Eixos e a Reforma dos Cuidados em Atenção Primária em Saúde (RCAPS) na cidade do Rio de Janeiro, Brasil

Reflections on co-managing investigative praxis in the context of a health emergency

This article deals with the interest of the scientific field in systematizing the co-management investigative praxis, in a health emergency scenario, based on the analysis of a research with a multicentric qualitative approach, using the framework of the Support Research and the analysis of critical hermeneutics. As a result, it was identified that the creation of a map guide contributed as a guiding document, aiming at organizing different techniques for the organization and formation of field researchers, as well as an instrument of data analysis. The training of researchers for the theoretical framework of Support Research, as well as their co-management and involvement in the different stages of research, proved to be a differential for the production of subjects and collectives with investigative praxis, allowing a dialogic exchange between coordinators and researchers and regular sharing of the results. It is concluded that the way in which the methodology was proposed, allowed the expansion of the reflective capacity and understanding of reality, contributing to the formation of researchers as active and critical subjects in the process of data collection, analysis and discussion, encouraging sensitive and attentive actions while seeking to identify the particularities of each context.

Decentralizing referral prioritization to general practitioners at the primary care level: A qualitative case study based on the Grounded Theory

BACKGROUND

Patient referral prioritizations is an essential process in coordinating healthcare delivery, since it organizes the waiting lists according to priorities and availability of resources.

OBJECTIVE

This study aims to highlight the consequences of decentralizing ambulatory patient referrals to general practitioners that work as family physicians in primary care clinics.

METHODS

A qualitative case study was carried out in the municipality of Rio de Janeiro. The ten health regions of Rio de Janeiro were visited during fieldwork, totalizing 35 hours of semi-structured interviews and approximately 70 hours of analysis based on the Grounded Theory.

RESULTS

The findings of this study show that the obstacles to adequate referrals are beyond the management of vacancies, ranging from the standardization of prioritization criteria to ensuring the proper employment of referral protocols in diverse locations assisted by overloaded health workers with different backgrounds and perceptions. Efforts in decentralizing patient referral to primary care still face the growing dilemmas and challenges of expanding the coverage of health services while putting pressure on risk assessment, as well as sustaining the autonomy of physicians' work while respecting the eligibility when ordering waiting lists.

CONCLUSION

A major strength of this work is on the method to organize and aggregate qualitative data using visual representations. Limitations concerning the reach of fieldwork in vulnerable and hardly accessible areas were overcame using snowball sampling techniques, making more participants accessible.

Associations between primary healthcare and infant health outcomes: a cohort analysis of low-income mothers in Rio de Janeiro, Brazil

Background

Expanding primary healthcare to urban poor populations is a priority in many low-and middle-income countries and is essential to achieve universal health coverage (UHC). Between 2008 and 2016 the city of Rio de Janeiro undertook an ambitious programme to rapidly expand primary care to low-income areas through the family health strategy (FHS). Infant health impacts of this roll out are unknown. This study examines associations between maternal FHS utilisation and birth outcomes, neonatal and infant mortality.

Methods

A cohort of 75,339 live births (January 2009-December 2014) to low-income mothers in Rio de Janeiro was linked to primary care, birth, hospital and death records. The relationship between maternal FHS use and infant health outcomes was assessed through logistic regression with inverse probability treatment weighting and regression adjustment. Socioeconomic inequalities in the associations between FHS use and outcomes were explored through interactions. Primary outcomes were neonatal and infant death. Thirteen secondary outcomes were also examined to explore other important health outcomes and potential mechanisms.

Results

A total of 9002 (12.0%) infants were born to mothers in the cohort who used FHS services either before pregnancy or in the first two trimesters. There was a total of 527 neonatal and 893 infant deaths. Maternal FHS usage during the first two trimesters was associated with substantial reductions in neonatal [adjusted odds ratio (aOR): 0.527, 95% confidence interval (95% CI): 0.345; 0.806] and infant mortality (aOR: 0.672, 95% CI: 0.48; 0.924). Infants born to lower-income mothers and those without formal employment had larger reductions in neonatal and infant mortality associated with FHS use. Maternal FHS in the first two trimesters use was also associated with more antenatal care consultations and a lower risk of low birth weight and preterm birth.

Interpretation

Expanding primary care to low-income populations in Rio de Janeiro was associated with improved infant health and health equity benefits.

Funding

DFID/MRC/Wellcome Trust/ESRC.

Participative management in Primary Health Care: an essay on an experience in a vulnerable urban territory

ABSTRACT Participatory management, although instituted in the norms of the constitution of the Brazilian Universal Health System (SUS), still faces challenges to be effective in practice at a local level, especially in complex urban territories, aiming at community strengthening and social participation. This essay aims to present and discuss aspects of a participatory management experience in a vulnerable territory, mediated by Primary Health Care. This experience of health co-management was developed between 2009 and 2013 in Manguinhos, a municipality of Rio de Janeiro. From the managers’ reports and the technical materials produced, the implementation of strategies analyzed were the mobilization to create a local intersectoral management council and those of information, education, and communication in health supported by institutional supporters and by the family health teams. We concluded that democratic managerial and sanitary practices can be developed through social technologies, which value participative and shared management among workers-users-management.

Gestão participativa na Atenção Primária à Saúde: ensaio sobre experiência em território urbano vulnerável

RESUMO A gestão participativa, embora instituída nas normativas de constituição do Sistema Único de Saúde, ainda encontra desafios para efetivação em âmbito local, especialmente em territórios urbanos marcados por violência e pobreza. O ensaio objetivou apresentar e discutir aspectos de uma experiência de gestão participativa em um território vulnerável, mediada pela Atenção Primária à Saúde. Essa experiência de cogestão da saúde foi desenvolvida entre 2009 e 2013 em Manguinhos, no município do Rio de Janeiro. A partir do relato de gestores e de materiais técnicos produzidos, analisou-se a implementação de estratégias, tais como a mobilização para criação de um conselho gestor intersetorial local e aquelas de informação, educação e comunicação em saúde suportadas por apoiadores institucionais e pelas equipes de saúde da família. Concluiu-se que práticas gerenciais e sanitárias democráticas podem ser desenvolvidas por meio de tecnologias sociais, que valorizem a gestão participativa e compartilhada entre trabalhadores-usuários-gestão.

