UPDATE ARTICLES

National primary care access and quality improvement program: issues to discuss

Roberta Rodrigues de Alencar Mota^I; Helena Maria Scherlowski Leal David^II

^I Nurse. Doctoral Candidate in the Nursing School Graduate Program at Rio de Janeiro State University (UERJ - Universidade do Estado do Rio de Janeiro) Brazil. E-mail: robertarodriguesmota@yahoo.com.br
^II PhD in Collective Health. Assistant Professor at the Public Health Nursing Department and at the Nursing Graduate Program, Nursing School, Rio de Janeiro State University (UERJ). Brazil. E-mail: helena.david@uol.com.br

DOI: http://dx.doi.org/10.12957/reuerj.2015.14725

ABSTRACT

This article reflects on the National Primary Care Access and Quality Improvement Program (PMAQ-PC) as a current strategy for reviewing primary care services used by the Ministry of Health. It highlights some of its most relevant features, as they relate to the effective implementation of the Unified Health System as a social policy designed to afford universal access and equity in health by decentralizing and strengthening health care at the municipal and local levels. Although introduced only recently (in 2011), the PMAQ-PC is currently in its second phase, which is considered very premature, since the entire national process is very complex, expensive and exhaustive, both for the primary care teams assessed and the teams of evaluators. Also, it is too short time to identify the problems, develop intervention strategies, and change conditions.

Keywords: Primary health care; health situation analysis; health care quality assurance; health care quality, access, and assessment.

INTRODUCTION

2011, besides the publication of a new version of the National Primary Care Program (PNAB - Programa Nacional de Atenção Básica), was also marked by the issue of Regulation No.1,654 from the Ministry of Health (MS - Ministério da Saúde), which institutes, in the scope of the Unified Health System (SUS - Sistema Único de Saúde), the National Primary Care Assessment and Improvement Program (PMAQ-AB - Programa Nacional de Melhoriado Acesso e da Qualidade da Atenção Básica) and its Financial Incentive.^1,2 It is important to highlight that with this movement from the MS, it was possible the agreement and publication of a series of Regulations and normative rules that have created new programs (among them the PMAQ-AB) and produced advances in existing programs and actions, enabling, according to some authors, a new PNAB for the country.³ The PMAQ-AB is considered the best PNAB synthesizer, precisely for articulating with several initiatives, establishing synthesis and synergy with almost all of them, being the new PNAB revealer.^4:361

With the PMAQ-AB introduction, the MS tries to strengthen the qualification of the actions offered in the primary care level.

The set of actions and activities developed within the scope of the PMAQ is one of the quality inductive strategies adopted by the MS aiming to improve the results of health actions offered to the population^5:15.

The regulation No.1,654 is directed to all Primary Care Teams (PCT), i.e., the contracted PCT, the Oral Health Teams and the Family Health Support Centers (NASF - Núcleo de Apoio à Saúde da Família). The teams can adhere to the PMAQ-AB as long as they are in accordance with the primary care principles and with the criteria defined in the PMAQ-AB Instruction Manual. ²

The PMAQ's main objective is:

To induce the increase in access and the quality improvement of primary care, ensuring a comparable quality standard in national, regional and local levels, providing greater transparency and effectiveness to governmental actions directed to Primary Health Care.^1:1

Among its specific objectives, we highlight: to extend the impact of PC on the population's health conditions and on the satisfaction of its users; to supply good practices and organization standards to Primary Health Centers (PHC), which guide the PC quality improvement; to promote greater compliance of the PHC with the PC principles; to promote quality and innovation in the PC management; to improve the Information System's supply and use; to institutionalize a PC assessment culture in SUS and a management culture based on the induction and monitoring of processes and results; to stimulate the PC focus on the user.¹

Since it is still a proposal in implementation and due to the introduction of some aspects and devices that intend to constitute innovations for the PNAB establishment in national territory, this article seeks to bring a reflection on the PMAQ-AB as a current strategy for primary care service assessment used by the MS, emphasizing, in a brief and preliminary analysis, some of its most relevant aspects, having as mainspring the establishment and implementation of SUS as social policy directed towards universal access and health equity, through the decentralization and strengthening of municipal and local health levels.

