Abstract

Objective:

to evaluate the performance of Primary Health Care (PHC) in Florianopolis, SC, Brazil.

Methods:

this was a cross-sectional population-based study with adults living in the catchment areas of the Health Centers (HC) located in the Northern Health District of Florianópolis in 2012; the Primary Care Assessment Tool (PCATool-Brazil) was applied do assess the presence and extent of PHC characteristics.

Results:

of the 598 interviewees, 68,4% reported that they considered PHC centers to be their usual source of care; while the usage subdimension of the First Contact Access characteristic was the best evaluated (8.4; 95%CI 8.2;8.6), the service delivery subdimension of the First Contact Access/subdimension accessibility was the worst evaluated (3.5; 95%CI 3.3; 3.6); four (36.6%) of the eleven PHC centers evaluated had a high overall and essential PHC score, although their overall mean score was low (6.4; 95%CI 6.2;6.5).

Conclusion:

considering the PHC model evaluated by PCATool-Brazil, PHC services need to be improved, especially with regard to their process and structure components.

Keywords:
Primary Health Care; Family Health Strategy; Health Evaluation; Cross-Sectional Studies

Introduction

Evaluating the magnitude of the Family Health Strategy (FHS) is a task for which collective effort is essential, given the heterogeneity of its actions in the national context. Methodological rigor is necessary when administering Primary Health Care (PHC) assessment tools, producing scientific knowledge and searching for evidence of the effectiveness of the care model, with a view to its possible reorganization in the country.¹1. Ministério da Saúde (BR). Secretaria de Atenção em Saúde. Departamento de Atenção Básica. Manual do instrumento de avaliação da atenção primária à saúde primary care assessment tool PCATool-Brasil [Internet]. Brasília: Ministério da Saúde; 2010 [citado 2017 ago 18]. 80 p. Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/manual_avaliacao_pcatool_brasil.pdf
http://bvsms.saude.gov.br/bvs/publicacoe...

One of the ways to evaluate PHC is found in the Primary Care Assessment Tool (PCATool), created to analyze PHC performance according to the presence and extent of its essential characteristics (First Contact Access, Comprehensiveness, Continuity of Care and Coordination of Care) and derived characteristics (Family Centeredness and Community Orientation). This analysis tool provides questions about health care services to be answered by adult and child service users, health service managers or health professionals, according to the version of the tool adopted: for adult users or child users. Based on the Donabedian quality assessment model, aspects relating to health care service structure, process and results are measured.¹1. Ministério da Saúde (BR). Secretaria de Atenção em Saúde. Departamento de Atenção Básica. Manual do instrumento de avaliação da atenção primária à saúde primary care assessment tool PCATool-Brasil [Internet]. Brasília: Ministério da Saúde; 2010 [citado 2017 ago 18]. 80 p. Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/manual_avaliacao_pcatool_brasil.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... The PCATool has been validated and used in different countries, such as Canada,²2. Rowan MS, Lawson B, MacLean C, Burge F. Upholding the principles of primary care in preceptors’ practices. Fam Med. 2002 Nov-Dec;34(10):744-9. United States,³3. Shi L, Starfield B, Xu J. Validating the Adult primary care assessment tool. J Fam Pract F. 2001 Feb;50(2):161-4.^,44. Clancy DE, Yeager DE, Huang P, Magruder KM. Further evaluating the acceptability of group visits in an uninsured or inadequately insured patient population with uncontrolled type 2 diabetes. Diabetes Educ. 2007 Mar-Apr;33(2):309-14. Spain,⁵5. Pasarín MI, Berra S, Rajmil L, Solans M, Borrell C, Starfield B. An instrument to evaluate primary health care from the population perspective. Aten Primaria. 2007 Aug;39(8):395-401. China,⁶6. Tsai J, Shi L, Yu W-L, Lebrun LA. Usual source of care and the quality of medical care experiences a cross-sectional survey of patients from a taiwanese community. Med Care. 2010 Jul;48(7):628-34. Argentina⁷7. Berra S, Audisio Y, Mántaras J, Nicora V, Mamondi V, Starfield B. Adaptación cultural y al sistema de salud argentino del conjunto de instrumentos para la evaluación de la atención primaria de la salud. Rev Argentina Salud Pública. 2011 sep;2(8):6-14. and Brazil,⁸8. 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 out;8(29):274-84.

