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Background: Two policies stood out in the 2000s geared towards changing the care model adopted in Brazil: The National Policy on Primary Health Care, based on a family health care model, and the National Policy on Health Promotion. The aim of this study was to analyze health promotion actions developed by family health care teams in the municipality of Belford Roxo. This town was chosen by virtue of its “below average” level of primary health care services offered in relation to other municipalities in Rio de Janeiro state. Methods: The following methodological strategies were employed: analysis of health systems, document analysis (2010 Annual Health Schedule and 2010 Annual Management Report), participant observation and interviews with nine health care professionals in the region of study, namely: the manager of the Regional Health Polyclinic (responsible for health care actions in the region), and nurses belonging to the eight family health teams. Giddens’ Theory of Structuration was used for analysis of the results. Results: Varying levels of health care activity were found, indicating that the managers have been either unable or lacked the commitment to perform the proposed actions. From a structural point of view, 87.5% of the teams were incomplete. Also of particular note was the lack of any physicians in the teams, which, despite its detrimental effect, was regarded by the interviewees as “natural”. Strong political party influence in the area hindered relations between the team and the local population. Health education, especially through lectures was the main health promotion activity picked up in this study. No cross-sectorial or public participation actions were identified. Connections between the teams for sharing responsibilities were found to be very weak. Conclusion: In addition to political factors, there are also structural limitations such as a lack of human resources that overburdens the teams’ daily activities. From this point of view, the political context and lack of professionals were restrictive factors for health promotion. Belford Roxo is not necessarily representative of other experiences in Brazil. However, problems such as patronage, political manipulation, poverty and incipient cross-sectorial actions are common to other Brazilian towns and cities. Keywords: Primary health care, Family health strategy, Health promotion, Health policy Background System (SUS), created and enacted in the 1988 Brazilian Historically speaking, health care has been focused on Constitution as a citizen’s right and duty of the the formulation and implementation of policies that, State. This health care proposal was grounded on over the course of time, have produced positive results the principles of it being public, universal, comprehensive, for health. equal, decentralized and involving social control and Brazil made a major political investment toward qualifying participation. its health care when it proposed the Unified Health Over the course of more than 20 years, the SUS has been implemented with serious financial and managerial * Correspondence: erikacm@terra.com.br difficulties, but has also led to unquestionable improve- National School of Public Health / Oswaldo Cruz Foundation ments of health indices and access to health services [1]. (Escola Nacional de Saúde Pública/Fundação Oswaldo Cruz), 1480, Leopoldo Bulhões Avenue, Rio de Janeiro 21041-210, Brazil © 2013 dos Reis Moreira and O’Dwyer; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. dos Reis Moreira and O’Dwyer BMC Family Practice 2013, 14:80 Page 2 of 11 http://www.biomedcentral.com/1471-2296/14/80 Two main policies aimed at changing the care model In local development and management, where adopted in Brazil can be identified: The National Policy cross-sectorial actions for health and quality of life on Primary Health Care (PNAB), based on a family are implemented, as a result of, and motivation for health care model, and the National Policy on Health the empowerment of population groups and Promotion (PNPS). individuals; Primary Health Care is regulated by a national policy, In the national development policies and model, which defines it as “a set of individual and collective where the determinant factors for equality are health care actions, encompassing health protection and actually defined [6]. promotion, disease prevention, diagnosis, treatment, rehabilitation, damage control and health maintenance Health Promotion is, therefore, presented as the oppor- with the objective of developing comprehensive care that tunity not to formulate an agenda for the improvement impacts on people’s health and autonomy and on the of the SUS, but also to point toward a new agenda, determinant factors and conditions for collective health.” redefining health policy for the new millennium and [2], p. 3. This policy established Primary Health Care as resurrecting the flag for public health reform to promote the main gateway to the health service system and reasserts change and fight social inequalities; actions required to its importance in the SUS care framework. ensure health and dignified life for the people [6]. Under the PNAB, the Family Health Strategy (ESF) is the priority and core model for reorganizing and ordering The reorientation of primary care in Brazil all SUS health care networks. The policy is built on the The debate on primary health care took on greater inter- system’s principles and guidelines and aims to contribute national magnitude in the 1970s. Questions arose which toward effective universality, comprehensiveness, equality, challenged the interventionist and specialist hegemonic access, coordinated care, trust and humanization [2]. The medical model, with over-fragmented care and little Health Promotion Policy was heavily influenced by the impact on improving public health conditions [7]. Ottawa Charter (1986), which defined that health is At the 1977 World Health Assembly, the World constructed through caring for oneself and for others, the Health Organization (WHO) proposed “Health for All ability to make decisions and have control over one’slife