The PMAQ-AB asan assessment Strategy

From the point of view of theoretical-methodological matrices that guide health assessment proposals, it seems to have been consensual for some decades already, the mark a population's health problems, and, therefore, also affect the actions directed to its resolution. In the implementation of the programs and strategies that compose the National Health Policy, the assessment matter has gained specificities, gradually defining the role of the Federal instance as the main formulator of the assessment processes together with the Federative Units and the cities.

The Basic Operational Norms landmark, issued in the 1990's, came to cement the practice of attempting to reach a consensus among the political-administrative execution levels in SUS through the proposal of instances and processes of association, now integrated into these policies' daily implementation, and using indices and targets related to the main public health matters. This does not mean, however, that there has been an effective institutionalization of assessment practices by the municipalities.

When it comes to PC, whose priority program is the current Family Health Strategy (FHS), there is an important implication, which is made explicit through the proposal of a change in the care model, which can be briefly understood as the idea of a displacement, the focus on healing actions, individually tailored and directed to illnesses diagnosis and treatment, granting centrality to the medical work, for interdisciplinary and interprofessional actions, which include the identification and confrontation of social and biological determinants, for risk factors, in addition to recovery and rehabilitation actions.⁶

This change would require significant transformations in health practice and actions, in the relations among the social actors involved, in the levels of municipal management. Some authors⁷ understand that the quantitative indices and targets cannot grasp the qualitative changes necessary for the implementation of changes, making it necessary the development of a health assessment institutional culture in the municipalities.

Advancing the institutionalization...

An important attempt to advance the institutionalization was the Baseline Studies of the Project for the Expansion and Consolidation of the Family Health (ELB/PROESF - Estudos de Linha de Base do Projeto de Expansão e Consolidação do Saúde da Família) developed in middle of the 2000's, through the meta-assessment studies in Brazilian cities, highlighting three dimensions: the political-institutional, the Care Organization and the Comprehensive Care. Results of these studies evidence the low assessment culture in the cities, an aggravated matter due to problems such as managers and professionals turnover, influences of local politicians, low professional qualification, among others7. Regarding the teams' practices, another analysis of the ELB-PROESF emphasized that their focus still resolved around individualand, when they were collective, around programmatic actions for deteriorations - hypertension/diabetes, tuberculosis, among others8. It is observed, therefore, that the implementation of assessment actions does not solely depend on the definition of indicators, and that an appropriate pedagogical approach can collaborate to extend the assessment capacity of the actors involved.⁹

In spite of these difficulties, the FHS, health care model adopted as a strategy in Brazil, has brought undeniable increase in access to health, understood as service coverage. Such expansion fostered the need for qualification of the services offered to the users in the primary care level, making it necessary the development of new assessment actions for decision-making in the health system management level.⁵

Guidelines

Currently, one of the main MS guidelines is to run the public management based on induction, monitoring and evaluation processes and measurable results, ensuring health care access and quality to the entire population. In this respect, multiple efforts have been undertaken aiming to adjust the strategies anticipated in the PNAB with the intent to recognize the quality of the PC services offered to the Brazilian society and to stimulate the expansion of access and quality in the various existing contexts in the country¹⁰, being PMAQ-AB the most recent.

The PMAQ-AB guidelines are the following: to provide a yardstick for comparison among the PCT; to stimulate a continuous and gradual improvement process of the access and quality standards and indicators; transparency in all its stages; to involve, to mobilize and to make federal, state, the Federal District and municipal managers, the primary health care teams, and the users responsible; to develop a negotiation and contractualization culture; to stimulate the effective change of the care model, the development of the workers and the service orientation according to the needs and the satisfaction of the users; and to define the volunteer basis for adhesion both for the PCT and for the municipal managers.²

On these objectives and guidelines, it is worth highlighting its broad and abstract nature in many aspects, which bring some questionings: what would be the strategy adopted to make transparency of the governmental actions possible? To what extent would the comparisons among the PCT not be stimulating competitiveness among them? What is the so called care model change made of? What is the guarantee that the adhesion of PCT and Cities will occur in a voluntary way?

