Universal health system based on Primary Care and advanced practice nursing

Sistema de salud universal basado en la Atención Primaria y la enfermería de práctica avanzada

ABSTRACT

Objective:

To reflect on advanced practice nursing in Primary Health Care considering the complexity of the Brazilian health system.

Methods:

Reflective study, based on the document “Expanding the role of nurses in Primary Health Care” and anchored in the literature and critical analysis of the authors.

Results:

Due to the complexity of the Unified Health System — in terms of infrastructure, human resources, funding — it is important for Brazil to carry out its own systematic process of discussion on the implementation of advanced practice nursing, considering the context of the current health care model, to define the role of this practice according to the characteristics of a universal health system and not a universal health coverage. Final considerations: The expansion of the workforce and the insertion of advanced practice nursing in Brazilian Primary Health Care needs to happen with greater recognition and incentives for the actions performed at this level of care. For example, they must occur through integration between professionals and the community in health promotion actions, with the availability of appropriate technologies for the work, in order to guarantee the quality and resolution of Primary Health Care.

Descriptors:
Health Systems; Universal Health Coverage; Primary Health Care; Unified Health System; Advanced Nursing Practice

RESUMEN

Objetivo:

Reflejar sobre la enfermería de práctica avanzada en la Atención Primaria de Salud considerando la complejidad del sistema de salud brasileño.

Métodos:

Estudio reflexivo, fundamentado en el documento “Ampliación del rol de enfermeros en la Atención Primaria de Salud” y basado en la literatura y análisis crítico de autores.

Resultados:

Por la complejidad del Sistema Único de Salud — cuanto a la infraestructura, recursos humanos, financiamiento — es importante que Brasil realice su propio proceso sistemático de discusión sobre la implementación de la enfermería de práctica avanzada, considerando el contexto del modelo de atención de salud vigente, para definir el papel de esa práctica conforme las características de un sistema universal de salud y no de una cobertura universal de salud. Consideraciones finales: La ampliación de recursos humanos e inserción de la enfermería de práctica avanzada en la Atención Primaria de Salud brasileña necesitan ocurrir con un mayor reconocimiento e incentivos para las acciones ejecutadas en ese nivel de atención. Por ejemplo, deben ocurrir vía integración entre los profesionales y la comunidad en las acciones de promoción de salud, con disponibilidad de tecnologías adecuadas al trabajo, de modo a garantizar la calidad y resolución de la Atención Primaria de Salud.

Descriptores:
SISTEMAS DE SALUD; COBERTURA UNIVERSAL DE SALUD; ATENCIóN PRIMARIA DE SALUD; SISTEMA ÚNICO DE SALUD; ENFERMERíA DE PRáCTICA AVANZADA

RESUMO

Objetivo:

Refletir sobre a enfermagem de prática avançada na Atenção Primária à Saúde considerando a complexidade do sistema de saúde brasileiro.

Métodos:

Estudo reflexivo, fundamentado no documento “Ampliação do papel dos enfermeiros na Atenção Primária à Saúde” e ancorado na literatura e análise crítica dos autores.

Resultados:

Pela complexidade do Sistema Único de Saúde — quanto a infraestrutura, recursos humanos, financiamento — é importante que o Brasil realize seu próprio processo sistemático de discussão sobre a implementação da enfermagem de prática avançada, considerando o contexto do modelo de atenção à saúde vigente, para definir o papel dessa prática conforme as características de um sistema universal de saúde e não de uma cobertura universal de saúde. Considerações finais: A ampliação da força de trabalho e inserção da enfermagem de prática avançada na Atenção Primária à Saúde brasileira precisam acontecer com um maior reconhecimento e incentivos para as ações executadas nesse nível de atenção. Por exemplo, devem ocorrer via integração entre os profissionais e a comunidade nas ações de promoção de saúde, com disponibilidade de tecnologias adequadas ao trabalho, de modo a garantir a qualidade e resolutividade da Atenção Primária à Saúde.

