Assessment of the management of the Family Health Strategy via the tool Assessment for Quality Improvement in municipalities of Minas Gerais, Brazil

Abstracts

The self-assessment of the quality ofthe Family Health Strategy(FHS) was assessed in the context ofmanagement and its correlation with characteristics of FHS and of the municipality. Managers, coordinators and Family Health Unit managers of municipalities in the Northeast region of Minas Gerais replied with tools 1, 2 and 3 of the Assessment for Improving the Quality of Family Health Strategy (AIQ). Scores were defined for each subdimension, according to the number of features compliant with the standards of the AIQ. We tested the correlation of this score with coverage and the deployment time of the FHS, with the municipal population and the HDI (Human Development Index). The lowest scores were for Work Management, Permanent Education and Inputs, Immunobiologicals and Medicines. There was a positive correlation between the municipal population and Strengthening of Coordination, Support for Teams, Permanent Education Management and Standardization and a negative one with Infrastructure and Equipment. The use of the AIQ tools permitted the identification of subdimensions and municipalities which will require greater attention and intervention by the municipal management.

Assessment of health services; Primary Healthcare; Health management; Family Health Program

Aferiu-se a autoavaliação da qualidade da Estratégia Saúde da Família (ESF) no âmbito da gestão e sua correlação com características das ESF e do município. Gestores, coordenadores e gerentes das Unidades Saúde da Família de municípios da região Nordeste de Minas Gerais responderam os instrumentos 1, 2 e 3 de Avaliação para Melhoria da Qualidade da Estratégia Saúde da Família (AMQ). Foram definidos escores para cada subdimensão, segundo número de conformidades aos padrões da AMQ. Testou-se a correlação desse escore com a cobertura e o tempo de implantação das ESF, com a população e o IDH (Índice de Desenvolvimento Humano) municipal. Os escores menores foram para Gestão do Trabalho, Educação Permanente e Insumos, Imunobiológicos e Medicamentos. Houve correlação positiva entre população municipal e Fortalecimento da Coordenação, Acompanhamento das Equipes, Gestão da Educação Permanente e Normatização e negativa com Infraestrutura e Equipamentos. O uso dos instrumentos da AMQ permitiu identificar as subdimensões e municípios que necessitarão de maior atenção e intervenção da gestão municipal.

Avaliação de serviços de saúde; Atenção Primária à Saúde; Gestão em saúde; Programa Saúde da Família

Introduction

The expansion of the Family Health Strategy (FHS) has initiated a discussion on questions regarding the qualification of teams and the resolvability of services, highlighting the need for monitoring and assessment of Primary Healthcare (PHC)¹. To this end, the Ministry of Health (MoH) has begun to argue in favor of the continuous upgrading of assessment processes in the routine of management and of health services². The Policy of Monitoring and Assessment of the Basic Healthcareestablished the Assessment for Improving the Quality of the Family Health Strategy(AIQ)³, in conjunction with states and municipalities, locating assessment as a permanent instrument for decisionmaking andquality as a fundamental attribute to be achieved in the Single Health System (SUS)⁴.

Donabedian's model was adopted as a conceptual reference for the elaboration of the AIQ. This model considers elements of structure, process and results, which are related to the assessment elements of the FHS teams: structure - inputs, teams, materials, human resources, physical environment and normative organization; process - organizational, technical-scientific and interpersonal aspects; result - access, adjustment and effectiveness forthe promotion of changes in the health of the population⁴.

As a support for the assessment, the MoH developed self-assessment tools, directed towards the municipal managementof health, the municipal coordinationof the FHS, the manager responsible for managing the Family Health Units (FHU) and the FHS Teams. They seek a diagnosis for the organization and functioning of the services and their practices on the basis of the principles, directives and fields of action of the FHS. The AIQ considers two major integrated units of analysis: Management and Team, containing dimensions of analysis, which are in turn broken down into subdimensions. Each subdimension has its quality standards, amounting to 300 standards in five tools⁴.

The AIQ has sought to promote, as the principal objective of its deployment, the monitoring and assessment of the quality stages of the FHS, making available tools for the diagnosis of problems and stimulating the debate on improvements in the field ofhealth, based on the results of the self-assessment processes. These processes may be adhered to freely by themanagers and do not determine financial incentives or sanctions for the municipalities and teams which have adhered to the programme⁴.

An effort was nevertheless made to facilitate a broader program, which could permit the expansion of access and the improvement in the quality ofBasic Healthcare (BH) throughout Brazil, with the guarantee of a quality standard that was comparable, nationally, regionally and locally and greater transparency and effectiveness of the government actions intended for BH⁵.

In order to achieve such objectives, the MoH introduced the National Program for Improvement of Access and Quality (PIAQ), via Decree No. 1.654 GM/MS, of 19 July 2011, which was the result of an extensive and important process of negotiation between the three spheres of management of the SUS⁵. The PIAQ may also be adhered to freely, although it links financial resources to the meeting of goals, previously established by the contractualization of objectives⁵.

Self-assessment, which is the final objective of the AIQ, is understood is the point of departure for the developmentphase of the PIAQ, which possessesthree other phases, which complement each other and conform to a continuous cycle (Adhesion and Contractualization; Development; External Assessmentand Recontractualization)⁵.

While other assessment instruments have been developed, the AIQ takes into account many of the assessment dimensions contained in the PIAQ, maintaining similar theoretical constructions, which seek a discussion of the quality of management and of teams as central units of analysis in the assessment questionnaires^{4 , 5}. As such, studies on the AIQ are valid and relevant, since this instrument may generate assessment indicators for the quality of FHS in Braziland even today, only a small number of studies have used this assessment instrument as a central theme of study^{6 - 8}.

