Infrastructure and work process in primary health care: PMAQ in Ceará

Vieira-Meyer, Anya Pimentel Gomes Fernandes; Morais, Ana Patrícia Pereira; Guimarães, José Maria Ximenes; Campelo, Isabella Lima Barbosa; Vieira, Neiva Francenely Cunha; Machado, Maria de Fátima Antero Sousa; Nogueira, Paula Sacha Frota; Nuto, Sharmênia de Araújo Soares; Freitas, Roberto Wagner Júnior Freire de

doi:10.11606/s1518-8787.2020054001878

Acessibilidade / Reportar erro

Brasil

Español English

sumário « anterior atual seguinte »

Sumário

Original Article • Rev. Saúde Pública 54 • 2020 • https://doi.org/10.11606/s1518-8787.2020054001878 copy

Infrastructure and work process in primary health care: PMAQ in Ceará

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

OBJECTIVE

To analyze the quality of the infrastructure and work process of the Family Health Strategy in the municipalities of Ceará between 2012 and 2014.

METHODS

Cross-sectional study, using secondary data from the external evaluation of the 1st (2012) and 2nd (2014) cycle of the National Program for Improvement of Access and Quality of Primary Care in Ceará. A total of 20 composite indicators were used to verify the quality of infrastructure and work process.

RESULTS

Data from 183 (99.4%) of the 184 municipalities of Ceará were collected in both cycles. A total of 1,441 teams were evaluated for the infrastructure and 800 for the work process. Among the 20 composite indicators evaluated, 18 presented an improvement, but in a non-homogeneous way, ranging between 0.0 and 413.5%. We observed that the lower the initial value of the indicator, the greater the variation in quality between 2012 and 2014. The indicators of infrastructure and work process were influenced by the regional health system and population size of the municipality, being more evident the influence on the variables of the work process.

CONCLUSIONS

We identified that quality improvements related to infrastructure and work process occurred in the period of implementation of the program in the state of Ceará in an equitable manner, being influenced by population size and regional health system, showing the influence of the context in the implementation of public policies of this nature.

Health Care Quality, Access, and Evaluation; Family Health Strategy; Health Infrastructure; Primary Health Care; Outcome and Process Assessment, Health Care

