Abstract

This article aims to characterize financial transfers within the scope of the Primary Care Block to the municipalities of the state of São Paulo, in the period between 2011 and 2017, and its relationship with the health care model change in Primary Health Care (PHC). This is a descriptive and exploratory study, of quantitative nature and with a retrospective longitudinal section. Transfers that occurred within the scope of the Variable Primary Care Floor (Variable PCF) were analyzed, aggregated according to its link with the model change. Family Health Strategy (FHS) coverage, number of home visits, and the percentage of municipalities that adhered to the Program for Access and Quality Improvement in Primary Care (PMAQ) were also considered. The results indicate the relevance of the Incentives for model change in the financing of primary health care in the state of São Paulo, especially for small municipalities, suggesting the interest of these municipalities in implementing the proposed measures. However, there are obstacles to identifying changes in practices, thus the current health care model is not properly explained from the analyzed indicators. In conclusion, complementing the use of funding as a model change-inducing device with evaluative processes specifically aimed at consolidating comprehensive PHC is needed.

Keywords:
Healthcare Financing; Primary Health Care; Health Management; Health Policy; Brazilian National Health System

Introduction

The health care model refers to the form or mode of production in health services, in a given historical-social context, based on the synergy of multiple factors, including: technologies, values, practices, legal framework, management model and financial and material resources, with the aim of building discourses, projects and policies (Fertonani et al., 2015FERTONANI, H. P. et al. Modelo assistencial em saúde: conceitos e desafios para a atenção básica brasileira. Ciência & Saúde Coletiva , Rio de Janeiro, v. 20, p. 1869-1878, 2015.).

For Primary Care (PC), in a universal system such as Brazil’s, the most appropriate care model is based on comprehensiveness, just like Giovanella and Mendonça (2012GIOVANELLA, L.; MENDONÇA, M. H. M. Atenção primária à saúde. In: GIOVANELLA, L., et al. (Org.). Políticas e sistema de saúde no Brasil. Rio de Janeiro: Fiocruz; Cebes, 2012. p. 493-545.) name as comprehensive or complete Primary Health Care (PHC), given its greatest potential to impact the health situation, people’s autonomy and the social determinants of the health-disease process. This model is characterized by the attributes of first contact, longitudinality, scope or completeness, care coordination, community orientation, centrality in the family and cultural competence, similarly to what Starfield (2002STARFIELD, B. Atenção primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília, DF: Unesco; Ministério da Saúde, 2002.) proposes.

There are disputes around the concepts that underlie comprehensive PHC, such as health promotion and the social determination of the health-disease process, which would have been emptied of their political content that transforms the social reality as they have been incorporated into the national health policy since the 1980s (Mendes; Carnut; Guerra, 2018MENDES, A.; CARNUT, L.; GUERRA, L. D. da S. Reflexões acerca do financiamento federal da Atenção Básica no Sistema Único de Saúde. Saúde em Debate , Rio de Janeiro, v. 42, p. 224-243, 2018.). Despite the importance of this debate, it is possible to state that a certain notion of comprehensive PHC is consolidated from the 2011 National Primary Care Policy (PNAB) (Brasil, 2011BRASIL. Ministério da Saúde. Portaria nº 2.488, de 21 de outubro de 2011. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes e normas para a organização da Atenção Básica, para a Estratégia Saúde da Família (ESF) e o Programa de Agentes Comunitários de Saúde (PACS). Diário Oficial da União, Brasília, DF, 22 out. 2011. Disponível em: <Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt2488_21_10_2011.html >. Acesso em: 10 ago. 2022
https://bvsms.saude.gov.br/bvs/saudelegi... ).

The PNAB 2011 has, in the Family Health Strategy (FHS), the priority model for implementing these comprehensive PHC premises, as it proposes proximity to the territory, actions in the community, intersectoriality, interdisciplinarity, longitudinality, bond, co-responsibility and articulation between surveillance and health promotion actions, with disease prevention and treatment. To this end, it provides for the participation of Community Health Agents (CHA) and professionals from the Family Health Support Center (FHSC), working in an integrated manner with intersectoral programs aimed at comprehensive care, such as Health at School, Health Academy and Street Office teams (Brasil, 2012bBRASIL. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Atenção Básica. Brasília, DF, 2012b.). All these programs, as well as the FHS and FHSC teams, receive funding from the federal government, but their execution and monitoring are the responsibility of municipal management.

Federal resource transfers have been used as one of the induction strategies for public health policies. Several authors understand that this aspect of financing the Brazilian National Health System (SUS), which is not limited to PC, tends to weaken the autonomy of municipalities in the design of policies based on local health needs, going against the principle of decentralization (Mendes; Carnut; Guerra, 2018MENDES, A.; CARNUT, L.; GUERRA, L. D. da S. Reflexões acerca do financiamento federal da Atenção Básica no Sistema Único de Saúde. Saúde em Debate , Rio de Janeiro, v. 42, p. 224-243, 2018.; Piola, 2017PIOLA, S. F. Transferências de recursos federais do sistema único de saúde para estados, distrito federal e municípios: os desafios para a implementação dos critérios da lei complementar n. 141/2012. Brasília, DF: IPEA, 2017.; Duarte; Mendes; Louvison, 2018DUARTE, L. S.; MENDES, Á. N.; LOUVISON, M. C. P. O processo de regionalização do SUS e a autonomia municipal no uso dos recursos financeiros: uma análise do estado de São Paulo (2009-2014). Saúde em Debate, Rio de Janeiro, v. 42, p. 25-37, 2018.). Even though there is no consensus among authors in the Public Health field regarding the use of this policy-inducing mechanism, it is necessary to assume its existence and wide use. Therefore, it should be noted that this type of strategy needs to be complemented with constant monitoring and evaluation of these investments. In the case of FHS, it would be worth highlighting the monitoring not only of the health indicators resulting from it, but also the care model that guides the practices that have promoted such results.