Descritores:
Sistemas de Saúde; Cobertura Universal em Saúde; Atenção Primária à Saúde; Sistema Único de Saúde; Prática Avançada de Enfermagem

INTRODUCTION

The concept of universality, understood as guaranteeing each individual access to health services in a given country, has been replaced by the notion of “universal coverage”. This term has been widely used by international organizations over the last 15 years, such as the World Bank (WB), International Monetary Fund (IMF), and the Rockefeller Foundation(¹), with a discussion of the notion of “coverage” related to issues involving health financing, understood in this light as an expense(¹).

Thus, while the perspective of building universal systems has historically been based on the development of robust social protection systems, linked to the idea of health as a right — as is the case in Brazil —, the concept of universal coverage does not radically assume its rupture with universality in the theoretical field, in practice it signals the interests of the market(¹). It appears that this offensive to universal policies has close relations with the process of financialization, a phenomenon that is characteristic of the current phase of capitalism.

Some well-defined assumptions of neoliberal logic approach this perspective of universal coverage or what could be called “inverse universality”. The first assumption refers to the decrease in the participation of the State in favor of greater inclusion of the private sector in provisioning health services. The second points to the selectivity of individuals, that is, certain groups of the population could or could not enjoy health care according to pre-established conditions, to the detriment of a human mass that would seek resources for their needs in other ways. Finally, the third adopts the focus discourse, that is, it guides the allocation of public health devices and resources to the most vulnerable segments and/or specific problems of the population, moving away from the perspective of integrality of actions and subjects.

Despite the particular Primary Health Care (PHC) context, the discussion regarding the consequences of universal coverage becomes more evident. As stated in the final report of the Alma Ata Conference up to the last International Conference on Primary Care, held in 2018 in Astana, this level of care would occupy the main spot of health systems(²). Furthermore, a robust PHC could be responsible for solving more than 80% of the population’s health needs. However, its structuring, especially in developing countries such as Latin America, took place selectively. Fiscal adjustment issues and structural macroeconomic reforms of a neoliberal approach were crucial to restrain the development of a strong and resolute PHC(³-⁴).

PHC is the health systems’ level of attention closest to the reality of individuals. The construction of a minimum and diversified “package” of services has always been stressed by international agencies, especially by the “technical” reports produced by the WB, always concerned with the control of public spending. Thus, the perspective of selective PHC would be linked to the proposal of universal coverage — a strategy through which individuals would not be fully covered, but with a minimum package of resources to meet their health needs. The selective approach disposes itself of the health-disease-care process social determinants by being limited to pre-determined health problems and isolated from the context in which the individual is inserted(^{1 2}).

To think of coverage that restricts the supply of services to the detriment of a universal system is to expose the social issue of inequalities existing in a society. In this game of power and resistance, PHC and the entire technological apparatus that involves this level of attention become the private sector’s targets of interest. In short, attacks on this level of attention are always directed at the State, accused of being a bad manager and a spendthrift.

Nursing is recognized across the globe as the “backbone” of any health system(⁵). In Brazil, there was an increase of approximately 40% in the number of these professionals between 2013 and 2018, totaling 2,119,620 qualified nursing professionals in 2018(⁶). They are crucial in the provision of integrated and people-centered care, as well as essential in achieving the goals of the Sustainable Development Goals(⁶).

Furthermore, nurses have an educational background that is particularly suited to the growing challenges of the 21st century, characterized by an accelerated demographic transition, accompanied by a triple burden disease scenario: the unsurpassed agenda of infectious diseases; the increase in deaths attributable to external causes; and the predominance of non-communicable chronic diseases. Basically, there is a reactive and fragmented health system in which the hospital is still the privileged locus of care(⁴).

In several countries around the world, advanced practice nurses already have well-established regulations, such as the United States of America, Canada, the United Kingdom, Australia, among others(⁷). In general, the functions of advanced practice nurses were implemented in these countries with the aim of maximizing access to PHC and enabling more accurate monitoring of patients and communities, especially in locations with significant care gaps(⁶).

According to the International Council of Nurses (ICN), advanced practice nurses (nurse practitioners) are

professionals with clinical skills and competence to make complex decisions, expand and improve nursing practice, promote greater inclusion and better care in health care, within the context of evidence-based practice and technological innovation; with a master’s degree being the minimum training requirement(⁸).

