The Family Health Strategy coverage in Brazil: what reveal the 2013 and 2019 National Health Surveys

Ligia Giovanella Aylene Bousquat Simone Schenkman Patty Fidelis de Almeida Luciana Monteiro Vasconcelos Sardinha Maria Lúcia França Pontes Vieira About the authors

Abstract

This paper examines the evolution of Brazil’s Family Health Strategy coverage from the findings of the 2013 and 2019 National Health Survey censuses. Indicators included Family Health Clinic coverage of residents and households, frequency of visits by Community Health Workers, and usual source of care, all stratified by rural and urban areas, Brazilian regions, states, education of the household head, and income quintile. In 2019, 60.0% of households were enrolled in a Family Health Clinic, and population coverage was 62.6%. Coverage was higher in rural than in urban areas in the Northeast and South regions. Between 2013 and 2019, coverage increased by 11.6%, while monthly health worker visits decreased. Coverage was highest among the most vulnerable population, as defined by the household head education level or by the family income. Availability of usual source of care was highest among those enrolled in a Family Health Clinic. The 2019 National Health Survey findings confirm that Brazil’s Family Health Strategy continues to be an equitable policy and the main SUS’ Primary Health Care model. However, recent changes in the national policy guidance, which are weakening the community approach and the priority given to the Family Health Strategy Program, may jeopardize those gains.

Key words:
Primary Health Care; Family Health Strategy; Health surveys; Health services coverage; Access

Introduction

Health systems leaded by primary health care (PHC), which are focused on people and communities, enabled to respond to the different health needs of population groups, have been associated with numerous positive health outcomes. Patients carrying one or more chronic conditions, for example, achieve better self-perception of health in countries of strong PHC structure, which supply continuity and comprehensive provision of services in public health systems11 Hansen J, Groenewegen PP, Boerma WG, Kringos DS. Living in a country with a strong primary care system is beneficial to people with chronic conditions. Health Aff (Millwood) 2015; 34(9):1531-1537..

In Brazil, positive health outcomes were achieved by means of the Family Health Strategy (FHS) expansion, a Brazilian community-oriented primary health care model. Among these outcomes, are the decrease in infant mortality, in hospitalizations for primary care sensitive conditions and in mortality from cardiovascular diseases22 Castro MC, Massuda A, Almeida G, Menezes-Filho NA, Andrade MV, Noronha KVMS, Rocha R, Macinko J, Hone T, Tasca R, Giovanella L, Malik AM, Werneck H, Fachini LA, Atun R. Brazil's unified health system: the first 30 years and prospects for the future. Lancet 2019; 394(10195):345-356.,33 Rasella D, Harhay MO, Pamponet ML, Aquino R, Barreto ML. Impact of primary health care on mortality from heart and cerebrovascular diseases in Brazil: a nationwide analysis of longitudinal data. BMJ 2014; 349:g4014.,44 Pinto LF, Giovanella L. The Family Health Strategy: expanding access and reducing hospitalizations due to ambulatory care sensitive conditions (ACSC) Cien Saude Colet 2018; 23(6):1903-1914.. FHS has been consolidated since the 2000s as the main PHC policy in the country, strongly grounded on the essential and derived attributes55 Starfield B. Atenção Primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: MS; 2002 and on the dimensions of social participation, intersectoriality and multidisciplinarity guided by the Unified Health System’ (SUS) principles of universality, integrality and equity.

Data released from “2008 Domiciliary Survey Health Supplement-PNAD” already indicated that 50.9% of the Brazilian population was covered by FHS, which increased to 53.4% in 2013 according to the 2013 National Health Survey (PNS in Portuguese), matched up to the Ministry of Health administrative data estimates at the time66 Malta DC, Santos MAS, Stopa SR, Vieira JEB, Melo EA, Reis AAC. A Cobertura da Estratégia de Saúde da Família (ESF) no Brasil, segundo a Pesquisa Nacional de Saúde, 2013. Cien Saude Colet 2016; 21(2):327-338.. Not less important was the increase in reporting a usual source of care by the vast majority of the population (78%), although differences across regions and level of education remained, according to the 2013 PNS 7 results. These inequalities reveal the contradictions and conditioning factors of the Brazilian health policy, limiting the consolidation of a universal public health system88 Machado CV, Lima LD, Baptista TWF. Políticas de saúde no Brasil em tempos contraditórios: caminhos e tropeços na construção de um sistema universal. Cad Saude Publica 2017; 33(Supl.2):e00129616..

Monitoring the evolution of health service coverage in general, and particularly the PHC’, is essential to identify some of the access barriers to health services and to contribute to inform health policies formulation. In this sense, it is mandatory to increase efforts towards instruments standardization, and improvement of data quality and availability so as to measure the coverage of a given intervention and access inequalities, also from a regional perspective that allows, among other aspects, comparability among countries99 Báscolo E, Houghton N, Del Riego A. Leveraging household survey data to measure barriers to health services access in the Americas. Rev Panam Salud Publica 2020; 44:e100..

The monitoring of indicators of health services access and use in Brazil has been carried out through population-based research such as the National Health Survey (PNS in Portuguese), which is an indispensable instrument for the evaluation and guidance of SUS improvement, especially in an environment of fierce and systematic attack on social policies.