by the Year 2000” as the main target for governments st circumstances, and through the struggle to ensure that and the institution itself. In 1978 the 1 International society provides the conditions that enable everyone to Conference on Primary Health Care was organized by achieve health [3]. The Ottawa Charter, inspired by the the WHO in partnership with UNICEF (United Nations principles of the Alma-Ata Declaration (1978) and by the Children’s Fund) in Alma-Ata, Kazakhstan. At this goal of “Health for all by the year 2000”,resulted from the conference primary health care was adopted as a strategy First International Conference on Health Promotion, and to achieve the Health for All by the Year 2000 goal and officially stated the finding that the main determinants of identified as a fundamental component of any effective health lay outside the treatment system. This document health care system. Whereas the notion of primary care proposed the notion of health as quality of life, resulting defended by the WHO and promoted in the wake of from a complex process conditioned by various factors, Alma-Ata pointed to comprehensive care, critics of that such as diet, social justice, the ecosystem, income and concept, interpreted as idealistic, triggered the promotion education [4]. of a selective proposal, which won the support of other In Brazil, Health Promotion was proposed as a international agencies, including UNICEF itself, which distinguishing element of the new health care model, had supported the Alma-Ata Conference [8]. spearheaded by the Family Health Strategy. Therefore, the Alma-Ata Conference is considered a It is important to highlight that the PNAB and the milestone in the broad discussion on Primary Health PNPS were published in the same period (March 2006), Care (PHC), and the Bellagio Conference, held by the in the same historical and political context. The Ministry of Rockefeller Foundation in Italy in 1979, with the theme Health published the National Policy on Health Promotion “Health and Population in Development”, can be seen as [5] with the intention of implementing the agenda which another milestone, as that event marked the emergence it had been promoting for some time, materializing the of tension between these two interpretations of PHC. political will to reorganize health care practices. Health The notion of selective primary care introduced a new promotion, therefore, proposes changes in at least three perspective, referring to a package of low-cost technical spheres: interventions to tackle the main diseases that afflicted the populations of developing nations [8]. In health care, where services are demedicalized and The idea of selectivity was promoted by the World redirected in such a way as to receive and help Bank (WB), which defended the concept of a “basket” of individuals and groups build autonomy; health services. It suggested that the public sector dos Reis Moreira and O’Dwyer BMC Family Practice 2013, 14:80 Page 3 of 11 http://www.biomedcentral.com/1471-2296/14/80 should only be responsible for providing a minimum set From 1998 to 2004 there was a significant growth in all of essential actions to those who cannot afford health regions, but with greater coverage in municipalities with care costs [9]. a low Human Development Index (HDI). In 2011, the In Canada there was the shift to outpatient care in the number of family health teams reached 31,981 in 5,279 1980s and early 1990s, with neoliberalism in full swing. municipalities [13]. Primary health care in that country was a strategy to Despite the growth over the past few years, there will rationalize services, reduce costs and facilitate care access probably always be some discrepancy between the concept and coordination, in line with the World Bank and its of Primary Health Care as designed by national policy and minimum service package [10]. how it is expressed in local realities; with it being neces- European Union countries in the 1990s also witnessed sary to comprehend how Primary Health Care and the the reorganization of primary care services being driven PSF are configured and under which conditions they are to reduce health spending and meet the demands of a inserted and operate in local health systems [15]. changing epidemiological profile, as well as to promote Adhesion to the PSF varied at different moments of its coordinated service provision through various care growth, reflecting the cultural and social diversity between levels [11]. the different regions of Brazil. The initial growth followed The Brazilian SUS was created in 1988, in revolutionary a trend of coverage in poorly assisted areas, represented fashion and despite the economic and political context. by small towns, beginning in North and Northeast Due to the international diffusion of the notion of selective [15-17]. Regardless of the phase of expansion of the family primary health care in the 1980s, the term Basic Health health strategy, the Southeast as a whole has displayed far Care was coined in Brazil to distinguish the country’s less growth than the other regions of Brazil [15]. In Rio de proposal for universal and comprehensive care from the Janeiro state, over the years hospitals have been prioritized selective concept. for the provision of health care services, generating a In 1991, the Ministry of Health regulated the Community unique disparity between hospitals and primary care units. Health Agents Program (PACS) based on trials developed In the state capital, coverage of the strategy was approxi- mainly in the Northeast of the country. The Community mately 3% until 2008. Health Agents (ACS) are residents of the service coverage Because of the challenges and controversies surrounding areas, trained to work with 100 to 250 families, totaling no the effectiveness of the family health strategy in metropol- more than 750 people. Their work is supervised and itan regions [15,16], for our field work we chose a munici- assessed by a nurse. There are no physicians in the PACS pality in the metropolitan region of the state of Rio de teams. Initially, very little progress was made in terms of Janeiro. We chose the municipality