Expansion of primary healthcare and emergency hospital admissions among the urban poor in Rio de Janeiro Brazil: A cohort analysis

Background

Robust evidence on the relationship between primary care and emergency admissions is lacking in low- and middle-income countries. This study evaluates how the phased roll out of the family health strategy (FHS) to the urban poor in Rio de Janeiro Brazil affected emergency hospital admissions and readmissions from ambulatory-care sensitives conditions (ACSCs).

Methods

A cohort of 1.2 million adults in Rio de Janeiro city were followed for five years (Jan 2012 to Dec 2016). The association between FHS use and the likelihood of emergency hospital admissions and 30-day readmissions were evaluated using multi-level Poisson regression models with inverse probability treatment weighting and regression adjustment (IPTW-RA) for socioeconomic and household characteristics. Inequalities in associations were examined across groups of causes and by key socioeconomic groups.

Results

Records from 2,551,934 primary care consultations and 15,627 admissions were analysed. In IPTW-RA analyses, each additional FHS consultation was associated with a 3% lower rate of ACSC admission (RR: 0.97; 95%CI: 0.95, 0.98), a 63% lower rate of 30-day readmissions from any non-birth cause (RR: 0.37; 95%CI: 0.30, 0.46), and an 57% lower rate of 30-day readmissions from ACSCs (RR: 0.43; 95%CI: 0.33, 0.55). Individuals who were older, had the lowest educational attainment, were unemployed, and had higher incomes had larger reductions in ACSC admissions associated with FHS use.

Interpretation

Investment in primary care is important for reducing emergency hospital admissions and their associated costs in LMICs.

Funding

DFID/MRC/Wellcome Trust/ESRC.

A regulação ambulatorial na Atenção Primária do Município do Rio de Janeiro, Brasil, a partir dos médicos reguladores locais

Resumo O artigo teve por objetivo caracterizar o processo de regulação assistencial realizado nas unidades de Atenção Primária à Saúde do município do Rio de Janeiro, com ênfase na dimensão ambulatorial. Foi realizado estudo transversal, por meio de um survey, com participação de 114 médicos reguladores locais, no ano de 2019. Quanto ao perfil dos reguladores locais, destacou-se o alto percentual com formação em Medicina de Família e Comunidade e o tempo de atuação relativamente adequado destes profissionais nas unidades. Para 52,6%, a infraestrutura para regulação é adequada, mas a conectividade apresenta problemas com frequência. No sistema de regulação, os mecanismos e horários de disponibilização de vagas produzem competição entre os reguladores das unidades, com sobrecarga de trabalho e iniquidades de acesso associadas. Observou-se importante envolvimento dos reguladores locais em atividades de avaliação e gestão de filas de espera. A maioria informou haver pouca ou nenhuma interação com a atenção especializada. Apesar do processo de regulação descentralizada ainda apresentar importantes limites, o estudo aponta a factibilidade e contribuição da entrada mais intensa da Atenção Primária na regulação do acesso.

Residency training in family medicine and its impact on coordination and continuity of care: an analysis of referrals to secondary care in Rio de Janeiro

OBJECTIVE

To measure the effect that residency training in family medicine (RTFM) has on continuity and coordination of care.

DESIGN

Observational cohort study using electronic health records.

SETTING

Rio de Janeiro, Brazil, public primary care system.

PARTICIPANTS

504 940 patients, 633 generalists (physicians without RTFM) and 204 family physicians (FP-doctors with 2 years of RTFM) from one health district between January 2015 and December 2018.

INTERVENTION

Two years of RTFM.

MAIN OUTCOME MEASURES

Relative risks of patients being referred to secondary care for outpatient consultations and diagnostics tests; and having a follow-up medical consultation in primary care within 3 and 6 months after being referred.

RESULTS

We examined 2 414 508 medical consultations and 284 754 referrals to secondary care. FPs were less likely to request ambulatory care services (including surgical specialties), but were more likely to request ophthalmology, physiotherapy, rehabilitationand surgical evaluations for their patients. Patients referred to secondary care by FPs were more likely to have a follow-up visit in primary care for almost every service requested. If all medical consultations were performed by FPs, a 37.6% (95% CI 32.4% to 42.4%) increased demand for rehabilitation services would be noticed. Oppositely, 1532 (95% CI 1458 to 1602) fewer requests for dermatology would happen every year.

CONCLUSIONS

RTFM improves coordination and continuity of care by making FPs more competent to retain those health conditions that can be properly managed in primary care and making FPs more competent to detect health conditions that require specific biomedical technologies and skills, increasing the demand for those services. Besides, it increases the chances of patients having follow-up visits in primary care. Policy-makers in low-income and middle-income countries must consider investing in RTFM to make primary care systems more comprehensive, with better coordination and continuity of care.

Detection and follow-up of chronic health conditions in Rio de Janeiro - the impact of residency training in family medicine

BACKGROUND

There is a need for evidence that residency training in family medicine can benefit the care of patients in primary care in low- and middle-income countries. We tested the hypothesis that two years of residency training in family medicine enables doctors to better detect chronic health conditions while requesting fewer laboratory tests and providing more follow-up visits.

METHODS

We performed a retrospective longitudinal observational analysis of medical consultations from 2013 to 2018 in primary care in Rio de Janeiro, comparing doctors without residency training in family medicine (Generalists) versus family physicians (FPs). Multivariate multilevel binomial regression models estimated the risks of patients being diagnosed for a list of 31 chronic health conditions, having a follow-up visit for these conditions, and having laboratory tests ordered from a list of 30 exams.

RESULTS

569.289 patients had 2.908.864 medical consultations performed by 734 generalists and 231 FPs. Patients seen by FPs were at a higher risk of being detected for most of the chronic health conditions, at a lower risk of having any of the 30 laboratory tests requested, and at a higher risk of having a follow-up visit in primary care.

CONCLUSIONS

Residency training in family medicine can make physicians more skilled to work in primary care. Policymakers must prioritize investments in capacity building of healthcare workforce to make primary care truly comprehensive.

Spatial analysis of tuberculosis cure in primary care in Rio de Janeiro, Brazil

Background

Tuberculosis (TB) presents a high burden of disease and is considered a global emergency by the World Health Organization (WHO), as the leading cause of death from infectious disease in adults. TB incidence is related directly to access to health services and socioeconomic determinants and inequality. Providing primary care settings can lead to improved access, shorter waiting times for patients, and enhanced TB case detection. The article aims to identify the spatial and temporal risk areas for TB and the relationship between TB cure and primary healthcare coverage from 2012 to 2014 in Rio de Janeiro, Brazil.