Among the advanced practice nurses, the nurse practitioner (NP) and the clinical nurse specialist stand out. Nurse practitioners are more engaged with care and clinical practice, while clinical nurse specialists are more involved with education and management activities(⁸). The ICN included seven clinical activities for advanced practice nurses: I. Autonomy to prescribe; II. Autonomy to request medical exams and devices; III. Carrying out diagnosis or advanced health assessments; IV. Autonomy to indicate medical treatments; V. Responsibility over Users; VI. Autonomy to refer/counter-refer users; VII. First contact(⁸).

OBJECTIVE

To reflect on advanced practice nursing in PHC considering the complexity of the Brazilian health system.

METHODS

Reflective study, based on the document “Expanding the role of nurses in Primary Health Care”, in the discursive formulation on the subject. It was supported by a bibliographic survey in two databases: LILACS and in MEDLINE via PubMed; and in the SciELO Virtual Library with the following descriptors: “Universal Health System”, “Universal Health Coverage”, “Primary Heath Care”, “Unified Health System”; and “Advanced Nursing Practice”. Based on the theoretical construction on reflective thinking, two guiding axes were addressed: I) Universal health systems based on Primary Health Care: the Brazilian case; and II) Advanced practice nursing and the expansion of nurses’ role in Primary Health Care: a debate on the two sides of implementation. It should be noted that the explanations and reflections were on these two guiding axes; and the interpretations were guided based on the concepts of “universal health system” versus “universal health coverage” (UHC).

RESULTS

Universal health systems based on Primary Health Care: the Brazilian case

PHC is considered an essential level of care for health systems, and its importance is based on the quality of life and the development of populations in countries that adhere to it as a support for health services. This is also demonstrated by the greater evidence in the flow of users within the Health Care Network (HCN), more timely and accurate treatment for chronic conditions, greater efficiency of care, increased use of preventive practices, better health indicators, greater user satisfaction, reduction of inequities in health, access to services, and guarantee of comprehensive care(²). Two distinct and interdependent characteristics are inherent to a strong PHC concept, being represented as a strategy for organizing health systems, at a first level of care; and as an entity that reorients the health care model. It is guided by essential attributes and derived attributes, which are internationally consolidated(²,⁹).

In Brazil, the choice to face inequities in health has elevated PHC to the position of organizer of the HCN and coordinator of care, in contrast to the limited perspective of several countries and international institutions, which understand it as a set of low-complexity health actions, provided to the low-income population, in order to reduce social and economic exclusion(⁹). However, Brazilian PHC has been under constant threats in recent years (e.g., Previne Brasil) and experiencing problems such as chronic underfunding, excess of users linked to the Family Health Strategy (FHS) teams, reduced number of medical professionals specialized in Family Health, little decentralization and internalization, in addition to bureaucratization and functional problems of the services(⁹).

In Brazil, one of the strategies adopted by the Brazilian government was the creation of the Mais Médicos [More Doctors] Program (PMM), established by Law No. 12,871, of 10/22/2013, based on three axes: 1) offering of jobs and new courses in Medicine with reformed curricular components; 2) investment for building Basic Health Units; and 3) provisioning of Brazilian and foreign medical professionals to vulnerable regions(⁹). In August 2019, the Médicos pelo Brasil [Doctors Throughout Brazil] Program (PMB) was instituted by Provisional Measure (PM) No. 890, which culminated in the creation of the Agência para o Desenvolvimento da Atenção Primária à Saúde [Agency for the Development of Primary Health Care] (ADAPS) to: i) expand the provision of health services in “care voids” or in areas of high vulnerability; ii) encourage the training of physicians specializing in Family/Community Medicine(⁹).

PM 890 was instituted at a time of crisis in the supply of doctors in the PHC, resulting from the withdrawal of Cuban doctors from the PMM, in addition to a significant and sharpening underfunding of the SUS [Brazil’s Unified Health System]. In the macro context, you have neoliberal policies in a far-right government, characterized by the loss of labor and social rights, growing privatization initiatives dispersed in various sectors of Brazilian society, including health. Thus, the creation of ADAPS signals a privatist perspective of PHC in the SUS(⁹). In addition, there is not enough evidence to confirm that privatization or outsourcing is more cost-effective than public provision(⁹). It should be noted that retaining doctors in PHC, especially in remote areas with high social and programmatic vulnerability, is a major challenge for all health systems.

