HCS in Brazil

8/7/2019 HCS in Brazil

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international journal of health planning and management

Int J Health Plann Mgmt 2004; 19: 303317.

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/hpm.766

Organization and delivery of primary healthcare services in Petropolis, Brazil

James Macinko1*, Celia Almeida2, Eliane dos Santos Oliveira2,and Paulo Klingelhoefer de Sa3

1Department of Nutrition, Food Studies, and Public Health, Steinhardt School of Education,New York University, USA2Department of Health Administration and Planning, National School of PublicHealth/Oswaldo Cruz Foundation, Rio de Janeiro, Brazil3Faculty of Medicine of Petropolis, Municipal Secretariat of Health, Petropolis, Brazil

SUMMARY

The objective of the study was to adapt and apply an instrument to measure the organizationalfeatures of the primary care system in the municipality of Petropolis. The study compared theperformance of the new Family Health Program (Programa Saude da Famlia or PSF) withtraditional primary care facilities using data from facility surveys and key informant inter-views. The main results include: (a) the methodology was capable of distinguishing betweenthe two types of primary care services in the municipality; (b) the PSF clinics scored higheron most dimensions of primary care, although in some areas the traditional health units had

equivalent scores; and (c) data obtained from interviewing key informants was generally com-patible with that obtained by conducting facility surveys. The results suggests that in spite ofmaking important advances in primary care, the municipality of Petropolis continues to faceseveral challenges including the need to improve access, enforce the gatekeeper role ofprimary care, and improve the coordination and community orientation of both types ofprimary care services. The methodology could be used to set objectives and monitor progresstowards improving the organization and delivery of primary care in Petropolis and elsewhere.Copyright# 2004 John Wiley & Sons, Ltd.

key words: primary health care; health care reform; family health program; Brazil

INTRODUCTION

Since the end of the 1980s the health system in Brazil has been undergoing a process

of health sector reform, the landmark of which was the new constitution approved in

1988. The constitution institutionalized universal social rights, including the right to

health, which then became a citizens right and the States obligation and responsi-

bility, and created the Brazilian national health system (Sistema Unico de Saude or

Copyright# 2004 John Wiley & Sons, Ltd.

* Correspondence to: Dr J. Macinko, Assistant Professor of Public Health, Department of Nutrition,

Food Studies, and Public Health, Steinhardt School of Education, New York University, 35 West 4thStreet, 12th Floor, New York, NY 10012-1172, USA. E-mail: [email protected]

Contract/grant sponsors:Fulbright Commission; Pan American Health Organization.


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SUS). The antecedents date back to the 1970s, when a political movement advo-

cated and actively worked for a new health system that could surmount the historical

segmentation of access to health care. This social and political movement and the

reform process itself coincided with a combination of economic crises, important

political changes (transition to democracy) and a significant revitalization of bothorganized civil society and the political party system. These factors had an impor-

tant influence on the governments policy agenda and its handling of social and eco-

nomic issues. Implementation of health sector reform was strongly influenced by

these conditions and fraught with contradictions and conflicts due to both domestic

and international political and economic conditions, as well as health sector con-

straints and the priorities of State reform (Almeida et al., 1999).

Throughout the Latin American region, health sector reforms have primarily had

the aim of streamlining healthcare financing and decentralizing authority for plan-

ning and implementation, and have increasingly incorporated other objectives such

as improving the quality of care and enhancing equity (Almeida et al., 1999). Theseobjectives have developed against the backdrop of widespread poverty, increasing

inequality, social unrest and environmental deterioration (Londono and Szekely,

1997; Szekely, 2001). However, unlike the health sector reform process of the past

decade in other countries within the Latin-American region, health sector reform in

Brazil was at first not included on the government agenda, either as a demand or as a

result of adjustment policies. On the contrary, the political and organizational inno-

vation proposed for the Brazilian health system ran counter to these policies,

because it was based on ideas that had guided the organization of health systems

in post-war Europe and was strongly influenced by the philosophy of Keynesian

welfare social rights and of the State as service provider (Almeida, 1999, 2000,

2002a, 2002b).

Certain dimensions of the decentralization process acquired specific characteris-

tics in the health area and formed the axis of SUS implementation. Although

changes were made in the rights and responsibilities of the different levels of gov-

ernment and in the rules for resource allocation, important links with the central

level were maintained. Decentralization was implemented by the Basic Operating

Norms (Normas Operacionais Basicas NOBs in 1991, 1992, 1993 and 1996)

and more recently by the Operating Norms for Health Care (Norma Operacional

da Assistencia a Saude-NOAS) in 2001 and 2002. Local government has sincebecome a stronger service provider and interregional differences in service supply

have diminished. The intensity of these changes, however, differed greatly from one

region to another, as well as within the same region or even within the same state

(Barros et al., 1996; Lucchese, 1996; Almeida et al., 1999).