Methods

A cross-sectional study was conducted in Rio de Janeiro, Brazil. All cases of TB reported to the Information System on Diseases of Notification (SINAN) from 2012 to 2014 were included. Socioeconomic variables from the 2010 Brazilian national census were also added. Socioeconomic variables were selected from multivariate analysis using principal factors analysis. Spatial association was verified with generalized additive model (GAM). It was possible to identify areas at higher risk of failure to cure TB.

Results

TB rates showed strong positive spatial autocorrelation. TB cure rate varied according to schooling (individuals with complete secondary schooling had higher cure rates than illiterate individuals; OR 1.72, 95% CI 1.30–2.29), alcohol consumption (OR 0.47, 95% CI 0.35–0.64), contact investigation (OR 2.00, 95% CI 1.56–2.57), positive HIV serology (OR 0.31, 95% CI 0.23–0.42), and census tracts with higher elderly rates (OR 9.39, 95% CI 1.03–85.26). Individuals who had been covered by primary healthcare (PHC) for 35 to 41 months had 1.64 higher odds of cure, compared to those with no PHC coverage (95% CI 1.07–2.51).

Conclusion

A comprehensive risk map was developed, allowing public health interventions. Spatial analysis allowed identifying areas with lower odds of TB cure in the city of Rio de Janeiro. TB cure was associated statistically with time of coverage by primary healthcare. TB cure rate also varied according to sociodemographic factors like schooling, alcohol abuse, and population density.

This methodology can be generalized to other areas and/or other public health problems.

Highlights

We studied standardized municipal TB cure rates in an area of social inequality in Brazil.

TB rates showed strong positive spatial autocorrelation.

Higher rates were associated with population density and socioeconomic conditions. Illiterate individuals were less likely to achieve TB cure.

TB cure was less likely in individuals with HIV and alcohol abuse.

TB cure was greater in areas with high primary healthcare coverage.

Telehealth to support referral management in a universal health system: a before-and-after study

BACKGROUND

Management of patient flow within a healthcare network, allowing equitable and qualified access to healthcare, is a major challenge for universal health systems. Implementation of telehealth strategies to support referral management has been shown to increase primary care resolution and to promote coordination of care. The objective of this study was to assess the impact of telehealth strategies on waiting lists and waiting times for specialized care in Brazil.

METHODS

Before-and-after study with measures obtained between January 2019 and February 2020. Baseline measurements of waiting lists were obtained immediately before the implementation of a remotely operated referral management system. Post-interventional measurements were obtained monthly, up to six months after the beginning of operation. Data was extracted from the database of the project. General linear models were applied to assess interaction of locality and time over number of cases on waiting lists and waiting times.

RESULTS

At baseline, the median number of cases on waiting lists ranged from 2961 to 12,305 cases. Reductions of the number of cases on waiting lists after six months of operation were observed in all localities. The magnitude of the reduction ranged from 54.67 to 88.97 %. Interaction of time measurements was statistically significant from the second month onward. Median waiting times ranged from 159 to 241 days at baseline. After six months, there was a decrease of 100 and 114 waiting days in two localities, respectively, with reduction of waiting times only for high-risk cases in the third locality.

CONCLUSIONS

Adoption of telehealth strategies resulted in the reduction of number of cases on waiting lists. Results were consistent across localities, suggesting that telehealth interventions are viable in diverse settings.

Record linkage under suboptimal conditions for data-intensive evaluation of primary care in Rio de Janeiro, Brazil

Background

Linking Brazilian databases demands the development of algorithms and processes to deal with various challenges including the large size of the databases, the low number and poor quality of personal identifiers available to be compared (national security number not mandatory), and some characteristics of Brazilian names that make the linkage process prone to errors. This study aims to describe and evaluate the quality of the processes used to create an individual-linked database for data-intensive research on the impacts on health indicators of the expansion of primary care in Rio de Janeiro City, Brazil.

Methods

We created an individual-level dataset linking social benefits recipients, primary health care, hospital admission and mortality data. The databases were pre-processed, and we adopted a multiple approach strategy combining deterministic and probabilistic record linkage techniques, and an extensive clerical review of the potential matches. Relying on manual review as the gold standard, we estimated the false match (false-positive) proportion of each approach (deterministic, probabilistic, clerical review) and the missed match proportion (false-negative) of the clerical review approach. To assess the sensitivity (recall) to identifying social benefits recipients’ deaths, we used their vital status registered on the primary care database as the gold standard.

Results

In all linkage processes, the deterministic approach identified most of the matches. However, the proportion of matches identified in each approach varied. The false match proportion was around 1% or less in almost all approaches. The missed match proportion in the clerical review approach of all linkage processes were under 3%. We estimated a recall of 93.6% (95% CI 92.8–94.3) for the linkage between social benefits recipients and mortality data.

Conclusion

The adoption of a linkage strategy combining pre-processing routines, deterministic, and probabilistic strategies, as well as an extensive clerical review approach minimized linkage errors in the context of suboptimal data quality.

Applicability and potentiality in the use of Business Intelligence tools in Primary Health Care

Data management tools, called Business Intelligence (BI), can be important to provide complete and customizable information for the demands of health management. The objective of the article is to present the evaluation of the applicability and potential of a BI tool in the planning of management actions of Primary Health Care. Exploratory study, with a quantitative approach, using the dimensions of efficiency and optimization as attributes of quality. A Family Clinic was selected in the city of Rio de Janeiro. Data from the territory, from the Bolsa Família Program register and some "Care Lines" were inserted in the BI, in order to explore the possibilities of combining and generating indicators. In this article, we present the use of Form A and the pregnant woman's Care Line. As a result, greater range of detailed indicators compared to a common tab, and optimization in obtaining lists and perform monitoring tasks by the teams and the manager. Regarding efficiency, its low cost and easy handling reduces the costs of creation and necessary professionals. As a conclusion, the BI tool enables greater organization and planning, facilitating the Family Health Clinic management, mainly for the monitoring of indicators and evaluation processes.

