4.5–5, 8) to 6.6 (95%CI 6.2–6.9) in Mato Grosso. It was estimated that 38.1% of Brazilians who used PHC rated it as good, ranging from 22.6% (95%CI 14.8–32.9) in Rondônia to 53.3% (95%CI 43 .5–62.8) in Mato Grosso.

Regarding sociodemographic variables (Table 2), 38.95% (95%CI 36.79–41.17) of women classified PHC as aimed at their attributes, as well as 41.67% (95%CI 38.73–44.66) of elderly users (60 years and over). The assessment attributed to PHC is higher among elder groups.

In terms of educational level, people with 0–8 years of schooling rated the services better [40.22% (95%CI 37.89–42.60)] than those with other educational levels (9–11 years and 12 years or more). When stratifying the population by ethnicity/skin color, no relevant differences were found between the black, brown and white populations. The population of the southern region of the country [45.35% (95%CI 41.47–49.28)] assigned a better score to their local PHC service than in other Brazilian regions. It is noteworthy that only 30% (95%CI 26.16–34.26) of respondents in the North Region consider PHC aimed at their attributes. As for the income of respondents, 66.65% (95%CI 49.43–80.33) of users with higher income, 5 or more MW, rated PHC well, followed by 42.2% (95%CI 38.58– 45.90) of users with income of 1-3 MW.

Table 3 shows a classification by morbidity and anthropometric measures of users who used health services and rated PHC with high scores. It was found that 42.04% (95%CI 38.72–45.43) of obese users (BMI ≥30 kg/m²), 44.75% (95%CI 41.97–47.56) of hypertensive patients, 46.25% (95%CI 41.50–51.07) of diabetic patients and 47.79% (95%CI 41.76–53.89) of users with heart disease rated the services positively. Among people with WMSDs, this number reached 52.14% (95%CI 41.10–62.98) and among those with lung diseases, 57.63% (95%CI 41.76–72.07). This positive assessment for PHC aimed at their attributes was also given by users with cancer [45.33% (95%CI 34.07–57.09)].

Regarding the association of exploratory variables with high PHC assessment (outcome), adjusted for sex and age, it was found that females presented PRaj=1.10 (95%CI 1.00–1.21), and the elderly PRaj=1.27 (95%CI 1.09–1.48), comparing them with adults aged 18 to 29 years. Residents of the South Region had PRaj=1.46 (95%CI 1.24–1.72), residents of the Southeast had PRaj=1.23 (95%CI 1.05–1.45) and of the Midwest region, PRaj=1.24 (95%CI 1.02–1.51), all compared to residents of the North Region. As for per capita income, users who earned 5 or more MW had PRaj=1.75 (95%CI 1.39–2.21), and users who earned 1-3 MW had PRaj= 1.14 (95%CI 1.03–1.27) compared to users with income up to one MW. All these results were statistically significant, but there was no difference in the assessment by ethnicity/skin color and schooling (Table 2).

Considering the analysis of statistically significant associations of morbidity variables adjusted for sex and age with high PHC rating, obese people had PRaj=1.15 (95%CI 1.03–1.28) compared to eutrophic users. Among individuals who self-reported having CNCD, PRaj was 1.29 (95%CI 1.17–1.43) for hypertensive individuals, 1.21 (95%CI 1.08–1.36) for the diabetic and 1.21 (95%CI 1.07–1.41) for people with heart disease. Users with lung diseases had PRaj=1.48 (95%CI 1.13–1.95) and those with WMSDs had PRaj=1.36 (95%CI 1.10–1.69). No statistically significant association was found for users with cancer (Table 3).

DISCUSSION

According to this study, PHC was better evaluated by women and by elderly users (aged 60 years and over), with an income of one to three MW and 5 or more MW, residents of the South, Southeast and Midwest regions, as well as users with hypertension, diabetes, heart disease, WMSD, lung disease and obesity.