After a period of fast FHS expansion experienced by the country in the years 2010, national policies were set up with the aim to induce and institutionalize multi-professional support, evaluation processes of access and quality, improvement of the infrastructure of Primary Health Care Units, and the provision of physicians for primary care, resulting in different outcomes according to its implementation characteristics1010 Giovanella L, Mendonça MHM, Fausto MCR, Almeida PF, Bousquat A, Lima JG, Seidl H, Franco CM, Fusaro ER, Almeida SZF. A provisão emergencial de médicos pelo Programa Mais Médicos e a qualidade da estrutura das unidades básicas de saúde. Cien Saude Colet 2016; 21(9):2697-2708.. As to the FHS, the 2019 PNS was the first national population-based survey conducted after the changes proposed by the 2017 National Primary Care Policy and by a set of laws and regulations creating a new type of financing, service portfolio and gathering of teams.

These measures will require close monitoring of the entire Brazilian society, as they include a strong induction towards relations between the State and private companies for the management and provision of services and as they weaken the spatial approach, community work, and comprehensive and multidisciplinary care1111 Morosini MVGC, Fonseca AF, Baptista TWF. Previne Brasil, Agência de Desenvolvimento da Atenção Primária e Carteira de Serviços: radicalização da política de privatização da atenção básica? Cad Saude Publica 2020; 36(9):e00040220..

The 2019 National Health Survey (PNS) collected data on access and use of health services by means of a national sample of households with the objective of identifying health conditions and lifestyles of the Brazilian population and of obtaining information on health care regarding access and use of services and care continuity and financing1212 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde 2019. Informações sobre domicílios, acesso e utilização dos serviços de saúde: Brasil, grandes regiões e unidades da federação. Rio de Janeiro: IBGE; 2020.. The aim of this paper is to analyze the FHS coverage evolution released from the National Health Surveys between the years 2013 and 2019, contextualizing its results in face of the recent changes in the national primary care policy carried out in the country.

Methodology

The paper analyzes the FHS coverage evolution between 2013 and 2019, estimated nationally for urban and rural areas and stratified by the national regions and federation units (UF).

The National Health Survey has as target the population living in private households in the rural and urban areas of Brazil, being carried out by means of a probabilistic sample of households. It results from the partnership between the Ministry of Health (MOH) and the Brazilian Institute of Geography and Statistics (IBGE, in Portuguese) and is part of the IBGE’ Integrated System of Household Surveys (ISHS). It adopts a subsample of the ISHS’ Master Sample that respects the same stratification as the primary sampling units (PSU), being composed by one or more census sectors.

The 2019 National Health Survey sample size resulted in 8,036 PSU premises covering 108,525 households at a 20% non-response rate1212 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde 2019. Informações sobre domicílios, acesso e utilização dos serviços de saúde: Brasil, grandes regiões e unidades da federação. Rio de Janeiro: IBGE; 2020..

The National Health Survey sampling plan was divided into agglomerates respecting three stages. In the first stage, the PSU were selected, i.e., census sectors or set of sectors. The probability was proportional to each PSU size as defined by the number of permanent private households, while the selection for the PSU sample respected an equally proportional probability. The number of households to be interviewed per PSU ranged from 12 to 18 households and was inversely proportional to the number of households per state.

Thus, for the states of Maranhão (MA), Ceará (CE), Pernambuco (PE), Bahia (BA), Minas Gerais (MG), Rio de Janeiro (RJ), São Paulo (SP), Paraná (PR), Santa Catarina (SC) and Rio Grande do Sul (RS), twelve households were drawn per PSU. As for the states of Rondônia (RD), Acre (AC), Amazonas (AM), Pará (PA), Piauí (PI), Rio Grande do Norte (RN), Paraíba (PB), Alagoas (AL), Sergipe (SE), Espírito Santo (ES), Mato Grosso do Sul (MS), Mato Grosso (MT), Goiás (GO) and Federal District (DF), 15 households were drawn. Roraima (RO), Amapá (AP) and Tocantins (TO) selected 18 households per PSU. For each sampled household, a resident 15 years or older was selected. At all stages, the selection method employed was the simple random sample.

The questionnaire contained three parts: i) for data collection regarding the household and household visits caried out by endemic agents and Family Health teams; ii) for all household residents, focusing on the collection of socioeconomic, health and health service use information; and iii) for a selected resident, themes related to lifestyle, work, chronic diseases, violence, among others, were deepened1212 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde 2019. Informações sobre domicílios, acesso e utilização dos serviços de saúde: Brasil, grandes regiões e unidades da federação. Rio de Janeiro: IBGE; 2020.,1313 Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS. Pesquisa Nacional de Saúde 2019: histórico, métodos e perspectivas. Epidemiol Serv Saude 2020; 29(5):e2020315..

As for the first two parts of the questionnaire, the information was provided by a resident considered able to provide information on behalf of the group of residents and on the household. The third part was answered by a randomly selected resident. The chosen collection technique was a personal computer-assisted interview. Data were collected between August 2019 and March 20201212 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde 2019. Informações sobre domicílios, acesso e utilização dos serviços de saúde: Brasil, grandes regiões e unidades da federação. Rio de Janeiro: IBGE; 2020.. Information was obtained from 108,457 households.

Databases were provided by IBGE, which already included the weight calculation for both residents and households to be considered in a complex sample. To ensure the comparability of the results in the two editions of the research, IBGE recalculated the 2013 PNS expansion factors grounded on the revision of the Population Projection of the Federation Units per gender and age, for the period 2010-2060, by means of the Demographic Components method. That is, IBGE reweighted the weights adopted for the 2013 PNS sample expansion1212 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde 2019. Informações sobre domicílios, acesso e utilização dos serviços de saúde: Brasil, grandes regiões e unidades da federação. Rio de Janeiro: IBGE; 2020..