9. Harzheim E, Starfield B, Rajmil L, Álvarez-Dardet C, Stein AT. Internal consistency and reliability of primary care assessment tool (PCATool-Brasil) for child health services. Cad Saúde Pública. 2006 Aug;22(8):1649-59.^-1010. Stein AT. A avaliação dos serviços de saúde deve ser realizada com instrumentos validados. Epidemiol Serv Saúde. 2013 jan-mar;22(1):179-81. and has shown itself to be adequate in different health and cultural contexts.

Even in Brazilian state capitals with successful PHC experiences, such as Belo Horizonte, MG, Curitiba, PR, Rio de Janeiro, RJ, and Florianópolis, SC, FHS has structure and process components that need to be improved. In Belo Horizonte, 147 managers of primary health care units (PHU) and the nurse of each one of the 538 local FHS teams were interviewed. The characteristics best evaluated by them were First Contact Access/usage subdimension, Continuity of Care and Comprehensiveness; while the worst characteristics were First Contact Access/accessibility subdimension and Community Orientation, showing that the structure characteristics of the PHU and organization of the work process of the FHS teams influence in this performance.¹¹11. Turci MA, Lima-Costa MF, Macinko J. Influência de fatores estruturais e organizacionais no desempenho da atenção primária à saúde em Belo Horizonte, Minas Gerais, Brasil, na avaliação de gestores e enfermeiros. Cad Saúde Pública. 2015 set;31(9):1941-52.

In Curitiba, the PCATool-Brazil was used with 190 FHS professionals (91 doctors and 99 nurses) in the municipality’s PHU. First Contact Access/accessibility subdimension was the only evaluated characteristic that obtained a low score for PHC, while the remainder had high scores.¹²12. Chomatas E, Vigo A, Marty I, Hauser L, Harzheim E. Avaliação da presença e extensão dos atributos da atenção primária em Curitiba. Rev Bras Med Fam Comunidade. 2013 out;8(29):294-303. In Rio de Janeiro, 2,710 people were interviewed using the child version of the PCATool-Brazil, and 2,430 people using the adult version. On average FHS teams in the municipality of Rio de Janeiro had a lower overall PHC score and the characteristics with the worst performances were Comprehensiveness and First Contact Access/accessibility subdimension; while the best scores were obtained for First Contact Access/usage subdimension Coordination of Care/information system subdimension.¹³13. 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. Ciên Saúde Colet. 2016 maio;21(5):1399-408.

The international literature shows that the applicability of the PCATool is varied. In Canada, Rowan et al. (2002) applied the PCATool with 134 Family and Community Medicine preceptors to assess whether they followed PHC principles. The highest result found was for the Coordination of Care characteristic, and the lowest for Cultural Competence.²2. Rowan MS, Lawson B, MacLean C, Burge F. Upholding the principles of primary care in preceptors’ practices. Fam Med. 2002 Nov-Dec;34(10):744-9. Tsai et al. (2010) interviewed 879 people, both children and adults, to examine the relationship between having a usual source of care and the quality of outpatient medical care experiences in Taiwan, where there is universal health insurance coverage: the fact of having a usual source of care was shown to be significantly associated with First Contact Access/usage subdimension, Continuity of Care, Family Centeredness and Cultural Competence.⁶6. Tsai J, Shi L, Yu W-L, Lebrun LA. Usual source of care and the quality of medical care experiences a cross-sectional survey of patients from a taiwanese community. Med Care. 2010 Jul;48(7):628-34. In the United States, Clancy et al. (2007) evaluated the perception of health care users with type 2 diabetes mellitus (DM2), with regard to group medical consultations (therapeutic group). 186 patients with uncontrolled DM2 were randomly assigned to receive individual or group care over 12 months. Compared to the patients who received individual care, patients receiving group care showed higher scores for Continuity of Care (p=0.001), Community Orientation (p<0.0001) and Cultural Competence (p=0.022).⁴4. Clancy DE, Yeager DE, Huang P, Magruder KM. Further evaluating the acceptability of group visits in an uninsured or inadequately insured patient population with uncontrolled type 2 diabetes. Diabetes Educ. 2007 Mar-Apr;33(2):309-14.

