The care network and sanitary conditions of family health units: is there any relationship?


Leidiane Andrade BarretoI; Mariluce Karla Bomfim de SouzaII; Elaine Andrade Leal Silva III

I Nurse. Graduated from the Federal University of Recôncavo da Bahia, Health Sciences Center. Santo Antônio de Jesus, Bahia, Brazil. E-mail: leilla-06@hotmail.com
II Nurse. Ph.D. in Public Health. Professor at the Federal University of Bahia. Salvador, Bahia, Brazil. E-mail: marilucejbv@yahoo.com.br
III Nurse. Master degree in Collective Health. Professor at the University of Recôncavo da Bahia, Santo Antônio de Jesus, Bahia, Brazil. E-mail: ealealsilva@hotmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2016.17440




Objective: to discuss the conceptions and operationalization strategies of the health care network, as well as the health conditions of family health units. Method: qualitative study conducted in 2014, with 30 interviews with managers, workers and users of eight family health units (USF) in a municipality in the Brazilian Northeast. It was approved by the Research Ethics Committee (CAAE: 24516113.1.0000.5030). Results: data pointed out fragility in the articulation between the different attention sectors, characterizing the fragmentation of the health system. The health conditions of the units reveal: lack of instruments, equipment, professionals and that there is not ideal structure to meet the health needs of the population. As consequence there is prejudice for the outcomes of these services, as well as changes in flows and overloads secondary and tertiary care. Conclusion: since the primary health care represents the basis, the resolutivity and the communication centre of the network, managers must guarantee the appropriate sanitary conditions of the FHU.

Keywords : Health care networks; sanitary conditions; primary health care; health centres.




The operationalization of care and management of the Unified Health System (SUS) has been highlighted by a fragmentation of services, actions and practices justified by several factors, such as existence of important gaps in care; Insufficient public funding; Inadequate configuration of attention models; Spraying of services in the municipality and little inclusion of surveillance and health promotion in the daily services mainly in Primary Health Care (PHC)¹.

These factors constitute challenges to be faced requiring the reorganization of the health system, based on the development of Health Care Networks (HCN) to promote a systemic integration between the various health services and actions in the way of implementing the SUS guidelines.

Therefore, this study aimed to discuss the conceptions and modes/strategies of the operationalization of HCN, as well as the sanitary conditions of family health units, understanding them as potential centers of communication of the entire network. From this discussion, it is intended to answer if there is any relation between the operationalization of HCN and the sanitary conditions of the family health units.



HCN consists of organizational arrangements of actions and health services, of different technological modalities that, integrated through technical, logistical and management support systems, aim to ensure, the integrality of care². According to the Pan American Health Organization, HCN have generated a positive impact on health models, reducing the fragmentation of care, improving the cost effectiveness of health services, reducing hospitalizations and increasing patient satisfaction³.

Considering the need to reorganize the health system and change the health care model, the National Primary Care Policy (NPCP) presents PHC or Basic Care (BC) as the main gateway and center of communication with all network and place its functions, to be basic and resolutive for most of the population's health problems4.

Therefore, PHC services, consisting of basic health units (BHUs), without or with family health teams, must have minimum resources to guarantee their functioning. In terms of the responsibilities of the spheres of government, NPCP emphasizes the guarantee of the conditions of the infrastructure necessary for the operation of the BHU, as well as the guarantee of sufficient material resources, equipment and inputs for its operation and for the execution of the set of actions considering the recommendations of the Ministry of Health´s Basic Care Department5.

However, the problems of health service infrastructure in many Brazilian realities substantiate questions about the effectiveness of BC services, in a way to relate them to some extent to professional practices and their responses to the demands of the population5,6.



This is a descriptive study with a qualitative approach. This is a cut from the larger project titled Health Conditions of Family Health Units: Challenges for the Work Process, Health of the Population, and Health Management 6 , funded by the Foundation for Research Support in the State of Bahia (Fapesb).

The study had family health units (FHU) of a municipality in the northeast of Brazil, with 94,077 inhabitants, which has 100% coverage of the Community Health Agents Program and just over 80% of Family Health Strategy 7. Two randomly selected FHUs per health district were included, totaling eight FHUs, one of which was rural.

The data collection was carried out between March and May 2014, through semi-structured interviews, with three different routes for each group of participants (managers, workers, and patients). The interviewees were identified with codes consisting of letters and numbers to ensure anonymity, with a numerical sequence represented by 1 to 8, corresponding to the sequence of interviews by a group of participants. The letter M represents the group of managers; T for the nursing technicians; P, high-level professionals such as doctor or surgeon dentist and U the group of patients.

The group of managers was represented by people who hold formal positions in the Municipal Health Department (health, director, and coordinators). The groups of M, T, and P corresponded to those working in the randomly selected FHUs, and the U group were those found at the opportunity of data collection. For a better delineation of the research, some inclusion criteria were defined for the selection of the subjects: being a professional in activity in the basic network of the municipality; Managers must present their management for at least one year in the performance of their duties; patients must be registered in the units for at least one year. Some criteria were defined for all participants as adulthood and to agree to participate in the study.

