2006 VD - ESF - Peres - BMC PDF
2006 VD - ESF - Peres - BMC PDF
2006 VD - ESF - Peres - BMC PDF
Address: 1Faculty of Nursing, University of the State of Rio de Janeiro, Rio de Janeiro, Brazil, 2Faculty of Dentistry, University of the State of Rio de
Janeiro, Rio de Janeiro, Brazil, 3Institute of Social Medicine, University of the State of Rio de Janeiro, Rio de Janeiro, Brazil and Tools, Evidence
and Policy Unit at Human Resources for Health Department, World Health Organization, Geneva, Switzerland and 4Emeritus Professor,
Universidade do Porto, Porto, Portugal
Email: Ellen M Peres* - ellenperes@openlink.com.br; Ana M Andrade - anandrade@globo.com; Mario R Dal Poz - dalpozm@who.int;
Nuno R Grande - ngrande@netcabo.pt
* Corresponding author †Equal contributors
Abstract
The article analyzes the practice of physicians and nurses working on the Family Health Programme
(Programa de Saúde da Família or PSF, in Portuguese).
A questionnaire was used to assess the evidences of assimilation of the new values and care
principles proposed by the programme.
The results showed that a great number of professionals seem to have incorporated the practice
of home visits, health education actions and planning of the teams' work agenda to their routine
labour activities.
Over the last decade, a series of reforms have been under- The Family Health Program (PSF), launched in 1995, is
taken, transferring responsibility for the administration considered an innovative mechanism for extending access
and provision of public services in health to the level of and promoting equity. The programme integrates public
the municipalities – one level below the states. In general, health actions with care and treatment and is based on
the management of the health system has improved with many successful experiences as observed in other health
this transfer of federal resources and responsibility [1-3]. systems, such as Canada, UK and Cuba [5,6].
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One of the main reasons for the success of this model is tive care – working with a referenced population in a
that it emphasizes health promotion and preventive care, defined territorial basis. The teams should establish a link
without forgetting treatment care, in a situation where with the families, and base their work on a broad concept
providers perceive their role to be one of prevention as of health that makes use of interdisciplinary and intersec-
well as treatment. This simple shift in the perception of toral actions to improve the quality of the population's
roles has been shown to be critical in predicting provider life.
behaviour.
Therefore, the selected indicators for this study refer to
Each PSF team was constituted by one family physician, activities that should be incorporated into health profes-
one nurse, two auxiliary nurses, and four to six commu- sional practices in order to change the health care delivery
nity health agents and is responsible for a catchment area model: home visits, health education activities, intersecto-
that includes 600–1000 families [7]. ral actions, as well as participation in meetings with com-
munity leaders and in the Local Health Council. Some
The PSF teams serve as the gateway to the health care serv- aspects of work organization, such as the planning of the
ices for individuals within the defined territory. In addi- team's actions and the use of local indicators for such
tion to direct assistance, the teams carry out a health planning, were also investigated.
situation analysis in collaboration with community lead-
ers and organize their service in accordance with the pop- Adhesion to those practices will indicate that the profes-
ulation's specific health profile. sional has changed his attitude, shifting from curative care
based on a negative health concept to health promotion,
The PSF implementation brings about an important founded in consistent educational activities and address-
change in the health system: previously organized by serv- ing the families of the catchment area.
ice demands, it is now organized based on the supply of
services, in a context of interdisciplinary and intersectorial Methodology
interventions. As a result, humanization of health care The objective of the study was to explore and characterize
and best client satisfaction are observed. the practice of the physicians and nurses of the Family
Health Programme team, looking for evidence of the
One of the critical problems faced by health authorities development of activities reflecting the values and princi-
and health service managers is the lack of personnel ples proposed by the programme.
trained to respond to the new demands of reoriented
health care services. This includes not only family physi- The six municipalities of the State of Rio de Janeiro where
cians and nurses to serve in primary health care programs, the Academic Institutions that compose the Rio de
but also non-traditional members of the health team, Janeiro's Training Centre in Family Health (TCFH) are sit-
such as counsellors, adult education specialists, anthro- uated were selected for this study.
pologists, community health promotion agents, etc.