Minas Gerais is a Brazilian state with social inequalities between its regions⁹. TheNortheast macroregion, composed of 63 municipalities¹⁰, is one of the poorest regions in the State, with major social inequality and a predominantly rural population¹¹. Assessing the quality of PHC in this situation is essential for establishing the response capacity of policies, programs and services to the healthcare needs of the population, principally in a context of scarce public resources for the health sector. In addition, considering the need to monitor the PHC, as well as the important role of the manager, of the municipal coordinator of the FHS and of the FHU managers in promoting, protecting and restoring the health of its residents, the self-assessment of the quality of FHS in the municipalities of the Northeast macroregion of Minas Geraisis justified in the context of management.

This study assessed the quality of the FHS, considering the AIQ cited by the managers, municipal coordinators of the FHS and managers of the FHU in the municipalities of the Northeast macroregion of Minas Gerais, and verified the correlation between the self-assessment scores and the Human Development Index (HDI), the municipal population, coverage and deployment time of the FHS.

Methodology

An ecological study, executed in the 63 municipalities of the healthcare macroregion of the Northeast of Minas Gerais, covering theMucuri and Jequitinhonha Valleys in geographical terms, subdivided into eight health microregions¹⁰. This macroregion has a territorial area of 56,641 km², a population density of 14.33 inhabitants/km² and an estimated populationin 2011 of 811,856 inhabitants¹⁰. In territorial terms, it is similar to the Centremacro region, in which the capital Belo Horizonte is located. In this latter macro region, however, population density is 105.49 inhabitants/km² with an estimated populationin 2011 of 6,145,218 inhabitants¹⁰. The average HDI of the Northeast macroregion is 0.636, considered as an average human development value. Minas Gerais has a high HDI value, of 0.731; like Brazil, with a HDI of 0.744¹².

The Northeast macroregion covers the Regional Health Superintendencies (SRS) of Teófilo Otoni, Diamantina and the Regional Health Management Area (GRS) of Pedra Azul. The SRS of Teófilo Otoni covers 32 municipalities; 25 municipalities are under the jurisdiction of the GRS of Pedra Azul and six belong to the jurisdiction of the SRS of Diamantina and comprise the micro region of Araçuaí¹³. At the time of collection of the data, the 63 municipalities had 264 FHS teams (February to April 2011). This included all of the managers, municipal coordinators of the FHS and managers of the FHU of the 63 municipalities, holding the position during the period of February/March2011, forming a group of 63 managers, 63 municipal FHS coordinators and 264 FHU managers.

The quality of the FHS was assessed by the three players involved in the management of the FHS through tools 1, 2 and 3 of the AIQ, which correspond to the threedimensions: Development of the FHS, Technical Coordination of Teams and theFamily Health Unit⁴.

Tool 1, aimed at the municipal health manager, assessed the dimension Development of the FHS, with 60 standards, organized into four subdimensions: Deployment/Implementation of the FHS in the municipality; Integration of the Service Network; Work Management and Strengthening of Coordination. The dimension Technical Coordination of Teams (tool 2), assessed by the coordinators of the FHS, included thesubdimensions: Planning and Integration; Support for Teams; Permanent Education Management; Management of the Assessment and Standardization, distributed across 40 standards. The Family Health Unit dimension (tool 3), with 40 standards in two subdimensions, Infrastructure and Equipment of the FHU and Inputs, Immunobiologicals and Medicines, was directed towards the managers of the FHU. The quality standards in each subdimension are accompanied by their description, which determines the characteristics necessary for ensuring that the FHS is or is not compliant with that standard⁴.

Initially, the project was disclosed to themanagers during the meetings of the Bipartite Intermanager Commissions (CIB) of the eight health microregions. The questionnaires intended for the managerswere distributed to them, with the managers requested to forward those intended for the coordinators and the FHU managers of the municipalities under their management.

The following information was also collected from the municipalities: population in 2010, from the Instituto Brasileiro de Geografia e Estatística[Brazilian Institute of Geography and Statistics] (IBGE)⁹; HDI in the Atlas of Human Development of Brazil, of 2000¹²; and time of deployment and population coverage of the FHS, on the website of the MoH/Department of Basic Healthcare, referring to March 2011¹⁴.

The data were analyzed using the statistical package SPSS for Windows v. 17.0, considering the municipality as the unit of analysis. For each municipality, the number of features compliant and non-compliant with the standards referring to the assessed subdimensions and dimensions was calculated, in order to obtain the average standard deviation of the compliance scores. In the case of tool 3, each FHU presented an adjustment score to the assessed subdimensions. Following this, for each municipality, the average of the compliance scores obtained for each of the FHUs was calculated for each municipality. The correlation between the scores of the subdimensions of each dimension and the variables referring to the municipalities and to the FHS was investigated by calculating the Spearman correlation coefficient (p < 0.05). The frequency of municipalities or FHUs in compliance with each of the standards was obtained for all of the assessed dimensions/subdimensions.

The research project was approved by the Research Ethics Committee of the State University of Montes Claros. All of the participants signed the free and informed consent form.

Results

There was a response rate of 79.4% (n = 50) and of 76.2% (n = 48) among themanagers and coordinators respectively. With regard to the participation of FHU managers, in eight municipalities there was a loss of 100%. All in all, 55 municipalities (87.3%) and 210 managers of the FHU (79.5%) replied.

Table 1 also demonstrates the management assessment of the FHS with regard to the three dimensions of the AIQ. In the dimension Development of the FHS, the managers assessed the subdimensionWork Management and Strengthening of Coordination more negatively, which presented the lowest average proportional scores. The best average performance was obtained by the Deployment/Implementation subdimension of the FHS in the municipality. For the dimension Technical Coordination of Teams, the maximum score for compliance with the standards was only missed by the Planning and Integration subdimension. In this dimension, the coordinators had a more negative assessment of the Permanent Education Management subdimension. The best proportional average performance was obtained in the Support for Teams subdimension. In the Family Health Unit dimension, in proportional terms the Inputs, Immunobiologicals and Medicines subdimension received a better assessment by the managers of the FHU than the Infrastructure and Equipment of the FHU dimension.