Regarding the overall PHC score, 38.1% of Brazilians who used the service in the last six months rated PHC with a high score and attributed a mean overall score of 5.9 (95%CI 5.8–5.9). This low evaluation result of Brazilian PHC was also reported in other studies that used the PCATool and obtained a score even lower than the national average, as shown in the study carried out in Porto Alegre (RS) in 2007, which attributed an average general score of 5.5 for basic health units (BHU) covered by the Family Health Strategy¹⁹19. Oliveira MMC. Presença e extensão dos atributos da atenção primária entre os serviços de atenção primária em Porto Alegre: uma análise agregada [dissertação de mestrado]. Porto Alegre: Universidade Federal do Rio Grande do Sul; 2007. In that same municipality, in 2012, the elderly population attributed a score of 5.7 to these BHU²⁰20. Oliveira EB, Bozzetti MC, Hauser L, Duncan BB, Harzheim E. Avaliação da qualidade do cuidado a idosos nos serviços da rede pública de atenção primária à saúde de Porto Alegre, Brasil. Rev Bras Med Fam Comunidade 2013; 8(29): 264-73. https://doi.org/10.5712/rbmfc8(29)826
https://doi.org/10.5712/rbmfc8(29)826... . In 2014, the PHC assessment reached a score of 5.721 in the city of Rio de Janeiro (RJ) and, in 2015, in Teresina (PI), the male population assigned a mean score of 5.5 to the local PHC²²22. Silva AN, Silva SA, Silva ARV, Araújo TME, Rebouças CBA, Nogueira LT. A avaliação da atenção primária a saúde na perspectiva da população masculina. Rev Bras Enferm 2018; 71(2): 236-43. https://doi.org/10.1590/0034-7167-2016-0651
https://doi.org/10.1590/0034-7167-2016-0... . These results point to the need to work on the qualification of PHC in Brazil, since, according to Donabedian⁹9. Donabedian A. Evaluating the quality of medical care. Milbank Q 2005; 83(4): 691-729. https://doi.org/10.1111/j.1468-0009.2005.00397.x
https://doi.org/10.1111/j.1468-0009.2005... , the best health results are a consequence of investment in structure and improvement in the health care process.

Travassos and Martins²³23. Travassos C, Martins M. Uma revisão sobre os conceitos de acesso e utilização de serviços de saúde. Cad Saúde Pública 2004; 20(Suppl 2): S190-S198. https://doi.org/10.1590/S0102-311X2004000800014
https://doi.org/10.1590/S0102-311X200400... point out that access to and use of health services are mediated by socioeconomic and demographic aspects, available resources, supply of health services, presence of morbidities, and other factors. Therefore, a greater presence of diseases means greater demand for services, which results in a better evaluation of PHC. A study by Silva et al.²²22. Silva AN, Silva SA, Silva ARV, Araújo TME, Rebouças CBA, Nogueira LT. A avaliação da atenção primária a saúde na perspectiva da população masculina. Rev Bras Enferm 2018; 71(2): 236-43. https://doi.org/10.1590/0034-7167-2016-0651
https://doi.org/10.1590/0034-7167-2016-0... states that the frequency of seeking care was associated with PHC scores: the more regular users needed the BHU, the higher the percentage of high scores attributed by them. This result was also found in another study²⁴24. Gonçalves MR, Harzheim E, Zils AA, Duncan BB. A qualidade da atenção primária e o manejo do diabetes mellitus. Rev Bras Med Fam Comunidade 2013; 8(29): 235-43. http://doi.org/10.5712/rbmfc8(29)814
http://doi.org/10.5712/rbmfc8(29)814... that confirmed an association between services with higher PHC scores, longer duration of illness (10.9 years) and greater frequency of use of health services (8.5 consultations/year). It is noteworthy that the NCDs investigated here are all long-lasting and require continuous use of PHC. That is, the longitudinality attribute investigated here is essential in care.

