Evaluation of quality of the family health strategy in the Federal District

AIM
To evaluate quality of the Family Health Strategy (FHS) in the National Program for Improving Access and Quality of Primary Care in the Federal District (FD) from the perspective of users.


METHODS
Evaluative research carried out in 25 basic health units of the Federal District through a validated questionnaire assessing the following dimensions: access, gateway, bond, service range, coordination, family focus, community orientation, and health professionals.


RESULTS
Service provision, qualification of professionals, quality of professional-user relationship, and continuity of care were the best evaluated dimensions, while family approach, community approach, and access were the worst. Access to the FHS was found to be compromised, besides failing to establish itself as gateway to the FD health system.


CONCLUSION
When they can access the local system, FD users do enjoy several services, but access is still a barrier, mainly because the very system is not prepared to meet users' needs/preferences. The dimensions regarding family focus and community orientation are precarious, which reveals the need for reflection on the care model adopted in the Federal District.


INTRODUCTION
Countries that have adopted Primary Health Care (PHC) as a basis for coordinating the health system have been successful in the quality of services provided to the population and with lower expenditures.In Brazil, since the creation of the Unified Health System (SUS), investments have been made in PHC, especially in the Family Health Strategy (FHS), for inducing transformation in the healthcare model.
In effect, studies have shown improvements in the FHS as regards reduction in infant mortality due to diarrhea (1)(2) , respiratory diseases (3) and malnutrition (4) , as well as reduction in hospitalizations due to care-sensitive causes and chronic diseases (5 -6) , in addition to the expansion of vaccination coverage (7) , which points out that its consolidation is related to the improvement of its healthcare processes and integration into the health care network (8) .
In the Federal District in 2014, however, the estimated population coverage by the FHS was only 28.9% (8) .The health secretariat recognizes that healthcare models, even with an organized, high-level density of services, have not been able to meet the health demands of the Brazilian population.In this perspective, the Healthy Brasilia Program foresees the strengthening of Primary Health Care in the Federal District by expanding FHS, as well as by restructuring and expanding PHC as the main gateway ordering health care networks (9) .
Despite the improvements in health conditions promoted by the expansion of FHS coverage, the quality of services provided to the population, as well as their capacity for re-organizing the system, are yet challenges to be achieved, given the fragility of PHC to establish itself as organizer of the health care network.
To that end, Starfield points out that PHC has essential attributes, which promote service quality and improve its capacity to interact with users and communities (10) .These are: first contact access and access whenever the user needs; longitudinality, which refers to the continuous relationship of the user with strong trust in the service; coordination, which includes articulation and integration of actions and services; integrality, which refers to all the promotion, prevention, cure and rehabilitation actions offered by the health system.The family approach refers to information about family factors related to the health-disease-illness process and the importance of the family as a subject of attention.Community orientation concerns the relevance of community health and cultural competence, which means understanding the cultural specificities of the community served (10) .
In this perspective, the evaluation of these attributes stands out as an important management tool that serves both to measure how the policy is achieving the expected results and to guide the improvement of any ongoing intervention (11) .Thus, user perception is important to produce information about the services rendered relevant to decision making.
In view of these challenges, the recent directives of the Ministry of Health in convergence with the implementation process of the National Primary Care Policy (12) created, through ordinance No. 1654/2011 (13) , which was revoked by ordinance No. 1645/2015 (14) , the National Program for Improving Access and Quality of Primary Care (PMAQ-AB), designed primarily to induce managers and teams to improve the quality of health services offered to users of the territory.The Program is considered as a strategy for affirming PHC as a welcoming and effective gateway to the Unified Health System (15) .User-centered assessments have been an important field in the evaluation of services and systems, since users are the main actors involved in health systems and their perceptions are highly sensitive to changes in healthcare management models (16) .Furthermore, knowing how users evaluate the health service is key to improving actions and services to be developed, besides involving users in the management process and making them the subjects of the process (16) .

AIM
To evaluate the quality of the Family Health Strategy registered in the National Program for Improving Access and Quality of Primary Care in the Federal District, based on users' perception regarding the organization of services: accessibility, gateway, coordination, community services and guidance to the community, as well as caregiving dimensions: professional links and family approach.

METHOD Ethical aspects
This study was submitted and approved by the Ethics Committee of the Teaching and Research Foundation of the Health Department of the Federal District.All of the participants signed a Free and Informed Consent Form, according to Resolution 466/12.

Type of study
Evaluation research, which is geared to value judgment of social practices, especially those resulting from a planned social action, such as health policies, programs and services (17) .

Place of study
The study was carried out with the Family Health Strategy teams of the Federal District, which joined the National Program for Improving Access and Quality of Primary Care.These units served 55,681 users.

Data source
To calculate sample size, the proportional division of users of rural and urban areas was considered, which totaled 382 users.The sample error adopted was 5% and the confidence level 95%.
We included users who had regularly attended any FHS unit for more than three months and who were over 18 years of age, and excluded those who had physical and mental conditions.
The analysis unit consisted of 353 users of 25 basic health units from 10 Administrative Regions of the Federal District, using a convenience criterion, considering acceptance for participation in the study.Three Units refused to participate, which resulted in the loss of 29 users.