For the analysis of the data, the technique of content analysis in its three stages was used: the pre-analysis, in which the documents are chosen, formulating the hypotheses and objectives for the research; The exploitation of the material, using specific techniques in accordance with the objectives; The treatment of results and interpretations8. The data were analyzed and discussed from two categories: Operation of the health care network; Health conditions.

The ethical principles for this study were observed, considering the aspects required for research involving human beings treated by Resolution 466/2012 of the National Health Council9. Approval was given by the Research Ethics Committee of the Institute of Collective Health of the Federal University of Bahia, with opinion number 520.954.



The material produced, from the interviews, enabling to analyze the conceptions, models and strategies for the operationalization of HCN and sanitary conditions of FHU.

Operationalization of the health care network

The managers' interviews revealed a convergent conceptual understanding of the HCNs. However, the reports, in general, denounce the fragility in the articulation between the care centers, characterizing the fragmentation of the health system.

One interviewee clearly presents his or her HCN conception:

The way to organize the health system, in which the patient has to be in a central position, [...] there is a difference between average, high complexity and basic care, but the patient has a path no longer defined by a pyramid [...]. (M4)

This report highlights the central role of the patient in the articulation of the network. The deponent refers to a model of organization in SUS, the pyramid model, which can be overcome by a new possibility to be explored, the proposal of the circle10. In this new paradigm, mechanisms are built that interconnect patients´ services and needs. However, the organization of health services is still attached to old models of organization coexisting with the experimentation, in some localities, of new practices close to the HCN proposal.

Some reports brought a reduced conception regarding HCNs and also exposed in the lack of compression on the subject:

Look, I understand that the Health Care Network is very important for the patient who has low financial condition [...]. (T5)

I can not; I can not talk about it. (P5)

The nursing above technician reduces BC's concept of network and affirms that the services offered by the network should exclusively benefit the financially disadvantaged population, revealing a lack of knowledge of the principle of universality proposed by the SUS, reinforcing the SUS concept for poor people.

In research carried out with patients of health facilities in Porto Alegre, it was found that the greatest use of the services provided by the FHU was given by people of lower socioeconomic level, justified by the greater access to this group to health services in more vulnerable situations and because they have no other means to solve their health demands11 .

For this study, it is considered a way of operationalizing the network the way in which HCN is organized and articulated, based on flows and counterflows. The following two reports are contrasting, observing that for some of them, the network is working perfectly and for others, this network does not exist:

[...] it is a direct link with all services [...] here we have the basic care that is the gateway and has other specialized services, so as a gateway we make all these referrals to enable the care of this population [...]. (M6)

[...] the organization of health networks is, unfortunately, a little distant from the work of Surveillance [...]. We should work much more together, associated, involved. [...] then, our health network does not exist [...]. (M5)

The report of a professional participant of the study refers to the need for the workers to know all the HCN and points out:

What happens in this network of care is that each one is functioning on its own [...], so each one is running like this ... it works very independently ... so that is bad for the municipality [. ..]. (P2)

From this report, it is assumed that there are few moments of collective discussion, training, meetings between professionals and coordination, compromising the articulation between professionals and services.

Another professional report mentions the difficulties in regulating specialized care services and also the dissatisfaction not only of the patients but also the professionals, who deal with these difficulties routinely.

It is very difficult for patients, [...] the patients arrive there on a day of the month leaving their referral, but this patient does not know what day will be evaluated, sometimes, next month, in which he may be attending or no[...]. (P3)

Different from this last report, a study carried out in three capitals of Brazil, Belo Horizonte, Florianópolis, and Aracaju, on the organization of reference flows for specialized care presents good examples of how it is possible to organize these services. In these cities, the consultations are scheduled in the FHU, according to the reference given by the doctor. Usually the request is inserted into a system, where the risk classification is done, with the date and the reference service requested, which will later be informed to the patient. The availability of PHC requires the access to consultations and procedures available in secondary care, and also when there is a low resolubility of primary care, the demand for secondary care increases12.

Here, there is another testimony:

Basic care cannot supply what it should supply and ends up filling the other references [...] (P4)

There is a recurrence in the city of the overload of specialized care and the lack of BC resolution, enhancing procedures that could be done at this level of care. Thus, the analysis of the results allows to point out that the lack of coordination of the HCns demarcated by the non-resolvability of BC compromises the organization in the network and potentiates the fragmentation of the services.

The poor resolution of PHC/BC, outraged by sanitary conditions that are still far from that recommended by the Ministry of Health, constituting a great difficulty for the organization of the care network, and requiring managers and other health workers to discuss ways and strategies for its operationalization, according to the different locoregional realities that characterize the Brazilian reality.