The Family Health Strategy is widely recognized as guiding the organization of SUS in the national territory, obtaining good results in health indicators referring mainly to maternal and child mortality and reduction of hospitalizations for causes sensitive to PC among patients with chronic diseases (Morosini; Fonseca; Baptista, 2020MOROSINI, M. V. G. C.; FONSECA, A. F.; BAPTISTA, T. W. de F. Previne Brasil, Agência de Desenvolvimento da Atenção Primária e Carteira de Serviços: radicalização da política de privatização da atenção básica? Cadernos de Saúde Pública , Rio de Janeiro , v. 36, e00040220, 2020.; IPEA, 2019IPEA - INSTITUTO DE PESQUISA ECONÔMICA APLICADA. Saúde. In. IPEA - INSTITUTO DE PESQUISA ECONÔMICA APLICADA. Políticas Sociais: acompanhamento e análise - n. 26. Brasília, DF, 2019. p. 85-128.; Macinko; Mendonça, 2018MACINKO, J.; MENDONÇA, C. S. Estratégia Saúde da Família, um forte modelo de Atenção Primária à Saúde que traz resultados. Saúde em Debate , Rio de Janeiro, v. 42, p. 18-37, 2018.; Pinto; Giovanella, 2018PINTO, L. F.; GIOVANELLA, L. Do Programa à Estratégia Saúde da Família: expansão do acesso e redução das internações por condições sensíveis à atenção básica (ICSAB). Ciência & Saúde Coletiva , Rio de Janeiro , v. 23, p. 1903-1914, 2018.). However, studies have already found that, often, the model of care that guides practices continues to be the biomedical one (Fertonani et al., 2015FERTONANI, H. P. et al. Modelo assistencial em saúde: conceitos e desafios para a atenção básica brasileira. Ciência & Saúde Coletiva , Rio de Janeiro, v. 20, p. 1869-1878, 2015.). These studies suggest that PC continues to transit between the FHS model and the hegemonic care model, which reiterates the importance of specific monitoring in this regard, aiming at strengthening the comprehensive PHC and a more complete model (Mendes-Gonçalves, 2017MENDES-GONÇALVES, R. B. Práticas de saúde e tecnologia: contribuição para a reflexão teórica. In: AYRES, R. C. M.; SANTOS, L. Saúde, Sociedade e História. São Paulo: Hucitec; Porto Alegre: Rede UNIDA , 2017. p. 192-250.; Paim, 2012PAIM, J. S. Modelos de Atenção à Saúde no Brasil. In: GIOVANELLA, L. et al. (Org.). Políticas e sistema de saúde no Brasil . Rio de Janeiro : Fiocruz e Cebes, 2012. p. 459-493.).

In addition to the challenging context regarding the evaluation of practices and the care model underlying them, the need to investigate investments for changing the model in Primary Care, in the sense of comprehensive PHC, is justified by the uncertainties about the possible impacts of the changes promoted upon approval of the 2017 PNAB (Brasil, 2017BRASIL. Ministério da Saúde. 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). Diário Oficial da União, Brasília , DF, 2017. Disponível em: <Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/prt2436_22_09_2017.html >. Acesso em: 10 ago. 2022
https://bvsms.saude.gov.br/bvs/saudelegi... ) and the new funding proposed by the Previne Brasil Program in 2019. These measures have been seen as retrogressions to the FHS model and, therefore, to the comprehensive PHC, we would therefore need to have adequate resources for monitoring related to this care model (Morosini; Fonseca; Baptista, 2020MOROSINI, M. V. G. C.; FONSECA, A. F.; BAPTISTA, T. W. de F. Previne Brasil, Agência de Desenvolvimento da Atenção Primária e Carteira de Serviços: radicalização da política de privatização da atenção básica? Cadernos de Saúde Pública , Rio de Janeiro , v. 36, e00040220, 2020.; Giovanella; Franco; Almeida, 2020GIOVANELLA, L.; FRANCO, C. M.; ALMEIDA, P. F. de. Política Nacional de Atenção Básica: para onde vamos? Ciência & Saúde Coletiva , Rio de Janeiro, v. 25, p. 1475-1482, 2020.).