The researchers adopted IBM SPSS 22.0 software. The stratification and conglomeration effects were considered for the estimation of indicators and their precision measurements.

The following indicators were calculated for the two editions of the PNS:

  1. . % of households enrolled in Family Health Units (FHU);

  2. . % of residents living in households enrolled in FHU;

  3. . % of households enrolled in the FHU per frequency of visit of the Community Health Worker (CHW);

  4. . % of residents of enrolled and non-enrolled households that sought for a usual source of care;

  5. .% of residents of enrolled and non-enrolled households that sought for a usual source of care, per type of service.

These indicators were stratified per rural or urban area, major regions, Federation units, schooling of the head of household, and per capita family income quintiles.

Prevalence was described and confidence intervals (95% CI) were estimated for 2019 PNS data. Pearson’s adjusted chi-square test was applied at the significance level of 5% in order to compare the 2013 to the 2019 PNS results.

Results

PNS allows for a two-way analysis of the FHU coverage according to the proportion of households, as well as the proportion of population regarding the number of residents living in those households.

In 2019, 60.0% (95%CI:58.9-61.0) of the respondents reported that their household was enrolled in the Family Health Unit (FHU) and 11.0% (95%CI:10.5-11.6) of them could not answer this question (similar value to 2013: 10.6%). Rural household coverage (77.0%) is higher than the urban one (57.3%). The regions with the highest household coverage are Northeast (71.1%) and South (64.8%). The Southeast has the lowest coverage (51.9%), although it comprises the highest number of enrolled households (16.6 million) (Table 1).

Table 1
Proportion of households enrolled in family health units (FHU) and people living in enrolled households, Brazil, Major Regions, Federation Units and situation of urban and rural households, 2019.

Based upon the number of residents in all households, the coverage increased to 62.6% (95% CI:61.5-63.7), a significant contingent of 131.2 million people. The differences observed between the regions as for household coverage are maintained for the denominator of residents. Five states have FHU population coverage greater than 80%: Piauí (90.7%), Tocantins (89.7%), Santa Catarina (87.2%), Paraíba (86.7%) and Sergipe (82.6%). Other eleven states have a coverage of more than 70% of their population. In numbers, São Paulo (21.9 million) and Minas Gerais (15.5 million) represent 28.5% of the total residents enrolled in FHU (Table 1).

Table 2 shows the population coverage evolution between 2013 and 2019. In the country as a whole, coverage increased by 6.5 percentage points (pp), from 56.1% in 2013 to 62.6% in 2019, corresponding to a 11.6% proportional increase in six years and the inclusion of 18.7 million residents in FHS.

Table 2
Proportional evolution (%) of people living in households enrolled in family health units. Brazil. Major Regions. Federation units and situation of the urban and rural household. 2013 and 2019. P values, Chi-square test for comparison between the two periods.

The increases were also significant across all regions as in the number of urban and rural households. The largest increases in population coverage occurred in the South (9.1pp) and North (8.8pp) regions. However, when the analysis is carried out per Federation unit, varied behaviors are observed. Pará and Federal District experienced high growth percentages, around 16 pp. Rio de Janeiro, Paraná, São Paulo, Santa Catarina, Mato Grosso, Amapá, Paraíba, Pernambuco, Piauí, Sergipe and Ceará also showed significant growth. Variations were not significant in the states of Acre, Amazonas, Roraima, Maranhão, Rio Grande do Norte, Alagoas, Bahia, Minas Gerais, Espírito Santo, Rio Grande do Sul, Mato Grosso do Sul and Goiás. Tocantins, which showed a coverage greater than 90% in 2013, has experienced a slight reduction (Table 2).

When analyzing the percentage variation between the two surveys, the increases in coverage of the Federal District (112.3%), Rio de Janeiro (38.2%) and Pará (35.8%) became even more significant (Table 2 second last column).

One of the main elements characterizing FHS is the CHW household visit (HV) to the families under whose responsibility each agent is entitled, scheduled to be carried out routinely according to the needs and demands of families and territories. Considering the households enrolled for more than one year, it can be noted that CHW visits reduced from 2013 to 2019 (Table 3).

Table 3
Proportion of households enrolled in family health units for more than one year who received community health workers (CHW) visits in the previous twelve months, as for the frequency. Brazil. Major Regions. Federation Units and situation of the urban and rural household. 2013 and 2019.

The proportion of households reporting monthly visits by the CHW in the previous year decreased from 47.2% (95% CI:45.7-48.8) in 2013 to 38.4% (95%CI:37.4-39.4) in 2019. Conversely, there was an increase in the proportion of those who never received an CHW household visit during the twelve months prior to the survey, from 17.7% (95% CI:16.6-18.8) in 2013 to 23.8% (95% CI:22.9-24.7) in 2019. The enrolled rural households receive CHW visits more frequently than the urban ones. In 2019, 66.3% of rural households received a monthly visit or every two months, while in urban households this percentage was 44.9% (Table 3).

It is noteworthy that, considering the evolution in numbers of households that received an CHW monthly or every two months, in the 2013 and 2019 PNS, there was an increase of 2.1 million households that began to receive monthly visits while 4.2 million households, although enrolled, did not receive any visits in 2019.