Compound index name	No. of questions	Description of the questions
Medication	47	Full list of 47 medicines.
Diagnostic tests	4	Test for Plasmodium (thick blood smear test); rapid HIV testing; rapid pregnancy test; rapid test for syphilis.
Vaccine	12	Oral rotavirus vaccine; tetravalent (2012) and pentavalent (2014); DTP (diphtheria, tetanus and pertussis); triple viral; 10-valent pneumococcal; pneumococcal (Salk and Sabin); 23-valent pneumococcal; meningococcal C; hepatitis B; seasonal influenza; double adult type dT; BCG ID.
Health attention equip	17	Vaccination card; pregnant woman’s booklet; children’s booklet; tongue lowerer in sufficient quantity; disposable needles of various sizes; bandages; thermal boxes for vaccines; measuring tape; disposable speculum; macrodrops and microdrops serum equipment; endocervical brush; Ayres spatula; adhesive tape, micropore tape and others; blade fixer; gauze; glass blade with frosted side; blade holder or plastic bottle with blade cap; capillary glucose measurement reagent strips; disposable syringes of various sizes; disposable syringes with coupled needle; hard container for disposal of sharps.
Medical equip	21	Adult blood pressure apparatus; child blood pressure apparatus; nebulization apparatus; anthropometric scale of 200 kg; children’s scale; anthropometric ruler; adult’s stethoscope; children’s stethoscope; light focus for gynecological exam; refrigerator for vaccines only; pharmacy-only refrigerator; glucometer; table for gynecological examination with leggings; table for clinical examination; ophthalmoscope; sonar; clinical thermometer; otoscope; monofilament kit for sensitivity test (esthesiometer); clinical lantern; extender cable thermometer.
Informatic equip	10	At least one computer in use; at least one webcam in conditions of use; a set of computer speakers; a stabilizer under conditions of use; at least one microphone in conditions of use; at least one printer in use; at least one TV in conditions of use; internet access; access of the team to Telehealth; room dedicated to the use of the internet.
Space adequacy	17	Sanitary for users (male and female); bathroom for employees; waiting room; vaccine room; doctor’s office; dentist’s office; inhalation room; procedure room; dressing room; observation room; sterilization room; collective activity room; good ventilation and air conditioning; adequate lighting; floors and walls of washable surfaces; good acoustics in health unit; offices with privacy for users.
Services offered	9	Vehicle (house calls and other external activities); meeting the needs of the team by vehicle; medical consultation; nursing consultation; dental consultation; dispensing medicines in the pharmacy; vaccination; user embracement and others.
Facility access	4	Wheelchair-adapted corridors; all external entrances and wheelchair-adapted doors; wheelchairs available to users; bathrooms for people with disabilities.
Unit identification	14	Proper signaling; hours of operation of the health unit according to the recommendations of the Ministry of Health; listing of activities offered by the team available to users; scale of professionals with name and working hours available to users; disclosure to users about BHU’s participation in “Saúde Mais Perto de Você – Acesso e Qualidade (PMAQ – Health Closer to You – Access and Quality)”; dissemination of the telephone number of the ombudsman of the Ministry of Health; use of the identification badge by professionals; non-disclosure of the team’s actions to users; opening shifts of the unit (morning, afternoon and evening); opening of the unit on all days of the week (Monday to Friday); offering services on weekends; working during lunch hours.
Infrastructure quality	10	Identification at UBS; accessibility; services offered; adequate space; computer equipment; medical supplies; inputs/materials; vaccines; diagnostic tests; medicines.
Infrastructure quality2	9	Identification at UBS; accessibility; services offered; adequate space; computer equipment; inputs/materials; vaccines; diagnostic tests; medicines.
Link to service	6	Contract with direct public administration; stability at work/obligation to hire; how the person got the job; career plan and salaries; receiving financial incentive or performance bonus; participation of the team in permanent education processes organized by the municipality.
Planning	10	Does the team plan activities on a monthly basis? Does the team perform analysis and monitoring of health information and indicators? Has the team carried out self-evaluation in the last six months? Does the team hold meetings often? Is there a definition of the team’s coverage area? Does the health team have territory maps? Are the records used by the team organized by family? Is there a standard model for filling out the cover sheet of medical records? Is there an electronic record implemented by the health team? Does the team consider the user’s vision for the reorganization and qualification of the work process?
City support	5	Does the team receive support or help for planning and organizing the work process? Does the municipality offer to the health team information that assists in analyzing the population’s health situation? Does the team receive aid or support for discussing data and monitoring the health system? Does the team receive permanent institutional support from the municipality to discuss the work process and help with the identified problems? Does the health team receive help from other professionals to assist and/or support the resolution of complex cases?
Patient welcome	7	Does the team embrace the spontaneous demand in the health unit? Does the team have a user removal service when necessary? Is the health team’s agenda organized for health education groups? Does the team renew revenues for users of continued care or programs such as hypertension and diabetes, without the need to schedule medical appointments? Is there a reservation of vacancies in the schedule or schedule of easy access to the professional so that the user can search and show test results? Is there a reservation of vacancies in the schedule or schedule of easy access to the professional so that the user can answer doubts after consultation or show how they situation has evolved? Does the team forward complaints of visual acuity or refractive evaluation demand, without the need for consultation appointment?