Table 1.
Assessment of the Development dimensions of the Family Health Strategy, Technical Coordination of Teams and Family Health Unit by the managers (n = 50), coordinators (n = 48) and managers of the UFH (n = 55) of the Northeast region of Minas Gerais. Minas Gerais. 2011.

		Maximum	Compliance scores
Dimension*	Subdimension	compliance
		score	Minimum	Maximum	Average (SD)
Development	Installation/Implementation of FH	19	11	19	16.08	(2.01)
of the Family	within the municipality
Health Strategy	Integration of the services network	19	5	19	13.50 (13.80)
	Work Management	10	1	9	4.50	(1.88)
	Strengthening of Coordination	12	1	12	7.56	(2.58)
Technical	Planning and Integration	8	0	7	5.00	(1.52)
Coordination	Monitoring of the Teams	7	0	7	5.50	(1.52)
of Teams	Management of Permanent Education	6	0	6	3.54	(1.61)
	Management of Valuation	10	0	10	6.77	(2.22)
	Standardization	9	0	9	5.69	(2.23)
Family Health	Infrastructure and Equipment of the	24	8	22	14.42	(3.62)
Unit	Family Health Unit
	Inputs, Immunobiologicals and	16	6	16	13.23	(2.38)
	Medicines

The municipalities with higher population reported significantly higher compliance scores in the subdimension Strengthening of Coordination, Support for Teams, Permanent Education Management and Standardization. The scores for the subdimensions Infrastructure and Equipment of the FHU and Inputs, Immunobiologicals and Medicines were significantly lower in municipalities with a higher population. The municipalities with a higher HDI presented lower scores for the subdimension Inputs, Immunobiologicals and Medicines (Table 2).

Table 2.
Spearman Correlation between compliant scores for the Development dimensions of the Family Health Strategy, Technical Coordination of Teams and Family Health Unit and characteristics of the municipality and of FHS. Minas Gerais. 2011.

		Population			Percentage			HDI of the			Installation
		of the			coverage by
Dimension	Subdimension	municipality			the FHS			municipality time of FHS
			p			p			p			p
		r	value		r	value		r	value		r	value
Development	Installation/Implementation of FH	-0.09	0.55	0.10		0.49		0.17	0.23	0.10		0.55
of FHS	within the municipality
	Integration of the services network	0.10	0.51	0.02		0.89		0.04	0.79	0.14		0.34
	Work Management	0.07	0.65	0.01		0.94		0.10	0.50	0.09		0.52
	Strengthening of Coordination	0.29	0.04	0.15		0.30		0.02	0.91	0.13		0.38
	Planning and Integration	0.23	0.11	0.12		0.41		0.09	0.53	0.19		0.21
Technical	Monitoring of the Teams	0.29	0.04	0.05		0.74		0.14	0.35	0.01		0.99
Coordination	Management of Permanent	0.63	0.00	0.26		0.08		0.18	0.21	0.02		0.90
of Teams	Education
	Management of Valuation	0.18	0.22	0.20		0.18		0.03	0.87	0.01		0.94
	Standardization	0.38	0.01	0.09		0.55		0.08	0.61	0.08		0.57
	Infrastructure and Equipment of	-0.43	0.00	0.15		0.28		0.60	0.07	0.23		0.09
Family	the Family Health Unit
Health Unit	Inputs, Immunobiologicals and	-0.59	0.00	0.21		0.12		-0.27	0.04	0.22		0.11
	Medicines

• r = Spearman correlation coefficient.

In the Deployment/Implementation subdimension for FHS within the municipality, the percentages of municipalities compliant with the standards of the AIQ varied from 42% to 100%, with the lowest two percentages obtained for the standards "The municipal health manager has formalized agreements and/or partnerships with organizations of civil society and/or social movements" (42%) and "The FHS is institutionalized through a legal instrument" (62%). The percentages of municipalities compliant with the standards of the subdimension Integration of the Service Network varied from 30% to 96%. 30% and 48% of the managers answered in the affirmative to the following standards respectively: "The health service network guarantees access to the dental prosthesis laboratory service for the attached population" and "There is planning of the supply of ophthalmologist services of the FHS, based on studies of demand". For the Work Management subdimension, the percentages of managers compliant with the standards varied from 22% to 74%. The standards "Municipal health management has institutionalized career plans, jobsand salaries regarding Family Health" (22%) and "Municipal management has an incentive program for the FHS, relating to the performance, compliance with goals and results achieved" (26%) had the lowest percentage of compliant features. In the Strengthening of Coordination subdimension, there was a variation from 34% to 90% in the percentages of affirmative answers to the standards, with the lowest values obtained for the standards: "Municipal health management and/or the coordination establish or use mechanisms for the monitoring of the degree of satisfaction of users of FH" (34%), "There is decentralized coordination, responsible for the monitoring of at most eight FHS" (38%) and "The coordination of Basic Healthcare (BH)/FH supports and promotes the training of Local Health Councils in the BHUs" (38%) (Table 3).

Table 3.
Frequency of municipalities with positive replies to the AMQ standard for the Development dimension of the Family Health Strategy (n = 50).