Large-scale implementation of the Family Health Strategy in the city of Rio de Janeiro, Brazil: evidence and challenges

The city of Rio de Janeiro has implemented, on a large scale, the model of Social Organizations (OSS) for the management of Primary Health Care (PHC). This option makes the understanding of the city's experience very relevant, especially since, until then, the OSS organizational model had been adopted predominantly in the SUS hospital management. Thus, the experience of PHC development at two conflicting moments of municipal management in relation to the OSS model is analyzed: the implementation and development of the PPPs (2009-2016); and their dismantling (2017-2020). Case Studies, Literature Review and analysis of public data from DATASUS/Ministry of Health were used. It was verified that: the adoption of outsourcing based on OSS can be directly associated with the rapid expansion of PHC in the city and PHC coverage improvement indicators; the diffusion of the OSS model is associated with the high priority given to health expenditures in the municipal budget; the sustainability of the adoption of the OSS model did not depend on the municipality's economic status, but on the government's political choice in the period of 2009 to 2016. The PPP arrangement resulted in important organizational advances, although it did not prevent the veto of the OSS model carried out during the 2017-2020 term.

Primary healthcare expansion and mortality in Brazil's urban poor: A cohort analysis of 1.2 million adults

BACKGROUND

Expanding delivery of primary healthcare to urban poor populations is a priority in many low- and middle-income countries. This remains a key challenge in Brazil despite expansion of the country's internationally recognized Family Health Strategy (FHS) over the past two decades. This study evaluates the impact of an ambitious program to rapidly expand FHS coverage in the city of Rio de Janeiro, Brazil, since 2008.

METHODS AND FINDINGS

A cohort of 1,241,351 low-income adults (observed January 2010-December 2016; total person-years 6,498,607) with linked FHS utilization and mortality records was analyzed using flexible parametric survival models. Time-to-death from all-causes and selected causes were estimated for FHS users and nonusers. Models employed inverse probability treatment weighting and regression adjustment (IPTW-RA). The cohort was 61% female (751,895) and had a mean age of 36 years (standard deviation 16.4). Only 18,721 individuals (1.5%) had higher education, whereas 102,899 (8%) had no formal education. Two thirds of individuals (827,250; 67%) were in receipt of conditional cash transfers (Bolsa Família). A total of 34,091 deaths were analyzed, of which 8,765 (26%) were due to cardiovascular disease; 5,777 (17%) were due to neoplasms; 5,683 (17%) were due to external causes; 3,152 (9%) were due to respiratory diseases; and 3,115 (9%) were due to infectious and parasitic diseases. One third of the cohort (467,155; 37.6%) used FHS services. In IPTW-RA survival analysis, an average FHS user had a 44% lower hazard of all-cause mortality (HR: 0.56, 95% CI 0.54-0.59, p < 0.001) and a 5-year risk reduction of 8.3 per 1,000 (95% CI 7.8-8.9, p < 0.001) compared with a non-FHS user. There were greater reductions in the risk of death for FHS users who were black (HR 0.50, 95% CI 0.46-0.54, p < 0.001) or pardo (HR 0.57, 95% CI 0.54-0.60, p < 0.001) compared with white (HR 0.59, 95% CI 0.56-0.63, p < 0.001); had lower educational attainment (HR 0.50, 95% CI 0.46-0.55, p < 0.001) for those with no education compared to no significant association for those with higher education (p = 0.758); or were in receipt of conditional cash transfers (Bolsa Família) (HR 0.51, 95% CI 0.49-0.54, p < 0.001) compared with nonrecipients (HR 0.63, 95% CI 0.60-0.67, p < 0.001). Key limitations in this study are potential unobserved confounding through selection into the program and linkage errors, although analytical approaches have minimized the potential for bias.

CONCLUSIONS

FHS utilization in urban poor populations in Brazil was associated with a lower risk of death, with greater reductions among more deprived race/ethnic and socioeconomic groups. Increased investment in primary healthcare is likely to improve health and reduce health inequalities in urban poor populations globally.

Leitos de saúde mental em hospitais gerais: o caso do Rio de Janeiro

RESUMO O objetivo deste artigo foi analisar o modelo de provisão de leitos de saúde mental em três hospitais gerais da cidade do Rio de Janeiro e sua relação com a Rede de Atenção Psicossocial. Foram realizadas entrevistas com gestores locais, um gestor municipal e dois ex-coordenadores nacionais de saúde mental. Os resultados apontaram que os hospitais estudados oferecem espaços restritivos, com predomínio de terapia farmacológica e forte influência do modelo biomédico. A presença dos leitos de saúde mental nos hospitais tem-se mostrado uma experiência bem-sucedida na melhoria do cuidado integral aos usuários. A interação com a Rede de Atenção Psicossocial foi apresentada como modelo de assistência preconizado, mas ainda enfrentando fragilidades em sua implementação. Os achados da pesquisa evidenciaram que a baixa implantação de leitos de saúde mental em hospital geral na cidade se deve a lacunas na formação de profissionais e ao estigma que faz com que gestores resistam em receber usuários com transtornos mentais em suas instituições. Modificações recentes na política nacional de saúde mental, no sentido de interromper o fechamento de leitos em hospitais psiquiátricos, devem acarretar alterações na direção da reforma psiquiátrica no País.

Intensive care inequity in Rio de Janeiro: the effect of spatial distribution of health services on severe acute respiratory infection

OBJECTIVE

To analyze the distribution of adult intensive care units according to geographic region and health sector in Rio de Janeiro and to investigate severe acute respiratory infection mortality in the public sector and its association with critical care capacity in the public sector.

METHODS

We evaluated the variation in intensive care availability and severe acute respiratory infection mortality in the public sector across different areas of the city in 2014. We utilized databases from the National Registry of Health Establishments, the Brazilian Institute of Geography and Statistics, the National Mortality Information System and the Hospital Admission Information System.

RESULTS

There is a wide range of intensive care unit beds per capita (from 4.0 intensive care unit beds per 100,000 people in public hospitals in the West Zone to 133.6 intensive care unit beds per 100,000 people in private hospitals in the Center Zone) in the city of Rio de Janeiro. The private sector accounts for almost 75% of the intensive care unit bed supply. The more developed areas of the city concentrate most of the intensive care unit services. Map-based spatial analysis shows a lack of intensive care unit beds in vast territorial extensions in the less developed regions of the city. There is an inverse correlation (r = -0.829; 95%CI -0.946 to -0.675) between public intensive care unit beds per capita in different health planning areas of the city and severe acute respiratory infection mortality in public hospitals.

CONCLUSION

Our results show a disproportionate intensive care unit bed provision across the city of Rio de Janeiro and the need for a rational distribution of intensive care.

