ABSTRACT

The aim of the study was to analyze the indicators related to the management and working process of the Family Health Care Expanded Support Centers according to the Primary Health Care and the Centers teams perspectives in Brazil. This is a cross-sectional study with historical series analysis, using secondary data from the External Evaluation of the Program for Improving Access and Quality of Primary Care. The data were obtained from modules II and module IV from the 2nd and 3rd cycles. Chisquare and the Mann-Witney test (p<0.05) were performed. The grades given by the Primary Health Care teams to the Centers were above 7 and increased 1 point in the 3rd cycle, beside, there was an upgrade in almost all items from the 2nd to the 3rd cycles, concerning to the meetings with the municipal management and the working process of the Primary Health Care and Centers teams in the planning of actions and its frequency. We came to the conclusion that there was an increase in most indicators related to management and working process from the perspective of Primary Health Care team and Family Health Care Expanded Support Centers in Brazil.

KEYWORDS
Primary Health Care; Unified Health System; Health evaluation; Health evaluation, access and evaluation; Quality improvement

Introduction

Seeking to implement a social welfare state, the Federal Constitution of 1988 was enacted and transformed health into a right of citizenship, creating a public, universal and decentralized health system, the Unified Health System (UHS)¹1 Brasil. Constituição, 1988. Constituição da República Federativa do Brasil. Brasília, DF: Senado Federal; 1988.. The principles of the UHS are equity, integrality and universality²2 Paiva CHA, Teixeira LA. Reforma sanitária e a criação do sistema único de Saúde: Notas sobre contextos e autores. Hist. Cienc. Saúde - Manguinhos. 2014; 21(1):15-35., and, since the 1990s, several actions and services are being implemented to form a regionalized and hierarchical health network³3 Evangelista MJO, Guimarães AMDAN, Dourado EMR, et al. O Planejamento e a construção das Redes de Atenção à Saúde no DF, Brasil. Ciênc. Saúde Colet. 2019; 24(supl6):2115-2124.

4 Mendes TMC, Oliveira RFS, Mendonça JMN, et al. Planos de cargos, carreiras e salários: perspectivas de profissionais de saúde do Centro-Oeste do Brasil. Saúde debate. 2018; 42(119):849-861.

5 Peiter CC, Santos JLG, Lanzoni GMM, et al. Healthcare networks: trends of knowledge development in Brazil. Esc. Anna Nery. 2019; 23(1):1-10.-⁶6 Santos L. Healthcare regions and their care networks: an organizational-systemic model for SUS. Ciênc. Saúde Colet. 2017; 22(4):1281-1289..

Primary Health Care (PHC), or Primary Care (PC), needs to be able to solve most health problems⁷7 Campos RTO, Ferrer AL, Gama CAP, et al. Avaliação da qualidade do acesso na atenção primária de uma grande cidade brasileira na perspectiva dos usuários. Saúde debate. 2014; 38(esp):252-264., guide the organization of the health system, seek answers to the main health needs of the population and collaborate to change the current care model⁸8 Arantes LJ, Shimizu HE, Merchán-Hamann E. Contribuições e desafios da Estratégia Saúde da Família na Atenção Primária à Saúde no Brasil: Revisão da literatura. Ciênc. Saúde Colet. 2016; 21(5):1499-1510.. Thus, over time, there has been a historical construction of programs and policies with the purpose of strengthening PHC and having, at this level, the main gateway to the system and the coordination of health care from the perspective of the configuration of Health Care Networks (HCN)⁵5 Peiter CC, Santos JLG, Lanzoni GMM, et al. Healthcare networks: trends of knowledge development in Brazil. Esc. Anna Nery. 2019; 23(1):1-10.,⁹9 Destéfano JDC, Rocha KB, Oliveira ALI. Avaliação dos resultados no 3º Ciclo do Programa de Melhoria do Acesso e da Qualidade da Atenção Básica dos Municípios da Região de Saúde Central. Rev. Cient. Esc. Estadual Saúde Pública de Goiás Cândido Santiago. 2019; 5(3):2-19.,¹⁰10 Evangelista MJO. Planificação da atenção à saúde: Uma proposta de gestão e organização da atenção primária à saúde e da atenção ambulatorial especializada nas redes de atenção à saúde. Consensus. 2016; (20):30..