The reduction in the proportion of CHW monthly visits was observed for the country as a whole, in all major regions and in urban and rural areas. The reduction is not constant for all states. In 16 states, the reduction in monthly visits was significant (Table 3). Also, the 2019 increasing proportion of those who never received visits in the twelve months prior to the research was also significant in all regions and in 15 states. Eight states did not show any significant difference, either in monthly visits or in any visit during the period (AM, AP, MA, AL, SE, BA, SP, MT) (Table 3).

Nevertheless, 60% or more households of eight states (TO, MA, PB, AL, SC, MT, MS and GO) received CHW visits monthly or every two months in 2019.

It is noted that the state of Rio de Janeiro and the Federal District, although achieving the highest proportional increases of FHS coverage, did not receive CHW visits in half or more of their households. Yet, the percentage of households reporting monthly visits in 2019 was only 12.7% and 4.1%, respectively (Table 3). The states of AC, RO, ES, RJ, DF, PR and SC experienced the most significant reductions in receiving at least one household visit during the previous twelve months, an increase of more than ten percentage points in the answer of those who did not receive a visit in the previous twelve months (Table 3).

The analysis of FHU coverage per layers of per capita household income shows a tendency of higher coverage in the lower quintiles of per capita income. The coverage decreased as the income rose, following the 2013 pattern. In 2019, FHU coverage was 74.0% for the first quintile and 38.1% for the fifth quintile, the one with higher per capita family income (Table 4a).

Table 4a
Proportion and number of residents (per 1,000) of households enrolled in family health units, as per level of education of the head of household and per capita family income quintile. Brazil. 2013 and 2919 PNS. P values, Pearson adjusted chi-square test for comparison between years.
Table 4b
Proportion and number of households (per 1,000) enrolled in family health units, as per frequency of household CHW visits (monthly and none) and per capita family income quintile. Brazil. 2013 and 2019 PNS database.

The analysis of this same coverage per level of education of the head of household, which can also be considered a proxy for income, reveals a similar pattern: the lower the level of education, the higher the FHU coverage. The 2019 coverage for non-educated head of household was 76.9%, while for those with complete higher education, it was 41.7% (Table 4a).

Between 2013 and 2019, a coverage increase was observed for all education levels of the head of household and for all income quintiles, except for the fifth quintile (Table 4a). Noteworthy is the significant 32% coverage increase of households whose head had completed higher education, growing from 31.6% in 2013 to 41.7% in 2019, almost doubling from 7.4 million to 13.5 million residents covered (Table 4a).

In all regions of the country, the coverage is higher in the lower income strata, with emphasis to the highest coverage in the first quintile showed by the Northeast region, which achieved 81.4% of residents covered. The South region showed more homogeneous rates and the highest coverage for the highest income quintile (52%), as well as the lowest variation of 19.7 percentage points between the first and fifth quintiles (from 71.8% to 52.0%). Conversely, the coverage variation of residents as to quintile income for the Northeast region was 43.2 points.

Monthly household visits are also more frequent for the lower-income population (Table 4b). The monthly visits were reduced for all income strata between 2013 and 2019, although the highest monthly visit frequency (44.4%) remained for households in the poorest first quintile. Similarly, the lowest frequency (26.5%) was addressed to the highest income fifth quintile. Consistently, the proportion of enrolled households that did not receive any visits in the previous year was lower for the lower income quintiles, that is, less than half for the first quintile when compared to the fifth quintile (Table 4b).

To know the availability of a usual source of care, the PNS asked whether the resident usually seeks for care in the same place, same physician or even in the same health service. The availability of a usual source of care is higher among FHU enrolled residents (78.7%; 95%CI:78.0-79.4) than among non-enrolled ones (72.5%; 95%CI:71.4-73.7) and among those who do not know the household enrollment status (95% CI:72.0-75.0). When compared to the 2013 data, a slight increase, from 78,7% to 80% was observed for enrolled residents who had a usual source of care (95%CI:79.0-81.0), and a reduction from 75.1% to 72.5% (p=0.0046) among those not enrolled (95%CI:73.9-76.3).

The three most frequent usual sources of care of enrolled residents are the (i) primary health care units (PHCU) - health centers or FHU - (56.1%); (ii) the private offices or private clinic or private hospital outpatient clinic (16.0%); and (iii) the public emergency care services, i.e., UPA (in Portuguese) or another type of 24-hour public emergency care or public hospital emergency room (13.3%) (Table 5). Among the population not enrolled, the usual source of care are the private offices (36.5%), followed by PHCU (28.1%) and public emergency care services (16.0%) (Table 5).

Table 5
Usual source of care for residents (per 1,000) as per enrollment in FHU and types of services used. Brazil, 2013 and 2019

The usual source of care of residents living in enrolled households are public in its vast majority (78.8%), while among those not enrolled this proportion decreases to 52.2%. In 2013, these percentages were respectively 80.8% and 54.9% (Table 5).

Comparing the 2019 results to the 2013 ones, PHCU was mentioned as a usual source of care by 56.1% (55.1%-57.2%) of the residents enrolled in 2019, while this percentage was 58.5% (57.2%-59.9%) in 2013, a significant difference (p=0.0092). On the other hand, there is a significant increase from 9.9% to 13.3% (p<0.0001) for public emergency care services as a usual source of care among those enrolled, and from 12.9% to 16.0% (p=0.0005) among those not enrolled (Table 5).

