[Influence of municipal management on the organization of children's healthcare in primary care services in the interior of the State of São Paulo, Brazil]

Primary health care organization in municipalities of São Paulo, Brazil: a model of care aligned with the Brazilian Unified National Health System's guidelines

This study analyzes the main organization patterns used by primary health care (PHC) services in municipal networks and evaluates them according to indicators of local management-administration interface. Evaluative research analyzed 461 municipalities in São Paulo, Brazil, that participated in the Primary Care Services Quality Assessment Survey (QualiAB) in 2017/2018, classified according to the organizational arrangements composition of 2,472 PHC services. Eight indicators of local management and administration were selected to evaluate the identified patterns. Results indicate two groups of municipalities: homogeneous, with services presenting the same arrangement (43.6%); and heterogeneous, with different arrangements (56.4%). These were subdivided into seven patterns that ranged from homogeneous-traditional, homogeneous-Family Health Strategy, homogeneous-mixed, and different combinations in the heterogeneous group. All indicators showed significant differences between groups (p < 0.001), especially the homogeneous-traditional group, which presented an organizational pattern far from the desired model of a comprehensive and problem-solving PHC. Those integrated with family health units (FHU) and basic health units with community health workers and/or family health teams (BHU/FHU) showed a pattern closer to a comprehensive model - with planning and evaluation actions committed to the local reality and qualification of care. Implementation of federal and state policies are essential for defining the PHC health care model adopted by municipalities.

Primary health care performance according to clusters of convergent municipalities in the state of São Paulo

OBJECTIVE

To describe the performance of Primary Health Care, according to conglomerates of São Paulo cities that present homogeneous indicators.

METHODS

This is a descriptive study, based on secondary data extracted from official sources of the Unified Health System, for the year 2018. An analysis matrix was created, with the proposition of performance (access, effectiveness and adequacy) and context indicators (population, health determinants and financing) selected and organized in dimensions and sub-dimensions. Cluster Analysis was used to identify the groups of homogeneous municipalities.

RESULTS

645 municipalities were divided in 6 conglomerates. Clusters 2 and 3 were formed predominantly by small municipalities with greater access to health; cluster 3 has less social vulnerability and greater investment in health. Clusters 1, 4 and 5 were formed by the largest municipalities with less access to health; cluster 4 presents greater social vulnerability, less coverage of private health plans and a greater percentage of health resources; cluster 5 was characterized by greater Gross Domestic Product per capita and greater coverage of private health plans. Cluster 6, formed by the city of São Paulo, was a particular case. Cluster 2 drew attention, as it was shown to have increased coverage, but signaled lower efficacy and adequacy levels. Cluster 3 had the best performance among all clusters.

CONCLUSION

These findings can support regional and municipal management, given the complexity of the territory of São Paulo, pointing to scenarios that demand broader public management initiatives.

Desempenho da atenção primária à saúde, segundo clusters de municípios convergentes no estado de São Paulo

RESUMO: Objetivo: Descrever o desempenho da atenção primária à saúde, segundo clusters de municípios paulistas que apresentaram indicadores homogêneos. Métodos: Trata-se de um estudo descritivo, com base em dados secundários extraídos de fontes oficiais do Sistema Único de Saúde, referentes ao ano de 2018. Foi elaborada uma matriz de análise, com a proposição de indicadores de desempenho (acesso, efetividade e adequação) e contexto (população, determinantes de saúde e financiamento), selecionados e organizados em dimensões e subdimensões. Para identificar os grupos de municípios homogêneos, foi utilizada a análise de cluster Resultados: Dos 645 municípios, constituíram-se seis clusters. Os clusters 2 e 3 foram formados, predominantemente, por municípios pequenos e com maior acesso; entre eles, o cluster 3 apresentou menor vulnerabilidade social e maior investimento em saúde. Os clusters 1, 4 e 5, em contrapartida, foram formados por municípios maiores e com menor acesso; entre eles, o cluster 4 apresentou maior vulnerabilidade social, menor cobertura de planos privados de saúde e maior percentual de recursos utilizados em saúde; e o cluster 5, maior produto interno bruto per capita e maior cobertura de planos privados de saúde. O cluster 6, formado pelo município de São Paulo, demonstrou ser um caso particular. Ainda, o cluster 2 chamou atenção. Apresentando maior cobertura, sinalizou menor efetividade e adequação. Entre todos os clusters, o cluster 3 alcançou o melhor desempenho. Conclusão: Os resultados podem subsidiar a gestão regional e municipal, diante da complexidade do território paulista, apontando para cenários que demandam maiores inciativas de gestão pública.

[Care for women with high-risk pregnancies in primary care services in the city of São Paulo, Brazil: the healthcare team's perspective]

The study aimed to evaluate care for women with high-risk pregnancies from the healthcare team's perspective in primary healthcare (PHC) services in the city of São Paulo, Brazil. This is an evaluative study with a qualitative approach that used the open interview technique for data collection from PHC personnel. The data were explored through thematic categories built from the content emerging spontaneously from the interviews, discussed according to Health Work Process Theory. The results evidenced three domains: a "normal work routine", organized from the perspective of exclusively biological practices and in which the management model sometimes fails to allow compliance with the recommended practices; a "referral and counter-referral" system, which sometimes allows more timely interventions, more unique to the pregnant women's needs, but still disconnected from the referral services; and "shared responsibility of the PHC team for the pregnant woman", characterized by flexibilization of the work routine that extends beyond application of clinical protocols, encouraging the building of a bond and favoring qualification of care. The study revealed the need for flexibilization of use of patient care protocols in the work process, which can promote the shared responsibility of PHC teams for care, to adjust it to each pregnant woman's unique needs, beyond the limits of services' organization based on the logic of exclusively biological practices.

[Mental health and organizational quality of primary healthcare services in Brazil]

The study aimed to assess the quality of care for persons with mental health distress in primary healthcare services in Brazil and the association with organizational structure variables. This evaluative study used data from the Brazilian National Program to Improve Acess and Quality in Primary Care (PMAQ-AB), collected in 2018. The study excluded teams that reported not performing this type of care. The sum of the 13 selected mental health indicators produced a score that was classified in three groups of quality: G1 (0 to 5 points - lower quality), G2 (6 to 9 points - medium quality), and G3 (10 to 13 points - higher quality), and the results were associated with nine organizational context variables favoring the teams' permanence in the respective quality groups. The study evaluated 36,384 teams, located in 5,026 municipalities (counties). The score ranged from 1 to 13 points (G1 = 9.7%; G2 = 25.1%; G3 = 65.2%). Having an environment favorable to dispensing medicines and privacy during patient consultations; existence of a medical specialist, psychologist, and pharmacist; inter-consultation with the Expanded Family Health Care Centers (NASF) and Centers for Psychosocial Care (CAPS); and weekly or biweekly team meetings, were more frequent in the teams with higher quality (p < 0.001). In conclusion, structural conditions related to infrastructure and availability of healthcare workers, as well as inter-consultation and spaces for reflection to discuss the (re)organization of work processes in care for patients with mental health distress are factors that influence the quality of care, requiring attention, especially given recent political setbacks.