Florianópolis has long been recognized for its PHC quality and coverage. Recognized as having the third best Brazilian Unified Health System (SUS) performance index (IDSUS) in 2012,¹⁴14. Ministério da Saúde (BR). Índice de desempenho do sistema único de saúde [Internet]. 2012 [citado 2017 ago 21]. Disponível em: Disponível em: http://idsus.saude.gov.br/index.html
http://idsus.saude.gov.br/index.html... its PHC is centered on the Family Health Strategy,¹⁵15. Prefeitura Municipal (Florianópolis). Secretaria Municipal de Saúde. Portaria SS/GAB n° 283, de 06 de agosto de 2007. Aprova a política municipal de atenção a saúde, estabelecendo diretrizes e normas para a organização da atenção básica baseada na estratégia de saúde da família [Internet]. 2007 [citado 2018 ago 21]. 16 p. Disponível em: Disponível em: http://www.pmf.sc.gov.br/entidades/saude/index.php?cms=saude+da+familia&menu=5
http://www.pmf.sc.gov.br/entidades/saude... however, as at the date of the publication of this article, there has been no assessment of its performance using the PCATool-Brazil.

The objective of this study was to evaluate PHC performance in Florianópolis, SC, based on the experience of adult users.

Methods

This was a cross-sectional population-based study, carried out in the Northern Health District (NHD) of the municipality of Florianópolis in 2012, using the PCATool-Brazil as an instrument to measure PHC performance.

Florianópolis is the capital of Santa Catarina state. Located in the Southern region of Brazil, the municipality had 421,240 inhabitants in 2010.¹⁶16. Instituto Brasileiro de Geografia e Estatística. Santa Catarina - Florianópolis - infográficos: evolução populacional e pirâmide etária [Internet]. 2010 [citado 2017 jun 28]. Disponível em: Disponível em: http://cod.ibge.gov.br/9D3
http://cod.ibge.gov.br/9D3... Its municipal health care network is organized into five health districts (Figure 1) to meet the needs of its entire population, of which 64,732 were adults covered by NHD during the period evaluated.¹⁷17. Prefeitura Municipal (Florianópolis). Secretaria Municipal de Saúde. População 2012 (rendimento/raça) [Internet]. 2012 [citado 2017 ago 18]. Disponível em: Disponível em: http://www.pmf.sc.gov.br/sistemas/saude/unidades_saude/populacao/2012r/uls_2012_index.php
http://www.pmf.sc.gov.br/sistemas/saude/...

Initially, PHC service users aged 18 or older living in households located in the catchment territory of 11 NHD Health Centers (HC) were included in the study.

OpenEpi® software was used to calculate the sample size. 459 questionnaires needed to be administered. The estimated sample size was increased by 30% to allow for losses and therefore 598 questionnaires were administered. The parameters used for this calculation were: (i) 95% confidence level, (ii) 5% absolute precision and (iii) design effect (Deff) of 1.2 to adjust for the cluster effect, estimating a proportion of 50% of users that would give a high score (≥6.6). Interviewees who did not have one of the HC under analysis as their usual source of care (n = 189) were excluded from the study.

The household sample was defined from clusters, stratified by Health Center and distributed proportionally to the size of their user populations. The selection of households for administration of the instrument was carried out by systematic sampling, by street and house. First the 11 Health Centers and the street names of their catchment areas were included on a Microsoft Office Excel 2010® spreadsheet in alphabetical order. A program function was then used to randomly relocate the order of the streets of the catchment areas of each HC and to determine in which street the interviews would start.

A coin was tossed in order to determine which side of the street the selection of the houses where people would be interviewed would begin: the first house to be visited was determined according to the which side of the coin was uppermost, moving to the second house on the opposite side of the street, followed by the third house on the same side as the first house, i.e. moving in a zigzag fashion until the end of the street was reached. Only after the interviews had been concluded in one street, did the interviewers move on to the next street following the order of the list, and so on, in an attempt to complete the number of interviews scheduled for each HC as described above, with the aim of minimizing the number of losses in relation to the estimated target.

