Client satisfaction from the perspective of responsiveness: strategy for analysis of universal systems?1

Objective: to analyze patient satisfaction in a Family Health Unit (FHU) of a municipality in the interior of São Paulo, Brazil, from the perspective of responsiveness. Method: this was a qualitative study with 41 patients of families who used the FHU at least once in the last six months. A semi-structured interview was used for data collection, performed from November of 2010 to January of 2011, focusing on the dimensions of responsiveness: dignity, autonomy, facilities and physical environment, immediate attention, choice, confidentiality, and communication. A thematic analysis was conducted. Results: four themes emerged from the analysis: the health unit environment; access and components of accessibility - favoring the responsiveness?; possibilities of developing a patient - health service staff relationship; and the FHU team - processing care and welcoming. Conclusion: responsiveness allows for the tracking and monitoring of non-medical aspects of care of the patients; it contributes to achieving universal coverage, emphasizing the quality of care.


Introduction
The concept of responsiveness refers to the way the health system can recognize and respond to the expectations of individuals in relation to non-medical aspects of care, taking into account how government actions meet the expectations and demands of the population, respecting the people's rights by aggregating the principle defi nition of universal validity to the assessment of health systems (1-4). Thus, responsiveness would review the interaction between the way the health system operates and patient satisfaction (3) .
The concept of responsiveness comprises two main aspects: respect for people, which includes questions such as: dignity, autonomy, communication and confi dentiality; and customer orientation that includes elements that infl uence satisfaction, but are not directly connected to health care: respect for rapid attendance, access to social support networks, quality of facilities; and choice of one's health care provider(1, 3).
Although criticism exists about the analysis of responsiveness, since it is a patient belief that presents bias, such as gratitude for the care received (4)  Responsiveness is one in ten actions resulting from lessons learned from various Latin American countries that showed that universal coverage is achievable.
Such specifi c action refers to effective mechanisms for monitoring and evaluating quality of care, in the technical and interpersonal dimensions, considering that the expansion of coverage requires investments in the quality of care (5) .
Thus, the notion of responsiveness, including the main aspects already mentioned, respect for people and customer orientation, can guide the initiatives that seek to evaluate, monitor and improve quality as a component of universal health coverage (5) .
In 1994, the Unifi ed Health System (SUS), in Brazil, had the Family Health Strategy (FHS) implemented and supported by the principles of Primary Health Care (PHC) as a way to address the problem of unequal access and to expand coverage; seeking to accomplish the process of democratization and the development of citizenship, involving the population in decision-making (6) .
Studies on health service evaluation (7-8) have indicated the importance of analyzing the impact of PHC actions on the health conditions of the population and patient satisfaction, highlighting the importance of giving them a voice and opportunity to participate in diagnostic processes and action planning. Thus, it is already possible to identify an increase in scientifi c production on patient satisfaction relating to PHC services, especially those related to Family Health (8) .
However, studies related to responsiveness remain rare in Brazil. Data saturation was verifi ed after 43 interviews, two of which were lost due to recording issues, when the iteration of responses related to the complete dimensions of responsiveness was deduced (11) .
Thematic analysis was used for data analysis; its set of procedures allowed the analysis of convergence,   16) In the construction of the relationship between patient -health service staff, confi dentiality, which is aspects involving privacy regarding the care provided by the health service and the services performed by the team, the respondents stated that professionals perform assessments, examinations and instructions appropriately. The link with Community Health Agents (CHAs), who visit them in their homes, proved to be important, both because this person is close and is known in the community, as well as due to the confi dence transmitted by the professional.
Another aspect of developing confi dence in the health service is the confi dentiality of information. There were some reports that confi dentiality was assured by The desire to look for a second opinion was also denied, due to confi dence in the care provided by the same team.
Respondents highlighted having the freedom to refuse treatment and guidance, and reported they never had to do this, as the professionals clarifi ed their doubts; they reported they could participate and offer opinions in the decisions about their health and treatment and that of their family. They also stated that the team adequately performed assessments and they felt supported, cared for and confi dent in the prescriptions and guidance offered, favoring the patient-health service link: The study participants explained that the professionals who treated them always asked what bothered them, and they never ceased to clarify things, stating that the health care team was available for guidance and information. They felt that appropriate care went beyond the team's commitment with the care itself, but resulted from the bond built on the patientprofessionals -health facility triad.