The MS recognizes that this change is not free from from impediments, therefore, it highlights some of the challenges the PMAQ proposes to face to ensure the primary care qualification: Precariousness of the physical network; Not such a welcoming environment at the PHC; Inadequate working conditions for professionals; Necessity of work process qualification in the PC teams; Instability of the teams and high turnover; Lack of knowledge of the management processes centered on quality induction and monitoring; Overload of the teams with an excessive number of people under its responsibility; Little integration of PC teams with the diagnostic and therapeutical support network and with the other points of the Health Care Network (HCN); Low integrality and resolution of the practices; Insufficient and inadequate financing of the PC.¹⁰ Although the mention of these many challenges in its original publication, it is neither perceived nor proposed a real reflection on these conditions' determinants.

Structure

The PMAQ is structured on four distinct complementary phases that configure a continuous cycle of PC access and quality improvement:

- Phase 2 – Development: it is the central stage of the program, since it is when the operation of the change occurs, mainly performed by the primary care teams and the municipal management. This stage is focused on the self-assessment and monitoring strategies of the actions¹¹. As a self-assessment instrument, the MS adapted the Assessment for Improving the Quality of Family Health Strategy (AIQ) model and also other health service evaluation tools, nationally and internationally used and validated, for instanceMoniQuor, PCATool e Quality book of Tools.¹²

- Phase 3 – External Assessment: where a set of actions will be conducted to verify the access and quality conditions of the cities and primary care teams. It is in this phase that a set of information about the access and quality conditions of the PCT is collected, what will enable the certifications of the teams participating in the program. From this assessment, the results and efforts reached by the PCT and municipal managers in the PC qualification process are acknowledged and valued.¹¹

- Phase 4 – Recontractualization: it must happen after the PCT certifications. From each team's performance assessmente, a new contractualizationof commitments and indices must occur, thus fulfilling the quality cycle expected for the program.¹⁰

It is in this team certification process that the strategies for its attainment emphasize the competitiveness for better results, being financially awarded those that present closer indicators to the agreed targets. There are enough studies that evidence that work overload of community health agents (CHA) and nurses, described from the management pressure for the need to meet the targets; they unfold in situations of physical and psychological distress, if we only mention two professional categories.^13,14 It is necessary, therefore, to discuss and question to what extent the imposition of competitive processes may be helpful for the care quality improvement, and also the cost of these processes over the well-being of health workers as well as the respect to their professional autonomy.

Assessment Instruments

Another matter to be addressed is the need for new assessment processes. Among the scarce publications that raise reflections and criticism to the PMAQ-AB, it is highlighted the questioning on the creation and assessment through this instrument.

From the technical point of view, since there are already established and validated instruments such as the AIQ and the Primary Care Assessment Tool (PCA- Tool), it is difficult to understand the necessity of creating a new instrument, even if it is based on preexisting ones. PMAQ-AB's own health indicators are often questionable, such as, for example, the uterine cancer preventive examinations coefficient carried through in women at 15 years old or older - the National Cancer Institute (INCA - Instituto Nacional do Câncer) recommends screening only in women from 25 to 64 years old; and to have a preventive examination done every six months in one woman should never be equated to one done every three months in six women. But the greatest question is: which educational institution group will be capable of verifying the quality of all tens of thousands of teams in the country?^15:7

The PCATool – Primary Care Assessment Tool was created at the Johns Hopkins Primary Care Policy Center^16,17 and elaborated based on the framework for assessing the quality of care proposed by Donabedian.¹⁸ Originally, it presents self-applicable versions directed to children, adults older than 18 years old, health professionals and to the health service coordinator/manager. ¹⁹

