ABSTRACT

The study aimed to describe how the participation of Community Health Workers (CHW) took place in the National Program for Access and Quality Improvement in Primary Care (PAQI-PC), and to evaluate their perspective regarding improvements in both the access and the quality of Primary Care (PC). This is a descriptive, cross-sectional study with quantitative approach, carried out with 133 CHWs linked to family health teams that joined the program. Results pointed out the need of greater efforts by municipalities to encourage the involvement of CHWs in evaluation processes and to improve their training, aiming at adjusting their level of apprehension and awareness of both the access and the quality in primary care.

KEYWORDS
Community Health Workers; Primary Health Care; Health policy; Family health; Health evaluation

Introduction

The structure of the Community Health Workers Program (CHWP) is based on the principles of territorial responsibility and population involvement, focused on families rather than on individuals, with an enlarged concept of health and appraisal for prevention and promotion. It laid the foundations for building-up the Family Health Strategy (FHS), with positive impacts on some of the main health indicators and improvements in the quality of life for formerly unassisted populations¹1 Macinko J, Guanai FC, Fátima M, et al. Evaluation of the impact of the Family Health Program on infant mortality in Brazil, 1990-2002. J Epid. Community Health.2006 jan; 60(1):13-19

2 Dourado L, Oliveira VB, Aquino R, et al. Trends in primary health care - sensitive conditions in Brazil: the role of the Family Health Program (Project ICSAP-Brazil). Med Care. 2011 jun; 49(6):577-584^-33 Aquino R, Medina MG, Nunes CA, et al. Estratégia de saúde da família e reordenamento do sistema de serviços de saúde. In: Paim JS, Almeida Filho N, organizadores. Saúde Coletiva: teoria e prática. Rio de Janeiro: Medbook; 2014. p. 353-371..

The relevance of this program is expressed in increased number of Community Health Workers, reaching 265,685 in 2016, which made it possible to attain health coverage for 63.13% of Brazilian population. In the state of Espírito Santo, they are now 5,119, covering 62.75% of the state’s population, close to 2016 national average⁴4 Brasil. Ministério da Saúde. Sala de Apoio a Gestão Estratégica [internet]. Brasília, DF: [sem data definida] [acesso em 2017 jun 4]. Disponível em: http://sage.saude.gov.br/#.
http://sage.saude.gov.br/#... . Many studies⁵5 Kluthcovsky ACG, Takayanagui AMM. O trabalho do agente comunitário de saúde. Rev. Bras. Med. Fam. Com. 2006 abr-jun; 2(5):23-29

6 Filgueiras AS, Silva ALA. Agente Comunitário de Saúde: um novo ator no cenário da saúde do Brasil. Physis. 2011; 21(3):899-9161^-77 Costa SM, Araújo FF, Martins LV. Agente Comunitário de Saúde: elemento nuclear das ações em saúde. Ciênc Saúde Colet. 2013 jul; 18(7):2147-2156 evidence the importance and the extension of the capillarity of this network of social actors. Those professionals play a decisive role in the reorientation and expansion of Primary Care (PC) in Brazil, considered to be a ‘nucleus’ or a ‘link’ between the health system and the community.

The process of institutionalization of the work those professional perform does not imply, however, that one may consider overcome the tensions resulting from the presence of a

Considering the origins and the historical process of those workers’ skills, as well as their bonds with common people, it can be assumed that their professionalization is prone to be understood as a contradictory and conflicting process from the point of view of institutional policies. In this sense, it is relevant to analyze the Community Health Worker

The theme of Primary Care evaluation is reinforced with the Program for Access and Quality Improvement in Primary Care (PMAQ-AB), aimed at launching a comprehensive process of cultural changes in the model of health care, at all levels, comprising both assistance and management in all governmental spheres. The program, to be developed in cycles (Quality Cycles), was launched in 2012 (first cycle), with a second cycle in 2013. Each cycle involves four phases: 1) Adherence to the program; 2) Development, with four strategies aimed at changing results obtained by the health teams: self-evaluation; monitoring; continuous education and institutional support; 3) External evaluation and certification, classifying the teams’ performance as a reference for the value of financial incentives to be received, by means of transferences between funds; and 4) Re-contracting new commitments¹⁰10 Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Autoavaliação para a Melhoria do Acesso e da Qualidade da Atenção Básica: AMAQ [internet]. Brasília, DF: Ministério da Saúde, 2012 [acesso em 2017 maio 13]. Disponível em: http://189.28.128.100/dab/docs/geral/amaq.pdf.
http://189.28.128.100/dab/docs/geral/ama... .