Exams	11	Does the team offer actions for pregnant women? Does the team offer actions for children? Does the team offer actions for patients with diabetes mellitus? Does the health unit perform the creatinine test? Does the health unit perform the lipid profile test? Does the health unit perform the electrocardiogram exam? Does the health unit perform the glycosylated hemoglobin test? Does the health unit perform a bacilloscopy test for tuberculosis? Does the health unit perform chest X-ray exam to diagnose tuberculosis? Does the health unit perform bacilloscopy examination for leprosy? Does the health unit perform the mammography exam?
Prenatal	14	Does the health unit perform the fasting blood glucose test in prenatal care network? Does the health unit perform the syphilis test (VDRL) in prenatal care network? Does the health unit perform HIV tests in the prenatal care network? Does the health unit perform the hepatitis B test in the prenatal care network? Does the health unit perform a summary examination and urine culture in the prenatal care network? Does the team supply the prenatal information system monthly? Does the team use the booklet or card to monitor pregnant women? Is there a record about the professional responsible for monitoring the pregnant woman? Is there a record of the pregnant woman’s dental consultation? Is there a record of the vaccination status of the pregnant woman? Is there a record on the collection of cytopathological exam of the pregnant woman? Does the team guide pregnant women about tetanus vaccines? Does the team receive the exams of pregnant women from the territory in a timely manner to perform necessary interventions? Is penicillin G benzathine applied in the health unit?
Child attention	9	Does the team perform childcare for children up to two years of age? Does the team use the child’s health booklet to monitor growth and development? Does the team have a copy of the child’s health booklets or another form with equivalent information in the unit? In the follow-up of the children of the territory, is there an actualized record on vaccination? In the monitoring of the children of the territory, is there a record on growth and development? In the follow-up of the children of the territory, is there a record on nutritional status? In the monitoring of the children of the territory, is there a record on foot testing? In the monitoring of the children of the territory, is there a record of family violence? In the monitoring of the children of the territory, is there a record on accidents?
Health promotion	12	Does the team offer educational and health promotion actions aimed to women (cervical and breast cancer)? Does the team offer educational and health promotion actions aimed at family planning? Does the team offer educational and health promotion actions aimed to pregnant women and postpartum women (breastfeeding)? Does the team offer educational and health promotion actions aimed to family planning? Does the team offer educational and health promotion actions aimed to older adults? Does the team offer educational and health promotion actions aimed to healthy eating? Does the team offer educational and health promotion actions directed to educational strategies related to sexual health and reproductive health? Does the team conduct groups focused on guidance on communicable diseases (such as dengue, tuberculosis, Hansen’s disease, HIV and trachoma), according to the need of the territory? Does the team conduct groups focused on guiding the use, abuse and dependence from using crack, alcohol and other drugs? Does the team conduct groups guiding the use, abuse and dependence of anxiolytics and benzodiazepines? Does the team address issues related to psychological distress or mental health promotion in the territory? Does the team encourage and develop physical practices and/or physical activities in the basic health unit and/or in the territory?
Home visit	9	Does the team have a protocol or criteria for house calls? Are families in the area covered by the primary care team visited with different frequency, according to risk and vulnerability assessments? Do community health agents have the schedule of visits made according to the priorities of the whole team? Does the team have a survey/mapping of enrolled users who need to receive care at home (except bedridden)? Does the team have a record of the number of bedridden and domiciled in the territory? In home care, do the team professionals perform clinical care (older adult user and/or one who needs home care)? In home care, do team professionals perform nursing procedures? Does the team have communication channels that allow users to express their demands, complaints and/or suggestions in primary care? Is there a local health council or other popular participation spaces?
School health	15	Does the team perform activities at the school? Does the team update the vaccination schedule? Does the team perform early detection of systemic arterial hypertension? Does the team perform detection of neglected health problems? Does the team perform anthropometric evaluation? Does the team perform ophthalmologic evaluation? Does the team perform nutritional assessment? Does the team perform oral health assessment? Does the team perform actions on food security and promotes healthy eating (educational activities on food promotion and healthy lifestyles)? Does the team promote body practices and physical activity in schools? Does the team conduct education for sexual health, reproductive health and prevention of sexually transmitted infections and AIDS? Does the team perform actions to prevent the use of alcohol, tobacco and other drugs? Does the team perform training actions for education professionals to work with health education? Does the team discuss with school teachers? Doesn’t the team perform health promotion and prevention actions?
Work process quality	10	Professional bond; planning; institutional support; user embracement; exams; prenatal care; child health; health promotion; health at school; house calls.

