Perceptions and evaluations of front-line health workers regarding the Brazilian National Program for Improving Access and Quality to Primary Care (PMAQ): a mixed-method approach

Saddi, Fabiana da Cunha; Harris, Matthew J.; Coelho, Germano Araújo; Pêgo, Raquel Abrantes; Parreira, Fernanda; Pereira, Wellida; Santos, Ana Karoline C.; Almeida, Heloany R.; Costa, Douglas S.

doi:10.1590/0102-311X00202417

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ARTICLE • Cad. Saúde Pública 34 (10) • 2018 • https://doi.org/10.1590/0102-311X00202417 copy

Perceptions and evaluations of front-line health workers regarding the Brazilian National Program for Improving Access and Quality to Primary Care (PMAQ): a mixed-method approach

As percepções e avaliações dos profissionais de saúde que trabalham na ponta em relação ao Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ): uma abordagem com métodos mistos

Percepciones y evaluaciones de los trabajadores de salud de primera línea, en relación con el Programa Nacional de Mejora del Acceso y Calidad de la Atención Básica (PMAQ): un enfoque metodológico mixto

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract:

Although it is well known that a successful implementation depends on the front-liners’ knowledge and participation, as well as on the organizational capacity of the institutions involved, we still know little about how front-line health workers have been involved in the implementation of the Brazilian National Program for Improving Access and Quality to Primary Care (PMAQ). This paper develops a contingent mixed-method approach to explore the perceptions of front-line health workers - managers, nurses, community health workers, and doctors - regarding the PMAQ (2^nd round), and their evaluations concerning health unit organizational capacity. The research is guided by three relevant inter-related concepts from implementation theory: policy knowledge, participation, and organizational capacity. One hundred and twenty-seven health workers from 12 primary health care units in Goiânia, Goiás State, Brazil, answered semi-structured questionnaires, seeking to collect data on reasons for adherence, forms of participation, perceived impact (open-ended questions), and evaluation of organizational capacity (score between 0-10). Content analyses of qualitative data enabled us to categorize the variables “level of perceived impact of PMAQ” and “reasons for adhering to PMAQ”. The calculation and aggregation of the means for the scores given for organizational capacity enabled us to classify distinct levels of organizational capacity. We finally integrated both variables (Perceived-Impact and Organizational-Capacity) through cross-tabulation and the narrative. Results show that nurses are the main type of professional participating. The low organizational capacity and little policy knowledge affected workers participation in and their perceptions of the PMAQ.

Keywords:
Public Policy; Health Policy; Incentive Reimbursement; Primary Health Care

Improvement of quality?/How has the PMAQ altered the work routine?	Health workers levels of Perceived-Impact *								Total		Ranking
	High		Medium		Low		No response
	n	%	n	%	n	%	n	%	n	%
Yes
Produced innovative changes in the work	17	50							17	14	2^nd
Guided work toward PMAQ goals	13	38							13	10	4^th
Did not alter my work routine			9	43					9	7	7^th
Other: added extra work + work done with resistance, without support/guidance, without structure			10	48					10	8	6^th
No response	4	12							4	3	8^th
Created an excessive workload			2	10					2	2	9^th
Total/Health worker	34	27	21	17					55	44
No
Did not alter my work routine					29	53			29	23	1^st
Created an excessive work load					13	24			13	10	4^th
Guided work toward PMAQ goals					12	22			12	10	5^th
Other: added extra work + work done with resistance, without support/guidance, without structure					1	2			1	1	10^th
Total/Health worker					55	44			55	44
No response
No response					10	100	4		14	11	3^rd
Total/Health worker					10	8	4		14	11
Total/Health workers	34	27	21	17	65	52	4	3	124	100