of Belford Roxo, a population coverage of the program. Expansion occurred town with a level of primary care services “significantly mainly in small municipalities in the North and Northeast below” the state average [18], making it a priority munici- regions, in areas where public primary care networks were pality in relation to investment in health care, lying fourth practically non-existent [7]. The aim was to close care from bottom in the state ranking. Table 1 shows the gaps, initially introducing these professionals as the Family growth of ESF implementation over the years. In this table Health Program (PSF) was being set up. The Family one can see that, although coverage of the Family Health Health Program was singled out as a priority policy in the Strategy is limited in the municipality, the number of 1990s, and pushed harder from 1995 onwards. teams has been increasing over time with a consequential The prioritization of the PSF was reflected by the growth in the provision of services and actions. adoption of a specific financial incentive [12] aimed to Despite the recent advances in the ESF, local health change traditional care patterns on a continental scale, levels are extremely low, which could be related to struc- strengthening primary health care actions in the SUS, tural or resource-related factors, such as the low provision of services on the network, low quality of the health proposed as a transformative practice. With this incentive provided by the Ministry of Health, services offered, and lack of human resources in health the Family Health Program grew across Brazil, with 3,062 care. This municipality is extremely unequal in terms of human development. According to the FIRJAN World family health teams implanted in 1,134 municipalities in 1998. Despite the early inclusion of towns on the outskirts Development Indicator (IFDM), the municipality of of metropolitan regions, from 2000 onwards the program Belford Roxo is one of the twelve worst out of all 92 municipalities of Rio de Janeiro state expanded in smaller municipalities, which situation has . begun to change recently [13,14]. In 2004, the northeastern, Belford Roxo is split into 5 administrative regions, on mid-western and southern regions of Brazil had the which basis the municipal health secretariat organizes highest proportions of PSF coverage, approximately 55%, health territories, under the charge of a Regional Health 41% and 38% of the population, respectively, followed with Polyclinic (PRS). In each regional health division, the northern and southeastern regions, with 34% and 30%. primary health care is organized through traditional dos Reis Moreira and O’Dwyer BMC Family Practice 2013, 14:80 Page 4 of 11 http://www.biomedcentral.com/1471-2296/14/80 Table 1 Progress of family health strategy (ESF) coverage Methods in the city of Belford Roxo from 1998-2011 The following methodological strategies were employed: Year Population Family health teams analysis of health systems, document analysis, participant observation and interviews with nine health care profes- Implemented Estimate of Estimate of population population sionals in the study region, namely: the manager of the covered covered (Percentage) Regional Health Polyclinic (responsible for health care 1998 408,949 0 0 0 actions in the region), and nurses belonging to the eight 1999 408,949 2 6,900 1.69 family health teams. We began the field work by observing 2000 425,194 14 48,300 11.36 group meetings and health education activities over the course of a month, according to the eight family health 2001 442,012 4 13,800 3.12 teams’ schedule. Forty hours of participant observation 2002 442,012 6 20,700 4.68 were distributed among the teams. These participant 2003 449,997 11 37,950 8.43 observation activities led the conclusion that the nurses 2004 457,201 17 58,650 12.83 were key to the study, as well as the director of the 2005 457,201 18 62,100 13.58 Regional Health Polyclinic. 2006 480,695 23 79,350 16.51 Nurses were selected as research subjects because they represent an essential category within the family health 2007 489,002 27 93,150 19.05 team with the “role” of team supervisors. For Araújo 2008 489,002 22 75,900 15.52 (2009), nurses have acted as facilitators both in family- 2009 495,694 28 96,600 19.49 centered and individual-centered nursing care [19]. 2010 501,544 29 100,050 19.95 The PRS director was invited to be interviewed as she 2011 469,332 32 110,400 23.52 is responsible for planning ESF activities. All the nurses Source: MS/SAS/DAB and IBGE. and the director promptly agreed to be interviewed. The research took place in 2011. The aim of the interviews was to investigate the notion of health promotion, which Basic Health Care Units (UBS), family health teams and health promotion actions were performed by the teams, a PRS. the integration between services and communication The regional health division with the most structural with other sectors, as well as the relationship between resources was studied, with it being understood that management and the ESF teams in the region. those resources would provide the basis for more All the interviews were recorded and transcribed. They structured work. The region studied had one Regional were conducted in a room at the health care unit, with Health Polyclinic (the first in the municipality), one complete privacy and at a time chosen by the interviewee. Family Health Support Unit (NASF) , 8 Family Health The interviewees were numbered in chronological order Teams, oral health teams, 5 Basic Health Care Units, 1 of the interviews. The research group analyzed the con- Referral Center and 1 Municipal Hospital. This region tent of the interviews through repeated readings of the has recently received investments to tackle these transcriptions, listening to the recordings and reviewing problems. the notes. Comparing codes with discursive excerpts and In addition to the analysis of official data, the quotes can guarantee the reliability and validity of the study also involved reviews of the 2010 Annual interview codification process. Health Schedule (PAS) and Annual Management Giddens’ Theory of Structuration