Variables	n^a	Year	Mean^b	SD	p^c	% variation
Infrastructure variables
Unit identification	1,408	2012	0.54	0.16	< 0.001	16.67
Unit identification	1,441	2014	0.63	0.13
Facility access	1,440	2012	0.22	0.29	0.001	136.36
Facility access	1,441	2014	0.52	0.34
Services offered	1,441	2012	0.79	0.14	0.000	13.92
Services offered	1,441	2014	0.90	0.11
Space adequacy	1,428	2012	0.61	0.18	0.000	16.39
Space adequacy	1,441	2014	0.71	0.18
Informatic equip	1,438	2012	0.16	0.20	0.000	56.25
Informatic equip	1,441	2014	0.25
Medical equip	448	2012	0.63	0.12	0.000	15.87
Medical equip	1,441	2014	0.73	0.11
Health attention equip	1,441	2012	0.88	0.11	0.000	6.81
Health attention equip	1,441	2014	0.94	0.08
Vaccine	1,441	2012	0.82	0.15	0.421	1.21
Vaccine	1,441	2014	0.83	0.13
Diagnostic tests	1,441	2012	0.04	0.12	0.000	413.5
Diagnostic tests	1,441	2014	0.19	0.34
Medication	1,441	2012	0.43	0.21	0.000	16.27
Medication	1,441	2014	0.50	0.17
Infrastructure quality	433	2012	0.51	0.89	0.000	21.56
Infrastructure quality	1,441	2014	0.62	0.10
Infrastructure quality2	1,392	2012	0.50	0.09	0.000	22.00
Infrastructure quality2	1,441	2014	0.61	0.11