		Municipalities
Subdimension	Standards	with positive	% of
		replies	municipalities
Installation/ Implementation of FH in the municipality	The Municipal Health Plan defines FH as a strategy for	49	98
	the reorganization of Basic Care
	The installation of FHS gives priority to the areas with	49	98
	less favorable socio-economic and health conditions and/
	or of social exclusion
	All of the teams are responsible for an attached	39	78
	population of up to 4,000 individuals
	Municipal health management supplies the Information	48	96
	Systems on a regular basis and within the established
	deadlines
	Municipal health management establishes OH teams	50	100
	The Municipal Health Plan details the guidelines and	47	94
	planning for the installation, implementation and
	consolidation of the FH
	Municipal health management carries out an analysis	35	70
	of the health situation of the municipality in order to
	support the installation of the FH
	The Municipal Health Secretariat maintains strategies for	44	88
	awareness raising and dissemination of FH among the
	population
	The directives and planning for the installation,	50	100
	implementation and consolidation of FH are agreed and
	approved with the CMS
	Municipal health management maintains analysis	41	82
	and monitoring of the health situation to support the
	implementation of FH
	The Municipal Health Secretariat maintains strategies	45	90
	for awareness raising and dissemination of FH among
	healthcare professionals of the municipal network
	Municipal health management develops actions in a form	45	90
	of articulated with other government sectors
	Municipal health management develops the FH strategy,	43	86
	installing OH in a proportion of at least one team for
	every two FHS
	The municipal management monitors supply and	43	86
	shortages of inputs in the FHU
	Municipal health management supports and legitimates	44	88
	popular participation and social control for FH
	FH strategy is institutionalized within the municipality	31	62
	through a legal instrument
	The organization of the teams in the UFH balances	43	86
	criteria of regionalization, comfort and sanitary safety for
	the development of activities
	The municipal health manager has agreements and/	21	42
	or partnerships formalized with organizations of civil
	society and/or social movements
	The municipal management develops the FH installing	37	74
	Oral Health in the proportion of one team for each FHS
Integration of the Service Network	Municipal health management expands and/or makes	45	90
	adaptations to the service network as a function of the
	installation of FH within the municipality
	Municipal health management expands and/or makes	36	72
	adaptations to the network of references, basing itself on
	studies of the demand verified and/or estimated in the FHS
	Planning exists for the supply of basic complimentary	45	90
	examinations for the FHS
	Municipal health management guarantees the collection and	47	94
	submission of all serology requests for diagnosing dengue
	fever
	Municipal health management develops strategies for	48	96
	ensuring a reference for the population attached to the FH
	teams for hospitalizations in the basic clinics
	Municipal health management guarantees the execution of	46	92
	high-risk prenatal tests for all referred pregnant women
	Planning exists for the supply of cardiology treatment for	29	58
	the FHS based on studies of demand
	Planning exists for the supply of orthopedic treatment for	30	60
	the FHS based on studies of demand
	The procedures of fixing tests, procedures and	42	84
	hospitalizations are carried out by a reservation center
	The municipal health manager monitors and specialized	41	82
	tests, requested by the FHS, which are not provided by the
	reference
	Planning of the supply of rehabilitation services for the FHS	33	66
	based on studies of demand
	Planning of the supply of ophthalmologist services for the	24	48
	FHS based on studies of demand
	Planning of the supply of a nose and throat treatment for	26	52
	the FHS based on studies of demand
	Planning of the supply of neurology treatment for the FHS	26	52
	based on studies of demand
	Municipal health management develops strategies for	30	60
	ensuring a reference for the population attached to the FH
	teams for dentistry specialties
	The health services network guarantees access to the dental	15	30
	prosthesis laboratory for the population attached to the FH
	teams
	Municipal health management develops integration	36	72
	strategies between the mental health service and the FHS
	Municipal health management monitors the use of urgent,	35	70
	emergency and first aid services of the public network for
	the population covered by the FH
	Support by other network professionals for the FH teams is	41	82
	provided systematically, on the basis of an established model
Work Management Strengthening of Coordination	Municipal health management develops strategies for	16	32
	ensuring that labor rights do not become precarious in the FH
	The criteria of the SMS for the selection and recruitment of	37	74
	FH professionals are described in an official document
	The criteria for selecting professionals for higher-level FH	18	36
	give value to Residential or Postgraduate Studies in Family
	Health
	The entry of high-level FH professionals is realized through	17	34
	a public competition to fill permanent positions or public
	sector jobs
	The entry of mid-level FH professionals is realized through	28	56
	a public competition to fill permanent positions or public
	sector jobs
	Higher-level FH professionals have been working in the	30	60
	municipality for more than two years
	The ACS have been working in the municipality for more	33	66
	than two years
	The municipal management has an incentive program for	13	26
	the FHS related to performance, meeting targets and results
	achieved
	Municipal health management has institutionalized career	11	22
	plans, positions and salaries regarding the FH
	80% of higher-level professionals in the teams have specific	22	44
	training in the area
	The SMS has a specific coordinating body for BH/FH	41	82
	The coordinating body of the BH/FH is formally included	32	64
	in the organizational structure of the Municipal Health
	Secretariat
	Municipal health management involves the coordination of	45	90
	the BH/FH in the process of agreeing on the BH indicators in
	the Health Pact
	Municipal management values the participation of the	43	86
	coordinating body of the BH/FH in congresses and meetings
	of the area
	The technician(s) responsible) for the coordination of the	31	62
	BH/FH has/have specific training in the area
	The coordinating body of the BH/FH consists of a multi-	25	50
	professional team for the support, supervision and technical
	monitoring work of FHS
	Decentralized coordination exists, which is responsible for	19	38
	the monitoring of at most 8 FH teams
	The SMS has a professional coordinator of the BH/FH,	32	64
	responsible for the area of OH
	Municipal health management and/or the coordinating body	17	34
	establish or use mechanisms for the monitoring of the degree
	of satisfaction of the users of the FH
	Technical areas work in an integrated manner with the	42	84
	coordination of the BH/FH
	The coordinating body of the BH/FH supports and promotes	19	38
	the training of Local Health Councils in the basic units
	Municipal health management develops a Humanization	32	64
	policy for the municipal network, in conjunction with the