It is worth pointing out that, in the health sector, PC evaluation turns to be a problem when it requires the collective mobilization of PC professionals.

Recognizing and including all PC professionals in PC evaluation are key elements for identifying the quality of the evaluation process and an important criterion for the results to be used as grounds for decision making¹¹11 Serapioni M. Avaliação da qualidade em saúde: delineamento para um modelo multidimensional e correlacional. In: Mercado FJ, Bosi MLM, organizadores. Avaliação qualitativa de programas de saúde: enfoques emergentes. Petrópolis: Vozes; 2013. p. 207-228.. Among professionals in family health teams, CHWs should be included and emphasized, since they are in charge of strategic and complex functions.

It is, thus, enhanced the relevance of the present paper, which is aimed at describing the participation of CHWs in PMAQ-AB in the state of Espírito Santo, and evaluating their perspective regarding improvements in PC access and quality as two first cycles of the program have been performed. It is intended, therefore, to highlight PC limits and potentialities, so as to contribute with empirical data to the qualification of the PC evaluation process.

Methods

A descriptive, transversal study with a quantitative approach was carried out. Information was obtained from 133 CHWs connected to t family health teams that adhered to PMAQ-AB in three municipalities in the state of Espírito Santo. These are large municipalities, located in the Metropolitan Region of the so-called Expanded Vitória, where 33.4% of the state’s population is concentrated¹²12 Instituto de Geografia e Estatística. Conheça cidades e estados do Brasil [internet]. Rio de Janeiro: IBGE; c2017 [acesso em 2018 maio 26]. Disponível em: https://cidades.ibge.gov.br/.
https://cidades.ibge.gov.br/... .

The study integrates a more comprehensive project about the CHW work process in Primary Health Care. Data were collected using a questionnaire filled out by agents who work in Basic Health Units (BHUs), on previously booked date and time. The questionnaire included 49 questions, 17 of which focused the CHW’s profile; the 22 following questions investigated the work process, and the 10 remaining questions investigated their perceptions about PMAQ-AB. As variables to be discussed, the paper highlights the awareness of PMAQ-AB, its purposes and the team’s adherence, their participation in both the self-evaluation and the external evaluation phases, and their perceptions about improvements in PC access and quality.

A pilot study was performed with CHW of a municipality that was not planned to be part of the sample, and the data collection tool proved adequate, requiring no reformulations. Data collection took place from November 2015 to June 2016.

The criterion established for participating in the study was the professional engagement in the teams that had adhered to PMAQ-AB in at least one of the program’s cycles. CHW who were temporarily out of job, either in leave or in vacation during the data collection period were excluded, as well as those who had not been acting in the teams in any PMAQ phase.

A descriptive analysis was performed with raw and relative frequencies of study variables using the Stata program, version 13.0.

The project of the study was approved by the Ethic Research Committee of Veiga de Almeida University, and made public in the Expert Report Nr. 876-415. Participants were informed of what was the purpose of the study and about data confidentiality, and a Free and Informed Term of Consent was submitted and signed. There were no interest conflicts between the researchers and the object of the research.

Results and discussion

Participation of CHWs in the self-evaluation of the team

The evaluation process proposed by PMAQ-AB starts with self-evaluation by the health team. In the present study, it was observed that around one third (33.8%) of the CHWs were not invited and, among those who were invited, almost 10% did not participate (table 1).

One may thus identify a gap between the recommendation by the Health Ministry and the teams’ reality. In this sense, some authors¹³13 Medrado JRS, Casanova AO, Oliveira CCM. Estudo avaliativo do processo de trabalho das Equipes de Atenção Básica a partir do PMAQ-AB. Saúde debate. 2015 out-dez; 39(107):1033-1043 put in question the up-down nature of the PMAQ-AB implementation of PMAQ-AB and point out the need for engagement and for a reflexive glance of the professionals, as a group, on their practices viewed as a primary requisite for changes aimed at in the qualification of the work process and the care to be offered.