Collection and organization of data
The Primary Care Assessment Tool (PCATool) (18) was used, which is a validated questionnaire composed of 87 questions associated with the following dimensions: 1) Accessibility: times and days of care, ease of consulting and obtaining medicines and how the population perceives the aspects of access; 2) Gateway: use of preventive medical consultation services and emergency care; 3) Bond: quality of relations between health professionals and population; 4) Service provision: types of primary care services offered by the units; 5) Coordination: articulation of actions that guarantee the quality in the continuity of care by professionals of the services and for consultations referred to specialists; 6) Family focus: consideration of family and family environment in service consultations; 7) Orientation to the community: regarding the service, it considers the social context of the health needs of the population in the planning of actions; 8) Health professionals: qualification of health service professionals.

Data analysis
Study participants answered a questionnaire with a likert scale, where never = 0, almost never = 1, sometimes = 2, often = 3, almost always = 4, and always = 5).The value of 0 was assigned to the worst performance and 5 to the best performance.A simple arithmetic mean score was obtained for each dimension evaluated, in a 0-5 scale.From this score it was possible to evaluate each attribute of basic attention according to users' experience of the service.Data analysis was carried out with Stata 12.0 and Excel 2013 software.

RESULTS
From the users' profile, Table 1 shows that there was a predominance of women, with a median level of education, low family income (up to four minimum wages), and unpaid family employment or unemployed.
Of the 8 dimensions of basic care, it can be seen in Table 2 that from those related to the organization of services: access (2.17) and community orientation (2.18) were the worst evaluated.And the dimensions services provision (4.99), coordination (3.92) and gateway (3.35) were the best evaluated.
Table 2 also shows that the caregiving dimensions: professionals (3.99) and bond (3.98) were well evaluated; yet the family approach (2.64) was negatively evaluated.
In the access dimension, three elements scored below one, namely: operating on weekends, operating after 6 pm on at least one day of the week, and available telephone number to make appointments or ask for information while the health unit is closed.When asked about waiting time greater than 30 minutes for care, the obtained score was 4.19, indicating that, in general, the interviewed population always waits more than half an hour for care (Table 3).
Table 4 summarizes the evaluated elements of the services set dimension.Prenatal control (4.93), care for adults (4.89) and care for the elderly scored better, while attention to violence (1.81), education about domestic accidents (2.00), and mental health problems (2.37) were the worst services as perceived by users.
Table 5 presents the assessment of gateway, coordination, family focus and community orientation dimensions.About the gateway, users were asked if they visited the health unit for preventive control (vaccinating, measuring pressure, routine exams), or when they had a health problem, and also if, when they needed an appointment with a specialist, they first had to consult with the doctor of the unit they attended.
Regarding the coordination category, the worst evaluated item was the user's right to have access to his/her medical record (1.51).The best evaluated were possession of a user's identification document, as well as results of exams and immunization card at the time of consultation (4.87) and possession of medical record during the consultation by health professional (4.75).
Regarding the family approach, the worst evaluated item was professionals asking about the living conditions of the individual and family (1.34).The best-evaluated item was if during the consultation professionals asked about diseases of the family.Finally, on the community orientation dimension, home visits and knowledge of the most important health problems in the community were well evaluated by users.However, consulting the family to know if the available services meet the health problems was the worst evaluated.To be continued for users to receive communication about the tests results received by the services.As for medical records, the services do have them, but users cannot access them.Services are hardly organized to be centered in the user, that is, to count on their more active participation in the caring process.
In general, the FHS units of the FD have a good set of services, that is, when users are able to enter health services, they can take advantage of actions commonly offered by PHC, from vaccination, chronic disease control and family planning to dental care, which can aid in prevention and health promotion.
The link was positive in the relationship between users and health professionals, reaffirming the importance of this attribute in the continuity of health actions and the longitudinality of care (24) .In addition, the way professionals relate to the community was evaluated as satisfactory, although the absence, mainly of physicians, and the lack of ability to solve problems were indicated as factors causing dissatisfaction.
It was observed that for FHS reorganization, the focus on family and community must be the central axis in care (25) .However, both these aspects remain as the greatest fragilities, since the focus on the individual and the disease is strongly present in the PHC context, which requires changes in care models, considering the socio-cultural context and the integrality of care.The maintenance of the individual clinical model may be associated with insufficient curricular content addressing the biological issues related to the context of social determination inherent to the care offer (24) .
Community orientation implies recognizing that all health needs of the population occur in a particular social context, and it is the teams' responsibility to shift to a more active behavior, extending their actions to the entire community 25 .Thus, working together with the population on plans to deal with problems and conditions of risk to the health of the population is essential, so that the coordination of care is carried out in a universal, integral and equitable way (25) .
Other studies on the assessment of primary care from user perspective were identified in the literature (26)(27)(28)(29) .Access and family orientation dimensions were evaluated below the cut-off point in two studies (26,29) .The access dimension is the most sensitive to user perception and testifies how the FHS is, in fact, guiding the system for PHC, while the family orientation dimension brings the information of the care being focused or not on the family served and reflects the service's approach (16) .In both dimensions, inadequacy to the FHS philosophy is highlighted (26) .
According to a literature review on the evaluation of performance of primary care using the PCATool, the access attribute shows a poor performance, reflecting possible territorial and organizational vulnerabilities of the service, such as reduced working hours and long waiting queues, while the longitudinality attribute was the third best evaluated, demonstrating that there is a relation between user and service (30) .Both results were close to those reported here.
Assessing the quality of PHC from a user perspective effectively contributes to the identification of health care network failures, supporting the shared decision-making process and assisting in the necessary changes to the professional practice and work process involved (26,28) .Moreover, such an evaluation contributes to the construction of interventions that are appropriate to the local reality (28) , besides being a tool for empowering the population (16) .