A questionnaire was submitted to 209 professionals – 78
To face these problems, the Brazilian Ministry of Health physicians and 131 nurses – working in Family Health
created the Training Centres In Family Health (TCFH) Teams of the selected municipalities and who had previ-
which are regionally distributed and aim to develop ously participated in the Specific Training in Family
human resources competencies in family health [8]. Health provided by the RJ's TCFH and had accepted to
contribute to the study.
This paper is one of the results of a project supported par-
tially by the World Health Organization (WHO) [9] that The questionnaire aimed to gather information about the
aimed to evaluate the impact of the activities of Rio de following.
Janeiro's Training Centre in Family Health (RJ-TCFH)
upon the profile of human resources engaged in the Fam- a) Home visits:
ily Health Programme in some municipalities of the State
of Rio de Janeiro [10]. - the number of home visits accomplished per month by
the professional.
Expected as an immediate consequence of the RJ-TCFH
actions is a shift in health professionals' practices from - the restriction of home visits to patients lying in bed or
individual medical care, early specialization, frequent and having locomotion disabilities (answering either 'yes' or
unnecessary use of high technology procedures and lack 'no').
of humanization, to a model which emphasizes health
promotion and preventive care – without forgoing cura-
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- facts that most frequently motivated the scheduling of competences for the home visit practice and therefore do
home visits (options: the request by another PSF member; not consider it a priority or even part of primary health
the PSF week plan; direct request by a community family). care. The home visit, therefore, represents an indicative of
change of the professionals' practice and their adhesion to
b) Work planning by the Family Health Team: the principles and guidelines of PSF.
- the main focuses of the last routine PSF meeting Figure 1 shows the number of days per month in which
(options: decision-making about administrative issues; the professionals perform home visits. The average value
reading and discussing of scientific issues or debate of was 7.1 days for the physicians and 8.1 for the nurses (also
selected cases; elaboration of the PSF week plan; elabora- interpretable as twice a week). All the professionals
tion of the PSF month plan; communication of recent claimed to perform home visits. However, the high per-
facts to the whole team). centage (10.3% of physicians and 14.5% of nurses) of lack
of answer to the question concerning the number of days
- the use of local indicators for the planning and monitor- per month suggests that there may be a number of them
ing of PSF actions. who do not want to admit their failure to perform home
visits.
c) Health education activities:
When asked about the circumstances that lead the profes-
- participation in health education activities as part of the sionals to perform home visits (Table 1), the number of
work in the PSF ('yes' or 'no'). answers stating that home visits were restricted to patients
lying in bed or having locomotion disability was some-
- the number of days per month dedicated by the profes- what high (30.7% of physicians and 20.6% of nurses),
sional to the accomplishment of health education activi- although the majority of professionals claimed that they
ties. did not make this restriction. As could be expected, the
former group also performed a lower number of home
d) Compromise towards the assisted community visits per month (Table 2).
- participation in community meetings as part of the work In relation to the criteria used for the scheduling of home
in the PSF ('yes' or 'no'). visits, most professionals – 69.2% of physicians and
61.1% of nurses (Table 3) – said that the scheduling is
- the number of days per month dedicated by the profes- determined by the Family Health Team week plan, which
sional to community meetings. is the expected attitude of a Family Health Team working
from an interdisciplinary point of view. As shown in Table
- participation in the Local Health Council of the PSF area. 4, this criterion was also the one that corresponded to the
higher averages of home visits by month, although the dif-
- the accomplishment of actions involving different public ference to the averages relative to the other criteria is not
sectors (e.g. education, sanitation, security, etc) as part of great.
the work in the PSF.
The results indicate that the home visit is being incorpo-
Results and Discussion rated into the professionals' practice. However, it is neces-
The home visit (HV) is reserved for health promotion as sary to rethink the real objectives of the home visits to
well as for health surveillance practices. This is a new those populations. For instance, should the home visits
approach, moving away from merely fragmented activities undertaken by graduate professionals be planned for fam-
(e.g. communicable diseases control). In the PSF, the ilies at risk? Should HVs prioritize the families to which
home visit is one of the core actions to improve the situa- attention cannot be given in the health centre? Is it possi-
tional analysis of the designated population, looking at ble, for those professionals, to perform actions of health
the social dynamics of that specific community. There- surveillance for all of the designated families, considering
fore, there is an enlargement of the objectives, which the other responsibilities they have in the health centre?
include health promotion, prevention, treatment and Clearly, if the resource constraints do not allow for a
rehabilitation in a perspective of an integral and human- change in the relationship between the team and the pop-
ized care. ulation, the expectations related to the home visits should
be reviewed.