It is worth highlighting that self-evaluation is a strategic management tool in the organization of the work process and for improving the health care quality the. In the first PMAQ-AB cycle, self-evaluation was performed by more than 80% of the teams all over the country, except for the Central-West region, where this percentage was 69.5%¹⁴14 Cruz MM, Souza RBC, Torres RMC, et al. Usos do planejamento e autoavaliação nos processos de trabalho das equipes de Saúde da Família na Atenção Básica. Saúde Debate. 2014 out; 38(esp):124-139..

It can be noticed that in the interviews about the teams’ work process carried out with professionals in the external evaluation phase, questions refer to information such as self-evaluation performed in the two preceding months, availability of documents to confirm the occurrence of self-evaluation, tools used and management support. There is, though, no reference to the participation of members of the team, which makes it impossible to infer which professionals were actually involved in the process.

Considered as the starting point of PMAQ-AB development phase, self-evaluation is a tool that allows for identifying and recognizing either positive or problematic dimensions of the work carried out by management and health care teams, so as to put in motion initiatives aimed at changing and improving the services. Taking into account its reflexive and problem rendering pedagogical potential, the Health Ministry recommends that

The collective participation of all the actors involved with PC in their different areas is important for the self-evaluation to actually come to be critical-reflexive action, allowing for the identification of situations in need of revision and/or change¹⁵15 Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ-AB): manual instrutivo. Brasília, DF: Ministério da Saúde , 2012..

The present study makes clear that, despite the awareness of PMAQ-AB, its purposes and the teams’ adherence stated by most CHWs, the mobilization of local teams towards an effective participation of these professionals cannot yet be noticed. This fact reinforces the existence of a realm of interests and disputes within family health teams, which varies according to the correlation of forces and both institutional and political arrangements, at regional and local levels⁸8 Mota RA, David HMSL. A crescente escolarização do agente comunitário de saúde: uma indução do processo de trabalho? Trab. Educ. Saúde. 2010 out; (2):229-248..

This health workers’ perspective is consonant with the statement that the evaluation is a negotiation that incites interests and disputes among the many actors involved¹⁶16 Tanaka O, Ribeiro EL, Almeida CAL. Avaliação em Saúde: contribuições para a incorporação no cotidiano. Rio de Janeiro: Atheneu; 2017.. The author adds that “only those who do have power would ask for an evaluation”¹⁶⁽³⁾16 Tanaka O, Ribeiro EL, Almeida CAL. Avaliação em Saúde: contribuições para a incorporação no cotidiano. Rio de Janeiro: Atheneu; 2017., which includes the power to recognize the importance of a given actor in the process, that could be highlighted by the participation of CHWs in the team’s self-evaluation process.

It stands out that, according to Costa and Ferreira^17(465)17 Costa EM, Ferreira DLA. Percepções e motivações de agentes comunitários de saúde sobre o processo de trabalho em Teresina, Piauí. Trab. Educ. Saúde 2011 nov; 9(3):461-478, community health professionals

CHWs and the external evaluation of the PMAQ-AB

It was also found that 55% of the CHWs did collaborate during the external evaluation phase, helping to fill out the questionnaire and/or finding documents/corroborating evidence. However, 40% of these professionals were not invited to help.

It is worth pointing out that the external evaluation – the third phase of PMAQ-AB – was supported by Teaching and Research Institutions (IES), responsible for submitting evaluative tools to the PC teams that had adhered to the Program, organized in three modules¹⁸18 Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Nota Metodológica da Certificação das Equipes de Atenção Básica Participantes do Programa de Melhoria do Acesso e da Qualidade na Atenção Básica. Brasília, DF: Ministério da Saúde, 2013 [acesso em 2017 maio 13]. Disponível em: http://189.28.128.100/dab/docs/portaldab/documentos/nota_metodologica_pmaq.pdf.
http://189.28.128.100/dab/docs/portaldab... :

In module II, in order to answer the external evaluation tool, it was determined that the team should choose the professional with college degree more deeply aware of team’s work process and from the community, who could rely on the collaboration of the remaining professionals of the team. Furthermore, as shown by the results of the present study, the participation of CHW was extremely important, mainly to help filling out the questionnaire and finding documents.

