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Texto & Contexto - Enfermagem

Print version ISSN 0104-0707On-line version ISSN 1980-265X

Texto contexto - enferm. vol.28  Florianópolis  2019  Epub Apr 29, 2019

http://dx.doi.org/10.1590/1980-265x-tce-2016-0426 

Literature Review

PRIMARY HEALTHCARE MANAGEMENT: WHAT IS DISCUSSED IN THE LITERATURE

GESTIÓN EN SALUD EN LA ATENCIÓN PRIMARIA: QUÉ ES TRATADO EN LA LITERATURA

Denise Elvira Pires de Pires1 
http://orcid.org/0000-0002-1754-0922

Lara Vandresen1 
http://orcid.org/0000-0002-1389-7932

Francele Machado2 
http://orcid.org/0000-0002-4436-8574

Rosani Ramos Machado2 
http://orcid.org/0000-0001-8287-4171

Felipa Rafaela Amadigi2 
http://orcid.org/0000-0003-1480-1231

1Universidade Federal de Santa Catarina, Programa de Pós-Graduação em Enfermagem. Florianópolis, Santa Catarina, Brasil.

2Universidade Federal de Santa Catarina, Departamento de Enfermagem. Florianópolis, Santa Catarina, Brasil.

ABSTRACT

Objective:

to identify what is discussed in studies published in Brazilian and international literature in the last ten years on Primary Health Care management.

Method:

an integrative review with a search carried out from 2006 to 2016, in the SciELO®, LILACS®, Scopus®, PubMed® and CINAHL® databases in the Portuguese, English and Spanish languages. The review followed the steps: formulation of the research question, definition of the inclusion and exclusion criteria, identification and selection of the studies, and summary of the subjects found in the studies. Resources from The Atlas.ti® software was used for data organization and analysis.

Results:

the corpus include 90 studies which predominantly originated from LILACS® and were performed in Brazil. The themes covered in the publications were: health policy and management in Primary Health Care, material resources management, human resources management, financial management, quality management, planning, characterization of managers, management role/ activities, challenges/difficulties in management, potentialities/facilities in management. There was a prevalence of studies that dealt with Primary Health Care management in the context of reflections on health policies and those dealing with the challenges/difficulties faced in Primary Health Care management. These findings demonstrate that the Primary Health Care model is complex and challenging, both for policymakers and for those managing it.

Conclusion:

the number of studies on Primary Health Care management is significant in the current literature and the predominance of health policy and difficulties in performing management issues reinforce the recognition of the centrality of the management for effective Primary Health Care.

DESCRIPTORS: Health management; Health administration; Administration of health services; Primary health care; Family health strategy

RESUMEN

Objetivo:

identificar lo que abordan los estudios publicados en la literatura nacional e internacional, en los últimos diez años, sobre gestión en la Atención Primaria a la Salud.

Método:

revisión integradora con la búsqueda realizada en el período de 2006 a 2016, en bases de datos, SciELO® LILACS®, Scopus®, PubMed y CINAHL, en portugués, Inglés y Español. Se siguiron las etapas: elaboración de la pregunta de investigación, definición de los criterios de inclusión y exclusión, identificación y selección de los estudios, y síntesis de los asuntos encontrados en los estudios. Para la organización y análisis de datos se utilizaron recursos del software Atlas.ti®.

Resultados:

el corpus de la encuesta totalizó 90 estudios, predominando los oriundos del LILACS® y realizados en Brasil. Los temas tratados en las publicaciones fueron: política de salud y gestión en la Atención Primaria a la Salud, gestión de recursos materiales, gestión de personas, gestión financiera, gestión de la calidad, planificación, caracterización de los gestores, papel/actividades de la gestión, desafíos/dificultades en gestión, potencialidades/facilidades en la gestión. En el contexto de las reflexiones sobre política de salud y los que se ocupan de los desafíos/dificultades enfrentadas en la gestión en la Atención Primaria a la Salud, los hallazgos señalan que el modelo de atención en la Atención Primaria a la Salud es complejo y desafiador, tanto para formuladores de políticas y para quien realiza la gestión.

Conclusión:

el número de estudios sobre gestión en la Atención Primaria a la Salud ha sido significativo en la literatura actual y la predominancia de los temas políticos de salud y dificultades para la realización de la gestión refuerza el reconocimiento de la centralidad de la misma para la efectividad de la Atención Primaria a la Salud.