In 1991, there was the creation of the Community Health Agents Program (Chap), and, in 1994, the Family Health Program (FHP), which later became the Family Health Strategy (FHS) in the National Primary Care Policy (NPCP) from 2006¹¹11 Pinto LF, Giovanella L. The family health strategy: Expanding access and reducing hospitalizations due to ambulatory care sensitive conditions (ACSC). Ciênc. Saúde Colet. 2018; 23(6):1903-1913., policy updated in 2011 and 2017¹²12 Melo EA, Mendonça MHM, Oliveira JR, et al. Mudanças na Política Nacional de Atenção Básica: entre retrocessos e desafios. Saúde debate. 2018; 42(esp1):38-51.. The Ministry of Health (MH), based on municipal experiences and national debates, created the Family Health Support Center (FHSC), through the Ordinance No. 154, of January 24th, 2008, and, with Ordinance No. 3,124, of December 28, 2012, redefined the parameters for linking modalities 1 and 2, in addition to creating modality 3¹³13 Brasil. Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Atenção Básica. Cadernos de Atenção Básica. Núcleo de Apoio à Saúde da Família. Brasília, DF: MS; 2014.. Therefore, each type 1 FHSC must be linked from five to nine Family Health Teams (FHt) and/or Primary Care teams (PCt) for specific populations (street clinic team, riverside and river teams); type 2 FHSC, three or four; and type 3 FHSC, from one to two FHt¹³13 Brasil. Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Atenção Básica. Cadernos de Atenção Básica. Núcleo de Apoio à Saúde da Família. Brasília, DF: MS; 2014.

14 Brasil. Ministério da Saúde. Portaria nº 3.124, de 28 de dezembro de 2012. Redefine os parâmetros de vinculação dos Núcleos de Apoio à Saúde da Família (NASF) Modalidades 1 e 2 às Equipes Saúde da Família e/ou Equipes de Atenção Básica para populações específicas, cria a Modalidade NASF 3, e dá outras providências. Diário Oficial da União. 29 Dez 2012.-¹⁵15 Parente AS, Mesquita FOS, Sarmento SS. Análise da distribuição e cobertura do NASF na IV Macrorregião de Saúde do Estado de Pernambuco. Id. on Line Rev. Mult. Psic. 2017; 11(36):435-453..

The FHSC work process is based on the theoretical-methodological framework of matrix support, initially limited to the FHS, and materialized in the sharing of problems and the exchange of knowledge and practices among professionals, as well as in the agreed articulation of interventions, taking into account the clarity of common and specific responsibilities of the PHC team¹³13 Brasil. Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Atenção Básica. Cadernos de Atenção Básica. Núcleo de Apoio à Saúde da Família. Brasília, DF: MS; 2014.,¹⁶16 Santos RABG, Uchôa-Figueiredo LR, Lima LC. Apoio matricial e ações na atenção primária: experiência de profissionais de ESF e Nasf. Saúde debate. 2017; 41(114):694-706.. In 2017, the updating of the NPCP enabled the work of FHSC with Basic Health Units (BHU), in a traditional model, having received the name of Family Health Care Expanded Support Centers (keeping the acronym FHSC)¹⁷17 Brasil. Ministério da Saúde. Portaria nº 2.436, de 21 de setembro 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. 22 Set 2017.. The flexibility of the work process of the new NPCP may negatively impact its operating format, due to the greater difficulty in operating in the logic of matrix support¹²12 Melo EA, Mendonça MHM, Oliveira JR, et al. Mudanças na Política Nacional de Atenção Básica: entre retrocessos e desafios. Saúde debate. 2018; 42(esp1):38-51..

The improvement of the health service offered requires the implementation and encouragement of actions and policies that include construction, expansion and reform of the BHU, guaranteeing the presence of more professionals in the teams, encouraging good practices in work processes, informational continuity and institutionalization of the continuous assessment for quality improvement¹⁸18 Almeida PF, Medina MG, Fausto MCR, et al. Coordenação do cuidado e Atenção Primária à Saúde no Sistema Único de Saúde. Saúde debate. 2018; 42(esp1):244-260.. In this sense, according to Donabedian¹⁹19 Donabedian A. The role of outcomes in quality assessment and assurance. QRB Qual. Rev. Bull. 1992; 18(11):356-360. principles, the use of relevant quality indicators and the understanding of the combination of results can identify substandard care and be a warning sign for the need for further investigation.