Discussion

The 2019 PNS results confirm that FHS is the SUS’ PHC predominant modality, reaching 62.6% of Brazilians in 2019. The Northeast and South regions coverage percentages are the highest, maintaining the 2013 PNS standard. However, most of the Brazilians enrolled in a FHU live in the Southeast region, mirroring the national population distribution pattern.

Coverage is higher among the most vulnerable population, whether considering the head of the household level of education or the per capita family income. Coverage is more significant in rural areas where, in general, is the population with worse living conditions and greater difficulties in accessing health services. In those localities, private services are residual, and SUS is responsible for health care. In this sense, FHS reaches more intensely the most vulnerable populations.

There is a clear speeding up in the expansion of FHS population coverage between 2013 and 2019 when compared to the period 2008-2013. In the six years between 2013 and 2019, coverage increased by 6.5 percentage points, meaning an average increase of 1.1 point per year, which allowed the inclusion of an additional 18.7 million people. Between 2008 and 2013, coverage had increased by 2.5 percentage points, from 50.9% to 53.4%6, equivalent to 0.5 point per year.

The increase in speed of the FHS expansion may be related to the success of the provision of physicians by means of the More Doctors Program (MDP) established by Dilma’s government in 2013, which contributed to the implementation of more 8,800 FHS teams between September 2013 (34,892), when the first arrival of MDP physicians to municipalities took place, and October 2018 (43,735), the last month of Cuban physicians’ participation, according to EgestorAB1414 Brasil. Ministério da Saúde (MS). E-Gestor Atenção Básica: espaço para informação e acesso aos sistemas de Atenção Básica [Internet]. 2017 [acessado 2010 Out 26]. Disponível em: https://egestorab.saude.gov.br/paginas/acessoPublico/relatorios/relHistoricoCoberturaAB.xhtml
https://egestorab.saude.gov.br/paginas/a...
. The Program was predominantly implemented in municipalities of greater vulnerability or metropolitan peripheries, places where several studies showed the improvement of coverage and care and the reduction of physicians’ shortage due to the MDP1515 Medina MG, Almeida PFL Juliana G, Moura D, Giovanella L. Programa Mais Médicos: mapeamento e análise da produção acadêmica no período 2013-2016 no Brasil. Saúde Debate 2018; 42(n. esp. 1):346-360.,1616 Girardi SN, Van Stralen ACS, Cella JN, Wan Der Maas L, Carvalho CL, Faria EO. Impacto do Programa Mais Médicos na redução da escassez de médicos em Atenção Primária à Saúde. Cien Saude Colet 2016; 21(9):2675-2684.,1717 Oliveira JPA, Sanchez MN, Santos LMP. O Programa Mais Médicos: provimento de médicos em municípios brasileiros prioritários entre 2013 e 2014. Cien Saude Colet 2016; 21(9):2719-2727..

Despite the fact that the insertion of MDP physicians in existing teams which previously had an intermittent presence of these professionals has reduced turnover, another 7,000 new teams were created1010 Giovanella L, Mendonça MHM, Fausto MCR, Almeida PF, Bousquat A, Lima JG, Seidl H, Franco CM, Fusaro ER, Almeida SZF. A provisão emergencial de médicos pelo Programa Mais Médicos e a qualidade da estrutura das unidades básicas de saúde. Cien Saude Colet 2016; 21(9):2697-2708. between 2013 and 2015, contributing greatly to the expansion of FHS coverage, since MDP physicians could only be inserted in FHS teams. When the MDP was dismantled in 2019, with the proposal to replace it for Physicians for Brazil, to be implemented by a private agency (ADAPS)1818 Giovanella L, Bousquat A, Almeida PF, Melo EA, Medina MG, Aquino R, Mendonça MHM. Médicos pelo Brasil: caminho para a privatização da atenção primária à saúde no Sistema Único de Saúde? Cad Saude Publica 2019; 35(10):e00178619., it may be assumed that this positive evolution will be interrupted.

It should also be noted that, in 2019, 11% of the respondents remained unsure whether their households were enrolled or not, a similar proportion to the 2013 research. That doubt suggests little knowledge of the respondent about the Family Health Strategy and the need for better communication.

The 2019 PNS results reinforce that Family Health remains an equitable policy to the extent that coverage is higher among the poorest, reducing socioeconomic differences in the access to PHC services1919 Andrade, MV, Noronha K, Barbosa ACQ, Rocha TAH, Silva NB, Calazans JÁ, Souza MN, Carvalho LR, Souza A. A equidade na cobertura da Estratégia Saúde da Família em Minas Gerais, Brasil. Cad Saude Publica 2015; 31(6):1175-1187.. Results are robust also in relation to income as to education, both understood as proxy for vulnerability. The FHS effects in reducing inequality are described in a rich bibliography under the most varied dimensions, among them racial inequities in mortality due to preventable causes2020 Hone T, Rasella D, Barreto ML, Majeed A, Millett C. Association between expansion of primary healthcare and racial inequalities in mortality amenable to primary care in Brazil: A national longitudinal analysis. PLoS Med 2017; 14(5):e1002306..

One of the most noticeable results is the decrease in the proportion of the enrolled population receiving monthly CHW visits despite the increase of that population. That reduction may result from several factors. On one hand, there was a marked expansion of coverage in the Federal District and in Rio de Janeiro, especially its capital, where the care model, somewhat legitimized by 2017 National PHC Policy, has prioritized the individual centered care, with a sharp reduction in the number of CHW21,22 On the other hand, the states of higher coverage experienced the expansion through middle-class housing territories, carrying various difficulties for the household visit such as the absence of residents during working hours, buildings and condominiums that hinder the CHW entrance, resistance of residents to the visit, among others.