The number of adults to be interviewed at each chosen household was limited to two. If there were more than two adults in the same household, the two eldest adults answered the questionnaire.

Community health agents (CHA) (n=83) were instructed and trained to carry out the interviews under the supervision of the FHS team nurses (n=24), FHS being the health care strategy used in Florianópolis.¹⁵15. Prefeitura Municipal (Florianópolis). Secretaria Municipal de Saúde. Portaria SS/GAB n° 283, de 06 de agosto de 2007. Aprova a política municipal de atenção a saúde, estabelecendo diretrizes e normas para a organização da atenção básica baseada na estratégia de saúde da família [Internet]. 2007 [citado 2018 ago 21]. 16 p. Disponível em: Disponível em: http://www.pmf.sc.gov.br/entidades/saude/index.php?cms=saude+da+familia&menu=5
http://www.pmf.sc.gov.br/entidades/saude... Field data collection lasted for five months (May to September/2012).

In order to minimize measurement biases, CHA did not interview in the catchment area in which they usually worked and were allocated to another HC in the NHD. A pilot study was carried out for the purpose of staff training and to clarify doubts regarding questionnaire administration.

The population studied was characterized by sex, age, skin color/race and usual source of care - Health Center, Emergency Care Unit, Municipal Polyclinic or Supplementary Health Unit (private health service).

As mentioned earlier in this report, PCATool-Brazil measures the presence and extent of PHC characteristics. Answers to the questionnaire are rated according to a Likert type scale of numbers, ranging from 1 (it is certainly not) to 4 (it certainly is) and the additional option of number 9, meaning I don't know/don't remember. PCATool-Brazil has 87 items, divided into ten components related to the essential and derived PHC characteristics as listed below.

Firstly, the essential characteristics are:

In accordance with the adult version of the PCATool-Brazil validation instrument, scores are standardized according to a scale ranging from 0 to 10, where scores equal to or greater than 6.6 are considered to be high - which corresponds to answers scoring 3 or 4 on the instrument’s original scale. The 0-10 scale is standardized in the following manner:⁸8. 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 out;8(29):274-84.

Microsoft Excel® 2010 was used for data input and statistical analysis. The descriptive analysis was performed by obtaining the absolute frequency, the percentage and the average.

The PHC performance score calculation was done in accordance with the Ministry of Health Manual for PCA-Tool-Brazil.¹1. Ministério da Saúde (BR). Secretaria de Atenção em Saúde. Departamento de Atenção Básica. Manual do instrumento de avaliação da atenção primária à saúde primary care assessment tool PCATool-Brasil [Internet]. Brasília: Ministério da Saúde; 2010 [citado 2017 ago 18]. 80 p. Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/manual_avaliacao_pcatool_brasil.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... The PHC score was calculated for each of the characteristics, in addition to the essential score (ES: result of the average between the essential characteristics scores and the degree of registration scores), derived score (obtained by averaging the derived characteristics) and average overall score (AS: result of the average between all characteristics [essential and derived] and the degree of registration).

The participation of the respondents in the survey was voluntary and they signed a Free and Informed Consent Form, as recommended by National Health Council (CNS) Resolution No. 466 of 12 December 2012. The Florianópolis Health Research Projects Monitoring Committee and the Federal University of Santa Catarina Human Research Ethics Committee (Opinion No. 1.635.663) approved the study project on 12 June 2016.

Results

We interviewed 598 users. Due to the methodology used there were no losses: the number of interviews planned for each health center was achieved. There was also no refusal on the part of participants. Individuals unable to be interviewed at the pre-determined time arranged a different day and time with the interviewer. The proportion of users who gave PHC high score for the services evaluated was 46.4% (n=190). The average age of the people interviewed was 47 years (SD=0.86), with a higher proportion of women (72.6%); 92% of people reported being of white skin color/race. The majority of respondents (68.4%; n=409) reported using the Health Centers as their usual source of care. These respondents formed the sample (n=409) for the subsequent analyses. Two other public services were mentioned as being the usual source of care in NHD: Emergency Care Unit (9.7%; n=57) and Polyclinic (2.2%; n=13); the remaining respondents reported that a Supplementary Health Unit (19.9%; n=119) was their usual source of care.

