Structure and work process regarding child care in Primary Health Care in Brazil: an ecological study with data from the Program for Primary Health Care Access and Quality Improvement 2012-2018**Article derived from the Ph.D. thesis entitled ‘Internações pediátricas por condições sensíveis à Atenção Primária no Brasil e indicadores do PMAQ-AB 2012-2018: estudo ecológico multinível [‘Pediatric hospitalizations due to Primary Care sensitive conditions in Brazil and 2012-2018 PMAQ-AB indicators: a multilevel ecological study’], defended by Danilo Marcelo Araujo dos Santos at the Federal University of Maranhão Postgraduate Program in Public Health.

Danilo Marcelo Araujo dos Santos Cláudia Maria Coelho Alves Thiago Augusto Hernandes Rocha Rejane Christine de Sousa Queiroz Núbia Cristina da Silva Erika Barbara Abreu Fonseca Thomaz About the authors

Abstract

Objective

To assess the structure of primary health care centers (PHCCs) and the work process of primary care teams in child care in Brazil.

Methods

This was an ecological study with data from the three cycles of the Program for Primary Health Care Access and Quality Improvement 2012-2018, by states and regions. Seven structural and thirteen procedural indicators were analyzed. Student’s t-test was used to compare indicator averages between regions.

Results

85,845 teams participated in the three cycles of the program, grouped into 68,320 PHCCs. In the last evaluation cycle (2017-2018), mean percentage adequacy rates were higher among the structure indicators: health center operation (99%), equipment/materials (82%), vaccine availability (74%) and medication dispensing (70%). Population without coverage (68%) and making appointments with specialists (52%) corresponded to the lowest percentages of adequacy of process indicators.

Conclusion

Process indicators had higher levels of adequacy than structure indicators.

Keywords:
Primary Health Care; Health Evaluation; Indicators of Health Services; Child Health; Ecological Studies

Introduction

At the 1978 World Health Summit in Alma-Ata, Republic of Kazakhstan, it was discussed and proposed that Primary Health Care (PHC) should be the main strategy and preferred gateway to health care.11. Pan American Health Organization - PAHO. Declaracion de alma-ata. Conferencia internacional sobre atención primaria de salud, Alma-Ata, URSS, [6-12 de septiembre de 1978 - Internet]. PAHO; 1978 [citado 2019 jun 5]. Disponível em: http://www.paho.org/hq/index.php?option=com_docman&task=doc_view&gid=19004&Itemid=270
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,22. Protasio APL, Machado LS, Valença AMG. Produções científicas sobre as avaliações no âmbito da Atenção Primária à Saúde no Brasil: uma revisão sistemática. Rev Bras Med Fam Comunidade [Internet]. 2015 [citado 2019 jun 5];10(34):1-9. Disponível em: http://dx.doi.org/10.5712/rbmfc10(34)868
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Brazil has followed the worldwide movement to strengthen PHC in order to develop comprehensive health care and autonomy for health system users, impacting on factors that determine and condition community health.22. Protasio APL, Machado LS, Valença AMG. Produções científicas sobre as avaliações no âmbito da Atenção Primária à Saúde no Brasil: uma revisão sistemática. Rev Bras Med Fam Comunidade [Internet]. 2015 [citado 2019 jun 5];10(34):1-9. Disponível em: http://dx.doi.org/10.5712/rbmfc10(34)868
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However, backsliding may occur, considering the alteration of fundamental points in the National Primary Health Care Policy in 2017, together with a scenario of political and economic crisis in Brazil.33. Brasil. Ministério da Saúde. Portaria MS/GM 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) [Internet]. Diário Oficial da União, Brasília (DF), 2017 set 22 [citado 2019 out 5]. Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/prt2436_22_09_2017.html
http://bvsms.saude.gov.br/bvs/saudelegis...

Aiming at institutionalizing the monitoring and assessment process in the Brazilian National Health System (SUS), especially in PHC, and agreeing on service qualification goals, several assessment methodologies have been proposed since the 1990s in Brazil. This evolution culminated with the implementation, in 2011, of the National Program for Primary Health Care Access and Quality Improvement (PMAQ-AB).44. Brasil. Ministério da Saúde. Portaria MS/GM no 1.645, de 2 de outubro de 2015. Dispõe sobre o Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ-AB) [Internet]. Diário Oficial da União , Brasília (DF), 2015 out 3 [citado 2019 jun 1]. Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2015/prt1645_01_ 10_2015.html
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-55. Santos TC, Ozorio JC, Ferreira AV, Ribeiro DT, Nascimento DT, Cunha FM, et al. PMAQ-AB e os pactos do SUS: função, dispositivo ou repetição? In: Gomes LB, Barbosa MG, Ferla AA, organizadores. Atenção básica: olhares a partir do programa nacional de melhoria do acesso e da qualidade - PMAQ-AB. Porto Alegre: Rede UNIDA; 2016. p. 75-99.