Levels/Reasons for adhering PMAQ	Manager		Community health workers		Nurse		Doctor		Total		p-value *
Levels/Reasons for adhering PMAQ	n	%	n	%	n	%	n	%	n	%
High
1. Order/Imposition			2	11	4	27			6	18
2. No response			6	32	0	0			6	18
3. Improved work quality/Attendance			8	42	6	40			14	41
4. Public funding			3	16	0	0			3	9
5. No response			0	0	5	33			5	15
Total high level			19	35	15	56			34	27	0.005
Low
1. Order/Imposition	6	75	18	58	8	80	16	100	48	74
2. No response	0	0	9	29	0	0	0	0	9	14
3. Improved work quality/Attendance	2	25	1	3	2	20	0	0	5	8
4. Public Funding	0	0	3	10	0	0	0	0	3	5
Total low level	8	36	31	56	10	37	16	80	65	52	0.007
Medium
1. Order/Imposition	2	20	1	20	0	0	0	0	3	14
2. No response	0	0	2	40	0	0	0	0	2	10
3. Improved work quality/Attendance	8	80	1	20	0	0	4	100	13	62
4.Work valued	0	0	1	20	0	0	0	0	1	5
5. No response	0	0	0	0	2	100	0	0	2	10
Total medium level	10	45	5	9	2	7	4	20	21	17	0.001
No response
No response	4	100							4	100
Total no response	4	18							4	3
Total
1. Order/Imposition	8	36	21	38	12	44	16	80	57	46
2. Improved work quality/Attendance	10	45	10	18	8	30	4	20	32	26
3. Public funding	0	0	6	11	0	0	0	0	6	5
4. Work valued	0	0	1	2	0	0	0	0	1	1
5. No response	4	18	17	31	7	26	0	0	11	9
Total	22	100	55	100	27	100	20	100	124	100	0.000

Front-liners	General aggregated mean of the notes (0-10) attributed to Organizational-Capacity			Means aggregated by levels of Organizational-Capacity
				High (mean > 7)			Medium (> 5 < 7)			Low (< 5)
	Statistics		95%CI *	n	%	95%CI **	n	%	95%CI **	n	%	95%CI **
Nurses	n	270
	Mean	5.02	4.33-5.68	3	11.1	0.0-22.2	11	40.7	22.2-59.3	13	48.1	29.6-66.7
	SD	1.75	1.26-2.10
	Variation	3.06	1.64-4.39
Community health workers	n	55
	Mean	4.63	4.23-4.98	3	5.5	0.0-10.9	19	34.5	21.8-49.1	33	60.0	47.3-72.7
	SD	1.43	1.17-1.66
	Variation	2.05	1.36-2.77
Managers	n	10
	Mean	6.79	6.12-7.48	12	54.5	31.8-72.7	10	45.5	27.3-68.2
	SD	1.16	0.69-1.48
	Variation	1.35	0.47-2.19
Doctors	n	5
	Mean	5.09	4.51-5.67				8	38.1	19.0-61.9	12	57.1	33.3-80.8
	SD	0.76	0.12-0.83
	Variation	0.57	0.01-0.68
Total		124		18			48			58

Levels of Organizational-Capacity/Front-liners	Levels of Perceived-Impact										p-value *
	High		Low		Medium		No response		Total
	n	%	n	%	n	%	n	%	n	%
Low (< 5)
Community health workers	13	65	16	55	4	44			33	57
Nurses	7	35	5	17	1	11			13	22
Doctors	0	0	8	28	4	44			12	21
Total low level	20	59	29	45	9	43		0	58	47	0.040
High (> 7)
Community health workers	2	50	1	100	0	0	0	0	3	17
Nurses	2	50	0	0	1	9	0	0	3	17
Doctors	0	0	0	0	10	91	2	100	12	67
Total high level	4	12	1	2	11	52	2	50	18	15	0.009
Medium (> 5 < 7)
Community health workers	4	40	14	40	1	100	0	0	19	40
Nurses	6	60	5	14	0	0	0	0	11	23
Managers	0	0	8	23	0	0	2	100	10	21
Doctors	0	0	8	23	0	0	0	0	8	17
Total medium level	10	29	35	54	1	5	2	50	48	39	0.013
Total
Community health workers	19	56	31	48	5	24	0	0	55	44
Nurses	15	44	10	15	2	10	0	0	27	22
Managers	0	0	8	12	10	48	4	100	22	18
Doctors	0	0	16	25	4	19	0	0	20	16
Total	34	100	65	100	21	100	4	100	124	100	0.000

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[1] Correspondence F. C. Saddi Programa de Pós-graduação em Ciências Políticas, Faculdade de Ciências Sociais, Universidade Federal de Goiás. Campus II da UFG, Prédio Humanidades, sala BT27, Goiânia, GO 74690-900, Brasil. fabianasaddi1@gmail.com