In evaluating the care model, it is important to understand the work process and the practices resulting from it (Mendes-Gonçalves, 2017MENDES-GONÇALVES, R. B. Práticas de saúde e tecnologia: contribuição para a reflexão teórica. In: AYRES, R. C. M.; SANTOS, L. Saúde, Sociedade e História. São Paulo: Hucitec; Porto Alegre: Rede UNIDA , 2017. p. 192-250.), as well as the arrangements made from regional diversities (Lima et al., 2019LIMA, L. D. de. et al. Arranjos regionais de governança do Sistema Único de Saúde: diversidade de prestadores e desigualdade espacial na provisão de serviços. Cadernos de Saúde Pública, Rio de Janeiro, v. 35, e00094618, 2019.; Morais et al., 2018MORAIS, H. M. M. de. et al. Organizações Sociais da Saúde: uma expressão fenomênica da privatização da saúde no Brasil. Cadernos de Saúde Pública , Rio de Janeiro , v. 34, e00194916, 2018.) and the realities of each municipality (Castro; Oliveira; Cunha, 2016CASTRO, C. P.; OLIVEIRA, M. M.; CUNHA, G. T. O programa nacional de melhoria do acesso e da qualidade na atenção básica sob a perspectiva de um estudo qualitativo. In: CECCIM, R. B.; et al. (Org.). Intensidade na Atenção Básica: prospecção de experiências, informes e pesquisa-formação. Porto Alegre: Rede UNIDA, 2016. p. 163-194.; Pinto; Giovanella, 2018PINTO, L. F.; GIOVANELLA, L. Do Programa à Estratégia Saúde da Família: expansão do acesso e redução das internações por condições sensíveis à atenção básica (ICSAB). Ciência & Saúde Coletiva , Rio de Janeiro , v. 23, p. 1903-1914, 2018.). It is not, therefore, about a banal task, as it requires the compilation of different indicators and an integrative analysis strategy.

Thus, this study aims to characterize financial transfers within the scope of the Primary Care Block (PC Block) to the municipalities of the state of São Paulo (SP) in the period between 2011 and 2017 and their relationship with the model changing process, towards achieving comprehensive PHC.

The state of SP was chosen and adopted as a privileged locus, due to the coexistence of sometimes antagonistic arrangements and models, represented by the implementation of FHS teams concomitantly with traditional Basic Units, which makes the Family Health Strategy’s coverage in the southeast region be smaller (Miclos; Calvo; Colussi, 2017MICLOS, P. V.; CALVO, M. C. M.; COLUSSI, C. F. Avaliação do desempenho das ações e resultados em saúde da atenção básica. Revista de Saúde Pública, São Paulo, v. 51, p. 86, 2017.). In a scenario with such characteristics, it is considered that it would be urgent to monitor the impacts of the financial transfer for changing the model, in the name of expanding practices consistent with comprehensive PC.

Methodology

This is a descriptive and exploratory study, of a quantitative nature and retrospective longitudinal section. In view of the objective of this study and the importance that the 2011 PNAB had in promoting actions and strategies aimed at a comprehensive PHC and the setbacks pointed out by the 2017 PNAB, the analysis covered the period from 2011 to 2017.

Information on resource transfers from the federal sphere to municipal governments was collected from the National Health Fund (NHF) website for the 645 municipalities in the state of São Paulo (SP). Transfers of these resources to the Municipal Health Funds (MHF) in SP within the scope of the Primary Care Block were selected. These financial transfers are carried out for two components: the Fixed Primary Care Floor (Fixed PCF) and the Variable Primary Care Floor (variable PCF).

Given that the value of the fixed PCF passed on during the study period had only the municipalities’ number of inhabitants as a reference, it is considered that the financial incentives linked to policies that promote change in the PHC model occurred within the scope of the variable PCF. In this way, the 39 records of actions and strategies identified in the Variable Basic Care Floor component were aggregated into categories that would allow discriminating the incentives that promote comprehensive PHC. Four categories were proposed, three of which refer to such discrimination: Community Health Agents (CHA); Family Health Program (FHP); and Other incentives for changing the model (Other incentives), the latter being the aggregation of less prominent incentives, but which need to be considered when aiming to change the model. It is understood that organizing transfers linked to comprehensive PHC into these three categories allows for a better qualification of transferred resources. The fourth and last category, called Other Variable PCF actions and strategies (Other Variable PCF), aims to identify transfers that are not linked to the model change. The aggregations according to the chosen categories are detailed in Chart 1.

When considering the importance of the Mais Médicos Program (PMM) as a potential factor for promoting comprehensive PHC in the analyzed period, given the need to hire doctors to register new FHS teams (Giovanella; Franco; Almeida, 2020GIOVANELLA, L.; FRANCO, C. M.; ALMEIDA, P. F. de. Política Nacional de Atenção Básica: para onde vamos? Ciência & Saúde Coletiva , Rio de Janeiro, v. 25, p. 1475-1482, 2020.; Brasil, 2015BRASIL. Ministério da Saúde. Secretaria de Gestão do Trabalho e da Educação na Saúde. Programa mais médicos - dois anos: mais saúde para os brasileiros. Brasília, DF, 2015.), it was necessary to estimate the values of scholarships paid to professionals linked to this policy in the municipalities of São Paulo. These amounts could not be identified in NHF transfers as they represent direct federal government spending. Adding this estimate in each municipality, in the period from 2013 to 2017, to the transfers of resources to the same cities within the scope of the AB Block allows to identify with greater precision the financial investments in the strengthening of the comprehensive PHC carried out by the federal government in the analyzed period.