was used for analysis Report (RAG). The examination of these documents of the results [20]. According to Giddens, social practices intended to relate managerial guidelines for health can be seen as procedures, methods or skilled techniques promotion practices to the field work. We prioritized appropriately executed by social agents using rules and questions that referred to activities carried out by resources. Therefore, agents are largely free to take health teams both individually and collectively and action, but are always conditioned by the structural also questions that described the integration between resources available. Giddens sees social practices as teams and with the Regional Health Polyclinic of structured within this duality of social object and Heliópolis. individual action, and rejects the dominance of either In this paper we will review how primary health care, extreme. a policy that remained a Ministry of Health priority Actors use their knowledgeability to create routine throughout the 2000s, incorporated this other priority practices or produce changes depending on the ‘circum- stances of the action’. These are the ways in which social directive: health promotion. We analyzed health promotion actions developed by family health care teams in the phenomena and materials facilitate or restrict human municipality of Belford Roxo. action, illustrating the duality of the structure [20]. dos Reis Moreira and O’Dwyer BMC Family Practice 2013, 14:80 Page 5 of 11 http://www.biomedcentral.com/1471-2296/14/80 The structure is formed by rules and resources. The presents the results achieved and offers any steering that normative aspect of the rules corresponds to practices may be necessary” [22], p.33. from the perspective of rights and duties and the ways In the analysis of the Annual Health Schedule, health in which the practices can be executed. The semantic promotion is part of the planning for some areas/sectors, dimension of the rules corresponds to the qualitative such as the technical coordination of health care for the and procedural meaning of the practices, associated to elderly, the health information, education and communi- their performance. The resources are the facilities or cation sector, worker health and technical coordination of power bases to which the agent has access and that he diet and nutrition. These groups plan health promotion manipulates to influence interaction with others. These actions, but still in an isolated manner, with no communi- resources may be authoritative (position or office held, cation neither within the health care sector nor between for example) or allocative (material) [21]. different sectors. Very little dialog with other sectors of Giddens believes that agents’ actions are contextualized local management was found and cross-sectorial relations, in time and space and depend on the availability of rules one of the foundations for health promotion, was and resources. Agents are always competent at engaging disregarded in the majority of the planned actions. these resources and the process of structuration occurs as When reviewing the Annual Management Report and the means and the result of the agent’s action and the checking the achievement of targets, including health engagement of the resources [20]. promotion, varying levels of health care activity were Access to the agent may come about through discursive found, indicating that the managers have been either consciousness or practical consciousness. The interviews unable or lacked the commitment to perform the were aimedatgivingexpression tothe discursive proposed actions. The documents may function merely as consciousness of the actors. Access to the practical an element of bureaucracy in the system We conducted consciousness was obtained through the participant the field work to investigate whether the municipality of observation, addressing the agent’s perceptions, culture Belford Roxo had incorporated the recommendations and professional practice. from a prescriptive point of view, or if that planning had The theory of structuration is extremely useful to influenced care workers, functioning as a rule and demonstrate structural changes over a longer time span; resource that the agents of the practice used to modify however it can also show how players engage resources their actions [20]. in microsocial spaces, whether intentionally or not. This study was submitted for review by the ENSP Discussion Ethics Committee and was duly approved; case number The discourse and the local scenario of practices were 0236.0.031.000-10. The subjects of this research were analyzed from two different perspectives: in terms of the informed of its objectives, benefits and risks, and were structural dimension and the organizational dimension. offered the choice to participate or not. An informed The structural dimension represented Giddens’ structural voluntary consent form was provided to all the inter- category, that is, the rules and resources for the action; viewees; information was provided under terms of strict whereas the organizational dimension represented the confidentiality and anonymity. action of the agents based on the engagement of those resources. Results The Health Care Plan, Annual Health Care Schedule and Annual Management Report were the focus of the Structural dimension document analysis. The organization of the Annual In this section we will focus on the composition of the Health Schedule is represented in Table 2. teams, their training and client allocation. Client allocation The Health Care Plan in defined in article 2 of Ministerial was considered a structural question, as it does not Directive 3.332/2006 of the Ministry of Health as an depend on the team and serves as a resource or rule instrument to be developed based on situational analysis, to be engaged. presenting the planning expressed in terms of objectives, According to a governmental decision, a Family Health guidelines and targets for a four-year period. It should team is responsible for the health care of a population identify health policies and commitments for a specific group of no more than 4,000 people