Recognizing the need to institutionalize health assessment, the MS, with Ordinance No. 1,654, of July 19th, 2011, established the Program for Improving Access and Quality of Primary Care (PIAQ-PC), which seeks to ensure a standard of comparable quality nationally, regionally and locally, in addition to strengthening the PHC, including a financial incentive for performance. On October 1st, 2015, Ordinance No. 1,645 revoked Ordinance No. 1,654, with new information about the Program⁹9 Destéfano JDC, Rocha KB, Oliveira ALI. Avaliação dos resultados no 3º Ciclo do Programa de Melhoria do Acesso e da Qualidade da Atenção Básica dos Municípios da Região de Saúde Central. Rev. Cient. Esc. Estadual Saúde Pública de Goiás Cândido Santiago. 2019; 5(3):2-19.,²⁰20 Brasil. Ministério da Saúde. Portaria nº 1.645, de 2 de outubro 2015. Dispõe sobre o Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ-AB). Diário Oficial da União. 5 Out 2015.,²¹21 Bezerra MM, Medeiros KR. Limites do Programa de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ-AB): em foco, a gestão do trabalho e a educação na saúde. Saúde debate. 2018; 42(esp2):188-202.. In the 1st cycle of the PIAQ-PC, only two items related to the FHSC were evaluated. In the 2nd cycle, for the first time, there was a specific FHSC module, in addition to the block of items about its support, within the PCt module, which were maintained in the 3rd cycle²²22 Brasil. Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Atenção Básica. Saúde mais perto de você - acesso e qualidade. Programa Nacional de melhoria do acesso e da qualidade da Atenção Básica (PMAQ). Manual instrutivo. Brasília, DF: MS; 2012.

23 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. Manual Instrutivo para as Equipes de Atenção Básica e NASF. Brasília, DF: MS; 2017.-²⁴24 Uchôa SAC, Martiniano CS, Queiroz AAR, et al. Inovação e utilidade: Avaliação Externa do Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica. Saúde debate. 2018; 42(esp1):100-113.

In this context, the aim of this study was to analyze the indicators related to the management and work process of FHSC from the perspectives of PCt and FHSC itself in Brazil.

Material and methods

Study design and ethical aspects

The cross-sectional study with analysis of the historical series was carried out with secondary data from modules II and IV of the 2nd (2013-2014) and 3rd (2015-2018) cycles of the External Assessment instrument of the PIAQ-PC.

All cycles of the PIAQ-PC were coordinated in a tripartite manner, by the Department of Primary Care (DAB) of the MH, the National Council of Health Secretaries (NCHS) and the National Council of Municipal Health Secretaries (NCMHS), with the collaboration of Higher Education Institutions (HEIs) as coordinating centers for External Evaluation²²22 Brasil. Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Atenção Básica. Saúde mais perto de você - acesso e qualidade. Programa Nacional de melhoria do acesso e da qualidade da Atenção Básica (PMAQ). Manual instrutivo. Brasília, DF: MS; 2012.,²³23 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. Manual Instrutivo para as Equipes de Atenção Básica e NASF. Brasília, DF: MS; 2017.. The data were in the public domain and were made available by the MH.

Universe of study and sample

The sample universe was the PCt (module II) and the FHSC (module IV) of the PHC that joined and received an External Assessment of the 2nd cycle (2013-2014) or 3rd cycle (2015-2018) of the PIAQ-PC, with this adherence being voluntary and not mandatory.

All PCt and FHSC teams were eligible, regardless of the professional category of the respondent in module II of the 2nd or 3rd cycle (nurse, doctor or other professional with higher education in the PCt), or module IV of the 3rd cycle (social worker, pharmacist, physiotherapist, speech therapist, acupuncturist, clinical physician, occupational physician, geriatrician, gynecologist and obstetrician, homeopathic physician, pediatrician, psychiatrist, veterinarian, nutritionist, psychologist, teacher of physical education in health, occupational therapist, health worker or social educator). Module IV of the 2nd cycle had no variable to demonstrate which FHSC professional would have answered the questionnaire.