The estimate was based on information sent by the Secretariat for Management of Work and Education in Health, of the Ministry of Health, on May 21, 2018, based on a request made by the authors. Of the 4,927 existing records in the original database (doctors’ contracts), 148 records with inconsistencies in the doctor’s dates of entry and/or departure, necessary for calculating the duration of employment and the amount spent, were excluded. From the adjusted database, it was possible to impute the value of R$ 10,513.00 for each complete month with the presence of a doctor linked to the PMM, thus estimating the total value of scholarships spent by the federal government in each of the 389 municipalities of the state of SP who participated in the program. The estimation results were aggregated into a fifth category.

The values of transfers from the NHF to the São Paulo MHF and the estimate of the PMM scholarships were deflated using the General Price Index - Internal Availability of Fundação Getúlio Vargas, average value of the year, converted to the price of December 2017, thus allowing the comparison in the historical series in real value.

Bearing in mind that the fixed PCF is transferred without requirements for specific actions by the municipalities; and the variable PCF, by adherence to the policies proposed by the federal government (Piola, 2017PIOLA, S. F. Transferências de recursos federais do sistema único de saúde para estados, distrito federal e municípios: os desafios para a implementação dos critérios da lei complementar n. 141/2012. Brasília, DF: IPEA, 2017.), it is understood that the relationship between the amounts transferred in these two transfer components indicates the tendency of municipal management to engage in certain health care strategies. The same can be said of the efforts made by the municipality in joining the PMM, since, after voluntarily joining the program, they assumed the commitment to provide housing, food and transportation for professionals, to adapt the functioning of the Basic Health Units (UBS), among others (Brasil, 2015BRASIL. Ministério da Saúde. Secretaria de Gestão do Trabalho e da Educação na Saúde. Programa mais médicos - dois anos: mais saúde para os brasileiros. Brasília, DF, 2015.).

In a second moment, the values of the categories “Community Health Agents (CHA)”, “Family Health Program (FHP)”, “Other incentives for model change (Other incentives)” and the estimated values for the “PMM Scholaships” were added to compose the Incentives for model change amount.

In order to differentiate the municipalities according to their effort in structuring actions and strategies linked to comprehensive PHC and adequately scale municipal efforts, the per capita value of the Incentives for model change and the fixed PCF was estimated, in the period from 2011 to 2017, and the relationship between them. The number of inhabitants used for the calculation was that of the population projection for the year 2014 by the State Data Analysis System Foundation (Seade)²2Data from <https://populacao.seade.gov.br/>. Access on: Oct. 31, 2020. (São Paulo, 2020).

In view of the importance of considering the population size of the municipality to understand the dynamics of FHS implementation, as already pointed out by several studies (Pinto and Giovanella, 2018PINTO, L. F.; GIOVANELLA, L. Do Programa à Estratégia Saúde da Família: expansão do acesso e redução das internações por condições sensíveis à atenção básica (ICSAB). Ciência & Saúde Coletiva , Rio de Janeiro , v. 23, p. 1903-1914, 2018.; Miclos; Calvo; Colussi, 2017MICLOS, P. V.; CALVO, M. C. M.; COLUSSI, C. F. Avaliação do desempenho das ações e resultados em saúde da atenção básica. Revista de Saúde Pública, São Paulo, v. 51, p. 86, 2017.; Castro; Oliveira; Cunha, 2016CASTRO, C. P.; OLIVEIRA, M. M.; CUNHA, G. T. O programa nacional de melhoria do acesso e da qualidade na atenção básica sob a perspectiva de um estudo qualitativo. In: CECCIM, R. B.; et al. (Org.). Intensidade na Atenção Básica: prospecção de experiências, informes e pesquisa-formação. Porto Alegre: Rede UNIDA, 2016. p. 163-194. ; Viana et al., 2008VIANA, A. L. d’A. et al. Atenção Básica e dinâmica urbana nos grandes municípios paulistas, Brasil. Cadernos de Saúde Pública , Rio de Janeiro , v. 24, n. 1, p. S79-S90, 2008.), municipalities were aggregated according to four groups by population size: (1) less than 10,000 inhabitants; (2) 10,000-50,000 inhabitants; (3) 50,000-100,000 inhabitants; and (4) more than 100,000 inhabitants.

With the objective of identifying the municipalities that stand out for their efforts in raising funds for the structuring of the comprehensive PHC, those that made up the fourth quartile of the per capita ratio between the Incentives for model change and the Fixed PCF, from 2011 to 2017. The 162 municipalities identified were called highlighted municipalities.

To verify the structuring of the comprehensive PHC, the following were selected for the same period: the Family Health Strategy coverage indicators, which indicate whether there was an increase in the number of FHS in the municipalities; home visits per inhabitant covered by the Family Health Team (FHT), understanding that the home visit is one of the main actions proposed by the comprehensive PHC; and, in addition, the percentage of municipalities that joined the Program for Access and Quality Improvement in Primary Care (PMAQ). We understand that PMAQ constitutes an evaluative initiative focused on the work process and guided by FHS guidelines, and that voluntary adherence to it, which could generate financial rewards through higher scores, can be an indication, albeit indirect, of the manager’s availability and confidence in being evaluated according to the attributes proposed by the comprehensive PHC.