Other possible related factors are the changes observed in the CHW responsibilities, due to the intensification of activities in the PHCU premises, in the team embracement, filling out of Bolsa Família (conditional income transfer for vulnerable families) forms and information systems, or even outside the PHCU for the delivery of exam indication and specialized scheduled consultations forms. These activities require extra work spent in bureaucratized activities, such as of administrative or support nature, to the detriment of time that should be addressed to household visits and field work2323 Nogueira ML Expressões da precarização no trabalho do agente comunitário de saúde: burocratização e estranhamento do trabalho. Saude Soc 2019; 28(3):309-323.,2424 Morosini MV, Fonseca AF. Os agentes comunitários na Atenção Primária à Saúde no Brasil: inventário de conquistas e desafios. Saúde Debate 2018; 42(n. esp. 1):261-274..

Morosini and Fonseca2424 Morosini MV, Fonseca AF. Os agentes comunitários na Atenção Primária à Saúde no Brasil: inventário de conquistas e desafios. Saúde Debate 2018; 42(n. esp. 1):261-274. warn us of the gradual change in the CHW field work, which is shifting from the territorial production of community diagnosis, complex in scope and filled with community action, to operational tasks such as just data inputting and record updating. Moreover, real possibilities of PHC privatization and pricing based on ADAPS and service portfolio2525 Giovanella L, Franco CM, Almeida PF. Política Nacional de Atenção Básica: para onde vamos?. Cien. Saude Colet 2020; 25(4):1475-1482. may additionally weaken the FHS community dimension, observed previously in the management privatization contexts via Social Healthcare Organizations (OSS)2222 Melo EA, Mendonça MHM, Teixeira M. A crise econômica e a atenção primária à saúde no SUS da cidade do Rio de Janeiro, Brasil. Cien Saude Colet 2019; 24(12):4593-4598..

Problems in the organization of the CHW work process were also revealed in a cross-sectional study conducted by Nunes et al in 2015. They employed a representative national sample, concluding that only 67% of CHW were centrally committed to visiting certain groups, based on individual needs, and performing monthly household visits2626 Nunes CA, Aquino R, Medina MG, Vilasbôas ALQ, Pinto Júnior EP, Luz LA. Visitas domiciliares no Brasil: características da atividade basilar dos Agentes Comunitários de Saúde. Saúde Debate 2018; 42(n. esp. 2):127-144..

It is recognized that the FHS care model centered on community-oriented health surveillance faces implementation limits. Nevertheless, potential negative effects of the care model reorientation, driven by the 2017 Primary Care National Policy and a series of initiatives adopted from 2019 forth, may lead to the imbalance between individual and collective care, reinforcing emergency care.

At the same time that the 2017 PCNP allowed the creation of FHS teams with only one CHW or of primary care teams without CHW, ordinance 2979 of 2019 equated the financing of primary care teams and FH teams and abolished the FHS priority, which weakened the SUS’ PHC community and collective dimensions. The continuity of these policies is an indication of an even wider reduction in CHW household visits over time.

Access to health care is a complex and multidimensional concept2727 Travassos C, Martins M. Uma revisão sobre os conceitos de acesso e utilização de serviços de saúde. Cad Saude Publica 2004; 20 (Supl. 2):S190-S198.. Having a usual source of care is a classic indicator of access and availability of services. It has been shown, for a long time now, that people who have access to a usual source of care receive more preventive and therapeutic services for chronic diseases2828 Ettner SL. The timing of preventive services for women and children: the effect of having a usual source of care. Am J Public Health 1996; 86(12):1748-1754.,2929 Mark TL, Paramore LC. Pneumococcal pneumonia and influenza vaccination: access to and use by U.S. Hispanic Medicare beneficiaries. Am J Public Health 1996; 86(11):1545-1550.,3030 Moy E, Bartman BA, Weir MR. Access to hypertensive care: effects of income, insurance, and source of care. Arch Intern Med 1995; 155(14):1497-1502.. As for the PNS, this indicator is investigated as the availability of a usual source of care.

One of the PHC features is to be the first point of service, i.e., the system gateway. In order to fulfill this feature and provide longitudinal care is that the PHCU be chosen as the usual source of care. Since 1998, with the implementation of the then new financing modality of per capita fund-to-fund transfers that expanded the PHC capillarity, population-based researches (PNAD-Health and PNS) have shown improvements in this indicator, revealing that an increasing proportion of residents gained access to a usual source of care3131 Giovanella L, Mendonça MHM. Atenção primária à saúde. In: Giovanella L, Escorel S, Lobato LVC, Noronha JC, Carvalho AI, organizadores. Políticas e sistema de saúde no Brasil. 2ª ed. Rio de Janeiro: Editora Fiocruz; 2012. p. 493-546..

Although PHCU remains the usual source of care for 69 million enrolled and non-enrolled residents, there is an increase in the population that seeks public emergency services, which may indicate a competition between the primary care model and the emergency care units (UPA), as first contact service. At the end of the 2000 decade, the country went through a federal induction for the implementation of emergency care units (UPA), within the scope of the national emergency care policy. As result, those units expanded under municipal management, although not succeeding in the health care regions integration, merely occupying the quantitative and qualitative shortfalls of PHC and hospital care3232 Konder MT, O'Dwyer G. As Unidades de Pronto-Atendimento na Política Nacional de Atenção às Urgências. Physis 2015; 25(2):525-545.,3333 O'Dwyer G, Konder MT, Reciputti LP, Lopes MGM, Agostinho DF, Alves GF. O processo de implantação das unidades de pronto atendimento no Brasil. Rev Saude Publica 2017; 51:125..