In general, the average overall PHC score was low (AS=6.4). Table 1 shows the mean scores of the characteristics and the mean essential, derived and overall scores for PHC, as well as the frequency of high scores (≥6.6) as evaluated by the users of the NHD Health Centers in 2012. The highest PHC evaluation score corresponded to the First Contact Access/usage subdimension characterisitic(8.4; 95%CI 8.2;8.6); The First Contact Access/subdimension accessibility was the worst (3.5; 95%CI 3.3; 3.6).

Figures 2 and 3 show, respectively, the essential and average overall PCATool-Brazil scores for all 11 NHD Health Centers. Four of the services evaluated (36.6%) were found to have a high PHC score, in terms of both the average essential score and the overall score.

Discussion

We found heterogeneity in the assessment of the overall score for Primary Health Care and for each of its characteristics individually in relation to the health centers of the Northern Health District of Florianópolis, Santa Catarina.

The results are similar to those of a systematic review conducted by Prates et al. of 22 articles published in national and international literature between 2007 and 2015 which evaluated the performance of PHC services using the PCATool instrument from the perspective of the service user. According to their review, the best assessed characteristic was First Contact Access/usage subdimension (AS 3.5; 95%CI 3.3;3.6), while the worst were First Contact Access/accessibility subdimension, Comprehensiveness, Family Centeredness and Community Orientation.¹⁸18. Prates ML, Machado JC, Silva LSD, Avelar PS, Prates LL, Mendonça ET, et al. Performance of primary health care according to PCATool instrument: a systematic review. Ciên Saúde Colet. 2017 Jun;22(6):1881-93. In our study, the First Contact Access characteristic showed important variability: while the accessibility subdimension received the worst score, the usage subdimension had the best (AS 8.41; 95%CI 8.22;8.61) out of all the characteristics evaluated.¹⁸18. Prates ML, Machado JC, Silva LSD, Avelar PS, Prates LL, Mendonça ET, et al. Performance of primary health care according to PCATool instrument: a systematic review. Ciên Saúde Colet. 2017 Jun;22(6):1881-93. This variation is also found in other studies that used PCATool-Brazil. Araújo et al., in their assessment of PHC performance from the perspective of the elderly, interviewed 100 elderly patients cared for by ten FHS teams from 20 PHU in Macaíba, RN, and obtained similar results (usage: AS 8.5; 95%CI 8.1;9.0) (accessibility: AS 3.8; 95%CI 3.6;4.1).¹⁹19. Araújo LUA, Gama ZAS, Nascimento FLA, Oliveira HFV, Azevedo WM, Almeida Júnior HJB. Avaliação da qualidade da atenção primária à saúde sob a perspectiva do idoso. Ciên Saúde Colet. 2014 ago;19(8):3521-32. Silva and Fracolli found the same variability when interviewing 527 adults aged over 18 years old registered with 33 FHS Health Units in Alfenas, MG (usage: AS 8.6; SD 2.0) (accessibility: AS 3.2; SD 1.5).²⁰20. Silva SA, Baitelo TC, Fracolli LA. Avaliação da atenção primária à saúde: a visão de usuários e profissionais sobre a estratégia de saúde da família. Rev Latino-Am Enfermagem. 2015 set-out;23(5):979-87.

These results suggest that although people are using FHS, there are difficulties regarding the accessibility of these services. Access means not only the user’s admission to health system or the availability of services and resources at a given time and in a given place, but also the match between the needs of the population and the delivery of these services.²¹21. Arakawa T, Arcêncio RA, Scatolin BE, Scatena LM, Ruffino-Netto A, Villa TCS. Acessibilidade ao tratamento de tuberculose: avaliação de desempenho de serviços de saúde. Rev Latino-Am Enfermagem. 2011 jul-ago;19(4):1-9.