For collecting data regarding FHS coverage, estimated data on the covered population and the total population were used, provided by the Ministry of Health (MS) in the E-gestor AB for the years 2011 to 2017, referring to the month of July. For collecting data on home visits, we surveyed the total number of visits carried out in 2011, made available by the Primary Care Information System (SIAB)³3Data available at: <http://www2.datasus.gov.br/SIAB/index.php?area=04 >. Access on: Oct. 31, 2020., and the total number of visits carried out by the FHT, PC Team and CHA Team in 2017, available in the Health Information System for Primary Care (SISAB)⁴4Data available at: <https://sisab.saude.gov.br/> Access on: Oct. 31, 2020.. It is noteworthy that SISAB replaced SIAB and was implemented between 2013 and 2015 through the “e-SUS AB” strategy (Thum; Baldisserotto; Celeste, 2019THUM, M. A.; BALDISSEROTTO, J. CELESTE, R. K. Utilização do e-SUS AB e fatores associados ao registro de procedimentos e consultas da atenção básica nos municípios brasileiros. Cadernos de Saúde Pública , Rio de Janeiro , v. 35, e00029418, 2019.). Finally, the data regarding adherence to the PMAQ were obtained from the databases collected in the 1st and 3rd Cycles made available on the Program’s website.

Results

Transfers from MHF to PC Block represented, on average, 28.2% of the total transferred to municipalities. In Table 1 it can be seen that the total amount transferred in this block over the seven years was 16.27 billion reais, in corrected values, half of which for the fixed PCF and the other for the variable PCF. It is also observed that the resources are increasing over the years 2011 to 2015, with a reduction in the years 2016 and 2017.

Among the values transferred to the variable PCF, a large part was directed to components linked to the inducing policies of the care model for a comprehensive PHC. Of the 8.13 billion reais transferred to the variable PCF, 90.0% of this amount included components linked to these policies, such as CHA (35.0%), FHP (34.0%) and Other incentives for model change (21.1%).

When added to the 1.16 billion reais related to scholarships paid under the PMM, in the period from 2011 to 2017, we arrive at the value of 8.49 billion reais, identified as Incentives for model change.

As shown in Table 2, the distribution of this value by São Paulo municipalities, aggregated by population size, allows us to verify that the largest ones, with a population above 100 thousand inhabitants, account for 62.0% of the Incentives for model change in the analyzed period (5.26 billion reais). At the other end, smaller municipalities, with up to 10,000 inhabitants, account for 8.9% of the value (703.43 million reais). It is worth mentioning that this same analysis, considering the 8.14 billion reais allocated to the Fixed PCF, makes it possible to identify a higher concentration in larger municipalities, of 71.2% (5.79 billion reais), while the smaller ones received 4.4% of these transfers (361.6 million reais).

On the other hand, the per capita analysis of resources shows that smaller municipalities have a higher value per inhabitant, both in relation to the fixed PCF and the Incentives for model change, of R$ 263.07 and R$ 511.75, respectively. At the other end, larger municipalities have the lowest values, with R$ 181.71 and R$ 165.03, respectively. A gradual increase in per capita values is observed as the population size of the municipality decreases.

The average ratio between the Incentives to change model and the fixed PCF of the municipalities shows that, the smaller the municipality, the greater the value of the Incentives for model change , as compared to the fixed PCF. While the mean ratio among the 645 municipalities is 1.6, in cities with less than 10,000 inhabitants it is 2.1, gradually decreasing as the population size increases, until reaching 0.8 in municipalities with more than 100 thousand inhabitants.

Figure 1 allows dimensioning in the set of highlighted municipalities the difference between the per capita transfer of Incentives for model change (R$ 372.36) and the fixed PCF (R$ 198.77), in the period from 2011 to 2017. The amplitude of this difference increases as the population size of the municipality decreases, and the per capita value of Incentives for model change in the population group with less than 10 thousand inhabitants (R$ 821.72) it is more than three times the value of the Fixed PCF (R$ 246.24).

The per capita value of Incentives for model change among the highlighted municipalities (R$ 372.36) represents 1.9 times the value among the total municipalities (R$ 198.89). It is possible to observe that the greatest differences are found in municipalities with larger populations.

The smaller the population size of the municipality, the greater the FHS coverage. It is observed that the highlighted municipalities had greater coverage in the two analyzed periods, 2011 and 2017, as well as a smaller variation difference in the period, as compared to the total of municipalities. Despite the lower coverage, the highlighted municipalities with more than 100,000 inhabitants show a wide variation in FHS coverage at the time analyzed (35.4%), as can be seen in Table 3.

Regarding home visits and highlighted municipalities, in 2011 only municipalities with more than 100,000 inhabitants differed in relation to the total set. In 2017, only municipalities with 50,000 to 100,000 inhabitants did not differ in relation to the total.

The highlighted municipalities showed greater adherence to the PMAQ in 2011 and 2017, especially those with more than 50,000 inhabitants. It is noteworthy that, in 2017, 100% of them joined the program.

Discussion

The study sought to aggregate and describe incentives for changing the model in PC in order to consolidate comprehensive PHC. Its results made it possible to highlight the importance of Incentives for model change in transfers from the NHF to the São Paulo MHF, in the analyzed period. It was verified that the incentives for the FHP and PACS continued to be preponderant, even though over time several new strategies have been formulated and financed. It was possible to observe that the smallest municipalities are relatively more benefited by the Incentives for model change.