DESCRIPTORES: Gestión en salud; Administración en salud; Administración de servicios de salud; Atención primaria a la salud; Estrategia de salud familiar

INTRODUCTION

Primary Health Care (PHC) has been presented as the best form of organization for healthcare services, and the main entrance point for the Brazilian population to access health care. Its objective is to meet the needs of the population by considering efficiency and effectiveness.1-2

Positive results are constantly being achieved due to the conception and formulation of PHC such as: greater community participation in health care; reduction of mortality and diseases related to the lack of sanitary and economic conditions; and the development of preventive and health promotion measures.2-5 These results made PHC a reference in the modification of the health services, in Brazil and internationally. However, a number of challenges still exist regarding its effectiveness as a strategy to achieve health for all and remain cost-efficient for countries, ensuring comprehensive care at all levels of care, achieving a broader understanding of the population's health needs and reducing disparities between regions.6

PHC in some European countries is identified as an outpatient service which aims to meet the acute health needs of people.7 In others, such as Brazil, it integrates a national policy aimed at organizing services to meet the needs of the population in the health area.1

While not requiring material technological resources that are excessively expensive, such as in secondary (medical specialties and complex exams) and tertiary (hospital) levels, the services performed in PHC are complex. It involves human relations, between workers in health care teams, between these and managers, between teams and users, between managers and the community.1,8

The terms management/administration are related to the knowledge applied in the management of health organizations and this management involves the actions of managing / administering care networks and care units in public and private spheres. Managing involves providing direct, unique care which often involves multiprofessional teams, and the various requirements necessary for health organizations to work.9

PHC is a challenge for management since it also involves typical dimensions of health management: people management (provision of workforce in number and qualification, and management of work relations); management of materials and processes (including structure, organizational flows, work processes, materials and equipment); and financial management; assumes the responsibility of providing universal, comprehensive, equitable, efficient and effective care that meets the health needs of the population.8

PHC management in Brazil is the responsibility of the municipality and it is essential that it is organized in a way that guarantees the quality and resolution of health care.4,8 The effective functioning of PHC, in part, is related to the understanding of the health needs of the population, the work processes involved, the management of the resources required and the provision of effective results.8

A study conducted in Brazil with managers from the public and private sector highlights the insufficiency of financial resources and weaknesses in health management. It also highlighted that this last point is related to the professional inexperience in the area of management, the delay in the inclusion of new technologies that contribute to management processes and work organization; and even more significantly in the public sector, is related to the difficulties in overcoming impediments imposed by the legislation that hinders the necessary agility, and to the party and electoral influences on managers, which generates turnover and discontinuity of initiated processes, and demotivation of workers and professionals.9

According to the Alma-Ata Declaration and the Federal Constitution in 1988, health is recognized as a fundamental right of the population and must be guaranteed by the involvement of the three governmental spheres: federal, state and municipal.8,10 However, the adequate financing and professional training focused on social and health practices did not accompany this expansion nor the management, which has made it difficult to offer quality and effective services to the population.10

PHC management is complex due to the specificity of health and primary health care itself, as well as the characteristics that it shares with many works in the service sector involving intangibility, simultaneity between production and consumption, impossibility of storage, difficulty in standardization, importance of the human factor and difficulty in evaluating costs.11

With the intention of promoting knowledge on PHC management, this review aimed to identify what studies published in Brazilian and international literature discuss in relation to Primary Health Care management in the last ten years.

METHOD

An integrative literature review12-14 whose purpose is to select and analyze scientific studies on a given theme.

The methodological process consists of five stages: formulation of the research question; definition of the inclusion and exclusion criteria of the studies; identification and selection of studies; evaluation of selected studies and final inclusion; preparation of the summary of the studies and the subjects found in them. In order to ensure the integrity of the integrative review, a protocol12,15 which was validated by an external researcher. Data collection was performed by two independent researchers (double blind modality), guided by the research question: what do the national and international studies discuss regarding the theme of Primary Health Care management?b