Burnout Syndrome in Family Health Strategy Managers

This paper analyzed the Burnout Syndrome (BS) among the managers of the Family Health Strategy (ESF) in the city of Rio de Janeiro and its associations with factors that influence the presence/absence of BS among these professionals. This is a descriptive study that used data from a questionnaire consisting of two parts: 1) manager profile and factors that could influence the presence of Burnout; 2) Maslach Burnout Inventory. The return rate was 63.5% (143) of the 225 questionnaires sent. The ESF managers are generally nurses (68.6%), young (63.6% under 39 years) female (76.9%), who have acted as managers for less than 5 years (85.2%). A BS presence was identified in 11.2% of the managers. The factors of an organizational nature were those that obtained the highest number of variables with an association. These data point to the need to make changes in the organizational practices of services and changes in work processes. Further studies on these issues can contribute to this.

Learning the clinic of social suffering: narratives of Internship in Primary Health Care

In Brazil, the mismatch between medical education and care needs in primary health care, especially for the most vulnerable populations, required changes in the National Curriculum Guidelines of the Medical School, with an increased workload of the internship in PHC. This work is exploratory, qualitative research, which investigated documents of the formative evaluation of the Integrated Internship in Family and Community Medicine and Mental Health of the Federal University of Rio de Janeiro, which serves vulnerable populations in the city of Rio de Janeiro. The documents produced by 55 students were analyzed, and dialectical hermeneutics was used as a method of analysis. The investigation showed different levels of sensitivity to social distress experienced by users of Family Clinics during the 22 weeks of internship. The narratives were grouped into five axes: highlighting the Medicine-society split; extreme vulnerability and health; daily structural violence and health; health service as a resource or intruder; territory as the power of life. The internship contributed to improve clinical views focused on users' needs, and further studies are required to evaluate the effective incorporation of these competencies into professional practice.

Trajetória profissional de egressos de Curso de Mestrado Profissional em Atenção Primária à Saúde no Município de Rio de Janeiro, Brasil: estudo avaliativo

Resumo Visando estudar a trajetória de egressos de duas turmas de Mestrado Profissional realizou-se estudo exploratório, com questionário eletrônico on line, anônimo, com quatro blocos: pessoal; atividade profissional atual; relação do curso-situação profissional e ainda perguntas abertas para pontos positivos/negativos. Resultados: a maioria mantinha-se na área da atenção primária e em serviços públicos; na assistência à saúde e muitos como preceptores; desenvolviam atividade no trabalho relacionada ao curso e 75% relatam alto o impacto do curso. Menor efeito foi percebido na remuneração e maiores na formação profissional, nas redes de relações; no crescimento pessoal e no trabalho. As estratégias pedagógicas ativas foram bem avaliadas. Conclusão: metodologia de avaliação factível e aplicável para sistemas de acompanhamento de egressos; permite conhecer a relação formação e trabalho.

Armed conflict at primary care: challenges for practice and training

OBJECTIVES

to analyze the training of Family Health Strategy health professionals who work in dangerous territories affected by the armed conflict and its consequences in their practice.

METHODS

a qualitative-intervention research carried out with thirteen health professionals, using as a theoretical-methodological framework the institutional socioclinic.

RESULTS

they present and discuss from the analysis of implications of researcher and participants with training, and professional practices and transformations that occurred as intervention work progresses.

FINAL CONSIDERATIONS

learning strategies should incorporate empirical and scientifically proven knowledge. Thus, the spectrum of this knowledge would expand dynamically where the situation of violence in its manifestation of armed conflict is a social and political issue and not just a gap in training.

A crise econômica e a atenção primária à saúde no SUS da cidade do Rio de Janeiro, Brasil

Resumo Este artigo aborda a crise na atenção primária à saúde do sistema público de saúde da cidade do Rio de Janeiro, a partir de 2018. Tal município teve forte expansão da atenção primária desde 2009, adotando Organizações Sociais para a contratação de profissionais e gerenciamento dos serviços, qualificando a infraestrutura das unidades e priorizando a medicina de família e comunidade, além de adotar práticas gerenciais como normatizações de ofertas, avaliação e remuneração por desempenho, “marketing”, dentre outras. Diante da recente crise econômica, a decisão do gestor municipal foi de reduzir equipes de saúde da família, considerando a atual Política Nacional de Atenção Básica e argumentando ser possível otimizar recursos (fazendo mais com menos). Neste processo, enfrentou resistências, que não foram suficientes para freá-lo. Pela ressonância desta cidade (segunda maior do Brasil e com destaque na imprensa nacional) e tomando como base documentos públicos e formulações sobre a gestão, a crise expressa na atenção básica deste município foi problematizada em torno das implicações da adoção de Organizações Sociais na sustentabilidade dos serviços, da condução dos processos de gestão e suas racionalidades bem como da atuação política de agentes sociais em defesa do SUS e da atenção primária em particular.

A crise financeira e a saúde: o caso do município do Rio de Janeiro, Brasil

Resumo Este estudo explorou os efeitos da crise financeira nas receitas e despesas, na produção de serviços e indicadores de saúde e de desempenho no município do Rio de Janeiro no período de 2013 a 2018. Analisou-se receitas, despesas, parâmetros de provisão de serviços e indicadores de desempenho e de saúde, a partir de dados de acesso livre e restrito. Utilizou-se a análise institucional de Giddens. As receitas e despesas sofreram redução, sendo maiores nos investimentos e receitas não vinculadas. A provisão de serviços encolheu, com queda da cobertura na Atenção Primária, produção ambulatorial, internações totais, número de leitos, médicos e agentes comunitários de saúde, cirurgias realizadas e taxa de ocupação de hospitais. Os tempos de espera para ambulâncias, exames e consultas ambulatoriais, bem como o número de solicitações pendentes na regulação aumentaram. Indicadores de saúde e desempenho persistiram, em sua maioria, dentro dos parâmetros anteriores, corroborando a potência assistencial da Atenção Primária, apesar do impacto financeiro e estrutural da austeridade. A conjuntura atual ameaça o direito à saúde e as respostas governamentais, como a desvinculação de receitas, sinalizam uma ampliação desse risco.

