ABSTRACT

This article has been originated in a research that aimed to identify and validate the relevance of the indicators present in an instrument of evaluation of Primary Health Care. Sixty experts evaluated 23 indicators of the dimensions 'user as the center of the process', 'organization of processes focused on users', 'link, competencies, skills and professional attitudes' and 'organizational ambience'. Four indicators obtained a maximum Content Validity Index (CVI): 'research with users of health services', 'expansion of the service portfolio', 'professional training, competencies and participation in professional education processes' and 'ambience and communication with the community'. The overall CVI was 0.91.

KEYWORDS
Primary Health Care; Validation studies; Health evaluation

Introduction

Primary Health Care (PHC) is characterized by a set of actions aimed at developing comprehensive care that impacts the autonomy of people and their health situation. Developed with a high degree of capillarity, PHC must be operationalized in defined territories, considering the specific characteristics of its population, through the exercise of care practices and management, in the form of teamwork (STARFIELD, 2004STARFIELD, B. Atenção primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília, DF: Ministério da Saúde, 2004.).

The PHC has essential attributes and derivatives. Starfield (2004)STARFIELD, B. Atenção primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília, DF: Ministério da Saúde, 2004. states that the essential attributes are recognized as structuring axes of the health care process, being associated with the quality of services, effectiveness and efficiency of their interventions. They are access, longitudinality, completeness and coordination of attention. In turn, derived attributes qualify PHC actions in family-centered orientation, community orientation, and cultural competence.

Considered the gateway to a network of universal access services, PHC must coordinate care in the health care network and implement integrality in the various dimensions (SUMAR; FAUSTO, 2014SUMAR, N.; FAUSTO, M. C. R. Atenção Primária à Saúde: a construção de um conceito ampliado. Journal of Management & Primary Health Care, Pernambuco, v. 5, n. 2, p. 202-212, 2014.). In Brazil, the National Primary Care Policy (PNAB), agreed between federal managers and representatives of the state and municipal spheres, defines the responsibilities of each government body, reviews policy guidelines and reaffirms the Family Health Strategy (FHS) as a priority for organization of the PHC (BRASIL, 2012______. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Atenção Básica. Brasília, DF: Ministério da Saúde, 2012.). The PNAB establishes that, among other competences, the municipal manager must define strategies so that the practice of service evaluation is institutionalized and integrated to the work process of the team. One of the forms of evaluation is through the adhesion to the National Program for the Improvement of Access and Quality of Primary Care (PMAQ), which constitutes one of the requirements for the transfer of part of the federal funding from PHC to the municipality.

Evaluating the performance of services and their impact on the health of the population allows managers to guide the implementation, consolidation and reformulation of PHC practices (BRASIL, 2012______. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Atenção Básica. Brasília, DF: Ministério da Saúde, 2012.). A study by Cavalcanti, Oliveira Neto and Sousa (2015)OLIVEIRA, S. N. et al. Unidade de Pronto Atendimento - UPA 24h: percepção da enfermagem. Texto & Contexto Enfermagem, Florianópolis, v. 24, n. 1, p. 328-344, 2015. about the identification of the challenges for PMAQ adherence concludes that municipal managers considered important, among other aspects, the improvement of monitoring and evaluation activities, as well as the process of management of the people (BRASIL, 2012______. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Atenção Básica. Brasília, DF: Ministério da Saúde, 2012.). It should be highlighted that, due to its complexity, the process of evaluation in basic care requires managerial competence, articulation and production of information for the definition of intervention strategies (FELISBERTO, 2004FELISBERTO, E. Monitoramento e avaliação na atenção básica: novos horizontes. Revista Brasileira de Saúde Materno Infantil, Recife, v. 4, n. 3, p. 317-321, jul./set. 2004.).

In the municipality of Curitiba, capital of the state of Paraná, in the southern region of Brazil, the PHC network has been built since the implementation of Municipal Health Units (MHU) close to the population served, since the 1970s. In 2014, the service network of the municipality was composed of 109 MHU, all of them with dental care, of which 65 were in the FHS modality. Such a network can offer territorial coverage of PHC services to the total population estimated for the municipality, which is 1.800.000 inhabitants.

