Structural aspects for Diabetes Mellitus in Basic Health Units in Brazilian capitals

The objective of this article is to analyze the structural conditions of health units and the guidelines, objectives/goals of municipal management related to the quality of those services in the capitals according to Brazilian regions, aimed at caring for persons suffering from Diabetes Mellitus. For that, a logical model and sub-dimensions/variables were developed to direct the search for data in the 3rd cycle of the Program for Improving Access and Quality of Primary Health Care. Descriptive analyzes of the capitals were performed by region of Brazil. For document analysis, we used the Health Plans of municipalities that presented a percentage of inadequacy greater than 50% for at least four dimensions among the seven analyzed in this study. The study revealed the need to adapt the structural conditions of Basic Health Units for most Brazilian capitals in some of the aspects analyzed, with worse results for physical structure and equipment. Based on the analysis of municipal health plans, particularities, strengths, and weaknesses were evidenced that deserve to be considered for defining the agenda and directing actions by health management. The identified conditions of inadequacy can have a negative impact on the quality of care for persons suffering from diabetes in Primary Health Care.


Introduction
Diabetes Mellitus (DM), as a public health problem, has an estimated prevalence of 9.2% on the Brazilian adult population 1 .It is considered a multifactorial chronic disease and is largely responsible for hospitalizations due to cardiovascular, cerebrovascular and renal complications 2 .The complications increase the health system expenses, as well as exert an impact on the years of life lost owing to disability and mortality.The management and prevention of diabetes and its complications, in Brazil, are mainly the responsibility of Primary Health Care (APS), which proposes to provide comprehensive, resolutive and high-quality care that impacts the population health 2, 3 .
APS, understood as a set of individual and collective actions and services aiming at the promotion, protection, recovery and rehabilitation of health, is characterized by the monitoring of different health-diseasecare conditions, and should be the main integrating and communicating center in the Health Care Network (RAS) 4 .In this sense, diabetes, as a chronic disease, should find at its level of care the ideal scenario for longitudinal care 5 .
In 2011, with the purpose of evaluating APS quality, the National Program for the Improvement of Access and Quality of Primary Care (PMAQ-AB) 6 was created, carrying in its proposal the adoption of evaluation as part of the action planning as to improve the quality of APS services 7 .So to know the scientific production on the rendering of health services in APS, a survey of studies was carried out in indexed databases, from which 17 articles were selected.Of these, ten contained a national approach 8-17 , with emphasis to the Brazilian regional division, one brought a municipal focus 18 and six considered the state realities for analysis [19][20][21][22][23][24] .It is noteworthy that such productions were concentrated in the years 2018 and 2017.Most of the selected studies used data extracted from the PMAQ-AB 1st cycle, only one study compared two cycles 14 , and the remaining applied data retrieved only from the 2nd cycle.
Regarding tracer conditions, only one study involved the diabetes 14 , although it is one of the main dependable conditions to primary care.The authors addressed service condition regarding structure as aspects that may reflect on the quality of care for persons suffering from diabetes 14 .However, the analysis of access, supply and use of health services needs to be added to evaluations on the quality of care offered.
Concerning the evaluation of health services, the structure is one of the components needed for the analysis of their performance, seeing that adequate structures favor the provision of timely and quality services 14 .In this sense, logical models, for being a visual scheme that shows how a program should be implemented and what results are expected, make up the first stage of planning an evaluation 25 .
The results of the evaluations can (and should) be useful to guide actions to improve the quality of services and, therefore, need to be part of the agenda of management commitments.Thus, health plan is composed of the management set of guidelines, objectives and goals addressed to the development of the actions throughout the study period, making part of the grounds of activities and programming of each SUS level of management 26 .Political commitment is understood as the responsibility of municipal public management for the development of strategies that operationalize policies and programs considered priorities for the municipality 27 .In order to comply with SUS principles and guidelines, the administrative and organizational structures of the Municipal Health Secretariats (SMS) must be understood as a primary and non-transferable responsibility of municipal managers and be consistent with the Municipal Health Plan and the Annual Health Program 28 .
In view of the problem referring the use of health services in APS and its relation with the quality of health care, this study aims to analyze the structural conditions of health units and the guidelines, objectives and goals of municipal management as to the quality of these services in the capitals of the states as per Brazilian regions, following the attention to persons suffering from DM.