Regarding demographic variables, women and elderly people evaluated PHC more positively and are the ones who most use health services²³23. Travassos C, Martins M. Uma revisão sobre os conceitos de acesso e utilização de serviços de saúde. Cad Saúde Pública 2004; 20(Suppl 2): S190-S198. https://doi.org/10.1590/S0102-311X2004000800014
https://doi.org/10.1590/S0102-311X200400... ,²⁵25. Perillo RD, Poças KC, Machado IE, Bernal RTI, Duarte EC, Malta DC. Fatores associados à utilização da atenção primária pela população adulta de Belo Horizonte, Minas Gerais, segundo inquérito telefônico. REME Rev Min Enferm 2020; 24: e-1300. http://www.doi.org/10.5935/1415-2762.20200030
http://www.doi.org/10.5935/1415-2762.202... –²⁷27. Melo LA, Lima KC. Fatores associados às multimorbidades mais frequentes em idosos brasileiros. Ciênc Saúde Coletiva 2020; 25(10): 3879-88. https://doi.org/10.1590/1413-812320202510.34492018
https://doi.org/10.1590/1413-81232020251... . Women sought services more often, because, in general, they have a greater perception of signs and symptoms of diseases and promotion/prevention practices, in addition to the demands of menarche, prenatal care and menopause²⁵25. Perillo RD, Poças KC, Machado IE, Bernal RTI, Duarte EC, Malta DC. Fatores associados à utilização da atenção primária pela população adulta de Belo Horizonte, Minas Gerais, segundo inquérito telefônico. REME Rev Min Enferm 2020; 24: e-1300. http://www.doi.org/10.5935/1415-2762.20200030
http://www.doi.org/10.5935/1415-2762.202... ,²⁶26. Malta DC, Gomes CS, Prates EJS, Santos FP, Almeida WS, Stopa SR, et al. Análise da demanda e acesso aos serviços nas duas semanas anteriores à Pesquisa Nacional de Saúde 2013 e 2019. Rev Bras Epidemiol 2021; 24 (suppl 2): E210002. https://doi.org/10.1590/1980-549720210002.supl.2
https://doi.org/10.1590/1980-54972021000... . Considering that the elderly use health services more often, this must be associated with multimorbidity, a greater perception of disease severity and health risks²⁶26. Malta DC, Gomes CS, Prates EJS, Santos FP, Almeida WS, Stopa SR, et al. Análise da demanda e acesso aos serviços nas duas semanas anteriores à Pesquisa Nacional de Saúde 2013 e 2019. Rev Bras Epidemiol 2021; 24 (suppl 2): E210002. https://doi.org/10.1590/1980-549720210002.supl.2
https://doi.org/10.1590/1980-54972021000... ,²⁷27. Melo LA, Lima KC. Fatores associados às multimorbidades mais frequentes em idosos brasileiros. Ciênc Saúde Coletiva 2020; 25(10): 3879-88. https://doi.org/10.1590/1413-812320202510.34492018
https://doi.org/10.1590/1413-81232020251... . In general, the use of and access to health services by this age group is relatively high²⁶26. Malta DC, Gomes CS, Prates EJS, Santos FP, Almeida WS, Stopa SR, et al. Análise da demanda e acesso aos serviços nas duas semanas anteriores à Pesquisa Nacional de Saúde 2013 e 2019. Rev Bras Epidemiol 2021; 24 (suppl 2): E210002. https://doi.org/10.1590/1980-549720210002.supl.2
https://doi.org/10.1590/1980-54972021000... . A study carried out in the capital of Minas Gerais in 2015 found that the elderly reported high quality scores for the PHC when compared to other adults¹⁸18. Perillo RD, Poças KC, Bernal RTI, Duarte EC, Malta DC. Fatores associados à avaliação da atenção primária à saúde na perspectiva do usuário: resultados do inquérito telefônico Vigitel, 2015. Ciênc Saúde Coletiva 2021; 26(3): 961-74. https://doi.org/10.1590/1413-81232021263.45722020
https://doi.org/10.1590/1413-81232021263... , just like a study²⁰20. Oliveira EB, Bozzetti MC, Hauser L, Duncan BB, Harzheim E. Avaliação da qualidade do cuidado a idosos nos serviços da rede pública de atenção primária à saúde de Porto Alegre, Brasil. Rev Bras Med Fam Comunidade 2013; 8(29): 264-73. https://doi.org/10.5712/rbmfc8(29)826
https://doi.org/10.5712/rbmfc8(29)826... carried out in Porto Alegre in 2012 showed higher scores for PHC by the elderly than by adults over 18 years of age. This last study also showed that services with a high PHC score are related to strong presence of evidence-based preventive practices recommended for the elderly population²⁰20. Oliveira EB, Bozzetti MC, Hauser L, Duncan BB, Harzheim E. Avaliação da qualidade do cuidado a idosos nos serviços da rede pública de atenção primária à saúde de Porto Alegre, Brasil. Rev Bras Med Fam Comunidade 2013; 8(29): 264-73. https://doi.org/10.5712/rbmfc8(29)826
https://doi.org/10.5712/rbmfc8(29)826... .