Among the findings of our study, PHC Continuity of Care obtained a lower average score, although it was near to the cut-off point of 6.6 (AS 6.4; 95%CI 6.2;6.6). This result is similar to that found by Chomatas et al. in Curitiba (AS 6.6; 95%CI 6.4;6.7).¹²12. Chomatas E, Vigo A, Marty I, Hauser L, Harzheim E. Avaliação da presença e extensão dos atributos da atenção primária em Curitiba. Rev Bras Med Fam Comunidade. 2013 out;8(29):294-303. This characteristic is a central and exclusive PHC feature. Greater extent of Continuity of Care tends to produce greater diagnostic and treatment accuracy, reducing the number of unnecessary referrals and the performance of procedures of greater complexity, and therefore lowering public health costs.²²22. Cunha EM, Giovanella L. Longitudinalidade/continuidade do cuidado: identificando dimensões e variáveis para a avaliação da atenção primária no contexto do sistema público de saúde brasileiro. Ciên Saúde Colet. 2011;16(Suppl 1):1029-104.

The Coordination of Care characteristic achieved a high average PHC score, both for the integration of care (AS 6.75; 95%CI 6.5;7.0) and for information systems (AS 7.0; 95%CI 6.8;7.2). Furtado et al. reached the same conclusion in a study in which they administered PCA with 44 mothers of children under one year old who used FHS in Ribeirão Preto, SP: using the original scale of the instrument, which varies from 1 to 4, the scores they found above 3.0 represent strong presence and extent of the Coordination of Care characteristic, with regard to its integration of care (AS 3.7; SD 0.4) and information systems (AS 3.6; SD 0.3) subdimensions.²³23. Furtado MCC, Braz JC, Pina JC, Mello DF, Lima RAG. A avaliação da atenção à saúde de crianças com menos de um ano de idade na atenção primária. Rev Latino-Am Enfermagem. 2013 mar-abr;21(2):554-61. This shows the ability of the FHS teams in ensuring continuity of care within the health care network. The availability of information in the service network about service users, i.e., the existence of medical records with information on service users at all points of the network, is essential for health care coordination. The aging population and the consequent increase in the prevalence of chronic diseases make information system integration increasingly necessary.²⁴24. Mendes EV. A construção social da atenção primária à saúde [Internet]. Brasília: Conselho Nacional de Secretários de Saúde - CONASS; 2015 [citado 2017 ago 7]. 194 p. Disponível em: Disponível em: http://www.conass.org.br/biblioteca/pdf/A-CONSTR-SOC-ATEN-PRIM-SAUDE.pdf
http://www.conass.org.br/biblioteca/pdf/...

As to the Comprehensiveness of care, both services available (AS 5.4; 95%CI 5.2;5.7) and services delivered (AS 5.1; 95%CI 4.9;5.3) obtained a low score. Lima et al. reached a similar conclusion after interviewing 215 women between 20 and 49 years old who used FHS services in Serra, ES, (available services: AS 5.05; SD 1.6) (service delivery: AS 3.9; SD 2.16).²⁵25. Lima EFA, Sousa AI, Primo CC, Leite FMC, Lima RCD, Maciel ELN. Avaliação dos atributos da atenção primária na perspectiva das usuárias que vivenciam o cuidado. Rev Latino-Am Enfermagem. 2015 maio-jun;23(3):553-9. The low score for Comprehensiveness points to the difficulty the local health services evaluated have in arranging the health care team in such a way as to ensure all necessary services for its population, as well as taking responsibility for the delivery of these services at other points in the care network.²⁴24. Mendes EV. A construção social da atenção primária à saúde [Internet]. Brasília: Conselho Nacional de Secretários de Saúde - CONASS; 2015 [citado 2017 ago 7]. 194 p. Disponível em: Disponível em: http://www.conass.org.br/biblioteca/pdf/A-CONSTR-SOC-ATEN-PRIM-SAUDE.pdf
http://www.conass.org.br/biblioteca/pdf/...