Work process variables
Link to service	782	2012	0.50	0.21	0.000	10.00
Link to service	789	2014	0.55	0.21
Planning	784	2012	0.81	0.11	0.000	6.17
Planning	786	2014	0.86	0.75
City support	698	2012	0.93	0.15	< 0.018	8.13
City support	798	2014	0.95	0.15
Patient welcome	792	2012	0.80	0.18	0.000	8.75
Patient welcome	800	2014	0.87	0.15
Exams	747	2012	0.96	0.74	0.521	0.00
Exams	800	2014	0.96	0.90
Prenatal	792	2012	0.87	0.84	0.000	3.44
Prenatal	800	2014	0.90	0.85
Child attention	799	2012	0.76	0.15	0.000	11.84
Child attention	800	2014	0.85	0.14
Health promotion	779	2012	0.56	0.20	0.000	25.00
Health promotion	783	2014	0.70	0.22
School health	686	2012	0.56	0.24	0.000	42.85
School health	766	2014	0.80	0.18
Home visit	797	2012	0.69	0.16	0.000	27.53
Home visit	800	2014	0.88	0.13
Work process quality	553	2012	0.76	0.80	0.000	10.52
Work process quality	734	2014	0.84	0.76

Infrastructure variables by municipality population size						Work process variables by population size of the municipality