In general, the way resources are transferred, for both the fixed PCF and the variable PCF, in particular for the FHP, seeks to correct inequalities in this distribution, favoring smaller municipalities with higher values. Regarding the fixed PCF, this adjustment is made according to population size and criteria that consider demographic density, vulnerability condition and population covered by private health plans (Mendes; Marques, 2014MENDES, A; MARQUES, R. M. O financiamento da atenção básica e da Estratégia Saúde da Família no Sistema Único de Saúde. Saúde em Debate , Rio de Janeiro, v. 38, p. 900-916, 2014.). This transfer method results in a constant distribution, which includes all Brazilian municipalities, regardless of the municipal management performance, and justifies the differences in per capita values according to the population sizes identified in this study.

Regarding the Incentives for model change, adjustments are also foreseen for the values transferred monthly to the FHS according to criteria that include the municipality’s population size. Ordinance no. 978, of May 16, 2012 (Brasil, 2012aBRASIL. Ministério da Saúde. Portaria nº 978 de 16 de maio de 2012. Define valores de financiamento do Piso da Atenção Básica variável para as Equipes de Saúde da Família, Equipes de Saúde Bucal e aos Núcleos de Apoio à Saúde da Família, instituídos pela Política Nacional de Atenção Básica. Diário Oficial da União, Brasília , DF, 2012a. Disponível em: <Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2012/prt0978_16_05_2012.html#:~:text=978%2C%20DE%2016%20DE%20MAIO,Pol%C3%ADtica%20Nacional%20de%20Aten%C3%A7%C3%A3o%20B%C3%A1sica. >. Acesso em: 10 ago. 2022
https://bvsms.saude.gov.br/bvs/saudelegi... ), provides for a transfer per registered team with a higher value for municipalities with less than 30,000 inhabitants (except in the states of the Legal Amazon, which may have up to 50,000 inhabitants), and larger municipalities that cover the remaining population of quilombos or residents in settlements. However, it should be noted that the resource is accessed through the municipal management’s adherence to the actions and strategies suggested by the Ministry of Health, demanding efforts in the organization of local assistance to meet the established requirements. The role of municipalities gains relevance when one considers that the federal resources passed on are still insufficient to cover the FHS expenses; estimates indicate that these represent only 33.8% of expenditures on the Family Health Strategy (Mendes; Carnut; Guerra, 2018MENDES, A.; CARNUT, L.; GUERRA, L. D. da S. Reflexões acerca do financiamento federal da Atenção Básica no Sistema Único de Saúde. Saúde em Debate , Rio de Janeiro, v. 42, p. 224-243, 2018.; Mendes; Marques, 2014MENDES, A; MARQUES, R. M. O financiamento da atenção básica e da Estratégia Saúde da Família no Sistema Único de Saúde. Saúde em Debate , Rio de Janeiro, v. 38, p. 900-916, 2014.).

It appears, then, that the high per capita values of Incentives for model change identified in smaller municipalities point to the importance of this type of financing, especially for less populous municipalities. This aspect is highlighted when considering the difficulties faced by managers in smaller cities in structuring their care network, related to economies of scale and the recruitment and retention of professionals (Araújo; Gonçalvez; Machado, 2017ARAÚJO, C. E. L.; GONÇALVES, G. Q.; MACHADO, J. A.Os municípios brasileiros e os gastos próprios com saúde: algumas associações. Ciência & Saúde Coletiva, Rio de Janeiro, v. 22, p. 953-963, 2017.; Miclos; Calvo; Colussi, 2017MICLOS, P. V.; CALVO, M. C. M.; COLUSSI, C. F. Avaliação do desempenho das ações e resultados em saúde da atenção básica. Revista de Saúde Pública, São Paulo, v. 51, p. 86, 2017.).

It is also worth mentioning the possible constraints imposed by the Fiscal Responsibility Law (LRF) on public administrations that, in many moments, can inhibit the expansion, or even lead to FHS reduction (Mendes; Marques, 2014MENDES, A; MARQUES, R. M. O financiamento da atenção básica e da Estratégia Saúde da Família no Sistema Único de Saúde. Saúde em Debate , Rio de Janeiro, v. 38, p. 900-916, 2014.). Although this topic is recurrent on the agenda of municipal managers, there is no consensus on the real limits imposed by the LRF on hiring personnel for health care (Medeiros et al., 2017MEDEIROS, K. R. et al. Lei de Responsabilidade Fiscal e as despesas com pessoal da saúde: uma análise da condição dos municípios brasileiros no período de 2004 a 2009. Ciência & Saúde Coletiva , Rio de Janeiro, v. 22, p. 1759-1769, 2017.).

Although this picture may indicate motivations for the non-engagement of municipal administrations in setting up an FHS, this study showed that a significant number of the 645 São Paulo municipalities received these incentives at some point, suggesting the importance of financial transfers to mobilize the implementation of such a model.

In 2011, 83 municipalities did not access resources linked to Incentives for model change and, in 2017, there were only 19 municipalities in these conditions. This data demonstrates that almost all municipalities in the state of SP are committed, to some extent, to implementing actions and strategies linked to comprehensive PHC. It is also possible to infer that there was a greater engagement from them over the analyzed period, not only due to the number of municipalities that became involved in the structuring of a comprehensive PHC, but also in relation to the amounts raised, which grew in the period from 2011 to 2015. The increase in values is largely due to the implementation of the PMM in the period.