This instrument measures the presence and the extension of the four key attributes (individual's first contact access with health system; longitudinality; completeness; care coordination) and the three attributes derived from the Primary Health Care (APS - Atenção Primária à Saúde): Family-centered health care, family counseling; community orientation; cultural competence.^17,19

This assessment model is based on the assessment of aspects regarding structure, process and health services results. Thus, due to the lack of tools to measure these interactions between users and professionals mediated by the health service structure in the APS context in our country, the PCATool would fill a gap, providing a basic individual measure about the structure and, mainly, the APS care process.¹⁹

The PCATool was adapted to the Brazilian reality, each version of the instrument was modified in an applicable tool by interviewers and went through a translation and a reverse translation process, adaptation, debriefing and validation of content and construct, in addition to the reliability analysis.^19:10

Despite these efforts, the PCATool was not broadly used in Brazil. Retaking Fontenelle's thought¹⁵, whose study dates back to little longer than 6 months after the issuing of the Regulation No.1,6542, the author describes some uncertainty as to the use of the PMAQ-AB, since until then the instruments of self-assessment and external assessment to be used were unknown. At the same time, it highlights that the systematic assessment of the APS opens the possibility of ratifying the FHS superiority. Moreover, because of a more significant participation of the nurse and the mandatory presence of the CHA, primary health care (PHC) should be more and more similar to what is preconized in the FHS. The author also concluded that, despite the advantages, it is unusual that the MS has not adopted an extensive and previously validated assessment instrument such as the PCATool.

Finally, it is worth discussing the explicit voluntary adhesion characteristic of the PMAQ-AB by the cities, questioning the real possibility of choice for the adhesion, given the political centrality of the decision-making process of the Brazilian health policy, what was implemented as a decentralized execution of health actions, but still dependent on federal financing and technical and political conduction by the MS.

Public policy assessment

The primary health care (PHC), constituted itself, since 1980's, as the main strategy for expanding the access to a basic set of prevention and health promotion services, focusing on poor and/or emerging countries, such as Brazil²⁰, financed by international agencies that, in the landmark of the state reforms in the 1990's, strongly induced the offer expansion of health services and actions. The field in which these politics have been materializing, however, is also of dispute between political projects and conceptual landmarks on what it is or it must be the PHC level, by its turn, a concept with enough fluidity and polysemy to allow appr opriations and various interpretations.²¹

About the PMAQ-AB, it is worth mentioning some aspects that seem to have great influence on the most recent configuration of the FHS implementation methods in the PC. The Program, implemented in 2011 by Regulation 16442, follows the new PNAB publication1, from October 2011. In general, the new PNAB kept the previous essence and incorporated the workload flexibility for doctors and the NASF implementation, among others provisions. The PMAQ-AB establishes defined assessment parameters, to be implemented in phases, which include from self-assessment processes by the municipal systems to external assessment. The results obtained in this assessment can unfold in financial incentives for the municipal health funds, in accordance with the demonstrated performance.

In this way, it is established an approach between this public policy assessment process and what has been called as the New Human Resources Policy - those built on total quality management concepts and processes, participatory management, among other denominations.²²

The PMAQ is recent and complex, not having been able to implement reality-changing strategies yet.²³

CONCLUSION

Although its recent implementation, the PMAQ-AB has also been questioned regarding other work processes in the teams. Being one of the main policies of the MS, inducement aspects to the competitive relation among teams and to the recognition attainment for merit, essentially connected to the production quantification and to the results indicators, with emphasis on illness reduction, they lead to questioning to what extent we have been advancing to a result-based health, instead of reaffirming the universal right to comprehensive health.

Currently, the PMAQ is in its second cycle, what it is considered rather precocious, since every national process is quite complex, costly and exhausting, both to the PCT that are assessed and to the evaluator teams. In addition, it is a fairly short time for problem identification, intervention strategy definition and reality change. The second cycle began before the PCT, in fact, was able to contractualize and implement changing strategies.

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