Material and methods
This is a descriptive study 29 of normative assessment for data analysis on the structural conditions of health units in Brazilian capitals as to the quality of care for persons suffering from DM, based on 2017 PMAQ-AB data.
The first stage consisted of the search and revision of norms and references published in the period 2001 to 2019 with the aim to construct the logical care model for persons suffering from DM. Donabedian's reference 30,31 supported the structure attributes.We grounded on the models proposed by Borges, Lacerda 27 and Santos 32 ; the DM care components; the guidelines contained in the 'Caderno de Atenção Básica # 36 -Strategies for the care of persons suffering from chronic disease: diabetes mellitus' 2 -; and the 'Manual of physical structure for basic health units: health and family' 33 , detailing the variables of the structural dimension.
The second stage consisted of the definition of a matrix containing seven analytical dimensions that corresponded to the aspects to be analyzed, such as: 1) human resources; 2) accessibility, external signaling; 3) coordination and information on the provision of actions and services; 4) physical structure; 5) ambience; 6) equipment, material resources and supplies; and 7) medicines.For each dimension, variables and sources of verification were identified following to the PMAQ-AB 34 instrument.The definition of the standards and of the meaning of each dimension and/or variable was carried out by means of the search for the documents and/or theoretical framework so to explain and define the qualification/adequacy for each reality analyzed by the previous construction of the logical model.
So to characterize the structure dimensions of the Basic Health Units (UBS) of the Brazilian capitals, data on the structural conditions of health units were obtained from database retrieved from the external evaluation of PMAQ-AB 3 rd cycle, made available for public access by the Ministry of Health 35 .Each selected dimension corresponded to variables retrieved from PMAQ-AB database.
For this study, a database was built containing the results and the respective variables related to the structure of health units of the Brazilian capitals for the care of persons suffering from DM.They originated in the 'Module I of the external evaluation instrument -Observation on the Basic Health Unit', in which the UBS infrastructure conditions, materials, supplies and medicines were assessed.The third stage revealed municipalities showing a percentage of inadequacy greater than 50% as for at least four dimensions among the seven analyzed in this study.Then, a documental analysis was carried out for these municipalities by means of the Municipal Health Plans (PMS) throughout the period 2018-2021.Seven capitals met this criterion.Among the selected municipalities, three plans were not found by the searches in the open access electronic sites of each municipality/capital. Thus, the municipalities that provided free access to the respective PMS on their institutional sites were included.Therefore, those whose plans could not be identified by the search were excluded.
Thus, four PMS from three Brazilian regions were analyzed as follows: North capitals (N1, N2); Northeast capital (NE1); and Midwest capital (CO1).In order to consider, for documental analysis, at least one capital per region, a capital from the Southeast region and another from the South region were selected, which met the following criteria: at least three dimensions with inadequacy above 50%; and the highest percentage obtained from the mean of the sum of the values of these three dimensions.Finally, the municipalities coded as SE1 and S1 were selected for the Southeast and South regions, respectively.
The findings as of the six PMS (PMS1... PMS6) were systematized in a matrix that explains which plans referred to the PMAQ-AB, the aspects of APS situational analysis, particularly on health units, and the guidelines, objectives and goals for each municipality during the 2018-2021 period.
Because it is a research based on secondary data retrieved from the database/PMAQ, of public and free access, available on the Ministry of Health platform, it was not necessary to submit the research project to the Research Ethics Committee.