FHU sanitary conditions

This study considers sanitary conditions - the set of elements capable of adequately favoring the effective functioning of health services, from the disposal of people, equipment, supplies, physical, electrical and hydraulic installations, solid and infectious waste management to influence risk and suffering reduction, and enhancing health in general. The provisional concept adopted for this study was elaborated from the reflections on previous researches regarding basic sanitation, infrastructure, and sanitary intervention5,6,10-13.

The terms referred above subsided the elaboration of a provisional concept, given the reflections generated and the production of the knowledge that allows the inquiries and the conceptual reconstructions. Thus, sanitary conditions greatly influence the actions taken by service health workers, who are sometimes limited to performing procedures, lack of materials or inadequate physical structure. Thus, the knowledge of such sanitary conditions becomes indispensable for the establishment of measures of risk protection, health promotion, and reorganization of the system.

When asked about the analysis of sanitary conditions in the municipality, it was noticed that most managers and workers were concerned with the precariousness and improvisation of the FHUs facilities:

Far from the ideal [...] the reality of the municipality is very far from what we expect for basic care; most FHUs still work in adapted real estate without the necessary conditions to do a good job in family health [...] (M1)

Given the analysis of the results regarding the precariousness of the physical structure, the interviewees revealed that this factor is attributed to the adaptations of the rented properties. In a study carried out in a BHU in the city of Porto Alegre, Rio Grande do Sul, the inadequate work conditions were related mainly to the physical structure of the units, functioning in old community centers that lacked rooms for attendance, lack of adequate accommodation of patients, organization of labor impaired, reflected by the lack of materials, encouraging workers to acquire these inputs, from their own resources.13 These realities have created challenges to ensure the qualification and resolution of PHC14.

Considering the results analyzed and the different positions of the participants, there is a consensus on certain aspects that compromise the sanitary conditions of the units, such as ventilation, availability of equipment for use by the population and access issues:

[...] there is a lack of fans in the area, we are all muffled [...] there is no water cooler here [...] then everything is still lacking to become a high-quality service, even if it is not the first quality, but second quality [...]. (U5)

Besides the structural issues, one of the participants highlighted the problem of medicines. The lack of medication is a factor hindering the continuity of care, which can cause dissatisfaction with working conditions in the health team, generating a sense of indignation at the patient´s suffering and the difficulty to act15.

[...] in these 6 months, there is the lack of important medicines for the population, so today, for example, a patient came to the consultation and I would indicate such medication because I think we have it there, but the patient said, no we do not have it here, we do not actually have [...]. (P3)

One manager interviewed highlighted the importance of sanitary conditions for health promotion, using a comprehensive health concept that is not restricted to curative practices. It also reveals the concept of healthy cities, an important strategy for promoting health:

When we talk about a health unit problem, we cannot dissociate health units from the rest of the city, the city has almost no sewage network, still has poor garbage collection, the city still suffers from the quality of drinking water, then the whole sanitary structure of the municipality needs to improve to generate a positive impact in the health unit as well.... (M5)

Contaminated and infectious garbage collection (by the company responsible for such service in the municipality) was also recorded in the investigated units, which has generated repercussions. It is noticed that the lack of articulation of other services extrapolating the health area, impacts on the organization and planning of the services provided. It is necessary to think that the sanitary conditions of the units involve an arsenal of resources, not only the ambiance. Some demands go beyond the health sector, and the articulation in the sense of collectively seeking to strengthen intersectoral actions is necessary with the managers so that alternatives and strategies are sought that will solve the problems that somehow interfere in other sectors besides health.

Considering the analysis of the interviews, most managers and professionals pointed out that deficiencies in health conditions were almost always related to the environment, physical structure and lack of inputs at work. While the patients interviewed brought the problems of hygiene of the units, the lack of equipment and medicines, converging to the perception of managers and professionals, but patients emphasize with greater intensity the lack of drugs and equipment.



The results of the research pointed out the lack of knowledge of some professionals and patients about the concept and modes of the operationalization of HCNs and denounce the fragmentation in the articulation among the health care network. The study revealed that most FHUs in the studied municipality work in rented properties, presenting deficiencies in the physical structure, lack of equipment, drugs, inputs, maintenance and improper waste disposal, directly influencing the quality of the services offered by SUS. This reality highlights the importance and necessity of directing health actions to improve sanitary conditions.

Thus, it is concluded that the lack of material, professional resources, and structure to meet the population's health needs can compromise the resolution in this service, as well as alter the flows of other levels of health care and overburden the services of secondary and tertiary care, thereby compromising the purpose of PHC.

Although they seem very different thematic axes and difficult to analogy, sanitary conditions of the units and operationalization of HCN of this study, with conditioning, linked relationship. The results of the research identify that the poor sanitary conditions of the FHUs can interfere in the organization and provision of services provided, the inefficiency of the communication between levels of care and in failures in the regulation process, generating problems for the operationalization of HCNs.

The limited literature on the subject is highlighted among the limitations of the research.



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