In terms of educational level, no association was found; however, families with per capita income between one and three MW rated PHC better, a result that goes against a study²¹21. Harzheim E, Pinto LF, Hauser L, Soranz D. Avaliação dos usuários crianças e adultos quanto ao grau de orientação para atenção primária à saúde na cidade do Rio de Janeiro, Brasil. Ciênc Saúde Colet 2016; 21(5): 1399-408. https://doi.org/10.1590/1413-81232015215.26672015
https://doi.org/10.1590/1413-81232015215... carried out in the city of Rio de Janeiro with 3,530 individuals in 2014, in which no difference was found in the assessment of PHC by adults of different social classes; however, it is understood that low-income populations are more vulnerable, access public health services more and tend to have more comorbidities and worse health indicators, such as the more intense involvement of NCDs²⁸28. Malta DC, Bernal RTI, Gomes CS, Cardoso LSM, Lima MG, Barros MBA. Desigualdades na utilização de serviços de saúde por adultos e idosos com e sem doenças crônicas no Brasil, Pesquisa Nacional de Saúde 2019. Rev Bras Epidemiol 2021; 24(suppl 2): E210003. https://doi.org/10.1590/1980-549720210003.supl.2
https://doi.org/10.1590/1980-54972021000... –³⁰30. Malta DC, Andrade SSCA, Oliveira TP, Moura L, Prado RR, Souza MFM. Probabilidade de morte prematura por doenças crônicas não transmissíveis, Brasil e regiões, projeções para 2025. Rev Bras Epidemiol 2019; 22: E190030. https://doi.org/10.1590/1980-549720190030
https://doi.org/10.1590/1980-54972019003... . At the same time, the study points out that high income, ≥5 MW, was also associated with a positive PHC assessment. Individuals with higher income tend to use services more²⁶26. Malta DC, Gomes CS, Prates EJS, Santos FP, Almeida WS, Stopa SR, et al. Análise da demanda e acesso aos serviços nas duas semanas anteriores à Pesquisa Nacional de Saúde 2013 e 2019. Rev Bras Epidemiol 2021; 24 (suppl 2): E210002. https://doi.org/10.1590/1980-549720210002.supl.2
https://doi.org/10.1590/1980-54972021000... and, therefore, may evaluate them well.

With regard to regions, the individuals who best evaluated PHC were those residing in the South, Southeast and Midwest regions, the richest in the country, and in FUs located in strata of higher human development index (HDI)³¹31. Programa das Nações Unidas para o Desenvolvimento. Instituto de Pesquisa Econômica Aplicada. Fundação João Pinheiro. Desenvolvimento humano nas macrorregiões brasileiras. Brasília: PNUD, IPEA, FJP; 2016.. Geopolitical region and HDI synthesize marked differences in urban and social infrastructure and in the greater coverage of educational and health services, contextual characteristics that were also associated with greater user satisfaction³²32. Saez MO, Facchini LA, Tomasi E. Avaliação da satisfação de usuários da atenção básica portadores de hipertensão e diabetes. APS em Revista 2019; 1(3): 206-21. https://doi.org/10.14295/aps.v1i3.49
https://doi.org/10.14295/aps.v1i3.49... . In addition, the quality reference standard is still found in a small number of BHUs and is mostly concentrated in the South and Southeast regions³³33. Giovanella L, Mendonça MHM, Medina MG, Lima JG, Fausto MCR, Seidl HM, et al. Contribuições dos estudos PMAQ-AB para a avaliação da APS no Brasil. In: Mendonça MHM, Matta GC, Gondim R, Giovanella L, orgs. Atenção primária à saúde no Brasil: conceitos, práticas e pesquisa. Rio de Janeiro: Fiocruz; 2018. https://doi.org/10.7476/9788575416297
https://doi.org/10.7476/9788575416297... , being, therefore, better evaluated. In addition to maintaining regional and social inequalities, this points to the need for new investments to achieve equity in health care.

