Potential access to primary health care: what does the National Program for Access and Quality Improvement data show?

Objective: to analyze the influence of contextual indicators on the performance of municipalities regarding potential access to primary health care in Brazil and to discuss the contribution from nurses working on this access. Method: a multicenter descriptive study based on secondary data from External Evaluation of the National Program for Access and Quality Improvement in Primary Care, with the participation of 17,202 primary care teams. The chi-square test of proportions was used to verify differences between the municipalities stratified based on size of the coverage area, supply, coordination, and integration; when necessary, the chi-square test with Yates correction or Fisher's exact test were employed. For the population variable, the Kruskal-Wallis test was used. Results: the majority of participants were nurses (n=15.876; 92,3%). Statistically significant differences were observed between the municipalities in terms of territory (p=0.0000), availability (p=0.0000), coordination of care (p=0.0000), integration (p=0.0000) and supply (p=0.0000), verifying that the municipalities that make up area 6 tend to have better performance in these dimensions. Conclusion: areas 4,5 and 6 performed better in every analyzed dimension, and the nurse had a leading role in the potential to access primary health care in Brazil.


Introduction
In 2005, members of the World Health Organization (WHO) committed to achieve the universal health coverage target provided by the Millennium Development Goals and post-2015 agenda, aiming to improve the health and welfare of the population. Universal coverage is defi ned as access to and appropriate use of the services according to the understanding of the health system functions; health workers who are available, motivated and qualifi ed; access to essential medicines and health products; integrated, quality, patient-centered services; health promotion and disease control; accurate information system for adequate decision-making; and fi nancing with protection against fi nancial risks (1) .
There is a growing movement in this direction among the 25 richest nations and those in development, such as Brazil, Mexico and Thailand, and even in those of low-income, as Ghana, Philippines, Rwanda and Vietnam (2) .
In Brazil, the issue of universal and equitable access has been a concern since the creati on of the Unifi ed Health System UHS (SUS) in 1988. This idea is reinforced by the Nati onal Policy of Primary Care -BANP (PNAB), in which the potenti al for access to comprehensive care management through multi disciplinary, interdisciplinary team work is emphasized (3) .
However, access has been strongly marked by social inequalities, with disadvantaged populations in vulnerable situations with an impact on the health status of these groups, causing more iatrogenic situations, poorer quality services and continued, more severe suffering with some health conditions, including preventable and premature deaths. Thus, new forms of system organization, with real universal coverage has been envisioned to achieve equity and integrality of actions (4) . Another challenge is shortage in the distribution, composition and competence of human resources, especially physicians, nurses and midwives (5) .
In response to the most critical component, physicians, incentive programs were adopted to supply and qualify these professional, through the Enhancement Program of Primary Care, and by importing foreign physicians with the More Medical Doctors Program (6) .
A signifi cant advance towards the access to health care services with quality and better working conditions occurred with the implementation of the fi rst cycle of the National Program for Access and Quality Improvement in Primary Care (PMAQ-AB) (7) . The program is organized The complexity of the universal coverage paradigm has elicited theoretical studies in recent years (8) on principles and repercussions in the Brazilian scenario, and some empirical studies about APS (9) ; use of services (10) ; medications (11) and educational practices (12) .
Despite the contributions on the subject, national studies that evaluate the relationship between contexts and the centrality of professionals in the work teams, focusing on access and equity, remain scarce. The aim of this article is, to analyze the infl uence of contextual indicators on the performance of municipalities, with regard to potential access to APS in Brazil, based on external evaluation of the PMAQ-AB and to discuss the contribution of the work of nursing.

Study design
This was a cross-sectional cohort study, using national data from the Bank of Evaluators of the External PMAQ. Health Units (BHUs) (7) .

Population and sample
The study population included professionals linked to the primary care team and qualifi ed in PMAQ (7) , namely physicians, nurses, and dentists. In each team, only one sampling unit was selected for the study.

Measurement instruments and data sources
The questionnaires with closed-ended questions were provided in tablets, administered by interviewers who had the same training, under supervision. Next, they were sent online to the Ministry of Health Evaluation of the fi rst cycle of the PMAQ-AB, were included here for data analysis (7). The dimensions that were representative of the potential levels of access according to the authors' judgment were chosen and are described in the analysis plan.

Classifi cation of municipalities according to the context variables
The municipalities listed in the study are and municipalities with a score lower than 5.4, and population between 100 and 500 thousand inhabitants; and area 6 -Municipalities with population over 500,000 inhabitants, or a score less than 5.85 (7) .
Variables under consideration to evaluate potential access: The variables considered for evaluating potential access are described in  After the analysis of the performance of the municipalities within the areas, in relation to access, multivariate statistics by multiple correspondence analyses (MCA) was used, given that the instrument variables were categorical.

Plan of analysis
The MCA implementation was based on the steps of Spencer (13) and Mingoti (14) , in which the tabulation of responses generated a matrix, with rows corresponding to the participating health professionals, and the columns corresponding to the variables. Subsequently, the matrix turned into a complete disjunctive table (CDT).
In the table, the columns represent characteristics of the variables, in which the intersection of Row I with Column J is the xij, which is 0 or 1, indicating that the area either has or does not have the characteristic. The component row or column infl uences the construction of the axes through its inertia, in relation to the center of gravity. The inertia means the variance of the data set (13) . From the MCA it was possible to extract the most representative dimensions in terms of inertia, which in the study corresponded to the fi rst two.
Its contribution to inertia was considered a criterion for selection of the variables. opportunity to choose a desired unit for treatment and follow up.