Advanced practice nursing and the expansion of nurses’ role in Primary Health Care: a debate on the two sides of implementation.

The progress that Advanced Practice Nursing (APN) can bring, especially in PHC, need to go beyond the mere understanding and discourse of simply replacing the medical professional(⁸). For example, initiatives aimed at developing evidence for the implementation and assessment of the APN’s role should be encouraged at a national level. Likewise, it is crucial to build a network of professionals and stakeholders in the development of APN, encouraging reflections on the political situation and barriers to its implementation in the context of the SUS(⁸).

The bicentennial of Florence Nightingale’s birth in 2020 polishes modern nursing by recognizing its global importance in health systems(⁵). However, despite its representativeness and the recognized relevance of her work, the profession remains in many ways still invisible and undervalued, especially in health decision-making processes(⁵-⁶,¹⁰). Brazilian nursing, for example, has historically been affected by gender-related oppression, lack of recognition, and lack of investment in resources to provide better training conditions, better conditions in the workplace, and better wages(⁶).

In Brazil, these repercussions can be even greater, because nurses, in many health services, especially in PHC, in addition to performing their care actions, coordinate these spaces, taking care of material goods, staffing, among other actions. In addition, in many municipalities, there is no specific career plan for professionals working in the FHS; it lacks a national base salary for nursing professionals, which results in low salaries; and these professionals still work with a very high workload(⁶,¹⁰). In addition, the claims and struggles before public authorities in favor of valuing nursing professionals in Brazil are historical. Thus, in addition to recognizing and valuing its numerical expression, it is essential to value high-quality nursing for leadership, elaboration, and implementation of health policies, participation in decision-making processes and in the planning of care provided to specific groups within the population(⁵-⁶,¹⁰).

In this perspective, it is imperative to invest in the qualification of nurses, through specialization programs, residency, professional master’s, and academic master’s and doctoral degrees, in order to prepare them to deal with health problems worldwide, so that their contributions, as well as their potential, are properly understood. Among the manifestations on the recognition of nursing as a key profession for health and for achieving universal health coverage and access, the global Nursing Now campaign (2018-2020) was launched in February 2018, implemented in collaboration between the ICN and the WHO, with the support of the Burdett Trust for Nursing(⁵). The urgency of raising the profile of nurses was highlighted so that this professional category develop their full potential, to impact health, gender equality, and the economy(⁵). Nursing Now is based on the assumption that health agendas will not be successful if there are no nurses in leadership positions, in the different spaces of health policy definition, and political decision-making for health, with greater effectiveness in performance of their functions(⁵).

Also in 2018, PAHO and the WHO prepared the document “Expanding the role of nurses in Primary Health Care”(⁷), in which they called on governments and nurses from countries in the Americas to implement the training of advanced practice nurses in PHC. The Federal Nursing Council (Cofen) has supported the APN initiative in Brazil, subsidizing professional master’s programs throughout the country.

According to PAHO/WHO, advanced practice nurses in PHC are professionals with postgraduate training who greatly contribute to the management of care for patients with mild acute illnesses and chronic conditions diagnosed via clinical guidelines/protocols. APN would differ from the professional practice of nurses in PHC due to the degree of autonomy in decision-making and in the diagnosis and treatment of patients’ health conditions(⁷). Scientific evidence demonstrates the impact of advanced practice nurses on health services and costs(⁶,¹⁰), even though the most developed countries and who present the highest physician-per-inhabitant ratio are those that have incorporated more advanced practice nurses than other developing or underdeveloped countries(⁶,¹⁰).