Data collect

The External Evaluation of the PIAQ-PC was carried out in cycles, in a multicentric way, under the responsibility of HEIs in the Brazilian states, divided by regions of responsibility, having trained and coordinated teams of independent interviewers, previously selected. The interviewers, in loco, collected the data from the teams’ professionals, using validated forms, registered on tablets, and analyzed the corroborating documents, when necessary. Participating professionals were invited to sign an Informed Consent Form.

The 2nd cycle had the participation of 30,523 PCt (85.4% of PCt registered in Brazil); the 3rd cycle had 38,865 PCt (93.9% of PCt registered in Brazil). Regarding the FHSC, in the 2nd cycle there were a total of 1,813 centers (78.5% of the FHSC registered in Brazil), and in the 3rd cycle, a total of 4,110 centers (91.2% of the FHSC registered in Brazil).

Variables

For the present study, all questions related to FHSC were initially considered, directed both to PCt and to FHSC itself. After this selection, only the questions that could be compared between cycles, considering their content or answer format, were kept in the analysis. Adjustments were necessary for comparability, as shown in box 1.

The dependent variables investigated were grouped into three blocks: Management; FHSC work process from the perspective of PCt; and work process from the perspective of FHSC itself.

The independent variable was the PIAQ-PC cycle: 2nd (2013-2014) or 3rd (2015-2018) cycle.

Data analysis

The data obtained were analyzed using the Statistical Package for the Social Sciences (SPSS) 20.0 and presented in absolute (n) and relative (%) frequencies. The presence of missing data in the database did not exclude the PCt or the FHSC teams from the global analysis, but there was an exclusion by variable evaluated. Thus, no variable had the total number of teams evaluated per module and per cycle.

The associations of the studied variables (outcomes) and the independent variable (cycles) were performed using the chi-square test (p<0.05). Among the variables whose answer options were ‘Yes’ or ‘No’, although the tables only present the category ‘Yes’, the category ‘No’ was also considered in the analysis. The Kolmogorov-Smirnov normality test was used for the evaluations related to the scores attributed by the PCt, showing a non-normal distribution (p<0.001), and, therefore, there was a comparison by the Mann-Witney test, with a significance level of 5%.

Results

Among the PCt evaluated, a total of 29,649 (97.1% of the PCt evaluated) were analyzed in the 2nd cycle and a total of 37,350 (96.1% of the PCt evaluated) in the 3rd cycle. Regarding FHSC, there was a participation of 1,774 (97.8% of the evaluated FHSC) in the 2nd cycle and 4,031 (98.1% of the evaluated FHSC) in the 3rd cycle of the PIAQ-PC.

Regarding management activities, it was noticed that there was a better proportion in relation to the ‘debate between management and the PCt about the professionals who should make up the FHSC’ between the 2nd (61.5%) and 3rd cycle (68.6%) (p<0.001). The ‘presence of a person in charge of the FHSC in municipal management’ was 93.2% in the last cycle, with no significant difference in relation to the previous cycle (p=0.415). In addition, there was an improvement in the proportion of ‘FHSC who have meetings with the municipality’s coordination’ (82.2% to 94.8%) (p<0.001) (table 1).

It is noteworthy that in the 3rd cycle there was a higher proportion of ‘PCt attended by matrix support in complex cases’, with 97.9%, of which 74.5% are ‘carried out by FHSC’. Regarding the FHSC work process, from the perspective of the PCt, there was an improvement in almost all items. Of these, the most performed are: ‘case discussion’ (93.4%) and ‘the demand for individual care to be provided by FHSC professionals is organized’ (89.7%) (p<0.001). And the least performed are: ‘the PCt schedules appointments directly in the FHSC professional’s agenda’ (72.9%) and ‘management of referrals and/or waiting lists for specialists between the PCt and the FHSC’ (67 .7%) (p<0.001). There was a reduction in only three items, two of which were dichotomous: ‘the FHSC action schedule is carried out with your PCt’ (85% to 80.9%) and ‘in unforeseen situations, your PCt gets support from the FHSC’ (99% for 96.7%) (p<0.001) (table 2).

In both cycles, the ‘average time to respond to the PCt request by FHSC’ is ‘two to seven days’ (53.2% and 59.4%), with an increase in the proportion also in ‘one day’ (10.1% to 12.1%) (p<0.001). And the majority of PCt stated ‘always’ to be ‘assisted by the FHSC in an adequate time’, with an increase from 43.2% to 52% (p<0.001). Regarding the ‘frequency of meetings between FHSC professionals with the PCt’, there was a reduction in the proportion of PCt who claimed to be ‘weekly’ (38.9% to 32.5%) and an increase in the ‘monthly’ frequency (24.5% to 34.9%) between the 2nd and 3rd cycle (p<0.001) (table 2).