The HV is here a central subject for the analysis. There is a
consensus that the health professionals do not have As we can tell from Table 5, 73% of physicians and 61.2%
opportunities in their training to develop the necessary of nurses claimed to perform health education activities
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120
100
80
physicians
%
60
nurses
40
20
0
1-
5
6-
9
-14 o re se t al
n To
10 d
m
spo
an re
15 n o
Number of days
from 1 to 5 days per month, with an average of 4.4 and 5.6 The number of days per year that the professionals partic-
days respectively, i.e. an average of once a week. Thus, ipate in meetings with community members showed great
health education activities also seem to have been incor- variation (Table 6), with an average of 4 days. This average
porated into the practices of physicians and nurses work- can be considered somewhat low: for an adequate integra-
ing in family health teams, constituting an important tion of the health team and the community, it is expected
strategy for the reinforcement of health promotion. that such meetings should occur at least once a month,
which would result in an average of at least 10 meetings
The community meetings are dedicated to social partici- per year.
pation in defining priorities and adopting strategies to
address problems. The assessment of the participation in the Local Health
Council of the HFT (Table 7) showed that only 15.3% of
the professionals gave a positive answer to this question,
n % n %
46 59.0 84 64.1
"The visits are only carried out to bed-bound patients or that cannot walk" 24 30.7 27 20.6
no response 8 10.3 20 15.3
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average average
"The visits are carried out not only for bed- 7.7 8.6
bound patients or those who cannot walk"
"The visits are only carried out to bed-bound 5.8 6.4
patients or those that cannot walk"
n % n %
Table 4: Average number of home visits, by the most frequent criteria adopted
n % n %
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n % n %
Table 7: Degree of participation in the Local Health Council relating to the Family Health Team
Degree of participation n %
Frequently 9 3.0
Sometimes 16 5.4
Almost never 12 4.0
Never 132 44.3
Local Health Council does not exist 120 40.3
No response 9 3.0
Participation n %
and only 4.3% said that their participation was frequent; habits, social conditions, environment conditions and so
6.2% participated occasionally and 4.8% rarely. Of all the on – and that health professionals have the responsibility
professionals, 43.1% admitted they had never partici- of interacting with these other sectors in order to provide
pated and 38.3 said that there was not any Local Health health promotion to the population they attend.
Council in their PSF area. These results indicate that this
activity, important for social control, is not yet recognized On the other hand, the overload of work concerning the
by the professionals as part of their tasks in the family population under the responsibility of a team can be a
health programme. barrier to the development of other actions to comple-
ment health care. One can even question whether the
The final assessed activity was the participation in inter- intersectoral actions should not be part of the local gov-
sectoral actions. Table 8 shows that only half of the pro- ernment activities towards healthy communities, reduc-
fessionals have already participated in these kind of ing the current burden and responsibility of the Family
actions. This means that the other half still has the view Health Team.
that the health professional's obligations are restricted to
what is considered the "health area", forgetting that The study also investigated some aspects of work organi-
health, in a broader concept, is influenced by a large spec- zation: the planning of the team's actions and the use of
trum of influences of variable kinds – living conditions, local indicators for such planning.