From Alma-Ata to Astana: the path of Primary Health Care in Portugal, 1978-2018 and the genesis of Family Medicine

Throughout the twentieth century, the profound changes that have taken place in Medicine can only be wholly explained if observed from a historical perspective, for they have always occurred in response to external influences, some scientific and technological, others of a social nature. Modern Family Medicine is one of the many new disciplines that have developed during medical history, and we critically discuss the last 40 years of primary health care in Portugal, which started in 1971, long before the Alma-Ata Declaration (1978). Along the way, in 2005, the Primary Health Care Reform emerges in Portugal, along with the new family health facilities, which until September 2019, attended about 94 % of Portuguese citizens, i.e., 9,5 million people. At the end of this course, in solidarity and voluntarily, this Reform inspired another one in Brazil, in Rio de Janeiro, in 2009. Finally, we present the challenges pointed out in the 2018 Astana Declaration, among them, the issue of the workforce in primary health care as an essential factor for the performance and sustainability of health systems.

Hospitalisations due to ambulatory care sensitive conditions (ACSC) between 2009 and 2018 in Brazil's Federal District as compared with other state capitals

This study compared standardised rates of hospitalisations due to ambulatory care sensitive conditions (ACSCs) in Brazil's Federal District from 2009 to 2018, as compared with those for selected state capitals, age groups and admissions groups. This ecological study used secondary data drawn from Hospital Information System microdata for the study period, during which, in the Federal District, the proportion of such admissions among 50-59 and 60-69 year olds declined, while those among children and adolescents held stable. Meanwhile, rates did not decrease in the ≤ 20 year age groups, a priority population in PHC, which may suggest that this population encountered barriers to access. The results showed that the expected reduction in the proportion of such admissions has not occurred, because coverage by Family Health Teams has been expanded only recently.

Access to health care facilities of suspected dengue patients in Rio de Janeiro, Brazil

Rio de Janeiro maintains a recurrent history of dengue epidemics. There is scarce evidence about the route of the population to get health care. The study aimed to describe the pattern of suspected dengue patients flow in search of health care services in Rio de Janeiro. The following data were analyzed: dengue reports from 2011 to 2013; the neighborhoods of patient's residence; the neighborhoods of health services. Neighborhoods of the city were used as unit of analysis focusing on access to health facilities of municipal Planning Area (AP) 3.3. Flow maps were elaborated to describe the routes between the neighborhood of residence and the heath service. Between 2011 and 2013 48,576 suspected dengue cases living in program area 3.3 were reported, 72% got health care in the AP 3.3, 37% of which in primary care. A total of 12,545 suspected cases attended health facilities outside the AP 3.3. A great geographical variation was observed in the search for Primary Care within the AP 3.3, as well as a relevant movement to the center and south zone of the city on access to care, comprising 2,647 different flows. The findings indicate a large flow within the municipality.

Serviços Residenciais Terapêuticos na cidade do Rio de Janeiro: uma análise da estrutura e do processo de cuidado

RESUMO O objetivo do artigo foi analisar a estrutura e o processo de cuidado nos Serviços Residenciais Terapêuticos existentes no município do Rio de Janeiro. Trata-se de um estudo transversal que se concentrou na coleta de informações primárias por meio de instrumento estruturado. A pesquisa foi realizada em todos os dispositivos em funcionamento no mês de dezembro de 2016. No Rio de Janeiro, as Residências Terapêuticas recebem essencialmente pacientes egressos de internações psiquiátricas de longa permanência (94,3%), com grande oferta de vagas em dispositivos com presença de equipe nas 24 horas do dia (63,8%). Foi constatado que parte significativa dos moradores apresentava baixa frequência nas atividades assistenciais dos Centros de Atenção Psicossocial (48,7%). O cuidado interno nos dispositivos residenciais aponta para uma modelagem com forte entrelaçamento entre a moradia e as ações de reabilitação psicossocial. A baixa rotatividade de usuários mostra uma tendência para constituição de serviços com cuidado de longo prazo, o que deve ser levado em conta na manutenção e na expansão do programa no intuito de planejar serviços efetivos. Os resultados apontam que as bolsas de apoio à desinstitucionalização e, principalmente, a renda contínua aferida mediante o Benefício de Prestação Continuada são vitais para a sustentabilidade do programa.

Planning and understanding the intensive care network in the State of Rio de Janeiro (RJ), Brazil: a complex societal problem

Objectives

To determine the optimal number of adult intensive care unit beds to reduce patient's queue waiting time and to propose policy strategies.

Methods

Multimethodological approach: (a) quantitative time series and queueing theory were used to predict the demand and estimate intensive care unit beds in different scenarios; (b) qualitative focus group and content analysis were used to explore physicians' attitudes and provide insights into their behaviors and belief-driven healthcare delivery changes.

Results

A total of 33,101 requests for 268 regulated intensive care unit beds in one year resulted in 25% admissions, 55% queue abandonment and 20% deaths. Maintaining current intensive care unit arrival and exit rates, there would need 628 beds to ensure a maximum wait time of six hours. A reduction of the current abandonment rates due to clinical improvement or the average intensive care unit length of stay would decrease the number of beds to 471 and 366, respectively. If both were reduced, the number would reach 275 beds. The interviews generated 3 main themes: (1) the doctor's conflict: fair, legal, ethical and shared priorities in the decision-making process; (2) a failure of access: invisible queues and a lack of infrastructure; and (3) societal drama: deterioration of public policies and health care networks.

Conclusion

The queue should be treated as a complex societal problem with a multifactorial origin requiring integrated solutions. Improving intensive care unit protocols and reengineering the general wards may decrease the length of stay. It is essential to redefine and consolidate the regulatory centers to organize the queue and provide available resources in a timely manner, by using priority criteria, working with stakeholders to guarantee clinical governance and network organization.

The Family Health Strategy: expanding access and reducinghospitalizations due to ambulatory care sensitive conditions (ACSC)

Since its creation in 1994, the Family Health Program has become the main strategy for changing care models and increasing access to the first contact service of the Unified Health System (SUS). A little more than ten years later, in 2006 the program was transformed into the Family Health Strategy (FHS) within the National Policy on Primary Care (PNAB). This article evaluates the effects of the implementation of the FHS over the last two decades in Brazil, demonstrating the access provided and the trends in ambulatory care sensitive conditions (ACSC). This is an ecological, time series study with secondary data referring to the number of family health teams that were established and the number of hospital admissions due to ACSC in the SUS from 2001-2016. The results show a 45% reduction of the standardized ACSC rates per 10,000 inhabitants, from 120 to 66 in the period 2001-2016. Although it was not possible to isolate the specific effects of primary care, it is quite plausible that this reduction in ACSC rates is linked to the progress of FHS coverage in Brazil, especially in terms of improved follow-up of chronic conditions, improved diagnosis and easier access to medicines.