In response to these challenges the Brazilian government developed several

special programs such as the community health workers (Programa de Agentes

Comunitarios de Saude or PACS) in 1991, and the family health program (Pro-

grama de Saude da Famlia or PSF) since 1994 to bolster the provision of primary

health care services. At the same time, major changes have been introduced in terms

of health policy meant to improve primary health care. For example, the NOB laidout the responsibilities of different levels of government in the provision of

health care and the government developed a national system of per capita funding

304 J. MACINKO ET AL.

Copyright# 2004 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2004; 19: 303317.


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for primary health care known as the Basic Health Floor (Piso de Atencao Basica or

PAB).

As one of the main program and policy responses to growing health inequities

within Brazil, the Family Health Program has witnessed considerable growth. It

has expanded from 900 teams in 900 municipalities in 1996, to about 5000 teamsin 1870 municipalities in 1999, to over 10 000 teams in more than 3000 of Brazils

5561 municipalities in 2000 (Aguiar, 1998; MS, 2000). The PSF program is com-

posed of interdisciplinary health teams based in a health center with a geographi-

cally defined catchment area and in most places includes a team of community

health workers. Innovative characteristics of the PSF program include its emphasis

on reorganizing primary care to become the gatekeeper of the health system, inte-

grating primary care with other social services, changing the focus of care from the

individual to the family, and developing community participation and outreach

methods such as regular visits to each household in a given geographic district.

In spite of the considerable investment in the Family Health Program, to date,there has been little research into the extent to which these innovative features have

actually changed the way Brazilians receive primary care. The vast majority of

existing evaluations focus on program financing, human resource needs, types of

municipalities most likely to adopt the PSF, and characteristics influencing the

adoption of the program at the local level (Vianna and Pierantoni, 2002; Svitone

et al., 2000; Escorel et al., 2002; Medina and Aquino, 2002; Ministerio da Saude,

1999; Canesqul and de Oliveira, 2002).

The study builds upon experiences using the Primary Care Assessment Tool

(PCAT), an instrument that previously has been used to evaluate primary care ser-

vices in the United States and Canada (Starfield, 1998, 2000; Shi et al., 2001).

Research in the USA and in European countries has suggested that strong primary

care systems are associated with lower costs, higher patient satisfaction and better

quality of care (Starfield, 1994; Starfield and Shi, 2002). There is mounting evidence

that they are also associated with better population health, at least in wealthy indus-

trialized nations (Macinko et al., 2003; Starfield, 1992; Starfield, 1998; Boerma and

Fleming, 1998; Bindman et al., 1996; Bunker, 2001; Casanova and Colomer, 1996).

Nevertheless, there is surprisingly little evidence of the impact of primary care on

population health in developing countries (Hill et al., 2000).

In our early discussions, municipal health authorities indicated their desire for arapid and valid way of measuring changes in primary health care center organization

and service delivery. The need for a rapid monitoring and evaluation tool was par-

ticularly important as the PSF program is growing by approximately 25% per year.

For this reason, we developed the pilot stage of the project that employed key infor-

mants as a way of streamlining the data collection process. This study presents

results from a rapid assessment of the organization of primary care services in Pet-

ropolis, Brazil. It aims to characterize essential features of the primary health care

system, test whether these features differ between the traditional and the newly

reformed PSF primary health care centers, and assess the extent to which key deci-

sion-makers are cognizant of these differences.In this paper, we use primary care rather than primary health care to refer to the

most basic level of health care provided in the health system. This is in accordance

PRIMARY HEALTH CARE IN PETROPOLIS 305



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with the term atencao basica (basic care) used in Brazil. We use the term clinics

to refer to the most basic level of health service that provides primary care. The Por-

tuguese translation of the word clinics has a different connotation in Brazil. Thus,

readers familiar with the Brazilian health system should read the word clinics as

unidades (health units) or centros (health centers) and not clnicas.

METHODS

Primary care measures

This study used a functional definition of primary care since primary care definitions

such as those developed by the Brazilian Ministry of Healththe sum of indivi-

dual and community-based actions located at the first level of health care and

oriented towards health promotion, disease prevention, treatment, and rehabilita-

tion (MS 1999; authors translation)do not readily lend themselves to measure-

ment of the degree of attainment of components related to primary care. A

functional definition of primary care includes structural elements such as accessibil-

ity, range of services provided, definition of a patient population and continuity of

care. It also includes process elements such as receipt of health services and health

problem recognition. All four major domains of primary carefirst contact care,

continuity (sometimes called longitudinality to capture its person-focused aspects

over time), comprehensiveness, and coordination of care can be assessed by

examining these structural and process elements of a health services system.

It is in this spirit that Starfield developed the following functional definition ofprimary care as that level of a health system that provides entry into the system

for all new needs and problems, provides person-focused (not disease-oriented) care

over time, provides care for all but very uncommon or unusual conditions, and coor-

dinates or integrates care provided elsewhere or by others (Starfield, 1998: 8).