• BH/FH coordinating body and other technical areas of the SMS, considering FH

In the Planning and Integration subdimension, from 27.1% to 89.6% of FHS coordinators replied in the affirmative to the standards. There was a lower percentage of affirmative answers to the following standards: "Municipal experiences with family health are presented at congresses and meetings in the area" (27.1%) and "The coordination of the BHC/FH is developing integration and partnership initiatives with academic institutions, permitting scientific output in the field of the BHC" (27.1%). The majority of the municipalities answered in the affirmative to the standards of the subdimension "Support for Teams" (68.8% to 91.7%). For the "Permanent Education Management" subdimension, the percentages of affirmative answers varied from39.6% to 75%. Two standards showed non-compliance for a higher percentage of coordinators: "Theoretical and practical training is offered in the basic areas for those higher-level FH professionals who require it" (39.6%) and "The coordination of the BH/FH permits specializationin the area for FHS professionals" (39.6%). For the subdimension "Management of Assessment" (41.7% to 91.7%), only two standards received affirmative answers from less than 50% of the coordinators: "Are epidemiological surveys of Oral Healthcarried out in the municipality" (41.7%) and "The coordination of the BH/FH selects criteria and indicators for assessing with the teams the impact on the health conditions of the population" (45.8%). In the "Standardization" subdimension, the percentages of coordinators with affirmative answers to the standardsvaried from 27.1% to 91.7%, with the lowest value attributed to the standard "The coordination of the BH/FH makes available protocols and technical information to the FHS/SB on the approach to urgent situations in Mental Health" (Table 4).

Table 4.
Frequency of municipalities with positive replies to the standards of the AMQ for the dimension Technical Coordination of Teams (n = 48).

Subdimension	Standard	n	%
			municípios
Planning and	The coordinating body of the BH/FH has a timetable of visits to the UFH and	43	89.6
Integration	meetings with the FHS
	The coordinating body of the BH/FH has a work plan which guides the	30	62.5
	activities to be developed
	The coordinating body of the BH/FH registers the monitoring of the	46	95.8
	situation of FH in the municipality, the number of teams, coverage,
	professionals and results
	The coordinating body of the BH/FH takes part regularly in the meetings of	39	81.3
	the Municipal Health Council
	The coordinating body of the BH/FH meets with the public and social sectors	35	72.9
	of the municipality
	The coordinating body of the BH/FH possesses and makes available to the	21	43.8
	FHS an updated register of the social resources of the municipality
	The municipal experiences with FH are presented at congresses and meetings	13	27.1
	in the area
	The coordinating body of the BH/FH develops initiatives for integration and	13	27.1
	partnership with academic institutions, making possible the realization of
	scientific production in the field of Basic Health Care
Monitoring of	The coordinating body of the BH/FH meets on a monthly basis with the FHS	44	91.7
the Teams	The coordinating body of the BH/FH guarantees a weekly shift to the FHS	34	70.8
	intended for a team meeting
	The coordinating body of the BH/FH uses instruments to monitor the	33	68.8
	actions and practices of the FH
	The coordinating body of the BH/FH develops strategies for administering	40	83.3
	conflicts between FH professionals
	The coordinating body of the BH/FH assesses the level of satisfaction of	33	68.8
	professionals with their work, taking into consideration criticisms and
	suggestions for planning actions
	The coordinating body of the BH/FH develops strategies with the teams for	43	89.6
	confronting problems encountered while providing care to the population
	The coordinating body of the BH/FH develops instruments for the	37	77.1
	organization and monitoring of FHS actions and practices in conjunction
	with the teams
Management	The coordinating body of the BH/FH ensures preparatory courses for FH	34	70.8
of Permanent	workers
Education	The coordinating body of the BH/FH takes part regularly and forums or	36	75.0
	meetings for the Development of the Permanent Education
	The coordinating body of the BH/FH decides, together with the FHS on the	34	70.8
	themes and activities to be developed in Permanent Education
	Theoretical and practical training is offered in basic areas for those	19	39.6
	higher-level FH professionals who require it
	Technical areas and FH develop Permanent Education activities in integrated	28	58.3
	fashion
	The coordinating body of the BH/FH ensures the execution of specializations	19	39.6
	in the area for FHS professionals
Subdimension	Standard	n	%
			municipalities
Management of	The coordination evaluates the output of FHS on a monthly basis	42	87.5
Assessment	The coordinating body of the BH/FH uses the information of	43	89.6
	the SIAB as a management instrument: assessment, planning and
	monitoring
	The coordinating body of the BH/FH analyses the reports of the SIAB	28	58.3
	on a monthly basis, in conjunction with the FHS
	The coordinating body of the BH/FH analyses data and reports of the	35	72.9
	SUS or health information system
	The coordinating body of the BH/FH chooses criteria and indicators	22	45.8
	for evaluating with the teams the impact on the health conditions of
	the population
	The coordinating body analyses the demand for FH tests and referrals,	27	56.3
	observing whether there is a match with the estimated requirement
	The coordinating body of the BH/FH debates the results and plans the	38	79.2
	objectives of FH with the teams
	The coordinating body of the BH/FH meets with the other areas of	26	54.2
	the SMS to discuss the results achieved in BH.
	The coordinating body of the BH/FH evaluates the established goals	44	91.7
	for the Basic Healthcare indicators of the Health Pact with the FHS
	Epidemiological surveys of Oral Health are carried out within the	20	41.7
	municipality
Standardization	The coordinating body of the BH/FH makes documents available to	32	66.7
	all of the FHS with the principles and guidelines of the FH strategy
	The coordinating body of the BH/FH uses a written standard with	28	58.3
	regard to the physical installation and equipment
	The BH/FH coordinating body makes updated information from the	32	66.7
	municipal reference and counter-reference system available to all of
	FHS units
	The coordinating body of the BH/FH provides a manual of basic	35	72.9
	pharmacy medicines
	The coordinating body of the BH/FH makes supporting technical-	37	77.1
	scientific material available to the teams on frequent situations in
	Basic Health Care
	The coordinating body of the BH/FH makes supporting technical-	44	91.7
	scientific material available to the teams on the most prevalent
	infectious and parasitic diseases in the country.
	The coordinating body of the BH/FH has documentation establishing	31	64.6
	the action of each FH professional
	The coordinating body of the BH/FH provides protocols and technical	21	43.8
	information to the FHS/OH on dealing with urgent situations
	The coordinating body of the BH/FH provides protocols and technical	13	27.1
	information to the FHS/OH on dealing with urgent situations in
	Mental Health

The percentage of the managers of the FHU who replied in the affirmative to the standards of the subdimension Infrastructure and Equipment of the FHU varied from 15.2% to 86.2%. The standards with the lowest percentage of compliant replies were: "The FHU has equipment available indicated for first aid in urgent cases and emergencies" (15.2%) and "The FHU has other equipment available for health care by the teams" (17,6%). In the "Inputs, Immunobiologicals and Medicines" subdimension, the percentages of municipalities compliant with the standards varied from 48.1% to 92.4%. The standard with the lowest compliance was: "The FHU has basic medicines available indicated for first aid for cases of grand mal epilepsy crises, in accordance with local protocols, which are stored in a suitable location" (48.1%) (Table 5).