Within this scenario of PHC service evaluation, monitoring and qualification, actions to prevent and promote child health must be a priority, especially in early childhood (from zero to 72 months), due to their greater susceptibility to diseases and illnesses, as well as the possibility of rapid progression to unfavorable outcomes.66. Konstantyner T, Mais LA, Taddei JAAC. Factors associated with avoidable hospitalization of children younger than 2 years old: the 2006 Brazilian National Demographic Health Survey. Int J Equity Health [Internet]. 2015 [cited 2019 Jun 9];14(1):69. Available from: https://doi.org/10.1186/s12939-015-0204-9
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,77. Pedraza DF, Araujo EMN. Internações das crianças brasileiras menores de cinco anos: revisão sistemática da literatura. Epidemiol Serv Saúde [Internet]. 2017 jan-mar [citado 2019 jun 6];26(1):169-82. Disponível em: https://doi.org/10.5123/s1679-49742017000100018
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In Brazil, PHC indicators have served to evaluate child care quality,77. Pedraza DF, Araujo EMN. Internações das crianças brasileiras menores de cinco anos: revisão sistemática da literatura. Epidemiol Serv Saúde [Internet]. 2017 jan-mar [citado 2019 jun 6];26(1):169-82. Disponível em: https://doi.org/10.5123/s1679-49742017000100018
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8. Pereira FJR, Silva CC, Lima Neto EA. Condições sensíveis à atenção primária: uma revisão descritiva dos resultados da produção acadêmica brasileira. Saúde Debate [Internet]. 2014 [citado 2019 jun 8];38:331-42. Disponível em: https://www.scielo.br/pdf/sdeb/v38nspe/0103-1104-sdeb-38-spe-0331.pdf
https://www.scielo.br/pdf/sdeb/v38nspe/0...

9. Costa LQ, Pinto Junior EP, Silva MGC. Tendência temporal das internações por condições sensíveis à atenção primária em crianças menores de cinco anos de idade no Ceará, 2000 a 2012. Epidemiol Serv Saúde [Internet]. 2017 jan-mar [citado 2019 jun 9];26(1):51-60. Disponível em: http://dx.doi.org/10.5123/s1679-49742017000100006
https://doi.org/10.5123/s1679-4974201700...
-1010. Araujo WRM, Queiroz RCS, Rocha TAH, Silva NC, Thumé E, Tomasi E, et al. Estrutura e processo de trabalho na atenção primária e internações por condições sensíveis. Rev Saúde Pública [Internet]. 2017 [citado 2019 jun 8];51:75. Disponível em: http://dx.doi.org/10.11606/s1518-8787.2017051007033
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especially in time-series analyses, describing the main causes of child hospitalization due to health-sensitive conditions.77. Pedraza DF, Araujo EMN. Internações das crianças brasileiras menores de cinco anos: revisão sistemática da literatura. Epidemiol Serv Saúde [Internet]. 2017 jan-mar [citado 2019 jun 6];26(1):169-82. Disponível em: https://doi.org/10.5123/s1679-49742017000100018
https://doi.org/10.5123/s1679-4974201700...

8. Pereira FJR, Silva CC, Lima Neto EA. Condições sensíveis à atenção primária: uma revisão descritiva dos resultados da produção acadêmica brasileira. Saúde Debate [Internet]. 2014 [citado 2019 jun 8];38:331-42. Disponível em: https://www.scielo.br/pdf/sdeb/v38nspe/0103-1104-sdeb-38-spe-0331.pdf
https://www.scielo.br/pdf/sdeb/v38nspe/0...
-99. Costa LQ, Pinto Junior EP, Silva MGC. Tendência temporal das internações por condições sensíveis à atenção primária em crianças menores de cinco anos de idade no Ceará, 2000 a 2012. Epidemiol Serv Saúde [Internet]. 2017 jan-mar [citado 2019 jun 9];26(1):51-60. Disponível em: http://dx.doi.org/10.5123/s1679-49742017000100006
https://doi.org/10.5123/s1679-4974201700...
However, such initiatives and their implementation are mostly concentrated in the South and Southeast regions of the Brazil;77. Pedraza DF, Araujo EMN. Internações das crianças brasileiras menores de cinco anos: revisão sistemática da literatura. Epidemiol Serv Saúde [Internet]. 2017 jan-mar [citado 2019 jun 6];26(1):169-82. Disponível em: https://doi.org/10.5123/s1679-49742017000100018
https://doi.org/10.5123/s1679-4974201700...
,88. Pereira FJR, Silva CC, Lima Neto EA. Condições sensíveis à atenção primária: uma revisão descritiva dos resultados da produção acadêmica brasileira. Saúde Debate [Internet]. 2014 [citado 2019 jun 8];38:331-42. Disponível em: https://www.scielo.br/pdf/sdeb/v38nspe/0103-1104-sdeb-38-spe-0331.pdf
https://www.scielo.br/pdf/sdeb/v38nspe/0...
few have used national sampling to associate PHC structural and procedural aspects with child care outcomes, and none have used data from the three PMAQ-AB evaluation cycles.77. Pedraza DF, Araujo EMN. Internações das crianças brasileiras menores de cinco anos: revisão sistemática da literatura. Epidemiol Serv Saúde [Internet]. 2017 jan-mar [citado 2019 jun 6];26(1):169-82. Disponível em: https://doi.org/10.5123/s1679-49742017000100018
https://doi.org/10.5123/s1679-4974201700...
,88. Pereira FJR, Silva CC, Lima Neto EA. Condições sensíveis à atenção primária: uma revisão descritiva dos resultados da produção acadêmica brasileira. Saúde Debate [Internet]. 2014 [citado 2019 jun 8];38:331-42. Disponível em: https://www.scielo.br/pdf/sdeb/v38nspe/0103-1104-sdeb-38-spe-0331.pdf
https://www.scielo.br/pdf/sdeb/v38nspe/0...
,1010. Araujo WRM, Queiroz RCS, Rocha TAH, Silva NC, Thumé E, Tomasi E, et al. Estrutura e processo de trabalho na atenção primária e internações por condições sensíveis. Rev Saúde Pública [Internet]. 2017 [citado 2019 jun 8];51:75. Disponível em: http://dx.doi.org/10.11606/s1518-8787.2017051007033
https://doi.org/10.11606/s1518-8787.2017...