This study identified that positive PHC assessment was associated with obesity and several NCDs. According to Oliveira¹⁹19. Oliveira MMC. Presença e extensão dos atributos da atenção primária entre os serviços de atenção primária em Porto Alegre: uma análise agregada [dissertação de mestrado]. Porto Alegre: Universidade Federal do Rio Grande do Sul; 2007, the presence of comorbidities increases the prevalence of strong PHC orientation by 46%, that is, chronic diseases are more prevalent in the population assisted in services classified with high scores. The results of the association between users with CNCD and high PHC assessment probably occur because this population uses health services more often and has more positive experiences with PHC teams²⁶26. Malta DC, Gomes CS, Prates EJS, Santos FP, Almeida WS, Stopa SR, et al. Análise da demanda e acesso aos serviços nas duas semanas anteriores à Pesquisa Nacional de Saúde 2013 e 2019. Rev Bras Epidemiol 2021; 24 (suppl 2): E210002. https://doi.org/10.1590/1980-549720210002.supl.2
https://doi.org/10.1590/1980-54972021000... ,³⁴34. Malta DC, Bernal RTI, Lima MG, Araújo SSC, Silva MMA, Freitas MIF, et al. Noncommunicable diseases and the use of health services: analysis of the National Health Survey in Brazil. Rev Saude Publica 2017; 51(Suppl 1): 4s. https://doi.org/10.1590/S1518-8787.2017051000090
https://doi.org/10.1590/S1518-8787.20170... . Some studies indicate that the quality of care characteristics in individuals with comorbidities are significantly higher in services with a high overall PHC score when compared to services with a low overall PHC score²⁴24. Gonçalves MR, Harzheim E, Zils AA, Duncan BB. A qualidade da atenção primária e o manejo do diabetes mellitus. Rev Bras Med Fam Comunidade 2013; 8(29): 235-43. http://doi.org/10.5712/rbmfc8(29)814
http://doi.org/10.5712/rbmfc8(29)814... ,³⁵35. Trindade TG. Associação entre a extensão dos atributos de atenção primária e qualidade do manejo da hipertensão arterial em adultos adscritos à rede de atenção primária à saúde de Porto Alegre [dissertação de mestrado]. Porto Alegre: Universidade Federal do Rio Grande do Sul; 2007.. People with NCDs use services twice as often compared to adults without NCDs³⁴34. Malta DC, Bernal RTI, Lima MG, Araújo SSC, Silva MMA, Freitas MIF, et al. Noncommunicable diseases and the use of health services: analysis of the National Health Survey in Brazil. Rev Saude Publica 2017; 51(Suppl 1): 4s. https://doi.org/10.1590/S1518-8787.2017051000090
https://doi.org/10.1590/S1518-8787.20170... . In the PNS 2019, it was also found that in all socioeconomic and demographic strata, the presence of CNCD increases the prevalence of medical consultations²⁶26. Malta DC, Gomes CS, Prates EJS, Santos FP, Almeida WS, Stopa SR, et al. Análise da demanda e acesso aos serviços nas duas semanas anteriores à Pesquisa Nacional de Saúde 2013 e 2019. Rev Bras Epidemiol 2021; 24 (suppl 2): E210002. https://doi.org/10.1590/1980-549720210002.supl.2
https://doi.org/10.1590/1980-54972021000... . In summary, adults who reported having morbidities tended to assign a higher overall score when compared to the group without morbidities. A study that evaluated PHC in the capital of Minas Gerais in 2015 also reported that hypertensive, diabetic and obese users evaluated PHC better¹⁸18. Perillo RD, Poças KC, Bernal RTI, Duarte EC, Malta DC. Fatores associados à avaliação da atenção primária à saúde na perspectiva do usuário: resultados do inquérito telefônico Vigitel, 2015. Ciênc Saúde Coletiva 2021; 26(3): 961-74. https://doi.org/10.1590/1413-81232021263.45722020
https://doi.org/10.1590/1413-81232021263... .