Table 5.
Frequency of teams with positive replies to the AMQ standard for the Family Health Unit dimension (n = 210).

Subdimension	Standard	n	%
			Teams
FHU	Each FHS has a clinic with basic equipment for attending its population	174	82.9
Infrastructure	The UFH clinics permit the visual and auditory privacy of health care	181	86.2
and Equipment	Clinics where gynecological examinations are carried out have, as a	179	85.2
	minimum, screens for dressing and undressing
	The ACS have basic equipment for external work	113	53.8
	The FHS have complete equipment and orthodontic equipment for the	146	69.5
	regular performance of its activities
	Considering the physical installation, all areas of the UFH have adequate	118	56.2
	conditions for carrying out basic health actions
	The UFH has a covered space, exclusively for reception and waiting, with	164	78.1
	a number of seats compatible with the expected demand
	The UFH has an exclusive refrigerator for vaccines with temperature	118	56.2
	control for the preservation of immunobiologicals
	The UFH plans the use and adaptation of environments for applying	146	69.5
	bandages, inhalation, sutures and the observation of patients
	There are sufficient quantities of gynecological-obstetric equipment for	169	80.5
	the work of the FHS
	The number of clinics of the UFH allows doctors and nurses to provide	172	81.9
	outpatient FH treatment at the same time
	The tensiometers and scales of the UFH are measured in accordance	81	38.6
	with technical parameters
	The ACS have other items of equipment for external work	56	26.7
	The UFH has a telephone line	65	31.0
	The UFH has computer equipment	97	46.2
	The UFH has a room for holding team meetings, internal activities of	110	52.4
	the ACS and Permanent Education activities
	The UFH has other items of equipment for treatment by the teams	37	17.6
	The UFH has equipment recommended for first aid in urgent and	32	15.2
	emergency cases
	Travel by the FH professionals to carry out planned external activities is	162	77.1
	carried out in a SMS vehicle
	The UFH has electronic equipment for educational activities	105	50.0
	The dentistry clinics allow the provision of DHT treatment and dental	93	44.3
	surgery in an integrated manner
	The UFH is equipped to treat individuals with special needs: ramps,	76	36.2
	banisters, width of the doors, restrooms and wheelchairs
	The UFH has access to the Internet and makes it available to FH workers	53	25.2
	on the basis of defined criteria
	Clinics where gynecological examinations are carried out have their own	148	70.5
Subdimension	Standard	n	%
			Teams
Inputs,	The UFH provides all of the vaccines for the basic calendar of the	162	77.1
Imunobiologicals	National and State Immunization Programs on a routine basis
and Medicines	The UFH provides on a regular basis and in sufficient quantities the	174	82.9
	basic medicines prescribed for the treatment of the most frequent
	parasitic infections
	The FHS/OH have materials and inputs for carrying out educational	160	76.2
	activities with the population
	The UFH regularly dispenses medicines indicated for the prevention	179	85.2
	and treatment of deficiency anemias and hipovitaminoses in
	sufficient quantities
	The UFH has basic inputs in sufficient quantities for the regular	194	92.4
	performance of health actions
	The UFH has OH inputs in sufficient quantities for the regular	157	74.8
	performance of health actions
	The UFH has printed material in sufficient quantities for the regular	194	92.4
	performance of health actions
	The UFH has glucometers and supplies tapes in sufficient quantities	159	75.7
	The UFH regularly dispenses basic antibiotics indicated for the
	treatment of the most prevalent infectious diseases in sufficient	165	78.6
	quantities, with these appearing in the standardized list of antibiotics
	of the SMS
	The UFH regularly dispenses sufficient quantities of the basic	176	83.8
	medicines indicated for the treatment of Systemic Arterial
	Hypertension
	The UFH regularly dispenses regularly dispenses sufficient quantities	178	84.8
	of the basic oral medicines indicated for the treatment of Diabetes
	Mellitus
	The UFH regularly dispenses NPH insulin indicated for the	157	74.8
	treatment of diabetes mellitus in sufficient quantities, deriving from
	adequate storage in a refrigerator
	The UFH has basic medicines indicated for first aid for cases of	152	72.4
	hypertensive crisis, in accordance with local protocols, with these
	stored under adequate conditions
	The UFH has inhalatory medicines for asthma attacks, stored in an	151	71.9
	adequate location
	The UFH has medicines for the treatment of diseases of the	139	66.2
	gastrointestinal tract
	The UFH has basic medicines indicated for first aid for cases of	101	48.1
	grand mal epilepsy crises, in accordance with local protocols, with
	these stored under adequate conditions

Discussion

In general, the managers, municipal coordinators of the FHS and FHU managers of the municipalities of the Northeast region of Minas Gerais assessed the quality of the FHS positively, as witnessed by the high average values of the compliance scores and of the percentages of affirmative answers to the standards. No studies were identified which had used the instruments directed towards management in other Brazilian regions, solely for FHS teams. For example, Montes Claros (Minas Gerais), the Team component of the AIQ was assessed by FHS professionals, with compliance scores exceeding 50% in each of the subdimensions, except for three of them: Community Participation, Social Control and Adolescent Health⁷.