The Donabedian triad for health care quality evaluation - structure, work process and outcome - was adopted by Araujo et al.1010. Araujo WRM, Queiroz RCS, Rocha TAH, Silva NC, Thumé E, Tomasi E, et al. Estrutura e processo de trabalho na atenção primária e internações por condições sensíveis. Rev Saúde Pública [Internet]. 2017 [citado 2019 jun 8];51:75. Disponível em: http://dx.doi.org/10.11606/s1518-8787.2017051007033
https://doi.org/10.11606/s1518-8787.2017...
in national data analysis for 2013 and 2014 and the first PMAQ-AB cycle. Those authors found that structural aspects (PHCC working hours, vaccine availability and medication dispensing) and work process (matrix support) were associated with child hospitalization.1010. Araujo WRM, Queiroz RCS, Rocha TAH, Silva NC, Thumé E, Tomasi E, et al. Estrutura e processo de trabalho na atenção primária e internações por condições sensíveis. Rev Saúde Pública [Internet]. 2017 [citado 2019 jun 8];51:75. Disponível em: http://dx.doi.org/10.11606/s1518-8787.2017051007033
https://doi.org/10.11606/s1518-8787.2017...
,1111. Donabedian A. The quality of care. How can it be assessed? JAMA [Internet]. 1988 [cited 2020 Nov 6];23;260(12):1743-8. Available from: https://jamanetwork.com/journals/jama/article-abstract/374139
https://jamanetwork.com/journals/jama/ar...

Structural deficiencies, such as underfinancing of actions and scarcity of qualified human resources, have compromised the execution of PHC actions, including those that are essential.1212. Bousquat A, Giovanella L, Fausto MCR, Medina MG, Martins CL, Almeida PF, et al. A atenção primária em regiões de saúde: política, estrutura e organização. Cad Saúde Pública [Internet]. 2019 [citado 2020 jan 9];35:e00099118. Disponível em: https://doi.org/10.1590/0102-311x00099118
https://doi.org/10.1590/0102-311x0009911...
Therefore, according to Donabedian’s theoretical model, health system evaluation should begin with knowledge of its structural aspects, which are essential for providing effective care.1111. Donabedian A. The quality of care. How can it be assessed? JAMA [Internet]. 1988 [cited 2020 Nov 6];23;260(12):1743-8. Available from: https://jamanetwork.com/journals/jama/article-abstract/374139
https://jamanetwork.com/journals/jama/ar...

The data analysis of the three PMAQ-AB evaluation cycles, as proposed in this study, will allow evaluation, over time, of the child care conditions provided by PHC in Brazil, supporting future analyses of association between structure, work process and outcome. Qualification of these findings increases the odds of better care process performance and, therefore, achievement of good results,1111. Donabedian A. The quality of care. How can it be assessed? JAMA [Internet]. 1988 [cited 2020 Nov 6];23;260(12):1743-8. Available from: https://jamanetwork.com/journals/jama/article-abstract/374139
https://jamanetwork.com/journals/jama/ar...
providing support for the accomplishment of the PMAQ-AB guidelines, which includes reinforcing the National Primary Health Care Policy.44. Brasil. Ministério da Saúde. Portaria MS/GM no 1.645, de 2 de outubro de 2015. Dispõe sobre o Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ-AB) [Internet]. Diário Oficial da União , Brasília (DF), 2015 out 3 [citado 2019 jun 1]. Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2015/prt1645_01_ 10_2015.html
http://bvsms.saude.gov.br/bvs/saudelegis...

The aim of this study was to examine the structure of primary health care centers (PHCCs) and the work process of primary care teams in child care in Brazil.

Methods

This is an ecological study which used secondary data from three PMAQ-AB cycles (2012, 2014 and 2017/2018), per Federative Unit and geographic macro-regions of Brazil. It is part of the multicenter research entitled ‘Avaliação externa e censo das Unidades Básicas de Saúde - PMAQ-AB’ [‘External evaluation and census of Primary Health Care Centers - PMAQ-AB’],1313. Macinko J, Harris MJ, Rocha MG. Brazil’s National Program for Improving Primary Care Access and Quality (PMAQ): fulfilling the potential of the world’s largest payment for performance system in primary care. J Ambul Care Manage [Internet]. 2017 [cited 2020 Jul 30];40(2 Suppl):S4-11. Available from: https://journals.lww.com/ambulatorycaremanagement/Fulltext/2017/04001/Brazil_s_National_Program_for_Improving_Primary.2.aspx
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conducted by consortia under the coordination of various universities and research centers in Brazil.