Variable	Population size (in inhabitants)	2012	2014	% change	p^a	Variable	Population size (in inhabitants)	2012	2014	% change	p^a
Unit identification	0–10,000	0.542	0.633	16.78		Home visit	0–10,000	0.663	0.848	27.90
	10,001–20,000	0.524	0.624	19.08			10,001–20,000	0.682	0.875	28.29
	20,001–50,000	0.532	0.641	20.48			20,001–50,000	0.680	0.868	27.64
	50,001–100,000	0.528	0.609	15.34	0.688		50,001–100,000	0.697	0.884	26.82	0.235
	100,001–500,000	0.587	0.686	16.86			100,001–500,000	0.741	0.931	25.64
	≥ 500,001	0.534	0.600	12.35			≥ 500,001	0.707	0.740	4.67
Facility access	0–10,000	0.270	0.632	134.07		School health	0–10,000	0.633	0.795	25.59
	10,001–20,000	0.200	0.517	158.50			10,001–20,000	0.605	0.808	33.55
	20,001–50,000	0.194	0.499	157.21			20,001–50,000	0.558	0.796	42.65
	50,001–100,000	0.218	0.496	127.52	0.256		50,001–100,000	0.440	0.771	75.23	0.137
	100,001–500,000	0.279	0.559	100.35			100,001–500,000	0.553	0.858	55.15
	≥ 500,001	0.233	0.600	157.51			≥ 500,001	0.577	0.555	-3.81
Services offered	0–10,000	0.831	0.926	11.43		Health promotion	0–10,000	0.615	0.638	3.74
	10,001–20,000	0.770	0.900	16.88			10,001–20,000	0.571	0.684	19.79
	20,001–50,000	0.797	0.898	12.67			20,001–50,000	0.556	0.708	27.34
	50,001–100,000	0.769	0.899	16.90	0.562		50,001–100,000	0.504	0.676	34.13	0.971
	100,001–500,000	0.815	0.918	12.63			100,001–500,000	0.641	0.781	21.84
	≥ 500,001	0.866	0.895	3.34			≥ 500,001	0.569	0.354	-37.78
Space adequacy	0–10,000	0.616	0.717	16.39		Link to service	0–10,000	0.419	0.462	10.26
	10,001–20,000	0.579	0.683	17.96			10,001–20,000	0.423	0.493	16.55
	20,001–50,000	0.584	0.725	24.14			20,001–50,000	0.548	0.600	9.49
	50,001–100,000	0.625	0.681	8.96	0.285		50,001–100,000	0.498	0.536	7.63	0.001
	100,001–500,000	0.653	0.762	16.69			100,001–500,000	0.473	0.552	16.70
	≥ 500,001	0.718	0.658	-8.35			≥ 500,001	0.823	0.770	-6.43
Informatic equip	0–10,000	0.220	0.328	49.09		Planning	0–10,000	0.809	0.857	5.93
	10,001–20,000	0.103	0.227	120.38			10,001–20,000	0.809	0.852	5.31
	20,001–50,000	0.126	0.243	92.85			20,001–50,000	0.818	0.868	6.11
	50,001–100,000	0.140	0.220	57.14	0.920		50,001–100,000	0.775	0.851	9.80	0.688
	100,001–500,000	0.311	0.347	11.57			100,001–500,000	0.855	0.891	4.21
	≥ 500,001	0.396	0.390	-1.51			≥ 500,001	0.858	0.663	-22.72
Medical equip	0–10,000	0.650	0.767	18.00		City support	0–10,000	0.930	0.963	3.55
	10,001–20,000	0.611	0.720	17.83			10,001–20,000	0.923	0.946	2.49
	20,001–50,000	0.643	0.732	13.84			20,001–50,000	0.948	0.960	1.26
	50,001–100,000	0.622	0.708	13.82	0.980		50,001–100,000	0.910	0.952	4.61	0.407
	100,001–500,000	0.692	0.780	12.71			100,001–500,000	0.937	0.986	5.23
	≥ 500,001	0.780	0.717	-8.07			≥ 500,001	0.758	0.418	-44.85
Health attention equip	0–10,000	0.889	0.945	6.29		Patient welcome	0–10,000	0.818	0.878	7.33
	10,001–20,000	0.872	0.939	7.68			10,001–20,000	0.809	0.860	6.30
	20,001–50,000	0.880	0.944	7.27			20,001–50,000	0.805	0.866	7.58
	50,001–100,000	0.877	0.938	6.95	0.725		50,001–100,000	0.757	0.857	13.21	0.212
	100,001–500,000	0.911	0.954	4.72			100,001–500,000	0.811	0.905	11.59
	≥ 500,001	0.875	0.932	6.51			≥ 500,001	0.845	0.678	-19.76
Vaccine	0–10,000	0.829	0.833	0.48		Exams	0–10,000	0.931	0.947	1.72
	10,001–20,000	0.825	0.831	0.72			10,001–20,000	0.951	0.942	-0.95
	20,001–50,000	0.796	0.821	3.14			20,001–50,000	0.958	0.957	-0.10
	50,001–100,000	0.826	0.814	-1.45	0.996		50,001–100,000	0.954	0.955	0.10	0.037
	100,001–500,000	0.853	0.852	-0.11			100,001–500,000	0.986	0.986	0
	≥ 500,001	0.891	0.801	-10.10			≥ 500,001	0.992	0.893	-9.98
Diagnostic tests	0–10,000	0.034	0.091	167.64		Prenatal	0–10,000	0.872	0.905	3.78
	10,001–20,000	0.012	0.158	1216.67			10,001–20,000	0.872	0.904	3.67
	20,001–50,000	0.030	0.067	123.33			20,001–50,000	0.857	0.901	5.13
	50,001–100,000	0.015	0.246	1540.00	0.036		50,001–100,000	0.861	0.888	3.13	0.693
	100,001–500,000	0.112	0.460	310.71			100,001–500,000	0.901	0.928	2.99
	≥ 500,001	0.105	0.305	190.47			≥ 500,001	0.892	0.815	-8.63
Medication	0–10,000	0.443	0.462	4.28		Child attention	0–10,000	0.730	0.774	6.03
	10,001–20,000	0.439	0.465	9.92			10,001–20,000	0.744	0.851	14.38
	20,001–50,000	0.449	0.502	11.80			20,001–50,000	0.751	0.843	12.25
	50,001–100,000	0.425	0.480	12.94	0.696		50,001–100,000	0.718	0.807	12.39	0.036
	100,001–500,000	0.393	0.546	38.93			100,001–500,000	0.834	0.935	12.11
	≥ 500,001	0.154	0.598	288.31			≥ 500,001	0.842	0.777	-7.71
Infrastructure quality	0–10,000	0.530	0.633	19.43		Work process quality	0–10,000	0.754	0.822	9.02
	10,001–20,000	0.489	0.606	23.92			10,001–20,000	0.752	0.824	9.57
	20,001–50,000	0.507	0.607	19.72	0.374		20,001–50,000	0.763	0.839	9.96
	50,001–100,000	0.513	0.609	18.71			50,001–100,000	0.725	0.822	13.38	0.338
	100,001–500,000	0.579	0.686	18.48			100,001–500,000	0.794	0.876	10.33
	≥ 500,001	0.603	0.650	7.79			≥ 500,001	0.795	0.702	-11.69
Infrastructure quality2	0–10,000	0.524	0.619	18.12
	10,001–20,000	0.480	0.594	23.75
	20,001–50,000	0.487	0.593	21.76	0.846
	50,001–100,000	0.491	0.598	21.79
	100,001–500,000	0.541	0.676	24.95
	≥ 500,001	0.527	0.642	21.82