Massuda, Poli Neto and Drehmer (2014)MASSUDA, A.; POLI NETO, P.; DREHMER, V. L. F. G. (Org.). A Atenção Primária à Saúde (APS) no SUS Curitiba: um desafio para o Brasil, passar de uma APS Programática para uma mais acessível e abrangente. In: SOUZA, M. F.; FRANCO, M. S.; MENDONÇA, A. V. M. Saúde da Família nos municípios brasileiros: os reflexos dos 20 anos no espelho do futuro. Campinas: Saberes, 2014. p. 127-77. affirm that the strengthening of PHC was established as one of the main goals of the managers of the Municipal Health Secretariat (MHS) of Curitiba. Among the strategies listed for such strengthening is the restructuring of the process of variable remuneration of the servers.

The variable remuneration process was instituted in Curitiba in 1990 as a way of encouraging the qualification of health care teams. At the end of the 1990s, there was a discontinuity of the process, justified, empirically, by the reduction of solidarity and collaborative processes among the teams. In 2002, MHU teams were encouraged to establish management contracts in basic care - annual pledge of responsibilities between MHU teams, Local Health Council and the district health manager with respect to the work processes and results achieved. Such contract served as the basis, in 2013, for the restructuring of the MHS variable remuneration model under the name of Quality Development Incentive (IDQ). The IDQ is composed of four evaluation processes: individual evaluation, self-assessment, community assessment and MHU evaluation; and results in variable remuneration of 20 to 40% of the basic salary of the server (AZEVEDO 2013AZEVEDO, J. C. R. et al. Avaliação de desempenho: um instrumento de gestão e democratização nas relações de trabalho. In: BRASIL. Ministério da Saúde. Secretaria de Gestão do Trabalho e da Educação na Saúde. Departamento de Gestão e de Regulação do Trabalho na Saúde. Prêmio InovaSUS: valorização de boas práticas e inovação na gestão do trabalho na saúde. Brasília, DF: Ministério da Saúde, 2013. p. 29-35.).

After 10 years of existence, the municipal management of Curitiba resumed the process of variable remuneration to base it on the attributes of the PHC. A preliminary evaluative model was constructed by a technical team of the central level, which used already consolidated instruments and included elements not yet contemplated in the instruments. The methodological approach used by the team included the phases of construction of a preliminary assessment instrument of dimensions and performance indicators, based on the attributes of the PHC; validation of the instrument; conducting pilot test in two MHU; and operationalization of the evaluation proposal.

The model included four dimensions for evaluation: i. user as the center of the process; ii. organization of processes focused on users; iii. competencies and professional skills; iv. organizational ambience. From its proposition, the question arose of the reliability and relevance of the instrument to qualify the attention given with regard to the attributes of PHC.

Since the result of the PHC evaluation in the municipality will be used to determine the variable remuneration, it is essential that its precursor criteria be explicit, avoiding values determined by personal or political criteria.

The research that originated this article is inserted in the second phase of the instrument construction process, validation. The instrument validation process is, among other requirements, associated to its internal validity and reproducibility, which demands validation of face, content and construct. The face validity verifies if the instrument is understandable to the participants, so as not to compromise the objectives; content validity analyzes the internal validity of the dimension of an instrument; and the one of construct verifies the validity of the singular characteristic that is being measured in relation to the dimension of the instrument (LUIS; ASSUNÇÃO; LUIS, 2012LUIS, H. P. S.; ASSUNÇÃO, V. A.; LUIS, L. F. S. Tradução e validação para português de um questionário de hábitos, conhecimentos e atitudes de saúde oral dos adolescentes. Adolescência & Saúde, Rio de Janeiro, v. 9, n. 1, p. 7-11, 2012.). The research reported here was limited to the validity of face and content and aimed to identify and validate the relevance of the indicators present in the PHC Assessment Tool.

Material and methods

Evaluative study, of instrument validation. 60 people participated in the study, whose recruitment process used two approaches. The first, by non-probabilistic intentional sampling, using the 'snowball' technique, in which 20 specialists from the PHC area were selected, called External Specialists (Es). The second, by intentional sampling, through which 29 health professionals from the MHS of Curitiba were selected, called Internal Specialists (Is); nine district managers (M); and two Health Advisors (HA) users. Due to the characteristics of the selection, there was no exclusion criterion.

To constitute the initial group of Es, nationally recognized professionals were selected for their expertise in PHC in research conducted or formulation of public policies, with training and minimum experience of five years in the PHC. 19 invitations were sent electronically. Of these, thirteen experts accepted to participate in the study (86%) and indicated another 22 people, of whom seven responded to the questionnaire.