Discussion
The PHC in Brazil prioritized the FHS implementing necessary changes with a view to consolidating the principles of the Unifi ed Health System (7,9) , making effective efforts to improve coverage, thereby meeting the health needs of population (6) .
The FHU should be structured to accommodate teams that can count on a working process, with structural resources and devices compatible with the necessary health actions (12) to face the challenges imposed on the health systems (6) . In the case discussed here, this refers to the organization of health services in order to include the expansion of coverage, with quality of care (5) .
This movement also includes the perspective of systems to offer comprehensive and integrated care, at all levels. Such care needs to be monitored and evaluated, institutionally and by the patients themselves, who now have a fundamental role in assessing the ability of the services to satisfy their needs and expectations (13) .
Responsiveness and its main aspects enabled us to present the evaluation of the FHU by participants of the study.
Regarding the respect for people, the patients value the "courtesy" which is considered a soft technology, namely a technology of relationship, in which intersubjectivity operates in the act of producing health actions, interaction processes, bonding, and listening, which have also been mentioned as fundamental in other studies (12,14) .
The dignity in care dimension was analyzed and listed as a respectful form of caring, with the welcoming by the staff without offense and that does not adversely affect the human rights of citizens and health clients.
In terms of human rights, dignity implies a set of rights and a guarantee, in which all individuals shall be treated with respect and remain free to achieve their own dreams and hopes. The most important way to ensure human dignity is the fi ght against unjust discrimination based on race, sex, religion, ethnicity, political opinion, property, disability or other status.
The right to health is closely linked to and dependent upon the realization of other human rights, such as the right to food, housing, work, education, human dignity, life, non-discrimination, equality, the prohibition against torture, privacy, access to information, and freedom of choice and expression (6) . The principles of human rights are internationally recognized and accepted, and are composed of civil, cultural, economic, political and social rights. In this manner, the quest for universal coverage led some Latin American countries to adopt health as a social and citizenship right (5) .
Each one of the responsiveness aspects are supported by one or more human rights principles, and these aspects are interconnected with each other. The care provided with respect, caring and dignity involves patient autonomy to participate and decide on one's own health and that of one's family, as well as the freedom to accept or refuse treatment and health guidance.
Regarding privacy and confi dentiality, (12) patients felt protected in the service evaluated, unlike those in the services of Rio de Janeiro, whose clients evaluated the former as the most fl awed aspect, although the confi dentiality of information was assured (4) . The other set of responsiveness aspects refers to customer orientation. One of the elements includes facilities and the physical environment. Thus, it appears that this dimension was poorly judged by FHU patients, shown to be inadequate and not conforming to the wishes and expectations of the population; however, this aspect is minimized when the issue is the quality of care provided in the unit.
Studies (8,12,(15)(16)(17) show that a majority of the FHS units had inadequate and/or improvised physical structure, or had diffi culty maintaining a fl ow for referral services, or even insuffi ciency support services (equipment, medications, etc.). These facts may suggest a lack of appreciation by the local authorities about these services, given the lack of investment to enable the structuring of services to change the model of care. Additionally, these services are evaluated as low cost, and focus on care for the poorest populations or in places where there is no installed health equipment. Accessibility in health is linked to the quality of care provided to the population, and "allows for the identifi cation of factors that facilitate or hinder the seeking and obtaining of this assistance" (16) .
The importance of the adequacy of appropriate space for care, with good lighting, ventilation and absence of noise, as well as other aspects that help to provide conditions necessary to ensure the comfort and confi dentiality of care are fundamental, ensuring the privacy of patients. In services, the needs of hospitalized patients or PHC units are not considered, or where there is scarcity of material resources, environments that offer no room to accommodate the social network of patients, and other care that assists in the preservation of their identities, worsening and increasing of patient vulnerability can be verifi ed, causing discomfort, concern, insecurity and embarrassment with the care provided (14) . Thus, the health care facility environment can not harm the integrity of patients, but rather, must provide a more welcoming space for the ills and sufferings that the patient expresses (14)(15)17) .
The immediate care dimension was explored from two perspectives. The waiting time for care dimension was satisfactory in terms of user expectation. In research on services in Rio de Janeiro, 40% of respondents were unhappy with waiting more than one hour (4) . The other perspective of immediate care (or rapid attendance) with regard to geographic accessibility, defi ned as the "dimension that refl ects the average distance between population and resources and should be measured in be covered by different resource characteristics" (16) .
As stated, the proximity of the unit (geographical accessibility) does not always mean accessibility to Rev. Latino-Am. Enfermagem 2016;24: e2674 the unit. Other dimensions such as organizational accessibility, are part of the service's response to the users' needs. In this sense, the operation of the FHU during working hours was considered inappropriate, as it is inconvenient for service workers. Other aspects, such as those related to obstacles to continuity of care at other levels, linked to the hierarchical level of network care (16) , namely, those related to referral and counterreferral, also hinder the achievement of universal access.
Also, the patient-worker relationship is "prepared" much before they meet, including the service aim, work execution, environment structuring and others. In terms of the environment, it should be prepared as relational space, where people try to solve problems in an appropriate and decisive manner (14) . The preparation of the physical space goes beyond architectural planning, but also ensures that the patient feels safe and respected to express his problems and needs (14) . For the patients, aspects related to infrastructure of the FHU compromise the way the population perceives the health unit, and how they can expose their health needs with less embarrassment, and with more safety, reliability, and comfort (12,14,17) . The relationship, a well maintained environment, and health seem to be directly linked to seeking out health services and the expectations of the population for dignifi ed, caring and effective care.
This discussion on responsiveness provides elements present in the relationship of the patient with the health services, mediated by a team that needs to have instruments to understand the patient's health needs and to program actions that enable the expression of: patient freedom for adhering to the treatment plan that the physician and/or team propose, with full patient participation in decisions about his own health.

Final considerations
The construction of patient satisfaction assessment tools to analyze social and cultural differences, and different ways of using the services, is a new and challenging practice, because of the need to capture the views of patients about the quality of health services, and also, this depends on resources and commitment so that monitoring can be consistently performed and which enable effective improvements in services, as well as the expansion of universal access. confi dentiality and privacy.
The study had the limitation of being conducted with only one FHU, in the context of low total coverage by the FHS, thus, having some bias resulting from this broader context of the municipality. Still, it contributes an assessment tool for patient satisfaction, which helps with the expansion of universal health coverage.