The limitations of the AIQ have been previously highlighted^{6 , 8 , 15 , 16}. In the deployment of the AIQ, in the city of Registro (São Paulo), it was observed that its feasibility depended on the efforts of the managers and that healthcare professionals encountered difficulties in completing the questionnaires⁸. The difficulties of analyzing the data generated by the tools was also highlighted, given that the methodology of the AIQ does not define it¹⁵. Nor can it be stated that the replies obtained comply with the reality of practice, since direct observation techniques were not used^{16 , 17}. The possibility of overestimation of the scores obtained by the AIQ is still subject to debate, since the reply standards are dichotomous and a perception of inefficiency on the part of the team may be generated by a high number of negative replies¹⁶.

In this study, we chose to obtain the sum of the compliance scores for each assessed dimension/subdimension, without considering the quality stages of the standards, with a methodology similar to that previously realised^{7 , 8 , 17 , 18}. This choice was made and the study then identified the non-linearity of the relationship between the quality stages of the AIQ and the complexity of deployment of the work processes recommended by the quality standards⁶. One of the difficulties encountered in this study was the return of completed questionnaires, which did not reach 100% of replies for any of the three tools. The lowest rate of response (76.2%) was among the FHS coordinators, which may be explained by the absence of a specific function in municipalities with up to three FHS. For the tool targeted at the managers of the FHU, there was a loss of 100% in eight municipalities under the jurisdiction of the GRS of Pedra Azul. This loss may be due to the difficulties faced by the managers in distributing and requesting the participation of the FHU managers and the poor efforts made by them in replying to the question and delivered by the manager. The loss of these data did not compromise the results of the survey, since the reality of health management in the municipalities which did not take part in the study is identified with the others with the same level of population.

The results revealed that the FHS were favorably assessed by the managers regarding the dimension Development of the FHS, in particular for the subdimension Deployment/Implementation, which characterizes the political and institutional definition of the FHS as a model of care dispensed to the population. At the same time, the study showed that many of the municipalities still needed to establish formal partnerships/agreements with the organizations of civil society and/or social movements. This need was also highlighted by Sarti et al.¹⁷, when only 8.5% of the FHS in their sample included representatives of social movements in their planning of actions. These partnerships will be able to establish articulated actions between the municipal health management and the works already developed by entities of civil society, in such a way as to favor an improvement in the quality of life of municipal residents¹⁹.

The worst result obtained in the Development of the FHS dimension was attributed to the Work Management subdimension. The need was detected to develop FHS professionals, since more than 70% of the municipalities were not compliantwith standards which they confirmed regarding Plans for Positions, Careers and Salaries (PCCS) and worker incentive programs. This question has already been discussed, with public policies elaborated, such as the proposal of PCCS approved at the 14^th National Health Conference²⁰. Such policies are important as sets of incentives and strategies for the gradual incorporation of management functions by federated entities²¹. At the same time, in the Northeast macroregion, the elaboration of local work management policies has received little discussion at the meetings of the microregional CIBs. Analyzing the consolidation agreements realized by the CIB-SUS/MG, we may observe the discussion on great demand for the accreditation of newteams, the shutting down of units, the qualification for the provision of certain clinical services, the approval of documents; with questions relating to human resources little discussed at these meetings²². This demand must be encouraged, for the construction of joint solutions and new proposals regarding work management, not only in the Northeast region, but in the whole of the state of Minas Gerais.

Problems in the area of Work Management within the SUS were listed in the study by the Institute of Social Medicine of the UERJ²³. Regarding management strictly speaking, state managers highlighted the inadequate remuneration ofworkers, increasing work and security, the limits of the Law of Fiscal Responsibility, government insensitivity to the sector, the absence of the PCCS, the absence of planning and the absence of competitions as the principal challenges relating to the execution of a satisfactory policy in the field of work management within the SUS²³. These results are similar to those encountered in this survey, which highlight that precarious labor rights, the depreciation of the qualifications of professionals, the absence of public competitions for entry into the health services, the abstaining of the municipality from incentivizing teams which meet established targets and the absence of the PCCS are the major problems in the Work Management subdimension assessed by the AIQ.

Strengthening of Coordination obtained the second lowest assessment within the Development of the FHS dimension, demonstrating the absence of monitoring of satisfaction of the user of the FHS in many municipalities. Verifying the opinion of users of the work developed by the FHS is an important form of assessment for prioritizing management actions with the focus on improving care, as well as in promoting popular participation and social control. Assessing the perception of the user with regard to the degree of satisfaction with the care provided by the FHS may contribute to "[...] guaranteeing that the improvements in the services are concentrated on what users want, in opposition to what decision-makers think that they want"²⁴.

Another critical point of the Strengthening of Coordination subdimension was the absence of support for the training local health councils in the UBS. The FHS has in its work methodology the incentivizing of social participation, aiming to contribute to the reorganization of work practices on the basis of the PHC²⁵. Local health councils are privileged tools for enforcing civic rights²⁶, as spaces which promote the creativity of users in proposing and collaborating local health policy. Incentivizing social participation, supporting and guaranteeing the training of the local health councils is the role of the manager. Such councils may extend community participation in inspection, proposal, execution, monitoring and support²⁷ for public health policies¹, facilitating the integration of ideas which reconcile the interests of service providers, workers and healthcare professionals, public managers and representatives of popular and union movements²⁸.

There was less compliance with the standards of the "Strengthening of Coordination" subdimension and specifically with the standard relating to the existence of decentralized coordination, responsible for support of at most eight FHS teams. In municipalities with a lower population, this is attributed to the fact that some municipalities of the Northeast macroregion of Minas Gerais do not possess a FHS coordinator, with this function assumed by themanagers themselves or by a professional who carries out works relating to the local administration of health or by a FHS professional, generally the nurse. This fact generates an overload of work, diversion of functions and the failure to execute or partial execution of the attributes relating to the municipal coordinator of the FHS. The correlation encountered is nevertheless in accordance with decision 340/2007 of the CIB-MG, which determines that municipalities with three or more deployed teams must have a municipal coordinating body responsible for FHS²⁹ and in many municipalities, three or fewer FHS were observed. It is also possible to highlight that in the municipalities where there is involvement and articulation of advisers, supervisors, coordinators and the health secretary in management, there is a change of conduct in the management work with the purpose of organizing and qualifying FH³⁰.