It must be remarked that, due to its mediating character, the work to be carried out by the CHW is a privileged evaluation field. However, it has been unveiled that PMAQ-AB is not able to realize this potentiality and the work performed by CHWs – which shows that this policy is not yet consolidated as a promoter of the changes these actors do observe¹⁹19 Mota RRA. A avaliação da Atenção Básica e o trabalho dos agentes comunitários de saúde: implantação do PMAQ-AB-AB no Médio Paraíba Fluminense [tese]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2015. 184 p..

The core function of the CHW is the relationship established with both the community and the team. Their mediating role is considered to be critical to make FHS proposals come true, and is continuously enlarging¹⁷17 Costa EM, Ferreira DLA. Percepções e motivações de agentes comunitários de saúde sobre o processo de trabalho em Teresina, Piauí. Trab. Educ. Saúde 2011 nov; 9(3):461-478. Besides, practices have been noticed that deviate this worker away from his/her function, particularly in the sense of placing him/her in charge of bureaucratic tasks thus reproducing the disease-centered biomedical model, to the detriment of health promotion actions, which calls for a reflection on the devaluation and depreciation of both the essence and the purpose of the CHW’s performance.

Function deviations betray the comprehension of the CHW’s work as non-specific and of low complexity, liable to be re-directed according to service needs, to activities that supposedly demand not much qualification²⁰20 Morosini MV, Corbo AA, Guimarães CC. O agente comunitário de saúde no âmbito das políticas voltadas para a atenção básica: concepções do trabalho e da formação profissional. Trab. Educ. Saúde. 2007 jul; 5(2):287-310. This professional is not considered as a legitimate member of the team, his work being submitted to prescription. As to PMAQ-AB, Mota shows that the program approached the CHW as a goal to be accomplished, with participation restricted to bureaucratic issues, such as organizing information.

AHW’s awareness of PMAQ-AB, its purposes and team adherence

Table 1 shows that most CHWs have stated being aware of PMAQ-AB (76.7%) and that, among those, 68.4% affirmed being familiar with the purposes of that program. Furthermore, 70.7% were informed that their team did join the program. In the evaluation process, these results corroborate the statement that the production of care in a social context as complex as the community requires recruiting workers who are familiar with knowledge and practices which differ from those produced by the education institutions that prepare workers for the health sector. The development of strategies derived from the popular praxis and conceptions is, thus, vital⁹9 Queirós AAL, Lima LP. A Institucionalização do Trabalho do Agente Comunitário de Saúde. Trab. Educ. Saúde. 2012 jul-out; 10(2):257-281.

Feitosa and collaborators highlight the professionals’ awareness of PMAQ-AB’s proposal as an articulating element of the collective construction of strategies, according to health demands of the population²¹21 Feitosa RMM, Paulino AA, Lima Júnior JOS, et al. Mudanças ofertadas pelo Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica. Saúde Soc. 2016; 25(3):821-829. According to the authors,

However, although most agents have answered affirmatively the above-mentioned questions, a significant number of them had no basic information on the program or on the participation of the team they were linked to for at least one PMAQ-AB cycle. One must keep in mind that the territory where the agent lives and renders services affects the production of his work concerning the incorporation of counter-hegemonic practices⁹9 Queirós AAL, Lima LP. A Institucionalização do Trabalho do Agente Comunitário de Saúde. Trab. Educ. Saúde. 2012 jul-out; 10(2):257-281. Thus, the tensions resulting from the CHW’s practices and knowledge must be carefully thought over, considering that, according to Luz (1981), quoted by Queirós e Lima⁹⁽²⁶⁰⁾9 Queirós AAL, Lima LP. A Institucionalização do Trabalho do Agente Comunitário de Saúde. Trab. Educ. Saúde. 2012 jul-out; 10(2):257-281,

Access and quality improvements in PC

When questioned about improvements after the PMAQ-AB concerning the access to PC, 36.8% of the agents noticed little progress, and 48.1% did not notice any progress. As to the PC quality, 38.3% also reported little progress, and 45.9% reported no progress at all. The high percentage of agents who did not notice any progress after two PMAQ-AB cycles is outstanding. This result is even more significant considering the large penetration of this professional in the community.