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Principal focus n %
When asked about the main focuses of the last routine towards interdisciplinary work. The use of local indicators
meeting of the PSF, 57% of the professionals said that it for such planning shows that the professionals are now
had been the elaboration of the PSF week plan (Table 9), working with a referenced population in a defined territo-
indicating that more than half of the health teams have rial basis.
incorporated the weekly planning of their activities into
their practices. Nevertheless, only 52.7% of the profes- The results suggest that resource constraints, leading to a
sionals (Table 10) claimed to use local indicators fre- low proportion of health care workers by designated pop-
quently for the planning and monitoring of their team's ulation, make more difficult the adoption of the desired
actions. Thus, this is a point that should be reinforced by practices by the professionals, especially those related to
educative interventions to be provided by the RJ'TCFH: intersectoral and local community actions.
the importance of local indicators to guide the team's
actions and of selecting the most adequate indicators to Although the change in the professionals' practices has
each individual (team) reality. not yet reached 100% of physicians and nurses working in
the PSF teams, we can presume that this is an on-going
Conclusion process of changes and that other actions, such as contin-
The practice of physicians and nurses of the PSF teams uous education, can contribute to strengthening the pro-
included in this research showed their assimilation of gramme.
some of the new values and care principles proposed by
the PSF that can result in a change to the health care deliv- Competing interests
ery model [11,12]. The principal author (EMP) was coordinator of the Centre
of Training, Education and Continuous Education on
The accomplishment of home visits not restricted to Family Health in the State of Rio de Janeiro, Brazil from
patients in bed and of health educations actions point to 1999 to 2002.
a paradigm shift towards the integration of health promo-
tion, preventive care and treatment and to the humaniza- Authors' contributions
tion of health care. The previous planning of the teams' All authors contributed equally to the design, analysis and
work, undertaken by the whole team, indicates a shift writing of the paper.
Table 10: Frequency on the use of local level indicators for planning and monitoring
Frequency n %
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Acknowledgements
The authors acknowledge and thank the work of Renato Möller, from PRO-
DEMAN/UERJ, for entering the raw data and preparing the tables.
References
1. Almeida C: Reforma de sistemas de servicios de salud y equi-
dad en América Latina y el Caribe: algunas lecciones de los
años 80 y 90. Cad.Saúde Pública 2002, 18(4):905-925.
2. Barros MCMM: Piso da atenção básica: um estudo de caso da descentral-
ização da saúde no Brasil. Dissertação (Mestrado). Campinas (SP). Univer-
sidade estadual de Campinas. Instituto de Economia 2003.
3. Gerschman S: Municipalização e inovação gerencial: um bal-
anço da década de 1990. Ciênc Saúde Coletiva 2001, 6(2):417-434.
4. Viana AL, Dal Poz MR: A reforma do sistema de saúde no Brasil
e o programa de saúde da família. Physis Revista de Saúde Coletiva
1988, 8:11-48.
5. Brazil. Ministério da Saúde: Programa de Agentes Comunitários de Saúde.
Avaliação Qualitativa do PACS Brasília (DF); 1994.
6. Brazil. Ministério da Saúde: Programa de Agentes Comunitários de Saúde/
Programa Saúde da Família – PACS/PSF Brasília (DF); 2000.
7. Brazil. Ministério da Saúde: Saúde no Brazil Brasília (DF); 1997.
8. Brazil. Ministério da Saúde: Proposta de Incentivo à Reorientação do
Ensino Superior em Saúde (documento preliminar para discussão) Brasília
(DF); 2002.
9. Peres MP: Rio de Janeiro's Training Center in Family Health:
Impact Evaluation of its Educative Interventions upon Pri-
mary Health Care Services Delivery. In Managing a Successful
TUFH Field Project Mini Symposium May 2001, Rockford Edited by: Bry-
ant J, Boelen C, Salafsky B. World Health Organization, Geneva;
2001:25-26.
10. Andrade A, Varella T, Peres E: A prática de médicos e enfermeiros de
equipes de saúde da família – Estudo Avaliativo em Cinco Municípios do
Estado Rio de Janeiro Rio de Janeiro (RJ), Universidade do Estado do
Rio de Janeiro (UERJ); (mimeo); 2005.
11. Brazil. Ministério da Saúde: Reduzindo as desigualdades e ampliando o
acesso à assistência à saúde no Brazil Brasília (DF); 2002.
12. Brazil. Ministério da Saúde: Brazil family health: an analysis of selected
indicators: 1998–2004 (Saúde da Família no Brazil: uma analise de indica-
dores selecionados: 1998–2004) Ministério da Saúde. Secretaria de
Atenção à Saúde. Departamento de Atenção Básica. Brasília (DF);
2006.
Page 8 of 8
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