A study carried out in 39 countries, with the objective of analyzing the stages of development of APN in PHC within different countries(¹¹), verified the importance of political and educational reforms to maximize the scope of clinical work of advanced practice nurses. And so, it found urgent the need for clear and standardized definition of roles, minimum training for the role, leadership and protagonism of nursing associations, regulatory bodies, regulation, and supervision of professional practice. In addition, national and international intersectoral articulations are relevant and recommended for this development and incorporation of advanced practice nurses. It should be noted that the successful implementation of APN in PHC depends on a thorough assessment of the services’ needs, the HCN, the particularities of each health system and, above all, the real health needs of the population of/in the territory. Equally important is the involvement of all stakeholders who provide assistance and collaborative care with nurses in the professional setting and with users, in order to align expectations about the scope of practice of advanced practice nurses at this level of care(¹²).

In order to understand the APN implementation and evaluation process, some barriers to health systems are interposed and need to be overcome. First, there is still some confusion in the APN terminology. Second, there are major flaws in defining advanced practice nurses’ roles and goals. Third, there is still an emphasis on the limited understanding of physician replacement. Fourth, there is an underutilization of all APN domains. Fifth, there is a clear failure in the analysis of macrostructural facts that encompasses different actors and stakeholders (society, health system, nurses, associations, regulatory and standardization bodies of professional practice, training institutions, workplaces); and finally, the adoption and incorporation of evidence-based practice by PHC nurses into the daily routine of services and clinical practice is still very incipient(¹²).

It should be noted that the APN contributes to expanding access and UHC; and, for its implementation, three policy lessons are essential: i) holding evidence-based debates on the quality, safety, and patient satisfaction with care provided by advanced practice nurses; ii) guaranteeing regulation, standardization, human resources, financing, and training policies adequate to this professional category; iii) understanding that advanced practice nurses improve nursing as a career, so it is important to develop policies that strengthen nursing to reach its full potential(¹²).

Although international experiences report different stages of APN development in different countries, discussions and research on APN in Latin America and the Caribbean are still incipient or even scarce. Especially in these regions, health demands and needs are very complex, in addition to the fact that health systems present significant health disparities and inequities(⁷). Despite the apparent benefits of implementing APN in PHC, the repercussions for advanced practice nurses may present weaknesses in their work process, as they assume an overload of work for physicians, intensifying their practice(¹⁰). An important point to consider, when discussing universal access to health, concerns the uniqueness and organization of the health system in which nursing professionals belong. In Brazil, for example, we have the SUS (a “universal health system”), which should not be confused with “universal health coverage” nor treated interchangeably with it. Experts in the field of public health and who study health systems in depth differentiate these two terms in a very clear and assertive way(¹,⁹).

In the last decade, the international debate on different conceptions of universal health care has intensified, being polarized in two aspects: Universal Health System (UHS) versus Universal Health Coverage (UHC). In Europe, in general, universality refers to the public coverage of national systems, under the designations of UHC or Universal Health Care. For developing countries, the term UHC consists of coverage of basic services (minimum service package), or public or private health insurance coverage(¹).

UHC presents itself as an ambiguous term, often used interchangeably with UHS and which has given different interpretations by health authorities and both governmental and non-governmental organizations in different countries. The UHC proposal is summarized in essential elements: 1) a focus on combined funding; 2) an affiliation by type of insurance; and 3) a limited service package. In fact, “coverage” consists of the ownership of insurance, that is, it refers only to financial coverage; and this does not mean, in theory, guarantee of access or provision of services and effective use(¹).

At the international level, UHC aims to make UHS compatible with pro-market reforms in order to harmonize the provision of services in contexts of scarce resources(¹). The purpose of UHC is to minimize the role of the State, confining it to the space of regulation of the health system. It is noteworthy that there are distinct characteristics of the UHS and UHC proposals in terms of type of citizenship and ideology, that is, in UHS, full citizenship prevails; on the other hand, in UHC, there is a residual citizenship, aligned with a neoliberal ideology(¹,⁹).

The UHS proposal is financed by public funds originating from general tax revenue and social contributions, which allows for greater solidarity, redistribution, and equity(¹). Above all, the UHS aims to ensure that all people have their real needs met without restrictions on access, that is, it enshrines the guarantee of universal access as a condition of full citizenship(¹,⁹). In the UHS proposal, the guarantee of comprehensive care, at the individual and/or collective level, presupposes coordination between services, being organized in networks, in territorialization, and guided by PHC. Universal systems integrate individual care and collective prevention and promotion actions, and their population focus requires the promotion of cross-sectoral policies to act/intervene in facing the social determinants of health(¹,⁹-¹⁰).