Logical model
The logical model considered the dimensions of management and care, their respective objectives, actions and activities whose final result/effect are: ensure access and quality of APS health care to persons suffering from DM so to provide reduction of morbidity and mortality and improve quality of life.As structure subdimensions, the following was defined: physical area and arrangement of the physical structure; ambience and accessibility; coordination an d information on the provision of actions and services; human resources; equipment, materials and supplies; and medicines.

Characterization of the structure dimensions of Basic Health Units in Brazilian capitals
The results are expressed by structure dimensions concerning the 2,176 UBS among the capitals evaluated, following data retrieved from the 2017 PMAQ-AB 3rd cycle.
Regarding the 'human resources' dimension, most of the capitals appoints a person to be responsible for their UBS management.However, it is noteworthy that Porto Alegre, Cuiabá and Belém show a small percentagerespectively 3.82%, 3.92% and 8.06% -of the evaluated unities carrying out a management service that entitles a person exclusively for the function.Also, few are the capitals in which the professional is not responsible for both the UBS management and the user care.The reality can be mainly stressed for the capitals of the Southeast region.Evidence is seen in Porto Alegre, in which approximately 91% of its units the professional who provides care is also responsible for the management of the unit.
As for 'accessibility', most units among capitals carry an adequate plate on the façade specifying the Signaling Guide, but not an external totem, neither a strip on the entrance wall nor an identifying painting on the UBS entrance wall.The capital Goiânia stands out for the highest percentages of these three items, respectively as 88.89%, 50.79% and 76.19%.The external signage, in which the variables are complemental to the dimension of accessibility, handrails in non-level places were mostly absent.The greatest variation was observed between Porto Velho (0%) and Florianópolis (85.71%).For most units among capitals, tactile floor and internal doors adapted for wheelchairs were also absent, a lack that achieved a rate of 80.20% in the city of Rio de Janeiro.
Concerning the dimension 'coordination and information on the provision of actions and services', the worst percentages concerned the health unit opening hours with regard to the provision of activities during the lunch break, exception to most units among Southeast and South capitals.In this aspect, the capital Florianópolis stands out, where only 10% of its units accounted positively for this variable.The 'physical structure' dimension detected the absence of many areas in most units, such as a parceling area in the pharmacy; dressing room; inhalation/nebulization; administration; and exclusive place for external shelter of solid waste.As for the bathrooms, a high number of units containing toilets was noted, especially for Palmas, Aracaju, Natal and Campo Grande, whose rate achieved 100%.However, a sharp decrease occurs when bathroom for disables is concern, Recife showing the lowest rate of 17.46%.As to the 'ambience', the aspects of washable floors and walls and privacy to users in the consultation offices represented the lowest percentages, mainly for the capitals Rio Branco (24.14%) and Recife (25.40%).
Regarding 'equipment, materials and supplies', most capitals inform the absence of the various items partially assessed within health units, e.g., adult stethoscopes, anthropometric scales, anthropometric rulers, glucometers, monofilament kits for sensitivity testing (aesthesiometer), reagent strips for glycemia measurement.The non-existence of refrigerators exclusive to medicines in the pharmacy responded for the higher rates, varying from 9.68% in Belém to 100% in Teresina.As to 'medicines', most capitals showed high frequency for glibenclamide and metformin, and low frequency for 50% glucose ampoules, drugs for clinical urgency, NPH insulin and regular insulin.The latter variables are mainly present among the capitals of the Southeast and South regions, achieving a frequency above 90% for most of them.
In summary, considering all the Brazilian capitals as a whole, and the percentage of adequacy, intermediate and inadequacy of UBS structure, all the cities assessed showed a percentage inferior to 25% among health units considered adequate, which provided all the items to fulfill the dimension 'physical structure'.This dimension revealed the highest inadequacy rate among the dimensions analyzed.Then, the 'availability of equipment, materials and provisions' was inferior to 25% in 22 capitals -Boa Vista, Macapá, Manaus, Palmas, Porto Velho, Aracaju, Fortaleza, João Pessoa, Maceió, Natal, Recife, Salvador, São Luís, Teresina, Brasília, Cuiabá, Goiânia, Belo Horizonte, São Paulo, Vitória, Florianópolis and Porto Alegre.The dimension placed as the second most inadequate, together with the dimension 'coordination and information made available to users'.