who live in a defined management level, as well as forming the basis for the geographical area. Family health teams consist of at execution, monitoring, evaluation and management of the least one physician, one nurse, one nursing assistant health system [22], p. 18. The Annual Health Care Schedule or technician, and community health agents (ACS). is “the instrument that supports the implementation of Each ACS should not be responsible for monitoring any the intentions outlined in the Health Care Plan” and the more than 750 inhabitants and each team for no more Annual Management Report is “the instrument that than 12 ACS, operating in previously defined areas [2]. dos Reis Moreira and O’Dwyer BMC Family Practice 2013, 14:80 Page 6 of 11 http://www.biomedcentral.com/1471-2296/14/80 Table 2 Annual health planning organization, 2010 – Belford Roxo/RJ, 2011 Benchmarks Guidelines Guideline 1: Expanding people’s access to healthcare services and improving the quality of healthcare actions Guideline 2 – Organizing and training the Superintendent’s for Basic Healthcare Office Staff Guideline 3: Guaranteeing comprehensive care by performing actions in the life cycle prioritized by Life Pact goals Guideline 4: Guaranteeing that people’s healthcare needs will be met through Benchmark I: determinants of health and health conditioning factors technical, interdisciplinary, strategic and scheduling actions Guideline 5: Improving effectiveness of specialized and reference outpatient and hospital services taking into account a Healthcare Network that is territorial, hierarchical and regional Guideline 6: Strengthening the pharmaceutical assistance policy Guideline 7: Guaranteeing the implementation of health inspection actions, preventing and controlling diseases affecting the population Guideline 1: Promoting intersectoral actions that contribute to improving life and health conditions of the population Guideline 1: Structuring and Training management by incorporating innovative Benchmark II: people’s health conditions and sustainable planning processes Guideline 2: Improving the process of decentralizing / regionalizing and territorializing the Healthcare network Guideline 3: Organizing and regulating access to outpatient, hospital and testing services Guideline 4: Strengthening people’s participation and social control in SUS Management Guideline 5: Work management and improvements to better meet the needs Benchmark III: improving municipal management of SUS users Guideline 6: Organizing and Strengthening health education actions Guideline 7: Improving the quality of Health communication and information processes Guideline 8: Municipal healthcare system maintenance – costs and investments In the municipality studied, 87.5% of the teams were “We don’t do pre-natal care because the doctor doesn’t incomplete. One recurrent difficulty in Brazil is establishing do it… we can’t do it on our own, only if the doctor is doctors within the family health strategy, something present… and he doesn’t have any available hours.” E2 achieved in only 12.5% of the teams studied. The SUS competes with the private health market for doctors, since In a study with similar objectives to this one, Beato et most of them work under both the public and private al (2011) showed how continued family health team systems. This dual commitment works to the detriment of stability over time helped improve the work process [24]. the public sector, involving even practices of differing On the flip side to Beato et al’s study, the lack of doctors quality [23]. Regardless of our analysis, the lack of in the teams studied distorts the work of the family health physicians does not seem to be the main problem with strategy, as indicated by the following statement: team composition; the issue is exacerbated by the fact that in many teams the prescribed working hours are “There were no doctors working at our clinic for a year not fulfilled. and a half… We no longer have that bond we used to It is common practice for SUS doctors to work only have, for example, in 2005, 2006, when I used to work. a fraction of their specified hours. According to The doctor came every day. So we were much more Giddens’ framework, we could say that this has been a integrated with the families because they had monthly structuring factor for care actions in the SUS. This appointments, one with the doctor and the next with situation is illustrated by how ‘naturally’ one interviewed the nurse. So we knew. I knew which children were nurse talks about the team doctor, who works less behind with their immunizations. I had everyone in than his contract hours but is not held accountable the palm of my hand … Today we’re basically for it. following up and that’s all. So it’s not like before when dos Reis Moreira and O’Dwyer BMC Family Practice 2013, 14:80 Page 7 of 11 http://www.biomedcentral.com/1471-2296/14/80 we had… It was really a PSF. But not today, today the installed as a form of aggression against the owner, their doctor no longer has the time to do house calls… She political opponent. no longer has time to provide the care they should be getting.” E8 “No, we don’t have any of that… Some do form a good relationship, but we have a lot of problems in This account reports the physical absence of the doctor this PSF…, it really does belong to a politician. The and the medical rationale that the policy on primary building is rented… We’re always having problems. health care and health promotion intends to overcome; We lose vaccines all the time because someone’s that of care based purely on curative activities. Geneua et disconnected the mains over the weekend… On al (2008) discussed medical practice in primary health Friday, they broke in here… someone tried to steal care and pointed out how difficult doctors found it to take things from the kitchen, stuff like that… And it an active role in the educational activities [25]. makes it hard… because we’re always denying people This difficulty for doctors to commit to non-care and things. We never have any vaccines (reports that health promotion activities was confirmed by one disconnecting the mains is a frequent