[Expansion of family medicine in Latin America: challenges and lines of actionExpansão da medicina familiar na América Latina: desafios e linhas de ação]

Este documento tiene por objetivos resumir los desafíos actuales de la medicina familiar en América Latina y proponer posibles líneas de acción para consolidar su desarrollo. En los últimos 40 años, los sistemas de salud de la Región de las Américas han encarado reformas cuyos resultados fueron negativos en términos de equidad, y la atención primaria de la salud, lejos de ser aquella estrategia destinada a reducirla, se restringió a una política focal y selectiva. En este contexto, las propuestas técnicas de expansión de las plazas de formación en medicina familiar y su inserción en las carreras de Medicina, han carecido de coherencia y de una dirección política clara, por lo que su falta de eficacia puede leerse como un síntoma de estas reformas incompletas. Al respecto, la Confederación Iberoamericana de Medicina Familiar realizó recomendaciones sobre el compromiso político de los gobiernos para asegurar la estructura y el financiamiento necesarios, consolidar el modelo de medicina familiar como mecanismo de instrumentación de la atención primaria de la salud, la jerarquización de los programas de formación, las condiciones laborales de los médicos de familia y la certificación profesional, entre otras. Estas recomendaciones técnicas, sin acción política coherente y oportuna, no serán más exitosas que los intentos previos.

Analysis of conditions sensitive to primary care in a successful experience of primary healthcare expansion in Brazil, 1998-2015

OBJECTIVE

To analyze trends in expansion of coverage of the family health strategy and hospitalization for conditions sensitive to primary care (CSPC) in a successful experience of primary healthcare expansion in Brazil.

STUDY DESIGN

Ecological study with data from the Brazilian National Health Information System.

METHODS

CSPC were analyzed between 1998 and 2015 in Rio de Janeiro, Brazil, by cause groups. Trends, variation, and correlation between indicators in the period were evaluated.

RESULTS

Most of the cause groups showed a reduction in hospitalization rate, particularly cardiovascular diseases and asthma, but an increase was seen for obstetric causes. The main causes of hospitalization were heart failure, cerebrovascular diseases, and bacterial pneumonia. The contribution of vaccine-preventable diseases, cardiovascular diseases, diabetes, nutritional deficiencies, and chronic lung diseases to the total number of hospitalizations was seen to decrease.

CONCLUSIONS

Analysis demonstrates that the family health strategy, as access to the healthcare system, decreases the majority of CSPC hospitalization rates.

Evaluation of Primary Health Care Units in the Rio De Janeiro City According to the Results of PMAQ 2012

To assess the quality of the primary health care network, the Ministry of Health created the Program for Improving Access and Quality in Primary Care (PMAQ), a national evaluation of family health teams. Thus, this study aims to present the geolocation of PMAQ 2012 quality indicators in the city of Rio de Janeiro. The PMAQ data show that, in the city of Rio de Janeiro, 65% of the teams achieved the performances “good” or “excellent,” 34.7% “regular,” and 0.3% “unsatisfactory.” The results show a clear PMAQ polarization between teams units classified as optimal and regular in program areas 5 and 3, respectively.

The role of Primary Healthcare in the coordination of Health Care Networks in Rio de Janeiro, Brazil, and Lisbon region, Portugal

Considering the trajectory of Rio de Janeiro e Lisboa region regarding strengths of the their health local systems to achieve health for all and equity, the study aimed to compare the organization of the Primary Healthcare from both regions, searching to identify the advancement which in terms of the Delivery Health Networks' coordination. It is a case study with qualitative approach and assessment dimensions. It was used material available online such as scientific manuscripts and gray literature. The results showed the different grades regarding Delivery Health Networks. Lisboa region present more advancement, because of its historic issues, it has implemented Primary Healthcare expanded and nowadays it achieved enough maturity related to coordination of its health local system and Rio de Janeiro suffers still influence from historic past regarding Primary Healthcare selective. The both regions has done strong bids in terms of electronic health records and telemedicine. After of the study, it is clearer the historic, cultural and politics and legal issue that determined the differences of the Primary Healthcare coordinator of the Delivery Health Network in Rio de Janeiro and Lisboa region.

Analysis of the attributes of primary health care using the electronic medical records in the city of Rio de Janeiro

Epidemiology plays a strategic role at this stage of the policy cycle, contributing to goal setting, resource allocation and use of information systems. In 2009, the Municipal Health Secretariat of Rio de Janeiro initiated a reform of the health care model under the main influence the Primary Health Care concept. This study evaluates the trend of selected pay-for-performance indicators that measure the health care process in the city's PHC. This a study on repeated panels, from the administrative and clinical records of electronic medical records in the period from 2012 to 2016. We selected seven indicators that analyzed longitudinal performance within the established goal, among those that represent access, longitudinality, coordination of care - APS attributes, as well as other characteristics of the services, such as care performance and economic efficiency. This study demonstrated that management decentralization to levels closer to the user is potentially successful for the recording of clinical data under an adequate monitoring of indicators, regular clinical audits and feedback to health professionals, along with data and indicators monitoring.

The use of the Primary Care Assessment Tool (PCAT): an integrative review and proposed update

This study proposes an integrative review of the literature based on articles and publications on the use of the Primary Care Assessment Tool (PCAT) as a tool for evaluating these services, discussing the results found in Brazil and in other countries of the world, from the initial matrix conceived by Professor Barbara Starfield's team and proposing updates for the Brazilian version. We identified 124 studies, of which 42 were selected after full reading and according to the established inclusion criteria. Of this subtotal, 17 (40.5%) were Brazilian studies. There is a need to update items of each tool's attribute, in particular "access - first contact", including new forms of doctor-patient communication such as: email, mobile application messages, use of videoconference software for communication and even use of telemedicine, among others. PCAT's use, application and calculation of scores is simple, which makes it useful and suitable for use in the local management of services, especially in its short version.