In relation to the grades given by the PCt for the activities carried out by the FHSC, high grades were verified - average and median above 7 for all evaluated items -, both in the 2nd and 3rd cycle. The items with the highest scores in both cycles were: ‘the support your team receives from the FHSC’, ‘improvement in the health indicators of the cases shared between your team and the FHSC’ and ‘FHSC’s contribution to deal with problems considered difficult’. The items with the lowest score in the 2nd and 3rd cycles were: ‘FHSC’s contribution to the reduction of unnecessary referrals to specialized care’ and ‘improvement of health indicators for the population in the territory’. In addition, there was an improvement in the score for all items evaluated by the team, in relation to the work of the FHSC (p<0.001) (table 3).

Regarding the work process from the perspective of the FHSC itself, in the 3rd cycle it was found that the most performed activities were: ‘FHSC actions articulated with the planning of the PCt’ (98.7%) and ‘identification of the main demands for support from the teams’ (98.1%). There was an improvement in the proportion of actions performed for most items, with the exception of those in which there was a high proportion in the 2nd cycle and close to the percentages in the 3rd cycle, which sought to know if the FHSC ‘performs therapeutic groups’ (p=0.126) and ‘health education activities’ (p=0.160) (table 4).

Discussion

The present study was the first to analyze two modules and two cycles of the PIAQ-PC to qualify the FHSC matrix support in the Brazilian PHC. In this sense, there was an increase in the absolute number of PCt and FHSC teams implemented and with adherence to the PIAQ-PC, as well as an improvement in the management and work process, both in the evaluation of the PCt and the FHSC. Considering that the FHSC work logic goes beyond the fundamental logic of clinic and health care in the traditional format¹³13 Brasil. Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Atenção Básica. Cadernos de Atenção Básica. Núcleo de Apoio à Saúde da Família. Brasília, DF: MS; 2014.,¹⁶16 Santos RABG, Uchôa-Figueiredo LR, Lima LC. Apoio matricial e ações na atenção primária: experiência de profissionais de ESF e Nasf. Saúde debate. 2017; 41(114):694-706., the result can show a constructive process of the actors involved, PCt and FHSC teams, over time, on the attributions of the FHSC and, furthermore, about its role in strengthening PHC, in addition to the maturity of the FHSC work process.

The proportion of PCt that debate with management about the professional categories that should make up the FHSC, according to the needs of the enrolled population, was reported as similar to that observed in other cross-sectional studies²⁵25 Araújo RE. Análise exploratória dos indicadores de resultados dos Núcleos de Apoio à Saúde da Família (NASF): a experiência de Belo Horizonte. [dissertação]. Belo Horizonte: Universidade Federal de Minas Gerais; 2014. 121 p.,²⁶26 Volponi PRR, Garanhani ML, Carvalho BG. Núcleo de Apoio à Saúde da Família: potencialidades como dispositivo de mudança na Atenção Básica em saúde. Saúde debate. 2015; 39(esp):221-231., and only the present study analyzed and verified improvement data. Volponi, Garanhani and Carvalho²⁶26 Volponi PRR, Garanhani ML, Carvalho BG. Núcleo de Apoio à Saúde da Família: potencialidades como dispositivo de mudança na Atenção Básica em saúde. Saúde debate. 2015; 39(esp):221-231. observed 8 hours of monthly meetings between managers and coordination of BHU, and 20 hours of both with the FHSC, in a large municipality in the state of Paraná. However, despite positive setting aside the of time for meetings with the management, the quality of the debate in search of solutions should be considered, an aspect not evaluated in this study.

A study pointed out that, regardless of the form of management, whether permissive or too authoritarian, discussions need to address the work process with clear objectives and goals to be met, in accordance with health plans²⁷27 Schimith MD, Brêtas ACP, Budó MLD, et al. Gestão do trabalho: implicações para o cuidado na Atenção Primária à Saúde. Enfermería Glob. 2015; 14(38):205-219.. It is known that the low level of dialogue between PCt managers and workers is an additional difficulty for the implementation of policies and programs in the health area²⁸28 Bertusso FR, Rizzotto MLF. PMAQ na visão de trabalhadores que participaram do programa em Região de Saúde do Paraná. Saúde debate. 2018; 42(117):408-419..