The initial search for identification of the studies occurred between April 26 and 30, in 2016 in Public/Publish Medline (PubMed) ®, Latin American and Caribbean Literature in Health Sciences (LILACS) ®, Scientific Electronic Library Online (SciELO)®, Scopus ® and Cumulative Index to Nursing and Allied Health Literature (CINAHL) ®. Search keys were developed for advanced research, based on the Health Sciences Descriptors (DeCS) and the Medical Subject Headings (MeSH) using the Boolean operators AND and OR. The terms used were: Gestão em Saúde/Health Management/Gestión en Salud; Administração em Saúde/Health Administration/Administración en Salud; Administração de Serviços de Saúde/Health Services Administration/ Administración de los Servicios de Salud; Atenção Primária à Saúde /Primary Health Care/Atención Primaria de Salud; Estratégia Saúde da Família/Family Health Strategy/Estrategia de Salud Familiar.

Full original scientific articles that contained the search terms in the title and/or abstract; published in the English, Spanish or Portuguese languages from 2006 to 2016; and which could be accessed by the Virtual Private Network (VPN) via the Federal University of Santa Catarina were included. The period of ten years from April 2006 to April 2016 is justified by the time that Primary Health Care became national policy in Brazil, under Ordinance No. 648, dated March 28, 2006, updated in 2011 and 2017.16

The first stage of the search resulted in 5105 articles from the five databases. When applying the language filters (English, Spanish or Portuguese) and period (2006 to 2016) the number of articles reduced to 2581, which then went to the study selection stage. At this point, the titles and abstracts were read and 423 articles were selected. Among these 423 articles, 197 were excluded as they were duplicated; outside the subject of interest; integrative reviews, editorials, newsletters, government documents or annals of congresses; and because they were not accessible in full, which resulted in a total of 226 articles.

In the evaluation stage, the 226 studies were submitted to a complete reading for the purpose of verification and relevance to the study theme, which resulted in 114 studies.

In the inclusion stage, the independent researchers agreed on the findings and concluded the final selection. In this stage, 24 papers were excluded because they were duplicated or did not answer the research question. The final corpus contained 90 articles.

The search process, selection and constitution of the corpus is shown in Figure 1

Figure 1 Methodological process of survey research in the integrative review, Florianópolis-SC, Brazil, 2017.17  

The submitted articles included in this review were organized according to article title, author, year, database, periodical and study site. For the last methodological step, the 90 articles included in the review, were stored in the Atlas.ti® software version 7.6.1, a tool that assists in the organization and qualitative analysis of data (Qualitative Research and Solutions), as primary documents in pdf format, and were evaluated and coded based on the purpose of this review.

For the analysis of each document, codes previously written in the software were formulated in order to help categorize the themes and subjects that the studies covered. The categories were: Health Policy; Material Resources Management; Characterization of Managers; People management; Financial management; Quality management; Planning; Paper/Management activities; Challenges/Difficulties in Management; Potentialities/Facilities in Management. Each document was then read and quotations were selected that identify each theme and sub-theme or subjects covered in each theme.

RESULTS

Regarding the type of study, the majority were descriptive qualitative studies, followed by mixed approach studies. Regarding the source, most articles were from the LILACS database, with 60%, followed by SciELO® with 17.78%, Scopus® with 12.22%, PubMed® with 7.78% and CINAHL® with 2.22%.

As for the publication period of the studies, there were more publications in the year 2014 with 18.89%; followed by the year 2010 with 16.67% and 2015 with 14.44%. The years 2009, 2011, 2012 and 2013 accounted for 10% for each year. The lowest number of publications occurred in the 2006, 2007, 2008, and 2016, respectively, with 1.11%, 2.22%, 3.33% and 3.33%. It should be observed, that the data for 2016 were only collected until April. Regarding the language, the Portuguese language predominated with 78.89%, followed by the English language with 11.11% articles, and the Spanish language with 10%.

Regarding the analysis of the study locations, the majority of the researches were performed in the American continent 86.67%. South America accounted for 85.56% of the publications, with 71 articles produced in Brazil, followed by Colombia with four, and Chile and Venezuela with one study in each country. 6.67% were produced and published in Europe, two of them originated in Portugal and two in Spain; England and Serbia produced one study each. Among the total of the studies, 3.33% were produced in the Asian continent, two originating from Lebanon and one from Pakistan. In addition, 2.22% of the productions came from the African continent. The lowest number of productions originated in Oceania region, 1.11%.