Family Centeredness (AS 5.8; 95%CI 5.5;6.1) and Community Orientation (AS 5.2; 95%CI 4.9;5.5) obtained a low overall PHC score, similarly to the results found by Marques et al.²⁶26. Marques AS, Freitas DA, Leitão CDA, Oliveira SKM, Pereira MM, Caldeira AP. Atenção primária e saúde materno-infantil: a percepção de cuidadores em uma comunidade rural quilombola. Ciên Saúde Colet. 2014 fev;19(2):365-71. when evaluating the PHC and maternal and child health based on interviews with 76 carers of children aged 0-5 years in a quilombola community in the state of Minas Gerais (Family Centeredness: AS 3.8; SD 2.6) (Community Orientation: AS 5.8; SD 1.9).²⁶26. Marques AS, Freitas DA, Leitão CDA, Oliveira SKM, Pereira MM, Caldeira AP. Atenção primária e saúde materno-infantil: a percepção de cuidadores em uma comunidade rural quilombola. Ciên Saúde Colet. 2014 fev;19(2):365-71. These results are evidence of the difficulty health professionals have in two relevant aspects: (I) having greater knowledge about the way patients’ families function and their dynamics, in order to resolve any conflicts and needs, and (ii) learning to recognize the needs of the population in their physical, economic and social development contexts.²⁴24. Mendes EV. A construção social da atenção primária à saúde [Internet]. Brasília: Conselho Nacional de Secretários de Saúde - CONASS; 2015 [citado 2017 ago 7]. 194 p. Disponível em: Disponível em: http://www.conass.org.br/biblioteca/pdf/A-CONSTR-SOC-ATEN-PRIM-SAUDE.pdf
http://www.conass.org.br/biblioteca/pdf/...

Among the limitations of this study, restricting interviews to up to two per household, owing to logistic and financial restrictions, may have increased the average age of the sample studied and reduced its representativeness. Nevertheless, the distribution of the age frequencies of the sample studied is similar to that of the adult population who effectively used PHC services in Florianópolis in the year 2017. Although the community health agents/interviewers were allocated to health centers other than those where they routinely worked, in order to minimize possible effects of measurement bias, they introduced themselves to the people to be interviewed as municipal government health professionals. This fact may have intimidated the interviewees when assessing their usual source of care as unsatisfactory and consequently may have given better evaluation scores, even though they participated voluntarily and signed a Free and Informed Consent Form to take part in the study.

Another possible limitation of the study is that PCATool-Brazil applies the same weight to all characteristics used by the instrument, assuming that the service performance can be assessed solely by the presence and extent of these PHC characteristics.²⁰20. Silva SA, Baitelo TC, Fracolli LA. Avaliação da atenção primária à saúde: a visão de usuários e profissionais sobre a estratégia de saúde da família. Rev Latino-Am Enfermagem. 2015 set-out;23(5):979-87. Moreover, the use of PCATool-Brazil is limited to adults. Not using other versions of the instrument - for children, health professionals or health service managers - may lead to limitations in the generalization of the performance results of the services assessed, which might be avoided if all those involved in service delivery were interviewed.

The performance of the PHC services evaluated should be enhanced by strengthening the structure and process components to achieve the best performance. The First Contact Access/accessibility dimension was the worst rated characteristic, contributing substantially to the reduction of the average overall and essential scores. Changes are therefore needed in order to improve accessibility to these services. Changes in the way consultation appointments are made are important and can contribute toward this.

Many FHS teams in Brazil have sought to improve their accessibility by deploying more agile models of appointment making, such as the so-called Advance Access, which allows for a greater balance between supply and demand for health services, reducing the waiting time for consultations - not without effort, with the necessary adaptations to the local reality.²⁷27. Wollmann A, Da Ros C, Lowen IMV, Moreira LR, Kami MT, Gomes MAG, et al. Novas possibilidades de organizar o acesso e a agenda na atenção primária à saúde [Internet]. Curitiba: Prefeitura Municipal de Curitiba; 2014 [citado 2017 ago 18]. 29 p. Disponível em: Disponível em: http://www.saude.curitiba.pr.gov.br/images/cartilha acesso avançado 05_06_14.pdf
http://www.saude.curitiba.pr.gov.br/imag...

As a conclusion of this report, its authors believe that the establishment of horizontal cooperation strategies between health teams and health managers, institutional support for planning, conducting monitoring and assessment of the presence and extent of PHC characteristics periodically, and the rational use of their results, can contribute to the reformulation and development of the quality of Primary Health Care in Brazilian municipalities.

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