Guidelines, objectives and goals of municipal management related to the structural aspects of health units
From the analysis of the six PMS during the 2018-2021 period, PMAQ reference was introduced as were the contents that refer to guidelines, objectives, actions, goals and programming related to the structural elements of APS health units.The reference on PMAQ-AB was identified in the plans PMS2, PMS3 and PMS6.Regarding the APS situational analysis, the coverage was 47.36% in PMS1, 43.95% in PMS2, 45.21% in PMS3, 62.6% in PMS5 and 62.5% in PMS6.As to the structural conditions of the units, the PMS2 health units are classified as inadequate infrastructure, while PMS3 reveals lack of supplies, equipment and medicines.
As for the objectives and goals acknowledged in the assessed health plans, we stress the broadening and reform of the units (PMS1, PMS2); the network broadening through the construction, expansion, reform and equipping of the units (PMS3, PMS5).PMS6, on the other hand, has as goal to qualify the structure of APS units and to implement extended opening hours.In addition, PMS2, PMS3, PMS4 and PMS5 carry issues concerning pharmaceutical services and goals related to the supply and access to medicines.

Discussion
The evidence collated between the logical model and the database organized from the PMAQ-AB emphasized that the adequacy of the UBSs structural conditions among the Brazilian capitals remains mostly below 50% for all dimensions of analysis, except for accessibility, being the dimensions of physical structure and equipment those accounting for the lowest percentages.
Differences were observed in the structural conditions of the units as per each region, the worse results being revealed for ambience and medicines in capitals of the North and Northeast regions.This result adds to the findings in the literature on the evaluation of health services according to each region.Studies have confirmed regional inequalities in relation to UBSs structures, by means of which the North and Northeast regions exhibited the highest precariousness in services when compared to physical structure, materials and supplies 9,14,36,37 .Taking the regions into account, significant differences were observed between the capitals in most dimensions, except for physical structure, in which all showed low adequacy.They all showed high adequacy for accessibility.
Regarding the dimension of human resources, the lack of a professional in charge of exclusively the management implies the multiplicity of tasks took on by that person and, consequently, the low effectiveness of his/ her work.This finding reveals that the worker, in addition to dedicating time to articulate resources and needs of the service and to coordinate the work team process as to APS objectives and purposes, needs to develop care actions.In this context, organizing the time between caring and managing makes work dynamics complex due to the fact that the activities to be developed, in most cases, are not intercessory and inter complementary actions 38 .
As to accessibility, the absence of external totem and handrail was a concern found in health units also in this as in other researches' results 39 .As for other aspects of accessibility analyzed in this study, such as tactile floor and wheelchair adaptations, they are provided for as fundamental rights of access to health services ensured by the Federal Constitution, besides enabling adequate care for persons suffering from DM, as they carry sequelae and restricted mobility 40 .
Structural dimensions are pivotal to ensure user accessibility 41, 42 .In addition to the attention to persons suffering from disabilities and reduced mobility, also provided for under the National Health Policy for Persons with Disabilities, these dimensions are central to ensure access for individuals with disabilities resulting from DM 33, 43 .
The results concerning coordination and information on the provision of actions and services show weaknesses due to the nonoperation of the unit during lunch time and to non-flexible hours, confirmed in other studies 15,19 .The unit opening at alternative hours may expand access to users who are prevented from attending the service during business hours and that could benefit from a service in flexible hours, especially the male population.
According to data retrieved from the Surveillance of Chronic Diseases by Telephone Inquiry 44 , women still represent the highest percentage of persons suffering from DM, although the increase in male prevalence be significant, which accounted for 54% between 2006 and 2018, while the women rate was 28%.These data call the attention to the coordination and availability of services, as well as to the awareness of the male population about the need for follow-up by health services.In respect to physical structure, results reveal that problems still persist in health units, such as lack of toilet for disabled persons, dispensing of medicines, and rooms for the pharmacy, offices, nebulization, collection, dressing, procedures and observation.A previous study on persons suffering from diabetes carried out in Cycles I and II of the PMAQ-AB revealed the low adequacy in this aspect as consequence of the assessed set of items, e.g., clinical office, pharmacy, reception, reception room and meeting 14 .