The results of the themes discussed in the literature on PHC management in the last ten years are organized in Box 1 and describe the thematic categories with the subjects related to them.

Box 1 Subjects covered according to thematic category, in the period 2006-2016, Florianópolis-SC, Brazil, 2017 

Thematic Category Articles and subjects addressed
Health Policy Analysis of PHC implementation;45-46,54,79,85,95,99,102 APS assessment;59,74,77,84,89,91,103 evaluation instrument;22,43assessment of the comprehensiveness;55,60financing;92,107access assessment24; healthcare network.57
Challenges / Difficulties in Management Healthcare services availability/access;20,56,96deficit of resources;25,58,98,100 manager training/ experience/ unpreparedness;32,39,87 analysis of management guidelines;18 management model;29 human resources/relations;30 data management;51 managers' perception of management;65 work process in PHC;71 implementation of PHC;73 quality assessment;78 organization of work in PHC.80
Quality management Instrument/model;23,27,35,41,48,53,61-62,68,83,101evaluation;21,33,47,49-50performance of services;26 evaluation policy.88
Role/Management Activities Coordination activity;52,70organization of work;34 team management;44 articulation of services in the healthcare network;63 planning;72 management model (traditional).105
Characterization of Managers Profile36,38,42,106 competences.90,93
Personnel management Workforce;40,76qualification;37 labour process;66 organization of human resources.68
Material Resource Management Technology/instruments;75,81-82,97environment.86
Planning Management Management model;19,31,69,94management tools.64
Financial Management Types of hiring.67,104
Potentialities / Facilities in Management Special resources (as NASF in Brazil).28

DISCUSSION

With regard to the publications on PHC management, it was verified that the number of manuscripts found in the last ten years was significant, reaffirming its importance in the health sector.9,108-109 This issue is relevant since policy-making and the healthcare practice are mediated by management. It involves aspects related to the coordination of collective work, as well as the provision of practice environments, including a complex range of elements that influence the efficiency and effectiveness of services.

The health policy category was the one that most stood out in the articles published on PHC management in the studied period. This finding can be explained by increasingly intense international debate on the universalization of access to health and the centrality that has been given to PHC in order to countries achieve this goal.109-112 The profile of publications highlights the significant number of articles found in the LILACS database and articles performed in Brazil. This prominence can be explained by the growth of PHC in the last decade.

The Family Health Program, established in 1994, was later named the Family Health Strategy, which became a national policy in 2006, reaffirmed in the new editions of the National Policy on Primary Care (PNAB) in 201116 and 2017.

In Brazil, after the Federal Constitution of 1988, which defined health as a universal right and duty of the state, tension began between advocates of neoliberal policy and of constitutional precept, influencing the sense of universal access. It is worth highlighting that, as of 2006, the creation and significant investment in PNAB, a Brazilian expression for PHC, expanded to cover 64.6% of the population in 2016113 incorporating precepts which approached a new healthcare model.114

There is a significant agreement in relation to the importance of PHC to the universalization of the right to health. However, its implementation has been difficult, which is similar to that found by PHC scholars as well as the scholars of this research.115 Many publications discuss management in the context of historical analyses and how PHC is being organized, how policies are included and what the repercussions of these policies are regarding the access of users to the health system.

Studies that discussed the analysis of the implementation of PHC and its evaluation as a policy, those that addressed policy evaluation instruments, those that dealt with comprehensiveness assessment and the health care network, and those that addressed the issue of financing are highlighted.

Another highlight in the publications was the category of challenges and difficulties in PHC management, including human resources and material health deficits and the difficulties in offering access to healthcare services. The management of the services of public organizations is already a challenge,116 coupled with the lack of human and material resources that influences the provision of health services.117-119

Other challenging factors for PHC management are inexperienced managers and training deficits in this area that influence the achievement of efficient and effective management; problems in the implementation of PHC itself and problems in the organization and working relationships; deficits in the availability of work instruments, especially those necessary for management work; and difficulties in evaluating the quality of services.