PHC plays a fundamental role in the surveillance of NCDs and in the monitoring of risk factors, as it develops prevention actions and health promotion, as well as harm reduction at a relatively low cost through timely detection and treatment²⁹29. Di Cesare M, Khang YH, Asaria P, Blakely T, Cowan MJ, Farzadfar F, et al. Inequalities in non-communicable diseases and effective responses. Lancet 2013; 381(9866): 585-97. https://doi.org/10.1016/S0140-6736(12)61851-0
https://doi.org/10.1016/S0140-6736(12)61... ,³⁶36. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Estratégias para o cuidado da pessoa com doença crônica. Brasília: Ministério da Saúde; 2014. [acessado em 02 nov. 2021]. Disponível em: http://189.28.128.100/dab/docs/portaldab/publicacoes/caderno_35.pdf
http://189.28.128.100/dab/docs/portaldab... . It is known that these users need continuous monitoring and supply of inputs. Therefore, PHC needs to guarantee the principles of comprehensiveness and coordination of care¹⁸18. Perillo RD, Poças KC, Bernal RTI, Duarte EC, Malta DC. Fatores associados à avaliação da atenção primária à saúde na perspectiva do usuário: resultados do inquérito telefônico Vigitel, 2015. Ciênc Saúde Coletiva 2021; 26(3): 961-74. https://doi.org/10.1590/1413-81232021263.45722020
https://doi.org/10.1590/1413-81232021263... ,³⁷37. Malta DC, Reis AAC, Jaime PC, Morais Neto OL, Silva MMA, Akerman M. O SUS e a política nacional de promoção da saúde: perspectiva resultados, avanços e desafios em tempos de crise. Ciênc Saúde Colet 2018; 23(6): 1799-809. https://doi.org/10.1590/1413-81232018236.04782018
https://doi.org/10.1590/1413-81232018236... ,³⁸38. Organização Pan-Americana da Saúde. Organização Mundial da Saúde. Relatório 30 anos de SUS. Que SUS para 2030? Brasília: OPAS/OMS; 2018. [acessado em 14 out. 2021]. Disponível em: https://apsredes.org/wp-content/uploads/2018/10/Serie-30-anos-001-SINTESE.pdf
https://apsredes.org/wp-content/uploads/... . Considering that users with CNCDs have their care recommended by the Ministry of Health as one of the actions of PHC³⁶36. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Estratégias para o cuidado da pessoa com doença crônica. Brasília: Ministério da Saúde; 2014. [acessado em 02 nov. 2021]. Disponível em: http://189.28.128.100/dab/docs/portaldab/publicacoes/caderno_35.pdf
http://189.28.128.100/dab/docs/portaldab... and the PNS 2019 conducted an interview with users who used the services in the last six months, it would be plausible to assume that their satisfaction was higher than that of spontaneous demand users.

This study shows that less than 40% of the Brazilian population evaluates PHC positively. In this context, it is necessary to direct the training and continuing education of health professionals and managers to the attributes of PHC and to the health needs of the population through expansion of approaches and distance education devices, which will benefit the quality clinical care and collective actions⁵5. Facchini LA, Tomasi E, Dilélio AS. Qualidade da atenção primária à saúde no Brasil: avanços, desafios e perspectivas. Saúde Debate 2018; 42(1): 208-23. https://doi.org/10.1590/0103-11042018S114
https://doi.org/10.1590/0103-11042018S11... . Another aspect to be considered is the challenge of improving the structure of services and the qualification of organization and care management processes by a multiprofessional team so as to increase the effectiveness of PHC⁵5. Facchini LA, Tomasi E, Dilélio AS. Qualidade da atenção primária à saúde no Brasil: avanços, desafios e perspectivas. Saúde Debate 2018; 42(1): 208-23. https://doi.org/10.1590/0103-11042018S114
https://doi.org/10.1590/0103-11042018S11... .