Despite positive results and resources invested in APS coming from the PMAQ-AB and from the Program for the Requalification of Basic Health Units (Requalifica UBS), inadequacy and insufficiency of UBS structure still persist, especially in the states of the North and Northeast regions, possibly related to low economic development and to the provision of services.In contrast, the South and Southeast regions, more developed and rendering a greater number of services, show more satisfactory results as to the infrastructure 45 .
So to the care of persons suffering from DM be adequately serviced, municipal health management must ensure that the UBS counts on adequate physical spaces that follows to the 'Manual of physical structure of basic health units: family health' 33 and to the elements contained in PMAQ-AB34 external evaluation instrument 34 .
In what the environment is concerned, this study evidenced the lack of acoustics in most health units as to avoid noise from the external and internal environments.The Ministry of Health adopts the broad concept of ambience, e.g., as a social, professional and interpersonal relation space that enables care in a resolutive, humane and welcoming way, in addition to a healthy environment for the work of health professionals 19, 46 .Another study concludes that the ambience is influenced by the structure and interaction among health professionals 47 .
As to the availability of equipment, materials and provisions, the findings reveal a low adequacy of health units in the assessed set of items.It was observed, for example, the absence of refrigerators exclusively for medicines in many units, confirming the results of another study 48 .Only health units provided with all the assessed equipment, materials and provisions can fully comply with the care of persons suffering from diabetes, since the availability of the set of listed items can be considered as an ideal situation to render health monitoring.Results reveal an important difference among capitals as for the availability of both reagent strips for capillary glycemia and adult blood pressure device.The 'Caderno de Atenção Básica # 36 -Strategies for the care of persons suffering from chronical disease: diabetes mellitus', states these elements as essential for the monitoring of glycemia and blood pressure with the aim to control and prevent complications 2 .
The results of this study as to the availability of medicines reveal an unfavorable situation concerning the 50% glucose ampoules, emergency medicines and insulins.The APS low availability of insulin for the care of persons suffering from diabetes may also be related to funding and absence of refrigerators for conservation 8, 48 .
Those medicines are essential for the care of persons suffering from diabetes and should always be available to the population.
Access to medicines and the guarantee of adequate drug treatment provide more DM effective control, enabling the reduction of morbidity and mortality and the improvement of health and life quality to the user.The drugs NPH human insulin and regular human insulin make up the Hypertension and Diabetes Drug Group.The Ministry of Health is responsible also for also the financing and acquisition as for its distribution to the warehouses and Pharmaceutical Supply Centers of the States and the Federal District.The State Health Secretariats are responsible for the distribution of human insulin and of regular human insulin to the municipalities 49 .
Although the structural characteristics of a health service alone cannot ensure the quality of care, it is possible to say that adequate structures ease a better health care.The relation between the structural and operational elements of health services is able to generate analyses not related to direct effects on the population health, but to the way of achieving the best health outcomes [50][51][52] .
Given the dimensions and the respective variables discussed here, the structural conditions of health units account for a problem related to the service and the health system, therefore requiring for initiatives and commitment from managers to improve the condition.In this sense, health plans should consider the situational analysis of people's health conditions, as well as health services, so to create the guidelines, objectives and goals to guide the management actions for the study period.
As for the set of six PMS analyzed, which included at least one capital per Brazilian region, it can be noted that half of them did not mention PMAQ-AB, a program that proposed to improve APS access and quality, given the criteria agreed with the municipalities for each evaluation cycle 35 .Therefore, the health situation evidenced by means of PMAQ-AB assessment should be mentioned in the chapter that analyzes the situation of health plans, as to define the guidelines, objectives and goals aimed at improving APS access and quality.
As for the units' structural elements, the health plans analyzed mentioned little about the environment, the management of health services, the operation and the information on health units.The plans stressed the need for reforms in health units, including the definition of objectives and goals related to themselves.The need to equip and re-equip the units was also included in two plans.It should be noted that these aspects are important for the population's access to public health services, directly influencing the quality of care provided, so that it surrounds aspects of the structure and reverberates the processes and results.Findings from other studies showed relations between structure, work process and quality of the Family Health Strategy services in the country 9,53, 54 .