Another study pointed out that, even with a monthly meeting between municipal management and the FHSC coordination, there are still managers not open to discussion²⁶26 Volponi PRR, Garanhani ML, Carvalho BG. Núcleo de Apoio à Saúde da Família: potencialidades como dispositivo de mudança na Atenção Básica em saúde. Saúde debate. 2015; 39(esp):221-231.. Democratic and participatory management between professionals and managers has a positive impact on strengthening bonds, as well as shared participation and shared accountability²⁶26 Volponi PRR, Garanhani ML, Carvalho BG. Núcleo de Apoio à Saúde da Família: potencialidades como dispositivo de mudança na Atenção Básica em saúde. Saúde debate. 2015; 39(esp):221-231.. The findings of this study showed a high proportion of the presence of a person responsible for the FHSC within the municipal administration, which may favor more productive debates. However, there is a lack of more accurate data to assess the effective participation of these professionals in management.

Regarding the work process of the FHSC, from the perspective of evaluating the PCt, there was an increase in almost all items analyzed, with better performance than that described in the literature²⁵25 Araújo RE. Análise exploratória dos indicadores de resultados dos Núcleos de Apoio à Saúde da Família (NASF): a experiência de Belo Horizonte. [dissertação]. Belo Horizonte: Universidade Federal de Minas Gerais; 2014. 121 p.,²⁸28 Bertusso FR, Rizzotto MLF. PMAQ na visão de trabalhadores que participaram do programa em Região de Saúde do Paraná. Saúde debate. 2018; 42(117):408-419., where the actions of the FHSC should reflect on the improvement of individual and collective health conditions²⁵25 Araújo RE. Análise exploratória dos indicadores de resultados dos Núcleos de Apoio à Saúde da Família (NASF): a experiência de Belo Horizonte. [dissertação]. Belo Horizonte: Universidade Federal de Minas Gerais; 2014. 121 p.. In the present study, the highest percentage of FHSC support was in the ‘case discussion’, and can be explained by the periodicity²⁹29 Gonçalves RMA, Lancman S, Sznelwar LI, et al. Estudo do trabalho em Núcleos de Apoio à Saúde da Família (NASF), São Paulo, Brasil. Rev. Bras. Saúde Ocup. 2015; 40(131):59-74.. The items ‘PCt performs appointment scheduling directly in the FHSC professional’s agenda’ and ‘management of referrals and/or waiting lists for specialists between the PCt and FHSC’ had less significant increases and, therefore, still show the need for improvements.

In fact, professionals from FHSC, FHt and PCt did not experience adequate training on matrix support and had to learn how to learn during the work process itself³⁰30 Bispo Júnior JP, Moreira DC. Educação permanente e apoio matricial: Formação, vivências e práticas dos profissionais dos Núcleos de Apoio à Saúde da Família e das equipes apoiadas. Cad. Saúde Pública. 2017 [acesso em 2021 jul 22]; 33(9):e00108116. Disponível em: https://www.scielo.br/scielo.php?pid=S0102-311X2017000905010&script=sci_abstract&tlng=pt
https://www.scielo.br/scielo.php?pid=S01... . Despite this, the results found in this study even indicate a better work process for the PCt with the support of the FHSC, in relation to the good results described in the state of Paraíba³¹31 Silva ICB, Silva LAB, Lima RSA, et al. Processo de trabalho entre a Equipe de Atenção Básica e o Núcleo de Apoio à Saúde da Família. Rev. Bras. Med. Fam. Comunidade. 2017; 12(39):1-10., which, as the authors themselves define, is the fourth state with the greatest coverage of FHSC teams, with data from the 2nd cycle of the PIAQ-PC. It is hypothesized that, over time, there may have been a qualification and/or an understanding of the FHSC process by the PCt, or that the interest in improving the performance of the PIAQ-PC itself may interfere with the responses given by the PCt and FHSC teams.