The Is were personally invited by one of the researchers. In each of the nine health districts in the MHS at the time of data collection, three professionals were selected by category, among dentists, nurses and physicians. The criterion for the selection was the minimum experience of ten years in the FHS of the city of Curitiba. To guarantee the minimum number of participants, 30 professionals were invited. Of these, 29 responded to the instrument in the time foreseen for collection.

The nine health district managers with experience in monitoring and evaluation were included. Finally, for the selection of the two HAs, participation in the board of directors of the Municipal Health Council was used as a criterion, justified by the fact that HAs follow the monitoring of health indicators of the Municipality through institutional documents, such as the Municipal Plan of Health, the Annual Health Plan and the quarterly management reports.

Data collection was carried out in the period from May 4 to June 27, 2015. To compose the instrument, the indicators included in the preliminary evaluation instrument, constructed in 2013 by the technical team of the PHC board of MHS of Curitiba. The selection of dimensions and indicators had as reference the attributes and values of the PHC (STARFIELD, 2004STARFIELD, B. Atenção primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília, DF: Ministério da Saúde, 2004.) applied by the FHS.

The 'user as the center of the process' dimension aims to evaluate in a more structured way the quality of the attributes of PHC in the view of the user, making it possible to identify the most difficult points that need to be strengthened. Due to its complexity, this dimension uses an instrument already validated, PCATool-Brazil (Primary Care Assessment Tool), reduced version (HARZHEIM , 2006HARZHEIM, E. et al. Consistência interna e confiabilidade da versão em português do Instrumento de Avaliação da Atenção Primária (PCATool-Brasil) para serviços de saúde infantil. Caderno Saúde Pública, Rio de Janeiro, v. 22, n. 8, p. 1649-1659, 2006.). The PCATool-Brazil evaluates the attributes of PHC, of which four are exclusive - access, longitudinality, integrality and coordination - and two are derived - family orientation and community orientation.

The 'organization of processes focused on users' dimension was built from three different attributes of the PHC: service portfolio, which measures the integrality and the polyvalence of the teams from the services offered to the users linked to its list; access and link, which relates the availability and coverage of services; and indicators of care process. Each attribute is composed of one or more factors that, together, make up the final score of the dimension.

The 'link, competencies, skills and professional attitudes' dimension is based on a set of knowledges: knowing (knowing), knowing how to do (skills), knowing how to be (attitudes), wanting to do (motivation) and being able to do (professional attitudes and means). The set is of individual character and consists of factors related to training, productivity, resolution capacity and length of stay in the same MHU.

The 'organizational ambience' dimension comprises the physical, social, professional and interpersonal space, being evaluated collectively by the team, enabling the inclusion of items directly related to the MHU organization.

The components and indicators of the instrument built by the MHS of Curitiba team are available in chart 1.

Participants responded to a two-part online questionnaire. The first one related to the sociodemographic and training profile and the second one on the relevance of the indicators present in the evaluation instrument.

The questionnaire was built on SurveyMonkey software (available at: <https://en.surveymonkey.com/>), which makes it possible to organize the data collected in an Excel® spreadsheet.

Individually, the participants attributed a degree of relevance to each of the indicators through structured responses, following the Likert-type scale: certainly relevant =4; probably relevant=3; probably not relevant=2 and certainly not relevant=1. In cases of attribution 'certainly not relevant', a justification was requested for response in the open field.

Data relating to the sociodemographic and training profile of the participants were presented in a descriptive way, with a mean and a simple percentage distribution, only with the purpose of characterizing them. To measure the proportion of participants who agreed on the relevance of the indicators present in the instrument, the Content Validity Index (CVI) was used, which allows analyzing each item individually and, afterwards, the instrument as a whole. The index score related to the item is calculated by the sum of the agreement of each item marked '3' or '4', divided by the total number of responses. For the instrument as a whole, the total number of items considered relevant (3 or 4) was divided by the total number of items. To be considered valid, both the item and the instrument should obtain the score ≥ 0.80 (ALEXANDRE; COLUCI, 2006ALEXANDRE, N. M. C.; COLUCI, M. Z. O. Validade de conteúdo nos processos de construção e adaptação de instrumentos de medidas. Ciência & Saúde Coletiva. Rio de Janeiro, v. 16, n. 7, p. 3061-3068, 2011.).