The assessment of the Technical Coordination dimension of the FHS highlighted in two subdimensions the unequal access to educational processes among the municipalities, with a high percentage of the coordinators replying negatively to questions on the feasibility of theoretical and practical training and of specialization for FHS workers. One of the foundations of the PHC is the development of healthcare professionals, through encouragement and constant monitoring of their training and capacity building³¹. On the other hand, we highlight educational actions, such as capacity building on specific issues, directed towards healthcare professionals, which take place in accordance with the need/interest identified by the manager, as well as planned actions introduced by the MoH. Figueiredo et al. observed that permanent education actions relating to health management itself are not carried out, with such actions not even cited in municipalities with less than 10,000 inhabitants³⁰. The functions and actions relating to planning and health management are basic premises of the FHS and the poor performance of these functions observed in the set of municipalities, both in this study and in others^{17 , 30}, indicates the need to assess the process of permanent education of the teams and the priority attributed to it by the managers¹⁷.

Another item with a negative assessment by the majority of the municipalities showed that joint activities with academic institutions are still in the very early stages. Larger municipalities have a growing interaction with training centers, whether university or not, explaining the correlation observed between the compliance scores of the "Permanent Education Management" subdimension and the municipal population. The integration between teaching and service is the work of students and lecturers of the courses in the area of health with health team workers, including managers, aiming at the quality of individual and collective health care, the quality of professional training and to the development/satisfaction of workers of the services³². Teaching-service co-operation relations tend to be concentrated only in those established between large municipalities and the training centers located within them. According to the Nacional Council of Health Secretaries, the state manager is responsible for permitting and mediating this access for smaller municipalities without training institutions within their territory³³. The MoH has two initiatives which permit teaching-service integration, the Pró-saúde and the Telessaúde Brasil program, which provide opportunities for learning and assist with improving the development of practices in the area of health^{34 , 35}.

The compliance scores were higher in municipalities with higher population for the subdimensions "Support for Teams", "Permanent Education Management" and "Standardization of the Technical Coordination of Teams Dimension". This correlation may be attributed to the presence of the coordinator in municipalities with a higher number of FHS. In Silva's view, "[...] the coordinators develop relevant management functions in a municipal context, both for the teams, and for the management [...]"³⁶. A previous study demonstrated that higher population coverage and longer deployment times did not necessarily indicate greater maturity in terms of organization of health services, but a higher probability of adjustment of the FHS to the quality standards of the AIQ¹⁷.

The study highlighted deficiencies in the Infrastructure and Equipment of the FHS of the Northeast region of Minas Gerais, with the compliance scores for this subdimension being lower than that of Inputs, Immunobiologicals and Medicines. On analyzing the replies to the standards, deficiencies were perceived with regard to the existence of equipment indicated for first aid in urgent and emergency cases and other items, which permitted care by the teams and consequently an increase in the resolvability of the PHC. This finding may be explained by the few investments allocated to the acquisition of equipment for the PHC, as well as by the historic character of the urgent and emergency care being provided exclusively in hospitals and specialized clinics. According to the CONASEMS, the BHUs which develop PHC actions require adequate physical installations, with the equipment and inputs necessary for the quality of the services provided³¹. In this way, adequate and organized infrastructure and available and functioning equipment are fundamental for receiving users in a dignified and respectful manner, under salubrious and biologically safe conditions for health workers.

The smaller municipalities presented higher compliance for the standards of the subdimensions Infrastructure and Equipment of the FHU. This correlation may be attributed to two factors: a) standardization of the minimum criteria for physical structure and equipment of the BHUs, within the context of the state of Minas Gerais (SES Resolution No. 604/2004)³⁷; b) transfer of financial resources by the state to the municipalities for investment in improving the infrastructure and quality of the PHC, with the smaller municipalities being the first to be considered with state resources for the construction and reform or expansion of BHUs (SES Resolution No. 760/2005)³⁸.

The subdimension "Inputs, Immunobiologicals and Medicines" received a better assessment by the FHU managers in the municipalities with a lower HDI. This relationship may be explained by the financial incentives granted to small-scale municipalities; by the high rate of coverage of the FHS for free dispensing of medicines for PHC¹⁷ - Programa Farmácia de Minas [Minas Pharmacy Program]; as well as by the higher vaccination coverage in populations with higher FHS coverage, notably municipalities with a lower HDI³⁹.

The use of the AIQ tools permitted the identification of the subdimensions requiring greater attention and more intervention by the municipal management. In addition to the descriptive analysis of the average scores of features compliant with the quality standards of the AIQ, the correlation with the population and with the municipal HDI permitted the identification of inequalities in the assessment pursuant to these indicators, allowing the establishment of priorities in the planning of actions. The percentage coverage of the population and the deployment time for the FHS were not significantly correlated with any dimension. This may have occurred as a function of the homogeneity among groups regarding these two variables, since in the majority of the municipalities,100% coverage and more than 10 years of deployment of the FHS were observed. In order for the population of the Northeast of Minas to obtain benefits with the better performance of the FHS, management, political and financial encouragement for its PHC network is fundamental, with assessment a fundamental process for promoting this growth.

It may be concluded that self-assessmentof the quality of the FHS in the Northeast macroregion of Minas Gerais, within the context of the management, was generally positive. The worst assessment was observed in the subdimensions of "Work Management", "Permanent Education" and "Inputs, Immunobiologicals and Medicines". The larger the municipal population, the better the assessment by the managers in with regard to the "Strengthening of Coordination", "Support for Teams", "Permanent Education Management and Standardization" and the worse the assessment of "Infrastructure and Equipment".

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Publication Dates

• Publication in this collection
  Apr 2015

History

• Received
  10 July 2014
• Accepted
  02 Sept 2014