The increase seen in the proportion of ‘organization of demand for individual care to be provided by FHSC professionals’ may apparently go against the technical-pedagogical action of FHSC, in order to produce educational support with and for the team³²32 Brasil. Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Atenção Básica. Caderno de Atenção Básica. Diretrizes do NASF: Núcleo de Apoio à Saúde da Família. Brasília, DF: MS; 2009., however, there was also an increase in the proportion of ‘shared consultations’, which may indicate an improvement and diversification of the FHSC work process, as it does not reduce fundamental attributes of its work. This demonstrates an understanding of what is the specialist’s core knowledge and what is common and shareable knowledge between the PCt and the FHSC³²32 Brasil. Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Atenção Básica. Caderno de Atenção Básica. Diretrizes do NASF: Núcleo de Apoio à Saúde da Família. Brasília, DF: MS; 2009..

Still on the work process from the perspective of the PCt, the reduction in the ‘FHSC action schedule carried out with the PCt’ and the reduction in ‘weekly meetings with monthly increases’ can be explained by Santos, Uchôa-Figueiredo and Lima¹⁶16 Santos RABG, Uchôa-Figueiredo LR, Lima LC. Apoio matricial e ações na atenção primária: experiência de profissionais de ESF e Nasf. Saúde debate. 2017; 41(114):694-706., who state that, due to the very busy schedule of consultations and meetings, there is little time available for unforeseen activities, thus, the results showed that these points need to be reinforced, without an overloaded agenda for professionals at FHSC. Despite this, in this study, there was an increase in ‘PCt request assistance’ in ‘up to one week’, which would explain more PCt claiming ‘always’ to be ‘assisted in an adequate time’. Also diverging from the authors, this study found a high frequency of ‘FHSC support for PCt in unforeseen situations’. The reduction in the 3rd cycle can be explained by greater adherence and/or expansion of the teams evaluated, a high frequency in the 2nd cycle, or even by qualification and/or understanding of the FHSC process by the PCt.

The high marks given by the PCt for the activities carried out by FHSC in both cycles, and also the significant improvement in the 3rd cycle, are in line with the study by Destéfano, Rocha and Oliveira⁹9 Destéfano JDC, Rocha KB, Oliveira ALI. Avaliação dos resultados no 3º Ciclo do Programa de Melhoria do Acesso e da Qualidade da Atenção Básica dos Municípios da Região de Saúde Central. Rev. Cient. Esc. Estadual Saúde Pública de Goiás Cândido Santiago. 2019; 5(3):2-19., showing that, among²⁴24 Uchôa SAC, Martiniano CS, Queiroz AAR, et al. Inovação e utilidade: Avaliação Externa do Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica. Saúde debate. 2018; 42(esp1):100-113. FHSC from 21 municipalities in the central-west region, 54% received the highest score in the classification for performance in the 3rd cycle of assessment of the PIAQ-PC. In this study, the highest scores refer to the ‘support that the PCt receives from the FHSC’, the ‘improvement of the health indicators of the cases shared between its team and the FHSC’ and the ‘FHSC’s contribution to deal with problems considered difficult’, positive points that can be explained by the synergistic dimension of matrix support to the concept of permanent education³²32 Brasil. Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Atenção Básica. Caderno de Atenção Básica. Diretrizes do NASF: Núcleo de Apoio à Saúde da Família. Brasília, DF: MS; 2009.. Despite the high scores and the improvement found in the 3rd cycle, the lower scores in the ‘FHSC’s contribution to the reduction of unnecessary referrals to specialized care’ and in the ‘improvement of health indicators for the population in the territory’ demonstrate that these points need greater attention. This is because it is known that PHC has the potential to solve most health problems⁷7 Campos RTO, Ferrer AL, Gama CAP, et al. Avaliação da qualidade do acesso na atenção primária de uma grande cidade brasileira na perspectiva dos usuários. Saúde debate. 2014; 38(esp):252-264..