The justifications of the participants were grouped by similarity and relevance to the four dimensions of the instrument, as a basis to potentiate the discussion and anchor face validity. No qualitative analysis of the justifications was performed.

The research was approved by the Committees of Ethics in Research of the Pontifical Catholic University of Paraná and the MHS of Curitiba (opinions nº 1.008.015 and nº 1.033.282).

Results

Characterization of specialists

The average age of the specialists was 47.8 years old; 55% are female; 38%, doctors; 30%, nurses; 18%, dental surgeons; 5%, physiotherapists; and 2% were distributed among other health professionals. The participants had an average of 2.12 specializations, of which 42% were in the collective health area; 55% in family health; 22% in health management; and 87% in other health-related specialties. Of the specialists, 37% were masters and 18% were doctors. Two participants were doctoral students.

Regarding the area of action, 48% were in the care; 32% in district or federal management; 17% in teaching; and less than 3% were retired. Of the total, 63% had a link with the MHS of Curitiba. The duration of the PHC ranged from six years to more than 30 years, with 43% of participants working from 11 to 20 years in the area.

Relevance of indicators

In graphs 1 to 3, the proportions of agreement for each indicator are presented, by group of participants (Es, M and Is). For the HA group, because it consisted of only two participants, the textual description of the results was chosen.

The two HAs considered all indicators relevant for PHC assessment. Among the indicators, seven were evaluated as certainly relevant: Research with users of health services; Expansion of service portfolio; Number of people linked to the team; Schedule of care continued by the health team; Expansion of forms of access; Percentage of users linked to the health team and attended at the Emergency Care Unit; and Vaccine coverage of the related population. One of the advisors, a retired one, included a commentary on the importance of the indicator related to the user satisfaction survey, noting that "it is very important to widely disseminate the results of research conducted [...]" (HA2). In relation to the organization of processes focused on users, the same counselor reinforced that the goals of the instrument should be the same as agreed with the Ministry of Health.

Although there is agreement about the relevance of the indicators by the Es, no item has been evaluated as certainly relevant by all external specialists (graph 1). The non-relevance justifications related to the indicators of attachment and attendance of the Emergency Care Unit (ECU) and supervised brushing are highlighted. The first was criticized for the understanding that such an indicator "[...] does not necessarily assess the user's link with the team, as accessibility issues may interfere". (Es14, doctor). In turn, the supervised brushing indicator "[...] need not be attributed to the Family Health/Primary Health Care Strategy" (Es20, doctor).

The group of managers (M) evaluated three items as certainly relevant (graph 2). In the same way as the Es group, some managers also answered for the lack of relevance of the linkage and attendance indicators of ECU and supervised brushing. One of the justifications for the ECU is that:

Another indicator considered by managers as not relevant is that related to the hours of continuous care, whose justification was that "[...] the availability of the service is fundamental for accessibility, but it does not guarantee it" (M3, nurse, free translation).

Although the set of indicators reached the relevance score, in the group of Is the highest number of non-relevance records for some indicators was detected, and none of the items had total agreement in the evaluation of 'certainly relevant' (graph 3). Again, the indicator related to the linkage and attendance of ECU was more criticized. Two Is justify the lack of relevance due to the difficulty of evaluating this indicator, since

and that the indicator "[...] does not assess the adherence of the user or team, numerous factors can lead the user to seek the ECU" (Is19, doctor).

In relation to the indicator that measures the resolution through the percentage of referrals for specialty, two Is justified the non-relevance by noting that:

and that "the percentage of referrals may reflect specificities of demand and not low resolution" (Is27, doctor, free translation).

Validity of content of indicators

In the overall evaluation, the 23 indicators had a CVI score ≥ 0.80 (table 1). The CVI of the instrument was 0,91. This result characterizes the validation of its content.

The indicators that obtained lower CVI were the 'Percentage of users linked to the health team and attended at the Emergency Care Unit' and 'PHC effectiveness measured by the percentage of referrals from users to specialists'.

Four indicators obtained a maximum CVI: 'Research with users of health services', 'Expansion of the service portfolio', 'Professional training, competences and participation in professional education processes' and 'Ambience and communication with the community'.

Discussion

In the 'User as the center of the process' dimension, the performance of opinion surveys on user satisfaction with the offered service was one of the indicators with a total consensus of relevance among the participants.