DISCUSSION
In this study, the predominance of women as users of FHS services was observed, corroborating other studies (19) , which reaffirm the role of women as the main responsible for health care.Regarding the level of schooling, many of them were found to have a low level, which makes it difficult for these women to enter the formal labor market with better remunerations (19) .
Access to the FHS teams in the FD is compromised, with a long waiting period for consultation, limited working hours (Monday to Friday during business hours), the impossibility of solving urgent health problems and by telephone.These stand as organizational barriers related to the access to basic units that has commonly compromised the quality of PHC (20)(21) .
The access problem undermines advances in the scope of integrality, besides posing fragility to the management and organization of the service network (22) .In this regard, it is important to highlight that the actions of reception and humanization in the coordination of care are essential in PHC and tend to become fragile when other mechanisms of access to services are not timely and continuous so as to guarantee access to other healthcare levels (21) .
In addition, it was observed that FHS in the FD has difficulty in establishing itself as the main gateway to the health system.In this logic, studies indicate that greater or lesser connection of the population to services to obtain diagnostic and therapeutic support consultations is characterized as a challenge to the search for integral care in PHC (20- 21) .Another factor that makes it difficult to adopt the FHS as a gateway is the existence of other forms of access to services, acting concurrently.In this regard, it is necessary to reaffirm the FHS as an essential gateway for the organization of access in an integrated network (23) .
In order to strengthen the care model, PHC must be accessible, open and take into account users' health demands from care actions between caregiving levels, with ordered flows and counterflows, so as to intervene on social determinants and guarantee the integrality of care.
Regarding the coordination dimension, actions related to access to laboratory tests are satisfactory, but there is a certain difficulty During the consultation, do the professionals of this unit usually ask about your living conditions and those of your family (unemployment, availability of drinking water, basic sanitation etc.)?Based on such principles as universality, integrality and equity, the family health proposal was conceived as a strategy to change the care model that, in its systemic perspective, is articulated in three dimensions: managerial -concerning the reorganization of actions and services; organizational -articulations between services; and technical-supportive -relationships between professionals/workers and care subjects (25) .In this sense, the need for continuing the debate about the necessary changes in management and attention models in the FHS becomes quite clear.

Limitations of the study
Some limitations can be acknowledged in this study.The feeling of gratitude (gratitude bias) can hinder a critical assessment by users about the care received.In addition, it presents common biases of transversal studies.

Contributions to the nursing area
Finally, the contribution of nursing in the evaluation of FHS is highlighted, since the nursing team plays a fundamental role in basic care.Thus, it is increasingly necessary to deepen the discussions about how the nursing team is needed in key work processes and in the management of care for qualification of basic care and especially in the Family Health Strategy (31)(32) .

CONCLUSION
From users' perspective, when they manage to enter the health system they can enjoy several services.However, access is still a barrier, especially because the system itself is not prepared to meet their needs/preferences.In addition, relations with families and their territory/community are still somewhat precarious.Both these cases reflect the need to deepen the discussion of the care model that has been adopted in the FD.
In addition, this study indicates the need to analyze more deeply the barriers to integral care in the Federal District, as well as the key posts to be worked for the provision of quality service to the population.Finally, user-centered assessments, especially in the perspective of basic care, should not be punctual tools; the potential of the continuous use of such action is seen as a way of diagnosing the quality of the services provided, in order to support actions, policies and health programs.

Table 1 -
Characterization of the interviewed users, by urban and rural unit, Federal District, Brazil, 2014 Source: Developed by authorsEvaluation

of quality of the family health strategy in the Federal District Shimizu
HE, Ramos MC.

Table 3 -
Scores assigned by users to the access dimension, Federal District, Brazil, 2014.
Source: Developed by authors

Table 4 -
Scores assigned by users to the services set dimension, Federal District, Brazil, 2014

Table 2 -
Scores assigned by users according to dimensions of Basic Attention, Federal District, Brazil, 2014

Table 5 -
Scores assigned by users to dimensions, Federal District, Brazil, 2014 Source: Developed by authors.

Table 5 (concluded) Evaluation of quality of the family health strategy in the Federal District Shimizu
HE, Ramos MC.