Infrastructure variables by region						Work process variables by region

Variable	Health region	2012	2014	% change	p^a	Variable	Health region	2012	2014	% change	p^a
Unit identification	Fortaleza	0.510	0.617	20.98		Link to service	Fortaleza	0.485	0.558	15.05
	Sobral	0.494	0.596	20.64			Sobral	0.526	0.531	0.95
	Cariri	0.618	0.685	10.84	0.002		Cariri	0.514	0.590	14.78	0.673
	Sertão Central	0.476	0.609	27.94			Sertão Central	0.371	0.479	29.11
	East Coast/Jaguaribe	0.583	0.677	16.12			East Coast/Jaguaribe	0.514	0.532	3.50
Facility access	Fortaleza	0.253	0.525	107.50		Planning	Fortaleza	0.786	0.844	7.37
	Sobral	0.184	0.475	158.15			Sobral	0.809	0.858	6.05
	Cariri	0.214	0.571	166.82	0.894		Cariri	0.837	0.878	4.89	0.016
	Sertão Central	0.155	0.501	223.22			Sertão Central	0.787	0.878	11.56
	East Coast/Jaguaribe	0.261	0.461	76.62			East Coast/Jaguaribe	0.846	0.847	0.11
Services offered	Fortaleza	0.786	0.903	14.88		City support	Fortaleza	0.889	0.915	2.92
	Sobral	0.780	0.890	14.10			Sobral	0.952	0.969	1.78
	Cariri	0.812	0.916	12.80	0.503		Cariri	0.937	0.969	3.41	0.043
	Sertão Central	0.745	0.917	23.08			Sertão Central	0.936	0.953	1.81
	East Coast/Jaguaribe	0.788	0.880	11.67			East Coast/Jaguaribe	0.948	0.968	2.10
Space adequacy	Fortaleza	0.639	0.701	9.70		Patient welcome	Fortaleza	0.803	0.844	5.10
	Sobral	0.594	0.688	15.82			Sobral	0.771	0.837	8.56
	Cariri	0.582	0.708	21.64			Cariri	0.778	0.906	16.45
	Sertão Central	0.597	0.649	8.71			Sertão Central	0.809	0.936	15.69
	East Coast/Jaguaribe	0.191	0.243	27.22			East Coast/Jaguaribe	0.969	0.944	-2.57
Informatic equip	Fortaleza	0.151	0.263	74.17		Exams	Fortaleza	0.956	0.952	-0.41
	Sobral	0.134	0.265	97.76	0.266		Sobral	0.967	0.980	1.34	0.310
	Cariri	0.141	0.250	77.30			Cariri	0.930	0.961	3.33
	Sertão Central	0.186	0.256	37.63			Sertão Central	0.946	0.935	-1.16
	East Coast/Jaguaribe	0.653	0.720	10.26			East Coast/Jaguaribe	0.879	0.902	2.61
Medical equip	Fortaleza	0.626	0.710	13.41		Prenatal	Fortaleza	0.879	0.902	2.61
	Sobral	0.644	0.754	17.08	0.017		Sobral	0.853	0.891	4.45	0.568
	Cariri	0.567	0.719	26.80			Cariri	0.867	0.909	4.84
	Sertão Central	0.657	0.773	17.65			Sertão Central	0.870	0.924	6.20
	East Coast/Jaguaribe	0.894	0.936	4.69			East Coast/Jaguaribe	0.776	0.861	10.95
Health attention equip	Fortaleza	0.883	0.941	6.56		Child attention	Fortaleza	0.756	0.833	10.18
	Sobral	0.887	0.958	8.00	0.363		Sobral	0.767	0.862	12.38	0.058
	Cariri	0.840	0.930	10.71			Cariri	0.704	0.850	20.73
	Sertão Central	0.877	0.938	6.95			Sertão Central	0.706	0.792	12.18
	East Coast/Jaguaribe	0.840	0.838	-0.23			East Coast/Jaguaribe	0.514	0.664	29.18
Vaccine	Fortaleza	0.788	0.797	1.14		Health promotion	Fortaleza	0.610	0.693	13.60
	Sobral	0.839	0.830	-1.07	0.666		Sobral	0.608	0.718	18.09	0.023
	Cariri	0.798	0.840	5.26			Cariri	0.463	0.733	58.31
	Sertão Central	0.818	0.827	1.10			Sertão Central	0.556	0.751	35.07
	East Coast/Jaguaribe	0.039	0.200	412.82			East Coast/Jaguaribe	0.524	0.772	47.32
Diagnostic tests	Fortaleza	0.047	0.234	397.87		School health	Fortaleza	0.561	0.766	36.54
	Sobral	0.025	0.085	240.00	0.497		Sobral	0.615	0.826	34.30	0.001
	Cariri	0.016	0.246	1.437.50			Cariri	0.493	0.829	68.15
	Sertão Central	0.058	0.352	506.89			Sertão Central	0.579	0.849	46.63
	East Coast/Jaguaribe	0.449	0.495	10.24			East Coast/Jaguaribe	0.706	0.882	24.92
Medication	Fortaleza	0.353	0.406	15.01		Home visit	Fortaleza	0.669	0.834	24.66
	Sobral	0.428	0.517	20.79	0.045		Sobral	0.692	0.896	29.47	0.042
	Cariri	0.447	0.498	11.40			Cariri	0.695	0.910	30.93
	Sertão Central	0.499	0.498	-0.20			Sertão Central	0.727	0.921	26.68
	East Coast/Jaguaribe	0.534	0.618	15.73			East Coast/Jaguaribe	0.750	0.822	9.60
Infrastructure quality	Fortaleza	0.482	0.607	25.93		Work process quality	Fortaleza	0.772	0.823	6.60
	Sobral	0.523	0.634	21.22	0.160		Sobral	0.771	0.851	10.37	0.171
	Cariri	0.481	0.622	29.31			Cariri	0.711	0.848	19.26
	Sertão Central	0.531	0.631	18.83			Sertão Central	0.757	0.844	11.49
	East Coast/Jaguaribe	0.509	0.606	19.05			East Coast/Jaguaribe	0.561	0.766	36.54
Infrastructure quality2	Fortaleza	0.475	0.595	25.26
	Sobral	0.505	0.620	22.77	0.154
	Cariri	0.467	0.611	30.83
	Sertão Central	0.519	0.615	18.49
	East Coast/Jaguaribe	0.047	0.234	397.87

Faculdade de Saúde Pública da Universidade de São Paulo Avenida Dr. Arnaldo, 715, 01246-904 São Paulo SP Brazil, Tel./Fax: +55 11 3061-7985 - São Paulo - SP - Brazil
E-mail: revsp@usp.br

Acompanhe os números deste periódico no seu leitor de RSS

[1] Correspondence: Anya Pimentel Gomes Fernandes Vieira-Meyer Fundação Oswaldo Cruz - Ceará Rua São José, s/n 61760-000 Eusébio, CE, Brasil E-mail: anyavieira10@gmail.com