A regulação municipal ambulatorial de serviços do Sistema Único de Saúde no Rio de Janeiro: avanços, limites e desafios

Resumo O federalismo é o pilar da República, composta pela união dos Estados, dos Municípios e do Distrito Federal, tendo como princípio básico a descentralização político-administrativa, nas relações políticas, econômicas e sociais. Na saúde, o provedor de atenção primária deve ser capaz de integrar todo cuidado que o paciente recebe através da coordenação entre os serviços. Objetiva-se avaliar os resultados dos encaminhamentos de consultas e exames ambulatoriais da APS do município do Rio de Janeiro, demonstrando os avanços, limites e desafios para a gestão no nível local. Estudo quantitativo que utilizou as bases de dados administrativas do Cadastro Nacional de Estabelecimentos de Saúde (CNES) e o Sistema Nacional de Regulação (SISREG), além de uma “linkage” entre ambas as bases. Entre 2011 e 2015, o nº de procedimentos agendados teve um aumento de 86%, como reflexo da descentralização da regulação ambulatorial para os médicos de família. Pode-se inferir que não há falta de especialistas para atendimento ambulatorial no SUS carioca em quase todas as áreas. Existem gargalos artificiais pela ausência de regulação da maior parte da carga horária contratada na especialidade, ou seja, a oferta de vagas é menor do que a capacidade instalada das unidades municipal, estaduais, federais e conveniadas ao SUS.

A Carteira de Serviços de Saúde do Município do Rio de Janeiro e as ações em saúde na Atenção Primária no Brasil

Resumo Objetivou-se identificar a oferta de ações e procedimentos pelas equipes de saúde da família (eSF), tendo por base a Carteira de Serviços (CS) do Município do Rio de Janeiro (MRJ) e os principais fatores associados a esta oferta, nos diferentes estratos populacionais. Foram utilizados dados do Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica, aplicado a 17.202 eSF, de junho a setembro de 2012 no Brasil. Foram variáveis desfecho: eSF pertencer ao MRJ; eSF ofertar todos os nove procedimentos da CS-MRJ. Foram conduzidas análises uni, bi e multivariada. Evidenciou-se melhor desempenho do MRJ em relação aos demais grandes centros urbanos (EP6#) (p < 5%) em 10 das 14 ações de saúde analisadas. O prontuário eletrônico apresentou 96% de implantação nas eSF do MRJ, contrastando com 34% nas dos EP6# e 14% no Brasil. Tanto no MRJ quanto no EP6# encontrou-se baixa oferta de serviços de saúde mental (cerca de 56%). Enquanto a oferta de procedimentos de baixa complexidade foi um problema maior nos grandes centros, a oferta de ações em saúde nas diferentes linhas de cuidado foi um problema maior nos municípios pequenos. No geral, o MRJ mostrou melhor desempenho quando comparado à média de municípios de grande porte. A carteira de serviço pareceu ser um importante instrumento gerencial.

Preceptoria em Medicina de Família e Comunidade: desafios e realizações em uma Atenção Primária à Saúde em construção

Resumo O fortalecimento da Atenção Primária à Saúde (APS) depende diretamente da formação de médicos especialistas em cuidados primários. Este texto tem como objetivo relatar as experiências de formação em Medicina de Família e Comunidade (MFC) no município do Rio de Janeiro entre os anos 2008 e 2016, tendo como objeto de reflexão o desenvolvimento de preceptores no âmbito da especialização médica, por meio do relato de experiência de três programas de Residência Médica em MFC (PRMFC): da Secretaria Municipal de Saúde (SMS), da Universidade Federal do Rio de Janeiro e da Escola Nacional de Saúde Pública. Dentro do cenário de reforma da APS no Rio de Janeiro criou-se a demanda por médicos especialistas para atuação na rede levando à ampliação dos PRM já estabelecidos e à criação do PRMFC-SMS, propiciando novos espaços de ensino em muitas unidades de saúde da rede municipal. Por caminhos distintos esses PRM avançaram na capacitação de seus preceptores, ofertando cursos e ações locais permanentes, na busca por maior qualificação profissional e melhor equilíbrio entre as responsabilidades de cuidado e de ensino. Investimentos permanentes no fortalecimento dos PRM e na capacitação de preceptores são essenciais para consolidar a reforma na APS em todo o Brasil.

Unidades de Saúde Familiar e Clínicas da Família – essência e semelhanças

Resumo O desenvolvimento, desde 2009, das Clínicas da Família (CF) no Rio de Janeiro tem paralelismos com as Unidades de Saúde Familiar (USF) implementadas em Portugal desde 2006. Neste ensaio, os autores assinalam o encontro em Portugal, em outubro de 2009, com gestores do Ministério da Saúde e da Subsecretaria de Atenção Primária, Vigilância e Promoção da Saúde do Rio de Janeiro, e destacam alguns aspetos essenciais tais como: a organização em equipes multiprofissionais com caráter estrutural permanente; as características das equipes; o seu desenvolvimento (“teambulding”); a organização e a autonomia técnica; os laços emocionais entre os elementos de cada equipe; os instrumentos formais de regulação da autonomia; a responsabilização e a prestação de contas/contratualização; os dispositivos de monitorização e de avaliação; o sistema de lideranças; fatores motivacionais dos profissionais e das equipes; as USF e as CF como organizações aprendentes. Estes aspectos podem resumir-se em “3P”: propósitos, orientação para objetivos de saúde e de bem estar; pessoas, que são a razão das organizações de saúde; processos, continuamente questionados, avaliados e aperfeiçoados.

A qualidade da Atenção Primária à Saúde na Rocinha – Rio de Janeiro, Brasil, na perspectiva dos cuidadores de crianças e dos usuários adultos

Resumo O objetivo deste artigo é avaliar a extensão dos atributos da APS, desde a experiência dos usuários, tanto adultos quanto cuidadores de crianças, comparando a área atendida pelas unidades de saúde do bairro da Rocinha com as demais áreas do distrito sanitário 2.1, no município do Rio de Janeiro. O instrumento de medida utilizado para avaliar a qualidade dos serviços prestados foi o Primary Care Assement Tool. Foi realizado estudo transversal, com amostras aleatórias independentes, com 802 entrevistados. Os resultados apontam melhor desempenho para o cuidado das crianças, quando comparado aos adultos. Os atributos “acesso” e “integralidade – serviços disponíveis” foram aqueles que tiveram os piores desempenhos, provavelmente devido a grande migração externa e interna existente dentro da própria Rocinha. Para melhoria desses atributos, recomendamos a adoção de uma lista única de moradores por ESF, com um número máximo de pessoas, contemplando além da delimitação territorial, a mobilidade interna das pessoas. Destacamos também a importância do fortalecimento do Programa de Residência em Medicina de Família e Comunidade, que desde 2012 forma especialistas, com apoio de preceptores, e viabiliza a ampliação da oferta da carteira de serviços de APS.