If, with regard to the financial resources passed on by the federal government, it was possible to observe the willingness of São Paulo municipal administrations to implement actions and strategies linked to comprehensive PHC, their effectiveness is not easy to measure, despite the existence of regional initiatives, such as the QualiAB, held in the state of SP (Castanheira et al., 2014CASTANHEIRA, E. R. L. et al. Avaliação de serviços de Atenção Básica em municípios de pequeno e médio porte no estado de São Paulo: resultados da primeira aplicação do instrumento QualiAB. Saúde em Debate, Rio de Janeiro, v. 38, p. 679-691, 2014.). Without specific indicators that frequently monitor the implementation of actions to which the Incentives for Model Change refer, in this study we analyzed the information regarding FHS coverage, adherence to PMAQ and Home Visits. Despite the heterogeneity of the composition of these indicators to guide the paths that PC is following in the municipalities, it became clear that they are insufficient to assess the changes in the work process of Primary Care, aiming at a comprehensive PHC in the territory. In this sense, it is important to emphasize the limitation of the data available in the E-gestor AB reports and the impact of the modification of the PC’s information system in the analyzed period. The implementation of the SIAB faces major challenges in the municipalities (Thum; Baldisserotto; Celeste, 2019THUM, M. A.; BALDISSEROTTO, J. CELESTE, R. K. Utilização do e-SUS AB e fatores associados ao registro de procedimentos e consultas da atenção básica nos municípios brasileiros. Cadernos de Saúde Pública , Rio de Janeiro , v. 35, e00029418, 2019.), impacting the quality of the few data that are published.

Realizing and finding alternatives to overcome this limitation is essential. Without proper monitoring, there is room for generic and imprecise claims related to the completeness resulting from the expansion of coverage (Onocko; Furtado, 2014ONOCKO, C. R., FURTADO, J. P. Desafios da avaliação de programas e serviços de saúde. Campinas: Editora Unicamp, 2011.; Castro; Oliveira; Cunha, 2016CASTRO, C. P.; OLIVEIRA, M. M.; CUNHA, G. T. O programa nacional de melhoria do acesso e da qualidade na atenção básica sob a perspectiva de um estudo qualitativo. In: CECCIM, R. B.; et al. (Org.). Intensidade na Atenção Básica: prospecção de experiências, informes e pesquisa-formação. Porto Alegre: Rede UNIDA, 2016. p. 163-194.). The risk is known that, even with the expansion, funding is still inducing a biomedical model when considering the payment through the monitoring of medical and nursing procedures, without the proper conditions to verify the teams’ more comprehensive practices (Morosini; Fonseca; Baptista, 2020MOROSINI, M. V. G. C.; FONSECA, A. F.; BAPTISTA, T. W. de F. Previne Brasil, Agência de Desenvolvimento da Atenção Primária e Carteira de Serviços: radicalização da política de privatização da atenção básica? Cadernos de Saúde Pública , Rio de Janeiro , v. 36, e00040220, 2020.). It is difficult to demonstrate this type of incongruity with data from the study period. Within the presented limitations, this research showed that the FHS Coverage has a direct relationship with the financial resource received, because for each new team registered by the manager, the MS transfers the corresponding value. In this way, growth was expected in municipalities with lower coverage, also considering the creation of the PMM, which allowed the presence of physicians in the teams, enabling their registration with the ministry.

As for information on Home Visits, it should be noted that the Ministry of Health replaced SIAB with SISAB in 2013, with the aim of qualifying and expanding the coverage of the Primary Care information system, which is evidenced by the increase in municipalities with information on home visits who responded to the PMAQ. However, it is necessary to consider that changing the system will probably not be enough to fill the gap in knowledge about the care model, if specific indicators are not increased and made available for this purpose. This proposition refers, in other words, to the construction of information on actions related to comprehensive PHC, considering its already recognized attributes, such as integrality, longitudinality and coordination of care, plus indicators related to territorial actions, collective care, intersectoral articulations and in network, and an expanded clinic - with regard to individual care (Morosini; Fonseca; Baptista, 2020MOROSINI, M. V. G. C.; FONSECA, A. F.; BAPTISTA, T. W. de F. Previne Brasil, Agência de Desenvolvimento da Atenção Primária e Carteira de Serviços: radicalização da política de privatização da atenção básica? Cadernos de Saúde Pública , Rio de Janeiro , v. 36, e00040220, 2020.; Giovanella; Franco; Almeida, 2020GIOVANELLA, L.; FRANCO, C. M.; ALMEIDA, P. F. de. Política Nacional de Atenção Básica: para onde vamos? Ciência & Saúde Coletiva , Rio de Janeiro, v. 25, p. 1475-1482, 2020.). It is important to highlight that the information currently collected by the SIAB presents potential for new analyses in this sense, as it allows exploring details of home visits and intersectoral actions and care coordination, being able, with a focus on work processes, to bring new elements for analysis of the care model practiced in Primary Care. In this way, the availability of these data for public consultation is essential to ensure monitoring and transparency in PC assessment, stimulating the building of a culture of formative assessment that contributes to the dissolution of the punitive nature of assessments. Returning to the challenges listed by Fertonani et al. (2020) for instituting a comprehensive PHC in the municipalities, this study contributed to show that the obstacles related to democratic radicalization in the formulation, implementation and evaluation of health policies in the territory are reproduced with the difficulties of access to data in their entirety, extending to the absence of indicators referring to the practices and care model adopted, as well as to the fragmentation of information that makes its analysis difficult.