occurrence), interviewee. and so we can’tprovide good service, we’ve got no medications…” E8 “The doctors hardly ever participate, because they come to treat patients … it’s usually the nurses, the Local party politics has also hindered the allocation of ACSs, the dental hygiene and the NASF staff.” E1 the family health services. Some teams did not cover people who lived on the same street, but covered other In this context, Machado and Porto (2003) stated that more distant neighborhoods. This was a result of the the behavior of several actors reflects certain power allocation not taking into consideration the needs of the structures and cultural practices that must be overcome local population and their proximity to the unit, damaging in order to give way to other more effective ones. Even the work process of the teams, who also take the blame when there are resources available to facilitate the for the problem. In this case, allocation, which should be a agents’ actions, the doctors fail to make use of such facilitating rule of ESF action, is transformed into a resources to change their practice and structure a form of restrictive rule. care more in line with guidelines for health promotion and health care model change [26]. ......what happens here is that some streets are not The population group allocated to each team varied listed, so this causes a huge problem for us here and from 400 to 1,500 families, and from 80 to 187 per ACS. for the users, who want to make appointments here It was found that 12.5% of the teams provided services and can’t. So this is a State issue when they brought to a larger population group than recommended. Bearing the PSF here and did this, they some listed streets that in mind the average family size in poor municipalities like are miles away… and some people who live around Belford Roxo is 4.2 members, we could see that the the corner are not listed, for example. So it’s a little majority of ACSs were working with less people than complicated… people don’t understand… they want determined in the ministerial directive. the service, they don’t understand, and they want to However, ACSs represented the main human resources attack us, they think it’s our fault. So it’s a love-hate shortage in the region. This was a surprising discovery, relationship, you know?” E8 as it had not been indicated in any nationwide studies. We found that this difference in relation to other Another structuring element revealed in the research scenarios in the country could be explained by the strong is that the health care professional most frequently and long-standing connection between party politics and present in the team, the nurse, had no prior professional public health services in the area. No specific elements experience in the family health strategy or primary care; were expounded that confirmed this hypothesis; however, they had either recently graduated or had previously since the agents must live in the community, this impres- worked in hospitals before coming to work with primary sion remains strong. The political dispute over welfare in care. This is perhaps not surprising, as we are going places like Belford Roxo is deeply rooted in the exchange through a phase of modification of the care model and of votes for personal interests. This issue has heavily until recently the hospital was the main setting for interfered in the formation of trust relationships between health care. During such a transition, staff training is the teams and the public. required in order to build the new model. Some units belonged to local politicians and were The way in which these professionals described health leased to the municipal health secretariat, and rival promotion reflected their lack of training to work in the groups “attacked” the unit where the health team was family health strategy. dos Reis Moreira and O’Dwyer BMC Family Practice 2013, 14:80 Page 8 of 11 http://www.biomedcentral.com/1471-2296/14/80 “… Prevention, because me offering prevention will “Everything we cover here is through talks, giving bring about health promotion for them. I go along and advice, promoting something, organize a game, have a do the prevention, check their pressure, give them snack so they feel welcome and talk… we use whatever advice.” E7 is available, like leaflets …” E8 The director of the polyclinic showed a broader under- Here is another account of these educational activities: standing of the concept, seeing health promotion as incorporating education, employment, right to leisure “Giving patients advice, giving the community advice time and acknowledging the need for cross-sectorial on how to prevent diseases before they appear; participation. monitoring preventions actions and not just coming to the unit when they’re ill, but rather coming beforehand to really promote health, and especially using talks, Organizational dimension because this is how they can learn to identify anything In this section we will discuss cross-sectorial characteristics in the early stages.” E1 and the planning and performance of health promotion actions. For actions to be cross-sectorial, joint efforts are Some teams, although failing to engage in any cross- required for the planning and tackling of local issues, sectorial activity, do request other local sectors (such as that is why this aspect has been categorized as an the economic sector) to carry out activities with the public. organizational dimension. Cross-sectorial work is an essential activity for health “… Every time we’ve promoted any action the promotion and was regarded as the use of the physical community has helped us; local businessmen, the space of the social apparatus in the area. In the case of church, we've held events at the church, nothing else. the Regional Health Polyclinic, the management created Whenever we want to do any social work, yes, only an association formed by local businessmen, families and then, otherwise (gesticulates to say no).” E2 the Catholic Church. There is a very close relationship and partnership with the Catholic Church, because the Even among teams that report planning their activities, polyclinic is built on land owned