The satisfaction of the user, besides being an indicator of quality, provides a performance evaluation from the perspective of such indicator, orienting strategic or operational decisions to improve the services provided in the health system (ZILS 2009ZILS, A. A. et al. Satisfação dos usuários da rede de Atenção Primária de Porto Alegre. Revista Brasileira de Medicina de Família e Comunidade. Rio de Janeiro, v. 4, n. 16, 2009.).

The integrative review of the literature developed by Rocha, Bocchi and Godoy (2016)ROCHA, S. A.; BOCCHI, S. C. M.; GODOY, M. F. Acesso aos cuidados primários de saúde: revisão integrativa. Physis, Rio de Janeiro, v. 26, n. 1, p. 87-111, 2016. reveals that timely access to health services is still a problem in several countries around the world, with some surveys evaluating user satisfaction using items such as scheduling and extended hours for the attendance. The authors argue that the research was designed with the purpose of subsidizing changes and anchoring government projects.

There seems to be consensus among researchers and health professionals about the importance of assessing the quality of services from the perspective of the people who use them and who depend on them. In addition to enabling strategies to improve the health system (ZILS , 2009ZILS, A. A. et al. Satisfação dos usuários da rede de Atenção Primária de Porto Alegre. Revista Brasileira de Medicina de Família e Comunidade. Rio de Janeiro, v. 4, n. 16, 2009.), the results of this type of research may be used by the teams evaluated to rethink their performance in the PHC space.

Among the instruments that include the user satisfaction item to evaluate the PHC is the PCATool. Research authors who have studied PCATool have concluded that the instrument is the most appropriate to the proposals included in the PNAB (GARUZI 2014GARUZI, M. et al. Acolhimento na Estratégia Saúde da Família: revisão integrativa. Revista Panamericana de Salud Pública, Washington, v. 35, n. 2, p. 144-149, 2014.; HARZHEIM 2013______. Validação do instrumento de avaliação da atenção primária à saúde: PCATool-Brasil adultos. Revista Brasileira Medicina Família e Comunidade, Rio de Janeiro, v. 8, n. 29, p. 274-284, 2013.; SHI; STARFIELD; XÚ, 2001SHI, L.; STARFIELD, B.; XU, J. Validating the adult primary care assessment tool. The Journal of Family Practice, Parsippany, v. 50, n. 2, p. 161-175, 2001.). Therefore, the choice of PCATool-Brazil, a reduced version, for the PHC evaluation process in Curitiba seems to be adequate, reflecting the pertinence of the use of globally recognized instruments.

The expansion of the service portfolio is the only indicator that makes up the dimension of the 'Organization of processes focused on users' to obtain total consensus of relevance. Such scaling up requires that the PHC team, adequately, recognize the most frequent health needs and provide the resources to address them, toward completeness.

The range of services available should respect the incidence or prevalence of the health needs of the population (STARFIELD, 2004STARFIELD, B. Atenção primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília, DF: Ministério da Saúde, 2004.). However, when addressing knowledge about the concept of health needs from the user's perspective, Moraes, Bertolozzi and Hino (2011)MORAES, P. A.; BERTOLOZZI, M. R.; HINO, P. Percepções sobre necessidades de saúde na Atenção Básica segundo usuários de um serviço de saúde. Revista da Escola de Enfermagem da USP, São Paulo, v. 45, n. 1, p. 19-25, 2011. concluded that there are still tensions involving the conflict between what users present as demands and the recognition of health needs by the professionals.

From this perspective, it is argued that the decisions about the expansion of the service portfolio of the PHC depend not only on the availability of equipment by managers but also on a team capable of recognizing the health needs of the community.

It is expected that the teams, in addition to recognizing the needs, know the life histories of users and families, making listening a priority to overcome the fragmented way of watching them (FRACOLLI , 2014FRACOLLI, L. A. et al. Instrumentos de avaliação da Atenção Primária à Saúde: revisão de literatura e metassíntese. Ciência & Saúde Coletiva, Rio de Janeiro, v. 19, n. 12, p. 4851-60, 2014., MORAES; BERTOLOZZI; HINO, 2011MORAES, P. A.; BERTOLOZZI, M. R.; HINO, P. Percepções sobre necessidades de saúde na Atenção Básica segundo usuários de um serviço de saúde. Revista da Escola de Enfermagem da USP, São Paulo, v. 45, n. 1, p. 19-25, 2011.). Despite this premise, it is still evident that, in everyday practices and in the same situation, different forms of care occur even among professionals of the same category (FRACOLLI 2014FRACOLLI, L. A. et al. Instrumentos de avaliação da Atenção Primária à Saúde: revisão de literatura e metassíntese. Ciência & Saúde Coletiva, Rio de Janeiro, v. 19, n. 12, p. 4851-60, 2014.). This fact can be overcome, among other possibilities, with the inclusion of the theme in the training processes and in the evaluation processes of health professionals.