The modification of the questions in the PCATool-Brazil adult short version16 questionnaire is one of the limitations of this study, where the terms describing different PHC professionals was replaced with “physicians” only. In this way, the general score presented is directly connected to the figure of the physician in PHC, unlike what has been validated in the country¹¹11. Harzheim E, Oliveira MMC, Agostinho MR, Hauser L, Stein AT, Gonçalves MR, et al. Validação do instrumento de avaliação da atenção primária à saúde: PCATool-Brasil adultos. Rev Bras Med Fam Comunidade 2013; 8(29): 274-8. https://doi.org/10.5712/rbmfc8(29)829
https://doi.org/10.5712/rbmfc8(29)829... ,¹³13. Fracolli LA, Gomes MFP, Nabão FRZ, Santos MS, Cappellini VK, Almeida ACC. Instrumentos de avaliação da atenção primária à saúde: revisão de literatura e metassíntese. Ciênc Saúde Coletiva 2014; 19(12): 4851-60. https://doi.org/10.1590/1413-812320141912.00572014
https://doi.org/10.1590/1413-81232014191... ,¹⁷17. Oliveira MMC, Harzheim E, Riboldi J, Duncan BB. PCATool-ADULTO-BRASIL: uma versão reduzida. Rev Bras Med Fam Comunidade 2013; 8(29): 256-63. https://doi.org/10.5712/rbmfc8(29)823
https://doi.org/10.5712/rbmfc8(29)823... . This perspective addressed by the PNS 2019 appears to be rooted in the old biological and medical-centered practices, which goes in the opposite direction of the assumptions of PHC, which guides the formation of a multiprofessional team that distributes tasks according to the characteristics of each category aiming to build a multidisciplinary care that is expanded by different types of knowledge¹1. Brasil. Ministério da Saúde. Gabinete do Ministro. 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). Brasília: Ministério da Saúde; 2017. [acessado em 14 out. 2021]. Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/prt2436_22_09_2017.html
https://bvsms.saude.gov.br/bvs/saudelegi... ,⁵5. Facchini LA, Tomasi E, Dilélio AS. Qualidade da atenção primária à saúde no Brasil: avanços, desafios e perspectivas. Saúde Debate 2018; 42(1): 208-23. https://doi.org/10.1590/0103-11042018S114
https://doi.org/10.1590/0103-11042018S11... ,³⁹39. Pinto LF, Quesada LA, D’Avila OP, Hauser L, Gonçalves MR, Harzheim E. Primary care asssement tool: diferenças regionais a partir da Pesquisa Nacional de Saúde do Instituto Brasileiro de Geografia e Estatística. Ciênc Saúde Coletiva 2021; 26(9): 3965-79. https://doi.org/10.1590/1413-81232021269.10112021
https://doi.org/10.1590/1413-81232021269... ,⁴⁰40. Organização Mundial da Saúde. Marco para ação em educação interprofissional e prática colaborativa. Genebra: OMS; 2010. [acessado em 02 nov. 2021]. Disponível em: https://www.gov.br/saude/pt-br/composicao/saes/dahu/seguranca-do-paciente/marco-para-acao-em-educacao-interprofissional-e-pratica-colaborativa-oms.pdf/view
https://www.gov.br/saude/pt-br/composica... . Another aspect to consider is that the assessment proposed by the instrument includes only respondents who used a health service and had medical consultations¹²12. Harzheim E, Gonçalves MR, D’Avila P, Hauser L, Pinto, LF. Estudos de PCATool no Brasil. In: Mendonça MHM, Matta GC, Gondim R, Giovanella L, orgs. Atenção primária à saúde no Brasil: conceitos, práticas e pesquisa. Rio de Janeiro: FIOCRUZ; 2018. https://doi.org/10.7476/9788575416297
https://doi.org/10.7476/9788575416297... , but not individuals who were unable to access the service. According to the PCATool-Brasil¹⁶16. Brasil. Ministério da Saúde. 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: Ministério da Saúde; 2020. [acessado em 03 out. 2021]. Disponível em: http://189.28.128.100/dab/docs/portaldab/documentos/12052020_Pcatool.pdf
http://189.28.128.100/dab/docs/portaldab... manual, the shortened version of this instrument allows the calculation of a general score only; specific scores for each of the essential and derived attributes are not determined¹²12. Harzheim E, Gonçalves MR, D’Avila P, Hauser L, Pinto, LF. Estudos de PCATool no Brasil. In: Mendonça MHM, Matta GC, Gondim R, Giovanella L, orgs. Atenção primária à saúde no Brasil: conceitos, práticas e pesquisa. Rio de Janeiro: FIOCRUZ; 2018. https://doi.org/10.7476/9788575416297
https://doi.org/10.7476/9788575416297... ,¹⁵15. Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, et al. National Health Survey 2019: history, methods and perspectives. Epidemiol Serv Saúde 2020; 29(5): e2020315. http://doi.org/10.1590/S1679-49742020000500004
http://doi.org/10.1590/S1679-49742020000... ,¹⁶16. Brasil. Ministério da Saúde. 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: Ministério da Saúde; 2020. [acessado em 03 out. 2021]. Disponível em: http://189.28.128.100/dab/docs/portaldab/documentos/12052020_Pcatool.pdf
http://189.28.128.100/dab/docs/portaldab... ,³⁷37. Malta DC, Reis AAC, Jaime PC, Morais Neto OL, Silva MMA, Akerman M. O SUS e a política nacional de promoção da saúde: perspectiva resultados, avanços e desafios em tempos de crise. Ciênc Saúde Colet 2018; 23(6): 1799-809. https://doi.org/10.1590/1413-81232018236.04782018
https://doi.org/10.1590/1413-81232018236... .