and provided by the we notice that such only pertained to making appoint- church. Apart from this partnership with the association, ments or scheduling activities within the health care unit, there are no other partnerships with structuring sectors without mentioning any involvement of other sectors or such as education, public security, social assistance or actions outside that sphere. housing. The polyclinic management reports that the None of the interviewees cited basing their planning partnership with the church and school consists in using or their activities on Ministry of Health documents, such collective community spaces for any talks given outside as the PNPS [5], or guidelines issued by the local health the health service. secretariat or family health strategy coordinator’s office, or even on any epidemiological evidence. For the “Most the time they’re held here in the unit, sometimes regional director, the identification of health problems at a church, but usually here.” E8 depends on Ministry of Health guidance and on the physician’s ability to correctly assess patients’ conditions, Another important promotional activity is changing acquired through practice. unhealthy living habits, such as alcohol abuse, smoking We imagine that the Polyclinic should play an important and taking drugs, unhealthy diets and lack of physical role in guiding and integrating the several family health exercise. A recent study [27] investigated health pro- teams, action planning and team training. However, the meetings between the different teams were identified as motion based on changes in lifestyle. One important finding of the study was how valuable the nursing merely a platform for the delivery of production reports. team is to health promotion. The authors identified “We meet up when we delivery production reports. The the patient, the health care professional and managers th as actors bearing responsibilities for making lifestyle 20 of every month.” E7 changes [27]. In our study it was evident that the responsibility-sharing bond was very weak. The nurses As regards factors that might interfere in the perform- address questions of lifestyle changes, but always in a ance of actions deemed to “promote health”, the nurses normative manner with very limited contextualization almost always reported lack of time, since most the and planning. teams are incomplete which leads to work overload, Health education, especially through lectures was the allied to a lack of institutional support. The lack of doctors main health promotion activity picked up in this study. in the teams ends up overburdening the nurses, who are dos Reis Moreira and O’Dwyer BMC Family Practice 2013, 14:80 Page 9 of 11 http://www.biomedcentral.com/1471-2296/14/80 charged with solving people's health problems and Health Strategy framework. However, the aim was to therefore unable to perform their own duties with the demonstrate the complexity in modifying a health care families. As well as this technical impact, there is also model in a poor metropolitan municipality, like many the symbolic importance of the doctor in the eyes of the others in Brazil, despite the structural investment in public, who often do not have faith in the team when the ESF. the doctor is not present. Primary health care is acknowledged as an innovation of global significance, which Brazil has adopted as its “Lack of doctors … the families don’t come if there’sno model for the SUS. Structuring a change in the care doctor… only when they need some medicine…” E6 model is a dynamic process that takes places over the course of time as the actors involved engage the structural Mattos [28] maintains that transforming the care resources. It is our understanding that the model based practices is the challenge for all the policies, with the on primary care and health promotion is a form of aim of providing some response to human suffering and structuring a new health care proposal; hence our producing comprehensive public health care. The attitude choice to analyze the actors’ actions in relation to this toward suffering was represented by a degree of concern new model, even in situations of co-presence and over a on the team’s part to meet the population’sneeds. short period of time. Through documental analysis of the Annual Health “If someone comes in, not an emergency, but if they’re Schedule and Annual Management Report for 2010, we unwell, with a high fever … we provide care for them. could identify that the health teams and professionals Sometimes we also attend to emergency cases.” E7 were encountering difficulties in incorporating many of the proposed actions. The nurses observed and interviewed referred to a lack In general, the objectives and targets proposed in the of enthusiasm and belief in the proposed reorientation of plans were not met due to a lack of technical cooperation the model. However, they were aware of how important between those responsible for executing the actions, an their work was. They acknowledged the heavier burden unequal distribution of resources and a lack of political imposed by the doctors’ absence, but did not criticize such coordination and partnerships to complete the actions. absence, as if it were a structuring rule of the ESF, not Another challenge is to implement continuous assessment being able to count on doctors’ participation. of actions with the presence of the health teams or team representatives, since activity reports and documents are “I don’t think I’ve helped very much… I couldn’t currently prepared by the technical coordination provide particularly good care because we didn’t have without any involvement of the local actors responsible a doctor, so it’s all about the consultations … and for the actions. Therefore this document is a management when you’re alone you can't get everything across… it’s resource to support the action of those professionals good when there are the two of you speaking to the which has not been employed to its full ‘facilitating’ public, the doctor and the nurse together, then it’s potential. completely different.” E6 The health care teams’ promotional actions are often unplanned, as