In the dimension 'organization of processes focused on the users', it is highlighted an item among those who received lower CVI - 'percentage of users linked to the team and attended in ECU'. Although the ECU presents itself as an observatory of the attention network, it can delimit problems in the PHS such as difficulties of access and of link of the users with the team, the item related to the attendance by the unit should not be analyzed in a limited way and out of the context organization of services.

A perceived reality in ECUs throughout the Country is a result of the delay in attending the MHU. This delay is determined by the search for agile service and the opportunity to solve problems, even if they are not urgent or emergency, generating, consequently, a flow of users that exceeds the service capacity (OLIVEIRA , 2015OLIVEIRA, S. N. et al. Unidade de Pronto Atendimento - UPA 24h: percepção da enfermagem. Texto & Contexto Enfermagem, Florianópolis, v. 24, n. 1, p. 328-344, 2015.; RANDOW ., 2011RANDOW, R. M. V. et al. Articulação com atenção primária à saúde na perspectiva de gerentes de unidade de pronto-atendimento. Revista da Rede de Enfermagem do Nordeste, Fortaleza, v. 12, n. esp., p. 904-912, 2011.).

In the 'link, competencies, skills and professional attitudes' dimension, the participants recognize the importance of professional qualification as an indicator of the quality of PHC. However, despite the recognition of the importance of the training of health professionals as essential for changes in the practice of health care (SCHERER, 2016SCHERER, M. D. A. et al. Cursos de especialização em Saúde da Família: o que muda no trabalho com a formação? Interface Comunicação Saúde Educação, Botucatu, v. 20, n. 58, p. 691-702, 2016.; VENDRUSCOLO; PRADO; KLEBA, 2014VENDRUSCOLO, C.; PRADO, M. L.; KLEBA, M. E. Formação de recursos humanos em saúde no Brasil: uma revisão integrativa. Educação em Revista, Belo Horizonte, v. 30, n. 1, p. 215-244, 2014.) and that qualified professionals can present technical competence for the transformation of the model of attention, there is a need to know the impact of training and professional qualification on the development of PHC attributes (LEÃO; CALDEIRA, 2011LEÃO, C. D. A.; CALDEIRA, A. P. Avaliação da associação entre qualificação de médicos e enfermeiros em atenção primária em saúde e qualidade da atenção. Ciência & Saúde Coletiva. Rio de Janeiro, v. 16, n. 11, p. 4415-4423, 2011.).

It should also be considered that, when analyzing the need for qualification of the middle level nursing for FHS, Ximenes Neto (2016)XIMENES NETO, F. R. G. et al. Necessidades de qualificação, dificuldades e facilidades dos técnicos de enfermagem na estratégia saúde da família. Sanare - Revista de políticas públicas, Sobral. v. 15, n. 1, p. 47-54, 2016. state that despite the change of work spaces from the hospital area to extra-hospital workplaces, the premise of training is still centered in the hospital clinic. A similar situation was identified in the training of higher level professionals, which determines a disconnection between work in PHC and training, which could be overcome, in part, by the offer of specializations in Family Health (SCHERER, 2016SCHERER, M. D. A. et al. Cursos de especialização em Saúde da Família: o que muda no trabalho com a formação? Interface Comunicação Saúde Educação, Botucatu, v. 20, n. 58, p. 691-702, 2016.).

In the presented view, the professional formation, whether of the medium or superior level, determines the emergence of a partnership of the service for the qualification of the team that works in the PHC.