Another limitation of this study was the sample size, which allowed analysis only for the FU¹⁴14. Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde: 2019: atenção primária à saúde e informações antropométricas: Brasil. Rio de Janeiro: IBGE; 2020.,¹⁵15. Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, et al. National Health Survey 2019: history, methods and perspectives. Epidemiol Serv Saúde 2020; 29(5): e2020315. http://doi.org/10.1590/S1679-49742020000500004
http://doi.org/10.1590/S1679-49742020000... ,³⁹39. Pinto LF, Quesada LA, D’Avila OP, Hauser L, Gonçalves MR, Harzheim E. Primary care asssement tool: diferenças regionais a partir da Pesquisa Nacional de Saúde do Instituto Brasileiro de Geografia e Estatística. Ciênc Saúde Coletiva 2021; 26(9): 3965-79. https://doi.org/10.1590/1413-81232021269.10112021
https://doi.org/10.1590/1413-81232021269... , which could, at most, be expanded to their capitals¹⁴14. Instituto Brasileiro de Geografia e Estatística. Pesquisa nacional de saúde: 2019: atenção primária à saúde e informações antropométricas: Brasil. Rio de Janeiro: IBGE; 2020. because of the filter used for the respondents. In this way, a gap is seen in a national PHC evaluation system by municipality with the extinction of the National Program for the Improvement of Access to and Quality of Primary Care (PMAQ-AB), when the financing program “Previne, Brasil” (Prevent, Brazil) was implemented⁴¹41. Brasil. Ministério da Saúde. Gabinete do Ministro. 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 13 de novembro de 2019. [acessado em 01 nov. 2021]. Disponível em: https://www.in.gov.br/en/web/dou/-/portaria-n-2.979-de-12-de-novembro-de-2019-227652180.
https://www.in.gov.br/en/web/dou/-/porta... . This caused impoverishment of information regarding the quality of PHC at the municipal level for decision-making. The PNS 2019 would be complementary to the PMAQ-AB, not a substitute.

Since 2017, as a result of austerity policies⁴²42. Paes-Sousa R, Rasella D, Carepa-Sousa J. Economic policy and public health: fiscal balance and population wellbeing. Saúde Debate 2018; 42(n. esp. 3): 172-82. https://doi.org/10.1590/0103-11042018S313
https://doi.org/10.1590/0103-11042018S31... such as Constitutional Amendment No. 95, an increase in inequality and vulnerability of the population has been observed, making it essential to monitor the quality of health care in population surveys⁴³43. Brasil. Presidência da República. Câmara dos Deputados. Legislação informatizada. Emenda Constitucional no 95, de 15 de dezembro de 2016. Altera o Ato das Disposições Constitucionais Transitórias, para instituir o Novo Regime Fiscal, e dá outras providências. Diário Oficial da União 15 de dezembro de 2016. [acessado em 01 nov. 2021]. Disponível em: https://www2.camara.leg.br/legin/fed/emecon/2016/emendaconstitucional-95-15-dezembro-2016-784029-publicacaooriginal-151558-pl.html
https://www2.camara.leg.br/legin/fed/eme... .

In conclusion, the study emphasizes the importance of inserting a module in the PNS that allows assessing the quality of PHC. The study identified that users who best evaluate PHC are those who use the services the most, such as women and the elderly, low-income people and people with morbidities such as NCDs, hypertension, diabetes, heart disease, lung disease, WMSD, obesity.

ACKNOWLEDGMENTS

We thank Filipe Malta dos Santos and Crizian Saar Gomes for the support and the debates on the analysis plan.

References

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History