Final comments

The 2019 PNS results reaffirm that FHS remains the main SUS’ PHC model, providing successful results over time, being community and equity oriented. The guidance of recent national policy has nurtured a significant rupture in relation to the incentive priority towards FHS, without, however, delivering answers and proposals to historical problems concerning PHC qualification. The possibility of not counting with CHW in the team should affect one of the care model pillars, the one that characterizes FHS in its community and health promotion components, grounded on the social determination conception of the health-disease process and the expanded clinic2525 Giovanella L, Franco CM, Almeida PF. Política Nacional de Atenção Básica: para onde vamos?. Cien. Saude Colet 2020; 25(4):1475-1482..

In this context, maintaining population-based research such as the PNS is essential for monitoring and improving health policy in the country, to foster international comparisons and, above all, to closely monitor the right to integral, public and universal health by all actors involved in its defense.

Finally, it is essential to underline the importance and potential of the Family Health Strategy capillarity, covering 131 million Brazilians by means of its territorial responsibility. It is also of capital importance to emphasize its community orientation in coping with the Covid-19 pandemic by means of health surveillance with detection, notification, screening and follow-up of cases and contacts in home isolation; communication and health education; care of mild and moderate cases; social support for vulnerable populations and risk groups in conjunction with local organizations and leaders; and in the care3434 Medina MG, Giovanella L, Bousquat A, Mendonça MHM, Aquino R. Atenção primária à saúde em tempos de COVID-19: o que fazer? Cad Saude Publica 2020; 36(8):e00149720. permanence of the huge population that relies on PHCU as its usual source of care.