Final remarks
The analysis of the structural conditions of health units in the Brazilian capitals revealed the need for adequacy for most of them regarding one or some of the aspects analyzed so that to achieve quality of care for persons suffering from DM.
This study reveals aspects of structure dimensions as to health units of Brazilian capitals, evidencing particularities, potentialities and weaknesses that deserve to be considered in the definition of the agenda and in the guidance of actions by health management.It should also be noted that the observed inadequacy conditions can impact negatively on the APS quality of care for persons suffering from diabetes.The structural conditions of health units should generate a management commitment to improve access and quality of health services.However, it was suggested that many elements related to the structure of the units, detailed by means of adequacy percentages, are not yet emphasized in the health plans of Brazilian capitals, meaning that they are not an objective/goal to be achieved.
As limitations, we can mention the use of secondary data retrieved from PMAQ-AB.In addition, the information for evaluation of the structure does not correspond to the total health units of the municipalities due to the exclusion of those that did not adhere to the program, and to the unavailability of some PMS as for documental analysis.However, the limitations do not reduce the quality of the results, since data obtained from the program are strong enough to fulfill the diagnosis of the structural conditions of the health units.So, it is to reinforce that the interruption or lack of a program to evaluate the quality of services implies losses also for the investment in structure as for the induction of improvements by means of the assessment of these aspects in an institutional approach.
Therefore, this study analyzed the structural conditions of health units by connecting them with the guidelines, objectives and goals set forth in the health plans of the capitals under assessment.However, further investigation may search for: the evaluation of factors that interfere in the quality of care for persons suffering from DM; the aspects that determine the inadequacy of the structural conditions of the units; the analysis of care effectiveness for persons suffering from DM; and the efficiency in the resources' appropriation for ensure managers decision-making.

Figure 1 .
Figure 1.Logical model of PHC care for persons suffering from DM

Table 1 .
Frequency of data structuring variables on the supply of actions and services of Basic Health Units of Brazilian capitals, as per region, 2017

Health unit opening hours (General) Listing (scope) of actions/ services and provision of the team (Strategic) Shift of professionals containing name and working hours (General) Ombudsman telephone number of the Ministry of Health or of the state or municipal health secretariat (General) Identification of all professionals (e.g. badges, uniforms, lab coat) (General) UBS regular opening hours UBS supplies all its activities during lunchtime Rg. Cap.
SAÚDE DEBATE | RIO DE JANEIRO, V. 47, N. 138, P. 571-589, Jul-SEt 2023

Table 1 .
Frequency of data structuring variables on the supply of actions and services of Basic Health Units of Brazilian capitals, as per region, 2017 35urce: PMAQ-AB35.

Table 2 .
Frequency of physical structure variables of Basic Health Units in Brazilian capitals, as per region, 2017

Table 3 .
Frequency of materials, equipment and supplies' variables of Basic Health Units in Brazilian capitals, as per region, 2017

Table 3 .
Frequency of materials, equipment and supplies' variables of Basic Health Units in Brazilian capitals, as per region, 2017 35urce: PMAQ-AB35.

Table 4 .
Percentage of adequacy of the structure analysis dimensions of Basic Health Units in the Brazilian capitals, as per region, 2017