Three editions (cycles) of PMAQ-AB have already been conducted. The first two cycles of the program had four phases, (1) adherence and agreement setting, (2) development, (3) external evaluation and (4) agreement resetting, whereas the third cycle was composed of a cross-cutting strategic development axis and three phases: (i) adherence and agreement setting; (ii) certification; and (iii) agreement resetting. In the third cycle, external evaluation of the program was conducted in the certification phase.44. Brasil. Ministério da Saúde. Portaria MS/GM no 1.645, de 2 de outubro de 2015. Dispõe sobre o Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ-AB) [Internet]. Diário Oficial da União , Brasília (DF), 2015 out 3 [citado 2019 jun 1]. Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2015/prt1645_01_ 10_2015.html
http://bvsms.saude.gov.br/bvs/saudelegis...

The first PMAQ-AB cycle took place in 2012, at the same time as the PHCC census which examined the infrastructure, equipment, facilities, human resources and materials of these centers. The second and third cycles of the program, held in 2014 and 2017/2018 respectively, consisted of external evaluation of the PHCCs and their teams. 85,845 teams participated in this study, which voluntarily adhered to PMAQ-AB, deployed at 68,320 PHCCs.

The secondary data for analysis were obtained from Ministry of Health databases containing the microdata of each evaluation cycle, available in digital format: http://aps.saude.gov.br/ape/pmaq.

PHCC structure variables and team work process variables were used, derived from modules I and II of each PMAQ-AB cycle, respectively (Figure 1). In primary data collection, module I variables were collected just once for each PHCC as a whole, while module II variables were collected from each team working at each PHCC.

Figure 1
Structure and work process indicators regarding childcare in the three cycles of the National Program for Primary Health Care Access and Quality Improvement (PMAQ-AB), 2012, 2014 and 2017/2018

Indicators related to PHCC structure and team work process were developed from the aggregation of variables that could be associated with child care, collected in the three evaluation cycles. Figure 1 describes the PHCC structure indicators: health center operation; health center operation at special times; medication dispensing at the health center; health center facilities; equipment, material and supplies availability; vaccine availability; and rapid testing at the health center. The team work process indicators are also described in Figure 1: emergency care at the health center; team planning; matrix or institutional support received; defined catchment area and existence of maps; population without coverage; appointment scheduling; specialist appointment scheduling; clinical protocol use; exam request; service supply and demand control center; child follow-up; educational activities; and home visiting (Figure 1).

Data analysis was performed using SPSS® version 23 statistical software. First, the average percentage of each indicator was calculated, obtained from the sum of the observed variables divided by the total of the variables. Considering that the work process refers to team activities and that the analysis unit is the PHCC, which has one or more teams, the average percentage of the teamwork process indicators per PHCC was calculated. Next, the structure and work process indicators of each PMAQ-AB cycle were grouped, separately, for the PHCC level, using the National Registry of Health Establishments (CNES) code. Modules I and II of each cycle of the program were grouped by using the same code. The next step consisted of data stacking the three cycles in a single database at state level. Data analysis consisted of calculating averages and standard deviations (SD) per federative unit and geographical macro-region. Indicator averages between the regions were compared within each PMAQ-AB cycle, using the Student’s t-test with Bonferroni correction at a 0.05 significance level.

The study was approved by the Research Ethics Committee of the Federal University of Pelotas (Opinion No. 38, May 10, 2012) and complied entirely with the ethical precepts recommended by National Health Council Resolution No. 466, dated December 12, 2012.

Results

Of the 68,320 participating PHCCs, 25,124 (36.8%) were from the Northeast and 22,656 (33.2%) from the Southeast (Table 1). The Midwest region had the lowest number of participants, 4,963 (7.3%).

Table 1
Distribution of primary health care centers participating in the National Program for Primary Health Care Access and Quality Improvement (PMAQ-AB), by geographic macroregions, Brazil, 2012, 2014 and 2017/2018

The average percentages of the seven PHCC structure indicators are shown in Table 2. The highest adequacy percentages in the last PMAQ-AB cycle (2017/2018) were: health center operation (99%), equipment, material and supplies availability (82%), vaccine availability (74%) and medication dispensing at the health center (70%).

Table 2
Mean and standard deviation of health care center structure indicators for primary health care in the three cycles of the National Program for Primary Health Care Access and Quality Improvement (PMAQ-AB), by geographic macroregions, Brazil, 2012, 2014 and 2017/2018

In the external evaluation of the first cycle (2012), the Northern region PHCCs presented the highest average adequacy percentage (99%) for the ‘health center operation’ indicator. Northeast region health centers had the lowest result, both in the first (89%) and second evaluation cycles (98%). In the third cycle, the PHCCs of all regions had at least 99% adequacy for this indicator.

In the three cycles of the program, the Southeast region obtained the highest average percentages of PHCC operation at special times (lunchtime, night shift or weekends), with 57% on average in the first cycle, 23% in the second and 25% in the third. The lowest scores for this indicator were seen in the Northeast (31%) and Southern (33%) regions in the first cycle, the Northeast (10%) and Midwest (11%) in the second cycle and the Midwest (9%) in the third cycle.

Medication dispensing at PHCCs was most frequently provided in the North (85%) in the first cycle, whereas in the second cycle the Northeast (87%) and South (85%) obtained the highest average percentages. In the third cycle, the Northeast (85%) PHCCs continued to have the best results. The Southeast had the lowest results for this indicator, with 68% on average in the first cycle, 63% in the second, and 49% in the third.

The regions with the highest average percentages of equipment, material and supplies availability at PHCCs were: Southeast (72%) and South (71%), in the first cycle; South (77%), in the second; and Northeast (84%), South and Midwest (83%) in the third. The lowest results in all cycles were found in the North, with 56% on average in the first cycle, 68% in the second and 74% in the third.