References

  • 1
    Hansen J, Groenewegen PP, Boerma WG, Kringos DS. Living in a country with a strong primary care system is beneficial to people with chronic conditions. Health Aff (Millwood) 2015; 34(9):1531-1537.
  • 2
    Castro MC, Massuda A, Almeida G, Menezes-Filho NA, Andrade MV, Noronha KVMS, Rocha R, Macinko J, Hone T, Tasca R, Giovanella L, Malik AM, Werneck H, Fachini LA, Atun R. Brazil's unified health system: the first 30 years and prospects for the future. Lancet 2019; 394(10195):345-356.
  • 3
    Rasella D, Harhay MO, Pamponet ML, Aquino R, Barreto ML. Impact of primary health care on mortality from heart and cerebrovascular diseases in Brazil: a nationwide analysis of longitudinal data. BMJ 2014; 349:g4014.
  • 4
    Pinto LF, Giovanella L. The Family Health Strategy: expanding access and reducing hospitalizations due to ambulatory care sensitive conditions (ACSC) Cien Saude Colet 2018; 23(6):1903-1914.
  • 5
    Starfield B. Atenção Primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: MS; 2002
  • 6
    Malta DC, Santos MAS, Stopa SR, Vieira JEB, Melo EA, Reis AAC. A Cobertura da Estratégia de Saúde da Família (ESF) no Brasil, segundo a Pesquisa Nacional de Saúde, 2013. Cien Saude Colet 2016; 21(2):327-338.
  • 7
    Stopa SR, Malta DC, Monteiro CN, Szwarcwald CL, Goldbaum M, Cesar CLG. Acesso e uso de serviços de saúde pela população brasileira, Pesquisa Nacional de Saúde 2013. Rev Saude Pubical 2017; 51(Supl.1):3s.
  • 8
    Machado CV, Lima LD, Baptista TWF. Políticas de saúde no Brasil em tempos contraditórios: caminhos e tropeços na construção de um sistema universal. Cad Saude Publica 2017; 33(Supl.2):e00129616.
  • 9
    Báscolo E, Houghton N, Del Riego A. Leveraging household survey data to measure barriers to health services access in the Americas. Rev Panam Salud Publica 2020; 44:e100.
  • 10
    Giovanella L, Mendonça MHM, Fausto MCR, Almeida PF, Bousquat A, Lima JG, Seidl H, Franco CM, Fusaro ER, Almeida SZF. A provisão emergencial de médicos pelo Programa Mais Médicos e a qualidade da estrutura das unidades básicas de saúde. Cien Saude Colet 2016; 21(9):2697-2708.
  • 11
    Morosini MVGC, Fonseca AF, Baptista TWF. Previne Brasil, Agência de Desenvolvimento da Atenção Primária e Carteira de Serviços: radicalização da política de privatização da atenção básica? Cad Saude Publica 2020; 36(9):e00040220.
  • 12
    Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde 2019. Informações sobre domicílios, acesso e utilização dos serviços de saúde: Brasil, grandes regiões e unidades da federação. Rio de Janeiro: IBGE; 2020.
  • 13
    Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS. Pesquisa Nacional de Saúde 2019: histórico, métodos e perspectivas. Epidemiol Serv Saude 2020; 29(5):e2020315.
  • 14
    Brasil. Ministério da Saúde (MS). E-Gestor Atenção Básica: espaço para informação e acesso aos sistemas de Atenção Básica [Internet]. 2017 [acessado 2010 Out 26]. Disponível em: https://egestorab.saude.gov.br/paginas/acessoPublico/relatorios/relHistoricoCoberturaAB.xhtml
    » https://egestorab.saude.gov.br/paginas/acessoPublico/relatorios/relHistoricoCoberturaAB.xhtml
  • 15
    Medina MG, Almeida PFL Juliana G, Moura D, Giovanella L. Programa Mais Médicos: mapeamento e análise da produção acadêmica no período 2013-2016 no Brasil. Saúde Debate 2018; 42(n. esp. 1):346-360.
  • 16
    Girardi SN, Van Stralen ACS, Cella JN, Wan Der Maas L, Carvalho CL, Faria EO. Impacto do Programa Mais Médicos na redução da escassez de médicos em Atenção Primária à Saúde. Cien Saude Colet 2016; 21(9):2675-2684.
  • 17
    Oliveira JPA, Sanchez MN, Santos LMP. O Programa Mais Médicos: provimento de médicos em municípios brasileiros prioritários entre 2013 e 2014. Cien Saude Colet 2016; 21(9):2719-2727.
  • 18
    Giovanella L, Bousquat A, Almeida PF, Melo EA, Medina MG, Aquino R, Mendonça MHM. Médicos pelo Brasil: caminho para a privatização da atenção primária à saúde no Sistema Único de Saúde? Cad Saude Publica 2019; 35(10):e00178619.
  • 19
    Andrade, MV, Noronha K, Barbosa ACQ, Rocha TAH, Silva NB, Calazans JÁ, Souza MN, Carvalho LR, Souza A. A equidade na cobertura da Estratégia Saúde da Família em Minas Gerais, Brasil. Cad Saude Publica 2015; 31(6):1175-1187.
  • 20
    Hone T, Rasella D, Barreto ML, Majeed A, Millett C. Association between expansion of primary healthcare and racial inequalities in mortality amenable to primary care in Brazil: A national longitudinal analysis. PLoS Med 2017; 14(5):e1002306.
  • 21
    Bousquat A, Barros NF, Gomes L. Brasília saudável: a estratégia de saúde da família e a conversão do modelo assistencial [relatório de pesquisa]. Rede de Pesquisa em APS: OPAS; 2019.
  • 22
    Melo EA, Mendonça MHM, Teixeira M. A crise econômica e a atenção primária à saúde no SUS da cidade do Rio de Janeiro, Brasil. Cien Saude Colet 2019; 24(12):4593-4598.
  • 23
    Nogueira ML Expressões da precarização no trabalho do agente comunitário de saúde: burocratização e estranhamento do trabalho. Saude Soc 2019; 28(3):309-323.
  • 24
    Morosini MV, Fonseca AF. Os agentes comunitários na Atenção Primária à Saúde no Brasil: inventário de conquistas e desafios. Saúde Debate 2018; 42(n. esp. 1):261-274.
  • 25
    Giovanella L, Franco CM, Almeida PF. Política Nacional de Atenção Básica: para onde vamos?. Cien. Saude Colet 2020; 25(4):1475-1482.
  • 26
    Nunes CA, Aquino R, Medina MG, Vilasbôas ALQ, Pinto Júnior EP, Luz LA. Visitas domiciliares no Brasil: características da atividade basilar dos Agentes Comunitários de Saúde. Saúde Debate 2018; 42(n. esp. 2):127-144.
  • 27
    Travassos C, Martins M. Uma revisão sobre os conceitos de acesso e utilização de serviços de saúde. Cad Saude Publica 2004; 20 (Supl. 2):S190-S198.
  • 28
    Ettner SL. The timing of preventive services for women and children: the effect of having a usual source of care. Am J Public Health 1996; 86(12):1748-1754.
  • 29
    Mark TL, Paramore LC. Pneumococcal pneumonia and influenza vaccination: access to and use by U.S. Hispanic Medicare beneficiaries. Am J Public Health 1996; 86(11):1545-1550.
  • 30
    Moy E, Bartman BA, Weir MR. Access to hypertensive care: effects of income, insurance, and source of care. Arch Intern Med 1995; 155(14):1497-1502.
  • 31
    Giovanella L, Mendonça MHM. Atenção primária à saúde. In: Giovanella L, Escorel S, Lobato LVC, Noronha JC, Carvalho AI, organizadores. Políticas e sistema de saúde no Brasil. 2ª ed. Rio de Janeiro: Editora Fiocruz; 2012. p. 493-546.
  • 32
    Konder MT, O'Dwyer G. As Unidades de Pronto-Atendimento na Política Nacional de Atenção às Urgências. Physis 2015; 25(2):525-545.
  • 33
    O'Dwyer G, Konder MT, Reciputti LP, Lopes MGM, Agostinho DF, Alves GF. O processo de implantação das unidades de pronto atendimento no Brasil. Rev Saude Publica 2017; 51:125.
  • 34
    Medina MG, Giovanella L, Bousquat A, Mendonça MHM, Aquino R. Atenção primária à saúde em tempos de COVID-19: o que fazer? Cad Saude Publica 2020; 36(8):e00149720.

Publication Dates

  • Publication in this collection
    14 June 2021
  • Date of issue
    2021

History

  • Received
    12 Nov 2020
  • Accepted
    03 Dec 2020
  • Published
    05 Dec 2020
ABRASCO - Associação Brasileira de Saúde Coletiva Rio de Janeiro - RJ - Brazil
E-mail: revscol@fiocruz.br