The recent changes proposed by the Ministry of Health, embodied in the Previne Brasil Program (Brasil, 2019BRASIL. Ministério da Saúde. Gabinete do Ministro. Portaria n. 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 n. 6/GM/MS, de 28 de setembro de 2017. Diário Oficial da União, Brasília , DF, 13 nov. 2019, Seção 1, p. 97. Disponível em: <Disponível em: https://www.in.gov.br/en/web/dou/-/portaria-n-2.979-de-12-de-novembro-de-2019-227652180 >. Acesso em: 20 jul. 2022.
https://www.in.gov.br/en/web/dou/-/porta... ), promote a structural change in the logic of PC incentives, which includes payment for performance, which could stimulate changes in the evaluative culture of Primary Care. However, by opting for indicators that are already traditional and centered on strictly biomedical care procedures (Brasil, 2020cBRASIL. Ministério da Saúde. Secretaria de Atenção Primária à Saúde. Departamento de Saúde da Família. Nota Técnica n. 5/2020-DESF/SAPS/MS. Brasília, DF, 2020.), it does not advance in inducing a process of monitoring the work process of a comprehensive PHC or the model of care underlying it (Morosini; Fonseca; Baptista, 2020MOROSINI, M. V. G. C.; FONSECA, A. F.; BAPTISTA, T. W. de F. Previne Brasil, Agência de Desenvolvimento da Atenção Primária e Carteira de Serviços: radicalização da política de privatização da atenção básica? Cadernos de Saúde Pública , Rio de Janeiro , v. 36, e00040220, 2020.).

These and the other changes imposed by the new financing of the PC policy have, moreover, little chance of being properly debated by the population, due to the pre-existing gaps in relation to the monitoring and evaluation of Primary Care practices. Thus, discussions tend to be maintained so as to exclude the population, even though it is the most affected, if the perspectives of precarious care are fulfilled, and of deepening the withdrawal of the social and democratic nature of health policy, as already pointed out by Giovanella, Franco and Almeida (2020GIOVANELLA, L.; FRANCO, C. M.; ALMEIDA, P. F. de. Política Nacional de Atenção Básica: para onde vamos? Ciência & Saúde Coletiva , Rio de Janeiro, v. 25, p. 1475-1482, 2020.) and Morosini, Fonseca and Baptista (2020MOROSINI, M. V. G. C.; FONSECA, A. F.; BAPTISTA, T. W. de F. Previne Brasil, Agência de Desenvolvimento da Atenção Primária e Carteira de Serviços: radicalização da política de privatização da atenção básica? Cadernos de Saúde Pública , Rio de Janeiro , v. 36, e00040220, 2020.).

Thus, there is still a need to build model evaluation strategies in PC capable of contributing to the monitoring and consolidation of the FHS, so that they can also be used to support arguments and mobilize the population against the threats of dismantling that often arise. Permanent channels, with transparency of data and their significance for public policy, are more than necessary.

Therefore, investments would be necessary in the effective implementation of the SIAB, with the publication of data already collected, aimed at increasing the indicators, which would start to condense relevant aspects of the work process linked to the comprehensive PHC, added to continuous efforts to simplify access, so that they are in the public domain and understandable to the lay public as well.

Final considerations

The exercise of aggregation, presentation and analysis undertaken in this article demonstrated the relevance of financial transfers aimed at inducing the care model. However, it was also noted that the evaluation of the change in the care model does not represent an aspect that is easy to understand, limiting the possibilities of monitoring the results of using financing as a mechanism that induces changes in favor of a model linked to the comprehensive PHC proposal.

From the identification of the Incentives for model change, the importance that these resources assumed in the financing of Primary Care in the state of SP, especially in smaller municipalities, was clear. On the other hand, the current care model is not properly explained from the analyzed indicators. Thus, the need to complement the use of funding as a device to induce model change with evaluation processes specifically aimed at consolidating comprehensive PHC was demonstrated.

It is known that funding alone, especially considering chronic underfunding and the freezing of health spending, does not guarantee a model change, which is a multidetermined aspect. However, the study in question indicates that its participation cannot be neglected, as the funding proved to be capable of promoting equity in the regional distribution of resources, by enabling access, especially for municipalities with small populations. And, by attracting small municipalities, it configures a powerful device for pollination of model change policies, as long as it is duly complemented by government plans - local, regional and federal - aimed at strengthening PC; continuous training of human resources, a culture of monitoring results, and the indispensable involvement of the population.

Given so many challenges, with such complex natures, the new proposal formed by the package of performance indicators suggested in the Previne Brasil Program seems overly reductionist. It is necessary to keep discussions open and maintain investments for a care model concerned with comprehensive health care for the population, something that cannot be objectively guaranteed in the current scenario

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