One of the indicators with the lowest CVI in this study is found in the link, competencies, skills and professional attitudes dimension: the effectiveness of PHC. In this area, in 2008, the MH instituted the creation of the Family Health Support Centers (Nasfs) to support the insertion of the FHS in the service network and to increase, among other aspects, the efficiency of actions (BRASIL, 2008BRASIL. Ministério da Saúde. Portaria GM nº 154, de 24 de janeiro de 2008. Institui os Núcleos de Apoio à Saúde da Família (Nasf). Ministério da Saúde, Brasília, DF, 24 jan. 2008.). Nasf is an initiative that can help in the operation of the PHC. It is reinforced that brazilian initiatives to strengthen and expand the FHS as coordinator of the health system are aligned with the european reforms that, by consolidating the role of the PHC gateway, extend the service's resolution and strengthen the coordination role of the health system. Health services (ALMEIDA; FAUST; GIOVANELLA, 2011ALMEIDA, P. F.; FAUSTO, M. C. R.; GIOVANELLA, L. Fortalecimento da atenção primária à saúde: estratégia para potencializar a coordenação dos cuidados. Revista Panamericana de Salud Pública, Washington, v. 29, n. 2, p. 84-95, 2011.).

The effectiveness of the PHC services refers to the ability to identify risks, offering from the initial consultation and other procedures, including qualified referral to specialized care, when necessary, until the solution of the health problems of the patient. This includes increasing individual and collective care technologies, through the clinical skills of health teams.

Longitudinality, rather than continuity of care for the user by the PHC team, is a therapeutic relationship built over time, both in cases of illness and in preventive care. As results, more accurate diagnoses and treatments, as well as reduced referrals to specialists (STARFIELD, 2004STARFIELD, B. Atenção primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília, DF: Ministério da Saúde, 2004.).

In the 'organizational ambience' dimension, the consensus regarding the 'ambience and communication with community' indicator may have been interfered with by proposals for improving the work environments of municipal management in Curitiba (2013/2016).

It is known that the adequacy of the physical structure and the improvement in the availability and maintenance of equipment and inputs can contribute to a quality assistance to the health of the population (PEDROSA; CORRÊA; MANDÚ, 2011PEDROSA, I. C. F.; CORRÊA, A. C. P.; MANDÚ, E. N. T. Influências da infraestrutura de centros de saúde nas práticas profissionais: percepções de enfermeiros. Ciência, Cuidado e Saúde, Maringá, v. 10, n. 1, p. 58-65, 2011.). On the other hand, a study that focused on the area of mental health reveals that a team with different professional backgrounds should prioritize the integrality of care actions with the objective of constituting a suitable environment for the therapeutic process (KANTORSKI 2011KANTORSKI, L. P. et al. Avaliação qualitativa de ambiência num Centro de Atenção Psicossocial. Ciência & Saúde Coletiva, Rio de Janeiro, v. 16, n. 4, p. 2059-2066, 2011.). Thus, it is concluded that the ambience is influenced by the structure and interaction established among health professionals.

In relation to the different groups of evaluators, it is verified that the group of Is and Es did not validate as certainly relevant any of the items. However, the Es group had a better perception of the indicators in relation to the others. Such fact can be justified by the selection profile of these indicators and by not directly involving one of the purposes of the instrument, which is the variable remuneration of Is and M.

Conclusions

The proposed instrument for PHC evaluation was validated in the city of Curitiba (PR). This process enables credibility and transparency in its implementation, as well as allowing other municipalities, with a similar organization, to use the indicators to adapt them to their reality.

The indicators 'user perception', 'service portfolio expansion', 'training and professional education' and 'ambience and communication with the community' were considered the most relevant. These indicators reflect, without disregarding others, important attributes of PHC, such as access, longitudinality, family-centered orientation and coordination of care.

Although validated, the indicator Percentage of users linked to the health team and attended at the Emergency Care Unit, was the one that received the lowest validity index, being the object of criticism justified by the interference offered by the context of the services organization. It is suggested that the indicator be considered as a sentinel event, making it possible to analyze the reasons for attendance in the ECUs of users linked to the MHU.

It should be emphasized that the instrument must become dynamic from the monitoring and evaluation of the results obtained and the need for the service. Therefore, future studies should investigate the characteristics that, intrinsically, permeate the work process in PHC to compose other indicators for the evaluation process such as the need for knowledge about ethics, rights of the users, interpersonal communication skills and teamwork.

Acknowledgements

To the Coordination for the Improvement of Higher Education Personnel, by the rate referring to the Program of Support to the Post-Graduation of Private Education Institutions (Prosup).

References

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