It is remarkable that, among the 64 agents who did not identify improvements in the access to PC after PMAQ-AB event, 28.1% were not aware of the program; 39% were not aware of its purposes; 39.1% had not been informed about the team’s adherence; 53.1% did not take part in the self-evaluation; and 60.9% had not been asked to collaborate during the external evaluation.

On the other hand, considering the 61 professionals who answered positively when asked about improvements to PC, the percentage was lower among those who were not aware of the program (6.7%), of its purposes (10%) and of the adherence of their team (5%); and, although 36.7% affirmed they did not take part in the self-evaluation, and 23.3% were not asked to collaborate during the external evaluation, this group reported more involvement in the process as compared to the previous group.

Similarly, among the 61 agents who found no improvements in PC quality after PMAQ-AB, a larger percentage (45%) of unawareness of the program can be noticed, as well as of the team’s adherence to the program (37.7%), when compared to the group that observed improvements – 6.2% and 7.9%, respectively. The group that observed progress presented a larger percentage of participation in both the self-evaluation and the external evaluation when compared to the group that did not observe any progress. In the first group, 35.9% did not participate in self-evaluation, and 26.6% were not asked to collaborate during the external evaluation; on the other CHW group, 52.4% did not participate in the self-evaluation and 57.4% were not asked to collaborate during the external evaluation.

An important aspect to be considered based on these results is related to the daily practice of the community health professional, since his/her functions surpass the health sector, enlarging attention to include multiple aspects of the population’s life conditions. Two main dimensions can be identified in the CHW’s activities: a technical dimension, related to the care offered to individuals and families, to damages prevention and to the monitoring of groups with specific problems; and a political dimension, directed to the organization of the community, in order to change their life conditions²²22 Gomes KO, Cotta RM, Cherchiglia ML, et al. A práxis do agente comunitário de saúde no contexto do programa saúde da família: reflexões estratégicas. Saúde Soc. 2009; 18(4):744-755.

Therefore, the population’s needs are not dealt with the same way by all members of the team. This is particularly clear when it comes to Community Health Workers, whose professional practice sets them apart from other health workers, mainly concerning the mediation of social and political conflicts⁹9 Queirós AAL, Lima LP. A Institucionalização do Trabalho do Agente Comunitário de Saúde. Trab. Educ. Saúde. 2012 jul-out; 10(2):257-281. This enlarged understanding may be influencing their apprehension of the meaning of PC access and quality.

On the other hand, an enlarged awareness of PMAQ-AB, more information about the team’s adherence and the external evaluation allowed for better identification of improvements by CHWs. The insertion of those professionals in the health care process makes it possible to organize the work from a multi-professional perspective, involving, at one time, complementarity and specificity, in order to improve attention to the population’s needs¹⁷17 Costa EM, Ferreira DLA. Percepções e motivações de agentes comunitários de saúde sobre o processo de trabalho em Teresina, Piauí. Trab. Educ. Saúde 2011 nov; 9(3):461-478, bringing forward the effort to shape the workers’ perception and professional practice, which has been advancing in the conquest of the professional regulation and the enlargement of its scope⁹9 Queirós AAL, Lima LP. A Institucionalização do Trabalho do Agente Comunitário de Saúde. Trab. Educ. Saúde. 2012 jul-out; 10(2):257-281.

Furthermore, attention must be paid to CHWs’ professional qualification, carried out by means of in-service training, with contents that vary according to local problems, where the evaluation is based on in-service activities, and the education material is structured according to the activities to be performed²⁰20 Morosini MV, Corbo AA, Guimarães CC. O agente comunitário de saúde no âmbito das políticas voltadas para a atenção básica: concepções do trabalho e da formação profissional. Trab. Educ. Saúde. 2007 jul; 5(2):287-310. In this context, despite the enlargement of CHW’s role, requiring new competencies in both the social and the political areas, particularly linked to the health promotion, the qualification process of these professionals is still centered in the technological control of the disease, which leads them to reproduce the fragmented and reductionist view of the biomedical model practice²²22 Gomes KO, Cotta RM, Cherchiglia ML, et al. A práxis do agente comunitário de saúde no contexto do programa saúde da família: reflexões estratégicas. Saúde Soc. 2009; 18(4):744-755.