Another category found was quality management, highlighting studies that discuss instruments and models used for quality evaluation in health services, as well as studies that address the importance and challenges of implementing a quality assessment and evaluation policy within the scope of PHC including the evaluation of the performance of these services. These studies highlight the need for internal restructuring of the service and the creation of new methods of work organization or even new policies to improve the quality of care. The issue of quality evaluation in PHC has also been a concern in the macro-level of health management represented by the implementation of the National Program for Improving Access and Quality of Primary Health Care, under Ordinance No. 1,654 as of July 19, 2011 and 1,645 as of October 1, 2015.8.10

Studies that address the role and activities involved in health management, with an emphasis on the coordination of collectives, work organization, planning, team management and articulation of the local units work in the health care network are also identified in the publications included in this review. As well as a reference related to the use of the traditional management model in PHC, based on verticalized and bureaucratized relationships.

With regard to the profile of PHC managers, the presence of nurses and females predominated. In Brazil, although the National Policy of Basic Attention (Política Nacional de Atenção Básica -PNAB, in Portuguese) does not dictate that the management activity belongs to this professional, the same assumes these activities due to the technical-scientific foundation that the nursing undergraduate degree in the country provides. However, the presence of women and the nurse in this activity is not restricted to the findings in Brazilian studies.

Key managerial competencies in this area were identified such as communication, team management, planning with prioritization, problem solving, performance evaluation and leadership. This is also mentioned by other authors and in official documents.5,8

Not one of the 90 studies included in this review focused on Primary Health Care management, focused on the set of aspects inherent to management, including methods and models of planning, the various aspects involved in material and people management, quality management, financial management and care processes.

With regard to personnel management in PHC, the studies deal with the composition and qualification of the workforce, the work process and the organization of the professionals and show how the conditions and how the work is carried out influences the effectiveness of PHC. The workforce profile in PHC, as well as factors that influence the retention and turnover of professionals contributing to PHC instability, were also mentioned in a study performed in Lebanon.120

In relation to material and financial resources, the studies address the presence of technological deficits and deficits of work instruments, including the PHC environment, as well as financing deficits. Regarding planning, studies that addressed planning models and instruments used in planning management were identified.

The planning, material management, personnel management and financial management categories, reveal important aspects of management and are fundamental for the quality of PHC services. Although these categories do not appear to be the most prominent in this review, they are indispensable for the proper management and organization of healthcare services.

One article addressed the potentialities/facilities in management focusing on the strategies that facilitate the PHC service, such as the Family Health Support Center. The implementation of the Family Health Support Center in the scope of the Family Health Strategy aims to support the consolidation of PHC and has the potential to promote changes in work processes in the production of health care reflecting in primary health care management.

As a limitation of the study, we can cite the thematic categorization, as one of the articles could be put into different categories and, in this case, we chose to categorize by the predominant theme in each article that is part of the corpus of the research. In addition, the time frame, the chosen languages and databases are highlighted as possible limitations of the study.

CONCLUSION

The publications analysed demonstrate that the theme of PHC management is the subject of research and concerns in academia, reinforcing what has been mentioned by policymakers and health systems managers in Brazil and worldwide. Ultimately, good management in primary health care can increase access, the comprehensiveness of care and the best use of available resources.

This review identified a variation in the number of publications over the analysed years, highlighting 2014 as the year with the highest number of articles. The results also reveal that PHC management has been portrayed in national and international scientific articles, mainly in relation to its aspects related to health policy and the challenges of management practice.

On the other hand, the study identified gaps in the knowledge produced in this area, in particular: the absence of writings that approach primary health care management in a conceptual manner; the weaknesses of information systems as strategic resources for decision-making and for the instrumentalisation of social control.

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FUNDING INFORMATION

This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001

Received: September 29, 2016; Accepted: November 09, 2017

CORRESPONDENCE AUTHOR

Lara Vandresen

laravandresen@gmail.com

CONTRIBUTION OF AUTHORITY

Study design: Pires DEP, Vandresen L, Machado F, Machado RR, Amadigi FR 142. Data collect: Pires DEP, Vandresen L, Machado F, Machado RR, Amadigi FR 143. Data analysis and interpretation: Pires DEP, Vandresen L, Machado F, Machado RR, Amadigi FR 144. Discussion of the results: Pires DEP, Vandresen L, Machado F, Machado RR, Amadigi FR 145. Writing and / or critical review of content: Pires DEP, Vandresen L, Machado F, Machado RR, Amadigi FR 146. Review and final approval of the final version: Pires DEP, Vandresen L, Machado F, Machado RR, Amadigi FR

CONFLICT OF INTEREST

No any conflict of interest.

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