Results
In Table 2, the performance of municipalities in terms of patient access is verifi ed, considering the area established in PMAQ.
Statistically signifi cant differences were identifi ed between the municipalities of area 1, 2 and 3 with area 4, 5 and 6, and the professionals of the last areas had more qualifi cations (p=0.0000).
Regarding the career plan, no statistically signifi cant difference (p = 0.0000) was observed, and the municipalities of area 4, 5 and 6 had better indicators; lowest values were found in areas 1, 2 and 3. Also, these areas showed statistically signifi cant differences associated with their training policy and continuing education (p=0.0000).
According to Table 2, statistically signifi cant differences in t erms of population coverage were observed, in which area 5 and 6 monitored a median number of people with access well above that of areas 1, 2 and 3. Also, statistically signifi cant differences were present between the municipalities in terms of coverage area (p=0.0000), availability (p=0.0000), coordination of care (p=0.0000), integration (p=0.0000) and supply (p=0.0000), verifying that the municipalities that form area 6 tend to have better performance in these dimensions. When compared by professional category (Table 3), a statistically signifi cant difference is again identifi ed, in which a higher proportion of both physicians as well as dentists tend to refer to more positive aspects of their units than nurses.
The proportion of nurses who tends to identify weaknesses in relation to the organization of services is much greater than other professionals.
In complementary education, for example, whereas there is one "No" for each 4 "Yes" assigned by physicians in this item, and almost one "No" for each three "Yes" assigned by dentists, among nurses this proportion was almost fi ve, which was statistically signifi cant (p =    was also observed in a study conducted in large cities, where more than half of physicians and nurses had participated in some training process in the prior 30 days (15) .
Although a statistically signifi cant difference was found between the areas with respect to career plan, all areas showed a weak performance in this item, which can be explained by the way in which professionals are recruitment. A study, conducted in Minas Gerais, showed that 75% of municipal health secretaries use temporary contracts for provision of services by professionals with higher education (16) .  (17) .
With regard to coverage areas in Brazil, currently, the population coverage estimated by the APS teams becomes important as an universal indicator of success with the guidelines and goals of SUS (18) . It is necessary to note that, although the average number of persons under the responsibility of the team is within the recommendation of the Ministry of Health (3) , this number is considered high, if we consider that, in Brazil, the teams are responsible for a large number of activities (19) .
To enable access to the population that is not covered by primary care, teams comply with the principle of universality, but also tend to undergo activity overloads, considering that more and more frequently the APS/FHT have new responsibilities delegated to them, and face responsibilities for diseases, priority groups, problems or specifi c situations (20) . A similar situation is seen in the UK and Europe, where professionals also develop a wide range of tasks, which include, among others: prevention activities, acute care/curative activities, treatment for patients with chronic conditions, and emergency treatment. These professionals are responsible for a roster of almost 2,250 people (21) .
Regarding availability, the unscheduled demand by patients to have their needs met and evaluated occurred in all areas, with better performance in areas 4, 5 and 6. These fi ndings differ from those found by Giovanela, Fausto and Fidelis, which showed barriers to spontaneous demand and non-priority groups. Home visits are on the professional schedules in all areas of the municipalities. Similarly, this activity was observed as a routine of physicians and nurses in four large cities (22) . When comparing the models of care, there was a predominance of home visits being conducted by the FHT, a similar result to that found in a study with southern and northeastern cities (10) .
In the coordination of care, despite the signifi cant differences between the areas, all areas presented unsatisfactory performance regarding the registration of referrals to other points of care, featuring a referral process without accountability and relationship with the patient.
In the integration of care, the existence of a central registration is present in the municipalities of the area analyzed, predominantly in 4, 5 and 6. Similar results were noted by physicians and nurses of the FHT that recognized the existence of a central registration for appointments and exams (23) .
With regard to the provision of health actions and services, there was a statistical signifi cance in all aspects evaluated. The availability of medicines in the basic pharmacy to meet the population was observed in municipalities of all areas. In some cities of the country, this distribution is more related to priority groups (15) . It is remarkable to note the low supply of complementary and integrative practices for patients of the area, which may be linked to the fact that this type of care integrates a specialized service network, such as acupuncture offered in Porto Alegre (24) .
In the work process of the APS teams, the nurse takes on several assignments, among them: planning, individual and collective care, management, and systematic assessment of developed actions (PNAB. 20123), which may justify the tendency of nurses to negatively evaluate the actions of the organization. In the daily nursing work of the FHT units, diffi culties occur, mainly related to lack of training for implementation of actions (25) .
Regarding the contribution of nurses to universal access, the study showed that the majority were nurses, which shows in a way the involvement of this category of professional with the APS. The nurse has a more focused training for this area, with wellaligned curricula to the SUS social policy, with content in anthropology and sociology, health management, leadership and community sanitation practices, making her more sensitive to innovations in the context of the APS, and more motivated to promote change.
One important issue is that most nurses eventually assume leadership in the teams, strategically, and taking the forefront of primary care as a new mode of social production in health. The low pay of these professionals in the private sector makes many fi nd the SUS to provide a chance for stability, which is very positive in terms of securing professionals in that category. One challenge is the establishment of a new model that values their core competence and recognizes their autonomy in prescribing and care. The hegemonic model with centrality in medical practice tends to push them out of this process.

Limitations
The study was not conducted in all the Brazilian

Conclusion
The study showed that there is a relationship between access and socioeconomic conditions: as the area of the municipalities increases, the access to services tends to be better. However, within a context of social inequalities and iniquities, weaknesses are perceived that jeopardize the organization of health activities in the municipalities regarding the availability, care coordination, integration, and supply, particularly in the municipalities grouped in areas 1 to 3. Given the involvement of the nurse with the organization of health care, this professional has contributed to the potential access of APS in Brazil.