Regarding vaccine availability at PHCCs, in the first two cycles of the program, the Midwest region had the highest average percentage (63% in the first cycle; and 71% in the second, along with the South), with no significant differences in relation to the other regions. In the third cycle, the Northeast (80%) obtained the highest average percentage of available vaccines.

In the first evaluation cycle, the North had a higher average percentage of rapid testing at PHCCs (10%). In the second cycle, the North continued to be the region with the highest provision of these tests (21%), followed by the South (20%). In the third cycle the South (80%) had the highest result (Table 2).

The results of the thirteen PHCC team work process indicators are shown in Table 3. The indicators with the lowest adequacy mean percentages in the last PMAQ-AB cycle (2017/2018) were ‘population without coverage’ (68%) and ‘specialist appointment scheduling’ (52%). Most of the process indicators achieved results above 70%, with no disparities between regions, in all evaluation cycles. The indicators with adequacy levels higher than 75% in all regions, in all three PMAQ-AB cycles, are worthy of mention: team planning; support received; defined catchment area and existence of maps; exam request; service supply and demand control center; child follow-up; and home visiting.

Table 3
Mean and standard deviation of primary health care team work process indicators in the three cycles of the National Program for Primary Health Care Access and Quality Improvement (PMAQ-AB), by geographic macroregions. Brazil, 2012, 2014 and 2017/2018

‘Emergency care at the health center’ indicator was customary among the PHCCs, with the indicator ranging from 73% (Northeast) to 77% (Midwest) in the first cycle, 75% (North) to 81% (Northeast) in the second cycle, and from 92% (South) to 94% (North and Midwest) in the third cycle.

Nationally, 39% of teams reported ‘population without coverage’ in the area around their PHCCs during the first cycle, 63% in the second, and 68% in the last evaluation.

In the first cycle, 52% (Southeast) to 59% (North) of PHCC teams made appointments for consultations; this average percentage ranged from 72% (Midwest) to 76% (South) in the second cycle, while in the third cycle the values ranged from 69% (Northeast and Southeast) to 71% (Midwest), without any significant regional differences. Nationally, specialist appointment scheduling scored 40%, 39% and 52% in the first, second and third cycles, respectively. In the last evaluation, the results showed no statistically significant differences between the regions.

Use of clinical protocols by PHCC teams scored a 60% (South) to 66% (Northeast) average in the first cycle; in the second cycle, it ranged from 59% (Midwest) to 65% (Northeast); and in the third cycle the highest score was 87%, in the North, with no statistical differences compared to the Northeast, Southeast and Midwest, all with 86%, while the South reported 85% of PHCCs following clinical protocols during care provision.

Educational activities conducted by PHCC teams were an indicator that showed homogeneity between the regions, except for the Midwest and Northeast, which showed the lowest average percentages in the first (MW: 65%) and second cycles (NE: 71%), respectively. In the third cycle, 86 or 87% percentage averages were found, with no statistically significant differences between the regions (Table 3).

Discussion

The results show few regional differences in the work process of PHCC teams in providing care to children in Brazil. Overall, it was found that PHCCs operate every working day, although there is a need to expand service provision to include special times.

There are differences in structural aspects between the regions, especially requiring adaptations to physical infrastructure and increasing availability of rapid testing and immunobiologicals. However, despite the structural deficiency scenario, staff work process adequacy scored higher percentages. Donabedian states that structure, work process and outcome are related in a probabilistic manner, not by causality.1111. Donabedian A. The quality of care. How can it be assessed? JAMA [Internet]. 1988 [cited 2020 Nov 6];23;260(12):1743-8. Available from: https://jamanetwork.com/journals/jama/article-abstract/374139
https://jamanetwork.com/journals/jama/ar...

The strengths of the study are primarily the significant and growing number of PHCCs and teams participating in each PMAQ-AB cycle, and the fact that the structure data were collected on-site by trained interviewers. This is a large national study, unprecedented in the evaluation of child care conditions in PHC, conducted in three periods within six years. However, the norms of PMAQ-AB, a voluntary program, constitute a significant limitation of this work. The teams were aware that they would be evaluated and therefore could have provided overstated data, since the better their performance, the greater the financial incentive they would receive. Caution is therefore needed in the generalization of the work process indicators. Other limitations of the study were restricting it to use of structural and procedural indicators without considering outcome indicators, as well as not including data from module III of the program that evaluated users’ perception of the quality of care given at the PHCCs.

The structure indicators show significant differences between PHCCs, according to the sociodemographic and political aspects of the different regions in Brazil.1414. Facchini LA, Tomasi E, Dilélio AS. Qualidade da Atenção Primária à Saúde no Brasil: avanços, desafios e perspectivas. Saúde Debate [Internet]. 2018 [citado 2019 jun 7];42:208-23. Disponível em: https://doi.org/10.1590/0103-11042018s114
https://doi.org/10.1590/0103-11042018s11...
This becomes all the clearer when the indicators related to physical infrastructure are analyzed, in particular availability of equipment, materials and supplies, the highest average adequacy percentages of which corresponded to the regions with the best economic indicators. The Midwest, Southeast and South had the highest scores for structure indicators, except for PHCC standard operating hours and rapid testing in the first cycle, medication dispensing in the first and third cycles, and vaccine availability in the third.