It is possible to combine the health services-oriented model of Starfield with a

broader conception of primary health care that reflects the community and multisec-

torial nature of primary care as practised in the developing world. This conceptua-

lization additionally allows for the synthesis of the categories proposed by Starfield

with the community-oriented approach suggested by Alma Ata.

Based on an analysis of Starfields (1998) work, and literature on Health for Allby the Year 2000 (WHO, 1978), a preliminary list of the main attributes of primary

care systems would include:

Accessibility the presence (or absence) of financial, organizational, and/or

structural barriers to receiving primary care;

First contactthe extent to which primary care serves as the entry point to

other levels of care (in non-emergency situations);

Longitudinality whether primary care is continuous (person-focused) over

time;

Comprehensiveness the extent to which all essential services needed toprovide for the majority of population health needs are offered at primary care

facilities;

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Coordinationthe extent to which primary care facilitates patients care

between levels and with other important social services and sectors;

Family-focusedthe extent to which primary care considers the patient within

the wider context of his or her familial environment;

Community orientationhow well primary care responds to communityneeds, promotes community participation in health, and is involved in intersec-

toral actions designed to promote health;

Provider characteristics the type and extent of training of primary care

providers.

In order to capture these primary care dimensions, the study utilized a version of

the Johns Hopkins University Primary Care Assessment Tool (PCAT). The PCAT is

a valid and reliable tool for measuring dimensions of primary care and includes ver-

sions for use with either health providers (facility-level survey) or clients (Shi et al.,

2001). The facility-level survey was translated from English to Portuguese, back-translated, and extensively pre-tested. Additional questions were added and several

sections (such as the list of essential primary care services provided) were adapted to

better reflect the primary care context of Brazil.

Two versions of the questionnaire were prepared. The facility survey was directed

toward health providers and questions refer to the health clinic in which they work.

The second version utilized the same questions but phrased them so that responses

would describe health managers understanding of the entire primary care system

that they oversee.

Population

The municipality of Petropolis is located in the state of Rio de Janeiro in the South-

Eastern portion of Brazil. Table 1 presents basic demographic and health data on

the municipality. It was chosen to test the methodology because of its history of

development of an acceptable level of health service coverage, its role as an early

adopter of the family health program, and the persistence of numerous traditional

Table 1. Characteristics of Petropolis, 2002

Indicator Petropolis Rio de JaneiroState (average)

Area (km2) 811 43 696Population 286 348 14 724 479Per capita income (in Brazilian Reais) 7588 9788Infant mortality rate (per 1000 live births) 23.20 19.74Low birth weight births (%) 10.34 8.58Live births to mothers with 4 or more prenatal visits (%) 90.53 89.67Mortality from cerebrovascular diseases (pr 100 000) 79.57 60.23Family health program coverage (% of population) 14.7 12.9

Source: Instituto Brasileiro de Geografia e Estatistica (IBGE) 2002.

PRIMARY HEALTH CARE IN PETROPOLIS 307



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clinics functioning alongside family health clinics. Petropolis is considered a mid-

sized municipality with a population close to 300 000. Per capita income is slightly

lower than the average for the state of Rio de Janeiro, and health indicators are, on

average, slightly worse than the average for the state of Rio de Janeiro. The family

health program currently covers about 15% of the population, traditional healthclinics cover up to an additional 60% of the population for primary care, and the

private sector covers the remaining proportion.

The facility survey was administered by a trained interviewer to health provi-

ders (physician, chief nurse, or both) in a sample of reformed (PSF) and traditional

clinics. The sample included all functioning clinics that had been in operation

for at least 6 months and that reported delivering a minimum of 1000 ambulatory

care procedures during the past year. The final selection represented 80% of all

government primary care clinics in the municipality of Petropolis and included

23 out of a total of 26 PSF and 10 out of a total of 15 traditional clinics. The num-

ber of ambulatory care procedures was verified using the Brazilian Ministryof Healths on-line database called SIASUS (Sistema de Informacao Ambulatorial

do SUS).

Key informants were selected from supervisors and municipal health authorities

in Petropolis. Informants were selected based on their experience working in the

health system in Petropolis (minimum of 5 years), their professional qualifications

(physician or nurse), and their current role as supervisor or manager of the entire

network of PSF or traditional clinics. Two informants were interviewed regarding

the performance traditional health clinics, two were asked about the PSF clinics, and

one was asked about the entire public primary care system.

Analysis

The questionnaire was designed with 100 questions; each pertaining a specific

dimension of primary care. Interviewers responded to a likert-type scale for each

question with values ranging from 0 (never) to 5 (always). Scores were then

summed for each question, and summed across each of the eight dimensions of pri-

mary care. Differences in scores between types of clinic (PSF vs traditional clinics)

were tested using the Chi-square (2) test. Differences were considered significant

at thep

HCS in Brazil

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