These data demonstrate that self-evaluation is not yet consolidated as a tool that enables for thinking over and improving the work process of the teams involved. They also evidence the difficulties for inserting the Community Health Worker into the health team, and the limited valorization of this professional as a PC evaluator. These results match other studies performed in different places¹⁹19 Mota RRA. A avaliação da Atenção Básica e o trabalho dos agentes comunitários de saúde: implantação do PMAQ-AB-AB no Médio Paraíba Fluminense [tese]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2015. 184 p..

What has improved from PMAQ on?

Alternatives for where improvements had been detected were presented to all 61 Community Health Workers who reported having observed progress in access to PC and to the 64 who reported the same about PC quality (table 2).

As to access to PC, improvements pointed out were mainly concerned to the number of appointments (43.3%) and to the users’ active search (35%). Increases in equipment and materials availability were not mentioned.

As to quality, improvements were observed as to appointments with doctors/nurses (56.2%), attention to pregnant women (56.2%) and childcare appointments (46.9%). Improvements in institutional support were not mentioned.

A research²¹21 Feitosa RMM, Paulino AA, Lima Júnior JOS, et al. Mudanças ofertadas pelo Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica. Saúde Soc. 2016; 25(3):821-829 carried out with middle and upper education health professionals involved as responsible assistants for PMAQ-AB municipal coordination revealed changes following the program implementation, mainly related to work organization, FHS material resources and infrastructure, and records organization.

In this study, it is worthy to notice the fact that improvements reported by Health Care Workers were related to both the quantity and the quality of appointments, as well as to attention to pregnant women and child care appointments. This results may be related with findings by Feitosa and collaborators²¹21 Feitosa RMM, Paulino AA, Lima Júnior JOS, et al. Mudanças ofertadas pelo Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica. Saúde Soc. 2016; 25(3):821-829, showing that records organization affected both attendance and reduction of waiting time. According to the authors, the use of family medical records, one of the requisites of PMAQ-AB, not only ensured the information registration, but also allowed for prompt access to the family health team’s actions, thus contributing to health actions planning.

It is also worth remarking that, although the service daily routine, marked by the rationality of the biomedical model, may affect the production of CHW professional practice⁹⁽²⁶⁰⁾9 Queirós AAL, Lima LP. A Institucionalização do Trabalho do Agente Comunitário de Saúde. Trab. Educ. Saúde. 2012 jul-out; 10(2):257-281, understanding CHW as a nuclear element for the re-orientation of health assistance in the country will necessarily include a conception of health as a social process that results from the population’s life conditions²⁰20 Morosini MV, Corbo AA, Guimarães CC. O agente comunitário de saúde no âmbito das políticas voltadas para a atenção básica: concepções do trabalho e da formação profissional. Trab. Educ. Saúde. 2007 jul; 5(2):287-310.

Final remarks

The importance of evaluation from a perspective of changes in the health care logics is evident, and the critical and active participation of all professionals in the accomplishment of these changes is decisive. Contrary to this logics, the participation of CHWs in the evaluation process, as proposed by PMAQ-AB, remained restricted to helping upper education professionals to answer the questionnaire and finding documents (shortly above 50%) during the external evaluation phase; and around one third of them have not even participated in the self-evaluation of the team.

It must be stressed the unique character of Community Health Workers – exclusive professionals at the UHS service –, as well as their importance and transformational capability in the process of changing the health care pattern. However, the poor valorization of these professionals in PC evaluation processes expresses the difficulties for their effective insertion into health teams. This fact might have hindered the results of this evaluation, since it ignored the life experience of the professional who is the nearest to the community – the main reason for better health care. Furthermore, the exclusion of a number of CHWs from the PC evaluation process may contribute to perpetuate this exclusion, thus hindering the support, the implementation and the development of basic actions targeted at the population that must be expanded and strengthened.

These results point to the need for stronger efforts in municipalities aimed at developing strategies to encourage the inclusion of Community Health Workers in the evaluation process and, consequently, to improve their training in order to adequate their apprehension, awareness of the process and the quality in PC, so that they may perform according to the system’s guidelines and to allow them to effectively contribute to consolidate that system.

References

Publication Dates

History