Investments in PHC, especially through PMAQ-AB, have improved the majority of the indicators analyzed. However, regional inequities related to the socioeconomic status of the geopolitical regions, Family Health Strategy coverage, and PHCC structure can be seen.1414. Facchini LA, Tomasi E, Dilélio AS. Qualidade da Atenção Primária à Saúde no Brasil: avanços, desafios e perspectivas. Saúde Debate [Internet]. 2018 [citado 2019 jun 7];42:208-23. Disponível em: https://doi.org/10.1590/0103-11042018s114
https://doi.org/10.1590/0103-11042018s11...
,1515. Bousquat A, Giovanella L, Fausto MCR, Fusaro ER, Mendonça MHM, Gagno J, et al. Tipologia da estrutura das unidades básicas de saúde brasileiras: os 5 R. Cad Saúde Pública [Internet]. 2017 [citado 2019 jun 10];33(8):e00037316. Disponível em: https://doi.org/10.1590/0102-311x00037316
https://doi.org/10.1590/0102-311x0003731...
Studies based on national data from the first PMAQ-AB cycle (2012), which analyzed PHCC structural adequacy for cervical cancer prevention and for care for people with diabetes mellitus, as well as a further nationwide descriptive study on PHCC structure for care for people with diabetes in the first two cycles of the program (2012 and 2014),1616. Tomasi E, Oliveira TF, Fernandes PAA, Thumé E, Silveira DS, Siqueira FV, et al. Estrutura e processo de trabalho na prevenção do câncer de colo de útero na Atenção Básica à Saúde no Brasil: Programa de Melhoria do Acesso e da Qualidade - PMAQ. Rev Bras Saúde Mater Infant [Internet]. 2015 [citado 2019 jun 10];15(2):171-80. Disponível em: https://doi.org/10.1590/S1519-38292015000200003
https://doi.org/10.1590/S1519-3829201500...

17. Tomasi E, Cesar MADC, Neves RG, Schmidt PRC, Thumé E, Silveira DS, et al. Diabetes care in Brazil: Program to Improve Primary Care Access and Quality-PMAQ. J Ambul Care Manage [Internet]. 2017 [cited 2019 June 10];40(Suppl 2):S12-23. Available from: https://doi.org/10.1097/JAC.0000000000000184
https://doi.org/10.1097/JAC.000000000000...
-1818. Neves RG, Duro SMS, Muñiz J, Castro TRP, Facchini LA, Tomasi E. Estrutura das unidades básicas de saúde para atenção às pessoas com diabetes: ciclos I e II do Programa Nacional de Melhoria do Acesso e da Qualidade. Cad Saúde Pública [Internet]. 2018 [citado 2019 jun 11];34(4):e00072317. Disponível em: https://doi.org/10.1590/0102-311x00072317
https://doi.org/10.1590/0102-311x0007231...
identified greater precarity in the PHCCs of the regions with lower socioeconomic indicators, i.e., the North and Northeast regions of Brazil.

In the first cycle, the Northeast did not perform better for any structure indicator and even had the worst scores for three of the indicators. However, in the third cycle, the Northeast was not among the worst performers, and obtained the best results for the ‘medication dispensing in the health center’, ‘equipment, materials and supplies’ and ‘vaccine availability’ indicators. In a national study conducted in 2012, when classifying PHCCs in five categories - unsatsfactory; rudimentary; limited; regular; reference -, pointed out that most PHCCs that were classified as ‘regular’ were located in the Northeast region, indicating efficiency in the application of financial resources. They also stressed that, despite poor investment in structure, it could be possible to achieve standards of excellence in the services they provide in the region.1515. Bousquat A, Giovanella L, Fausto MCR, Fusaro ER, Mendonça MHM, Gagno J, et al. Tipologia da estrutura das unidades básicas de saúde brasileiras: os 5 R. Cad Saúde Pública [Internet]. 2017 [citado 2019 jun 10];33(8):e00037316. Disponível em: https://doi.org/10.1590/0102-311x00037316
https://doi.org/10.1590/0102-311x0003731...

The ‘health center operation’ indicator showed good results in all regions of Brazil, right from the first PMAQ-AB cycle, scoring 100% adequacy in the North and Southeast (third cycle), with no statistical differences for the other regions. This finding shows PHCC compliance with Ministry of Health instructions to operate at least five days a week.33. Brasil. Ministério da Saúde. Portaria MS/GM 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) [Internet]. Diário Oficial da União, Brasília (DF), 2017 set 22 [citado 2019 out 5]. Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/prt2436_22_09_2017.html
http://bvsms.saude.gov.br/bvs/saudelegis...

PHCC operating at special times (lunchtime, night shift and/or weekends) was more common in the Southeast, in all evaluation cycles. However, in the third cycle, only a quarter of PHCCs in that region operated at those times. Unavailability of special times at PHCCs is a hindrance and compromises access to services.1919. Lima JG, Giovanella L, Fausto MCR, Bousquat A, Silva EV. Atributos essenciais da Atenção Primária à Saúde: resultados nacionais do PMAQ-AB. Saúde Debate [Internet]. 2018 [citado 2019 jun 11];42:52-66. Disponível em: https://doi.org/10.1590/0103-11042018s104
https://doi.org/10.1590/0103-11042018s10...