PHC is recommended as a strategy for universal coverage, but it can have very different meanings. In the UHC proposal, PHC refers to a limited package of essential services and medicines defined in each country, coming closer to a selective PHC approach to achieve a minimum universalization. It differs from the comprehensive and robust proposal of the UHSs, in which PHC occupies the center of the care network, organizes the network and coordinates care, in addition to being the foundation of the health system(¹,¹⁰). The concept of UHC is more linked to the demands of national insurers, financial capital, and international organizations for increased participation in the commercialization of health. It should be noted that the strengthening of the private sector represents the greatest threat to the SUS and the universal right to health. The UHC proposal is unclear as to its assumptions and purposes. The use of similar concepts, and interchangeably within the PAHO/WHO document(⁷), to those envisaged for a universal health system makes it difficult to understand the changes underway.

In this sense, respecting the doctrinal and organizational principles of the SUS, these ongoing transformations must happen through the development of policies that strengthen training (especially in graduate studies), the regulation of this professional practice, permanent education, and recognition and valuing advanced practice nurses so that they assume and perform their full potential within the scope of the SUS(⁹). Researchers claim that, in fact, Brazil has all the conditions to expand, recognize, and value the role of advanced practice nurses in PHC. However, it will require strong and integrated collective work, encompassing the government, professional associations, the National Health Council, universities, among other actors, in the sensitization of not only health professionals but also of the general population(⁶).

FINAL CONSIDERATIONS

PHC, as an important level of care for guaranteeing universal access to health systems and putting integrality into effect, requires greater attention to human resources related problems. This is because there is an insufficiency and shortage of professionals, as well as unpreparedness to meet the conditions of this level of care, which encompasses a diverse and complex health reality. Furthermore, the SUS currently faces threats to its consolidation, evidenced by the various attacks at the political level, added to the risk of dismantlement due to the neoliberal wave that is advancing in Brazil, in addition to fiscal austerity policies. At the international level, the SUS is threatened by the UHC proposal and the political action of those who defend market-oriented health systems to the detriment of PHC-based UHSs.

Due to the cultural, historical, social, political-administrative, financing mechanisms, and human resources diversity, and given the real health needs of the population, it is crucial for Brazil to carry out its own systematic process to prioritize and define the role or roles of the APN to be implemented within the scope of the SUS. This systematic process of defining the roles of Brazilian advanced practice nurses needs to include in its core the promotion and strengthening of PHC with appreciation of the workforce of advanced practice nurses, through a career plan recognized and desirable by these professionals. It should also: include the basis for certification/accreditation; become a primary choice among postgraduate and permanent education programs; guide job and salary plan reviews and performance evaluations; encourage the training of nurse teachers.

It is expected that the expansion of the workforce to work in the SUS and the insertion of the APN will allow greater recognition and incentives for the actions performed at this level of care. For example, such actions must occur via integration between professionals and the community in health promotion actions, with the availability of appropriate technologies for the work, in order to ensure that there is quality and resolution of PHC and, above all, that users assisted by this level of care feel welcomed and obtain better outcomes in their health-disease-care process.

SUPPLEMENTARY MATERIAL

Lopes-Júnior LC; Bolina AF, Lazarini WS, Sarti TD, Andrade J, Elauar RB, et al. Atenção Primária à Saúde forte e robusta: uma necessidade premente. In: Silva Júnior FJG, Sales JCS, Galiza FT, Lopes-Júnior LC (Orgs.). Políticas, Epidemiologia e Experiências no Sistema Único de Saúde (SUS) - possibilidades e desafios do cenário brasileiro.2ed.Curitiba-PR: CRV, 2021;2:19-35. doi: 10.24824/978652511188.9

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Edited by

EDITOR IN CHIEF: Álvaro Sousa

ASSOCIATE EDITOR: Carina Dessotte

Publication Dates

• Publication in this collection
  09 May 2022
• Date of issue
  2022

History

• Received
  24 July 2021
• Accepted
  11 Feb 2022