Regarding the work process from the perspective of evaluating the FHSC itself, almost all items improved in the 3rd cycle. The high percentage can be explained by the fact that these activities have a defined frequency²⁹29 Gonçalves RMA, Lancman S, Sznelwar LI, et al. Estudo do trabalho em Núcleos de Apoio à Saúde da Família (NASF), São Paulo, Brasil. Rev. Bras. Saúde Ocup. 2015; 40(131):59-74.. The study by Brocardo et al.³³33 Brocardo D, Andrade CLT, Fausto MCR, et al. Núcleo de Apoio à Saúde da Família (Nasf): panorama nacional a partir de dados do PMAQ. Saúde debate. 2018; 42(esp1):130-144., which also used interview data with a 2nd cycle FHSC professional, shows the distribution by Brazilian region, and the good performance in the regions with the highest number of evaluated teams - Southeast and Northeast - may explain the lack of improvement in some items from the 2nd to the 3rd cycle. In addition, they are among the first actions that the FHSC carried out³²32 Brasil. Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Atenção Básica. Caderno de Atenção Básica. Diretrizes do NASF: Núcleo de Apoio à Saúde da Família. Brasília, DF: MS; 2009., and, due to their high frequency since the previous evaluation cycle, there was no improvement.

This study had the limitation of using secondary data and, therefore, it presents some difficulties, such as, for example, measurement variation and comparison between cycles. In an attempt to improve the understanding of the findings, only adaptable items for comparison were kept in the analysis. In addition, there may be an overestimation of the result, since most of the teams that participated in the PIAQ-PC, upon knowing the items that would be evaluated, may have prepared in advance, thus presenting better results. Although the PIAQ-PC is voluntary, in the present study, the participation of almost all PCt and FHSC teams was verified, which may allow a better understanding and generalization of the results.

Most studies in the literature on FHSC evaluation are primarily qualitative, thus, the PIAQ-PC was a fundamental tool for quantitative study at the national level, either by rethinking practices or by encouraging performance-based financing instilled in the program⁹9 Destéfano JDC, Rocha KB, Oliveira ALI. Avaliação dos resultados no 3º Ciclo do Programa de Melhoria do Acesso e da Qualidade da Atenção Básica dos Municípios da Região de Saúde Central. Rev. Cient. Esc. Estadual Saúde Pública de Goiás Cândido Santiago. 2019; 5(3):2-19.. Despite the positive results shown, the PIAQ-PC was replaced, in 2019, by Previne Brasil (Brazil Prevents)³⁴34 Brasil. Ministério da Saúde. Portaria nº 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 nº 6/GM/MS, de 28 de setembro de 2017. Diário Oficial da União. 13 Nov 2019., in operation since 2020. This new program has been receiving harsh criticism³⁵35 Massuda A. Mudanças no financiamento da atenção primária à saúde no Sistema de Saúde Brasileiro: avanço ou retrocesso? Ciênc. Saúde Colet. 2020; 25:1181-1188. for its simplistic evaluation of performance by result, and for ignoring evaluation indicators of structure and process, in relation to how such a task was carried out in the PIAQ-PC.

The 2017 NPCP does not affect the results of the 2nd and 3rd cycles of the PIAQ-PC³³33 Brocardo D, Andrade CLT, Fausto MCR, et al. Núcleo de Apoio à Saúde da Família (Nasf): panorama nacional a partir de dados do PMAQ. Saúde debate. 2018; 42(esp1):130-144., as there was no restructuring or reformulation of the data collection instrument that had interfered with the responses of the PCt and FHSC teams evaluated²³23 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. Manual Instrutivo para as Equipes de Atenção Básica e NASF. Brasília, DF: MS; 2017.. Thus, with the results still referring to the old name of the program, and using the new one for updating, this study highlights the path of positive results for FHSC and hopes that it will continue along the same path. However, it raises the possibility that such achievements may be lost, because, although the new NPCP also brings benefits with flexibility, it can also be harmful because the MH renounces its coordination responsibility, which is quite risky in a country with such different local and regional realities and a decentralization process that still needs improvement³⁶36 Morosini MVGC, Fonseca AF, Lima LD. Política Nacional de Atenção Básica 2017: retrocessos e riscos para o Sistema Único de Saúde. Saúde debate. 2018; 42(116):11-24..

Conclusions

There was greater implementation and adherence of PCt and FHSC teams in Brazil between the years evaluated, in addition to an improvement in the performance of the verified items, on the management and work process of FHSC, both from the perspective of the PCt as well as from the FHSC itself. The data reinforce the possibility of a maturing of multidisciplinary work and matrix support, with greater understanding of the work process, accountability and division of tasks between the FHSC and the PCt, in addition to the commitment to performance and resoluteness, thus qualifying and strengthening PHC processes in Brazil.

References

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