20. 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 [Internet]. 2019 [citado 2020 jan 5];35(2):e00095418. Disponível em: https://doi.org/10.1590/0102-311x00095418
https://doi.org/10.1590/0102-311x0009541...
-2121. Shimizu HE, Ramos MC. Avaliação da qualidade da estratégia saúde da família no Distrito Federal. Rev Bras Enferm [Internet]. 2019 [citado 2020 jan 5];72(2):385-92. Disponível em: https://doi.org/10.1590/0034-7167-2018-0130
https://doi.org/10.1590/0034-7167-2018-0...
To change this situation, in 2019, the Ministry of Health launched the ‘Saúde na Hora’ [‘Health on the Spot’] program to extend service provision times at PHCCs by providing financial incentives to the Family Health Strategy and Oral Health teams.2222. Brasil. Ministério da Saúde. Portaria MS/GM no 930, de 15 de maio de 2019. Institui o Programa ‘Saúde na Hora’, que dispõe sobre o horário estendido de funcionamento das Unidades de Saúde da Família [Internet]. Diário Oficial da União , Brasília (DF), 2010 maio 16 [citado 2019 nov 1]. Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2019/prt0930_17_05_2019.html
http://bvsms.saude.gov.br/bvs/saudelegis...

PHCC building infrastructure showed better adequacy in the Southeast and Midwest, in the first and third evaluation cycles, and in the South in the second cycle. However, in the third cycle, even in the regions with the best scores, only half the PHCC building structure items were found to be in ideal conditions. Deficient physical infrastructure is admittedly one of the limitations to comprehensive child health care in PHC.2323. Damasceno SS, Nóbrega VMD, Coutinho SED, Reichert APS, Toso BRGO, Collet N. Saúde da criança no Brasil: orientação da rede básica à Atenção Primária à Saúde. Ciênc Saúde Coletiva [Internet]. 2016 [citado 2019 jun 11];21(9):2961-73. Disponível em: https://doi.org/10.1590/1413-81232015219.25002015
https://doi.org/10.1590/1413-81232015219...
Such structural inadequacies are linked to the large number of health centers operating in makeshift locations, such as adapted residences, for example.2323. Damasceno SS, Nóbrega VMD, Coutinho SED, Reichert APS, Toso BRGO, Collet N. Saúde da criança no Brasil: orientação da rede básica à Atenção Primária à Saúde. Ciênc Saúde Coletiva [Internet]. 2016 [citado 2019 jun 11];21(9):2961-73. Disponível em: https://doi.org/10.1590/1413-81232015219.25002015
https://doi.org/10.1590/1413-81232015219...

The ‘equipment, materials and supplies’ indicator scored better, so that in the third cycle, PHCCs had more than eight out of ten material resources needed for child care. This data represents an improvement in PHC provision and resolutive capacity, meeting the wishes of health workers for better care conditions in this health care scenario2323. Damasceno SS, Nóbrega VMD, Coutinho SED, Reichert APS, Toso BRGO, Collet N. Saúde da criança no Brasil: orientação da rede básica à Atenção Primária à Saúde. Ciênc Saúde Coletiva [Internet]. 2016 [citado 2019 jun 11];21(9):2961-73. Disponível em: https://doi.org/10.1590/1413-81232015219.25002015
https://doi.org/10.1590/1413-81232015219...
Lack of equipment and supplies at PHCCs is an important limitation for team performance.1515. Bousquat A, Giovanella L, Fausto MCR, Fusaro ER, Mendonça MHM, Gagno J, et al. Tipologia da estrutura das unidades básicas de saúde brasileiras: os 5 R. Cad Saúde Pública [Internet]. 2017 [citado 2019 jun 10];33(8):e00037316. Disponível em: https://doi.org/10.1590/0102-311x00037316
https://doi.org/10.1590/0102-311x0003731...

Vaccine availability was greater in the Southeast, Midwest and South in the first two cycles. Whereas in the last cycle, the Northeast performed better, with eight out of ten vaccines available at its PHCCs. However, nationally, a quarter of vaccines were unavailable in the third cycle. A similar result was found in a study that evaluated management and quality of PHCC services in the midwestern region of São Paulo state.2424. Nunes LO, Castanheira ERL, Dias A, Zarili TFT, Sanine PR, Mendonça CS, et al. Importância do gerenciamento local para uma atenção primária à saúde nos moldes de Alma-Ata. Rev Panam Salud Pública [Internet]. 2018 [citado 2019 nov 4];42:e175. Disponível em: https://doi.org/10.26633/RPSP.2018.175
https://doi.org/10.26633/RPSP.2018.175...
Unavailability of immunobiologicals recommended for child care may have contributed to the failure of many Brazilian municipalities to meet vaccination goals, and coverage of several vaccines shows a decline in relation to previous years.2525. Braz RM, Domingues CMAS, Teixeira AMDS, Luna EJDA. Classificação de risco de transmissão de doenças imunopreveníveis a partir de indicadores de coberturas vacinais nos municípios brasileiros. Epidemiol Serv Saúde [Internet]. 2016 out-dez [citado 2019 jun 22];25(4):745-54. Disponível em: https://doi.org/10.5123/s1679-49742016000400008
https://doi.org/10.5123/s1679-4974201600...
,2626. Waissmann W. Cobertura vacinal em declínio: hora de agir! Vigil Sanit Debate [Internet]. 2018 [citado 2019 nov 5];6(3):1-3. Disponível em: https://visaemdebate.incqs.fiocruz.br/index.php/visaemdebate/article/view/1189
https://visaemdebate.incqs.fiocruz.br/in...
Other factors that influence this scenario could be hesitation by the population to adhere to vaccination programs2727. Sato APS. Qual a importância da hesitação vacinal na queda das coberturas vacinais no Brasil? Rev Saúde Pública [Internet]. 2018 [citado 2019 nov 20];52(9):1-9. Disponível em: https://doi.org/10.11606/S1518-8787.2018052001199
https://doi.org/10.11606/S1518-8787.2018...
and lack of time for those responsible to take their children to PHCCs at regular service hours, since less than one fifth of PHCCs worked at special times in the third cycle.2525. Braz RM, Domingues CMAS, Teixeira AMDS, Luna EJDA. Classificação de risco de transmissão de doenças imunopreveníveis a partir de indicadores de coberturas vacinais nos municípios brasileiros. Epidemiol Serv Saúde [Internet]. 2016 out-dez [citado 2019 jun 22];25(4):745-54. Disponível em: https://doi.org/10.5123/s1679-49742016000400008
https://doi.org/10.5123/s1679-4974201600...

Rapid testing at PHCCs was the indicator with the second greatest discrepancy between the regions. In the Southeast and Northeast, only slightly more than half the rapid tests were available, while in the South, eight out of ten test types were available. Nationally, the data show that testing availability needs to be expanded, since only six out of ten rapid tests recommended by the Ministry of Health were provided at PHCCs, according to this study.

Rapid testing allows pregnancy detection in the first trimester, start of prenatal follow-up, and especially early detection of syphilis, HIV, hepatitis and malaria, enabling timely diagnosis and appropriate treatment for each condition. A study that analyzed data from the second PMAQ-AB cycle found that PHCCs where rapid testing for syphilis was available expanded case reporting among pregnant women, enabled adequate treatment and reduced vertical transmission of Treponema pallidum.2828. Figueiredo DCMM, Figueiredo AM, Souza TKB, Tavares G, Vianna RPT. Relação entre oferta de diagnóstico e tratamento da sífilis na atenção básica sobre a incidência de sífilis gestacional e congênita. Cad Saúde Pública [Internet]. 2020 [citado 2020 abr 5];36(3):e00074519. Disponível em: https://doi.org/10.1590/0102-311x00074519
https://doi.org/10.1590/0102-311x0007451...
Therefore, rapid test availability at PHCCs produces immediate benefits for the population, especially pregnant women and children.

The results of this study show that the work process indicators are more adequate and show greater uniformity between the regions, most of which achieved results above 70% in all evaluation cycles. The exceptions were: ‘appointment scheduling’ in the first cycle; ‘clinical protocol use’ in care provision in the first and second cycles; and specialist appointment scheduling and ‘population without coverage’ in all three cycles. Using national data from the 2014 PMAQ-AB in their study, found that six out of ten teams achieved a high level of quality (70% adequacy or more) in childcare, as a result of investments, establishment and strengthening of programs with direct or indirect impact on child health. 2929. Cruz MJB, Santos AF, Araújo LHL, Andrade EIG. A coordenação o do cuidado na qualidade da assistência à saúde da mulher e da criança no PMAQ. Cad Saúde Pública [Internet]. 2019 [citado 2020 abr 5];35(11):e00004019. Disponível em: https://doi.org/10.1590/0102-311x00004019
https://doi.org/10.1590/0102-311x0000401...

In all three evaluation cycles, it was found that over 70% of PHCCs provided emergency services, in all regions, with minor differences between them. In the third cycle, nine out of ten teams performed emergency services, showing compliance with Ministry of Health recommendations. PHCCs, as part of the Health Care network, must ensure initial care for less complex emergency situations3030. Laurindo MV, Ribeiro LML, Lima PS, Bastos ECB, Costa ANB, Vasconcelos FF, et al. A importância de adaptar as unidades básicas de saúde para o atendimento de urgências e emergências de menor complexidade. Braz J Hea Rev [Internet]. 2019 [citado 2020 abr 22];2(3):1688-709. Disponível em: http://www.brazilianjournals.com/index.php/BJHR/article/view/1434
http://www.brazilianjournals.com/index.p...
and thus it is essential that their teams are prepared to adequately attend to these scenarios.3030. Laurindo MV, Ribeiro LML, Lima PS, Bastos ECB, Costa ANB, Vasconcelos FF, et al. A importância de adaptar as unidades básicas de saúde para o atendimento de urgências e emergências de menor complexidade. Braz J Hea Rev [Internet]. 2019 [citado 2020 abr 22];2(3):1688-709. Disponível em: http://www.brazilianjournals.com/index.php/BJHR/article/view/1434
http://www.brazilianjournals.com/index.p...

It can be concluded that in all three PMAQ-AB evaluation cycles, the PHCC teamwork process showed better results and greater uniformity between the regions, when compared to the service structure indicators. Well applied investments in the structure of primary health care centers should promote immediate improvements in these indicators, facilitating the provision of universal, equitable, comprehensive and quality care in all regions, in order to meet the goals of promoting and protecting child health in Brazil.

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Publication Dates

  • Publication in this collection
    26 Mar 2021
  • Date of issue
    Jan-Dec 2021

History

  • Received
    29 June 2020
  • Accepted
    01 Oct 2020
Secretaria de Vigilância em Saúde - Ministério da Saúde do Brasil Brasília - Distrito Federal - Brazil
E-mail: leilapgarcia@gmail.com