training deficiencies limit and steer their However, there are also cases where the unit has no actions toward treating disease. bond with the population and contact occurs mainly to When health promotion actions are performed, the meet health care needs at a given moment in time. It is involvement of other social actors is still limited. This easy to perceive how this habit of seeking care only study found out that other sectors, such as education, when really necessary weakens the bond between the the environment, labor and social assistance, are not team and user, as well as the health promotion outlook, integrated into activities aimed at improve people’s especially when there is no doctor figure participating in health. Additionally, partnerships occur on the basis of the team activities. This practice is perpetuated because the availability of venues for teams to perform their desired doctor’s work in the team is usually limited to exclusively activities. In other words, there is no cross-sectorial curative care. support network focused on public health promotion. As a result of this lack of a support network allied to an Conclusions unfavorable context such actions become increasingly We opted to study a regional health care division with less frequent in the teams’ daily routines. Despite the largest care network in a very poor municipality, these criticisms of the lack of cross-sectorial actions, with major historical health care deficiencies. The result we understand that this is a role that should also be of the study cannot be considered representative of the shared with the NASF and other structures within municipality, which is still implementing the Family the municipality. dos Reis Moreira and O’Dwyer BMC Family Practice 2013, 14:80 Page 10 of 11 http://www.biomedcentral.com/1471-2296/14/80 The study revealed the presence of political factors We recommend the assessment of other regions with hindering the establishment of partnerships with other similar characteristics, as well as regions in different sectors and even the smooth running of the unit. When social and care scenarios. It is our understanding that a health care facility cannot offer the public basic actions further qualitative studies are necessary in order to like medical care and immunization, its task to develop understand how the ESF is being structured as an partnerships and trust-based relationships becomes organizational basis of the care model. significantly harder. This situation has prevented the Other experiences in Brazil have reported positive health teams operating in this context from becoming a results, based on heavy investment in partnerships, reference for the local population. These teams have training and health care funding [29]. therefore been unable to reinforce any community action We hope that the matters addressed here will motivate as subjects in the self-care process. a fresh debate on the topic of health promotion and, Another particular feature of this region, which clearly above all, the various ways in which better living and illustrates how the microsocial relations are structuring, health conditions can be achieved for individuals. was the way in which the client allocation was allowed to be executed. The exclusion of neighboring streets Endnotes from the health units is a new, locally-established rule IFDM is an annual study conducted by the FIRJAN that has generated dissatisfaction and delegitimized the System (Rio de Janeiro State Federation of Industries) potential bond intended by the ESF. and that follows the development of all 5,564 Brazilian In addition to political factors, there are also structural municipalities in three areas: Employment, Income, limitations such as a lack of human resources that over- Health and Education. It is based exclusively on official burdens the teams’ daily activities. Lack of physicians or public statistics, provided by the Ministries of Labor, reduced hours worked by those professionals is a limiting Education and Health. factor for the execution of health promotion activities, The Family Health Support Unit (NASF) consists of however the nurses refrain from criticizing this role, teams that are composed of professionals from different restricted to curative practice, which hinders the formation areas. They provide support and work in partnership of abondbetween the publicand theteam. From this with Family Health professionals, focusing on health point of view, the political context and lack of professionals practices in areas under the responsibility of the FH were restrictive factors for health promotion. team NASF is an innovative strategy that aims to help, Therefore, as regards health promotion actions in expand and improve health care and management in primarycareinBelford Roxo,the resultsofthisstudy Basic Care/Family Health. indicate that tackling issues as structural as poverty Abbreviations and party political coercion requires a better qualified ACS: Community health agent; APS: Primary health care; WB: World bank; professional, integrated into his work and supported ESF: Family health strategy; HDI: Human development index; IFDM: FIRJAN by other instances, such as polyclinics and health World development indicator; FIRJAN: Rio de Janeiro State Federation of Industries; NASF: Family health support unit; WHO: World health departments. There are several regions in Brazil with organization; PAS: Annual health schedule; PNAB: National policy on basic serious socio-environmental weaknesses and governmental health care; PNPS: National policy on health promotion; PSF: Family health proposals have addressed the problem from a normative program; RAG: Annual management report; SUS: Unified health system (Sistema Único de Saúde); UNICEF: United nations children’s fund. perspective. However, these resources are unable to change the care model and promote health in situations of Competing interests such difficulty, as reported in the case of this study. The authors declare to have no conflict of interests. Despite the difficulties identified in nurses’ practice, Authors’ contributions these professionals are crucial to the success of the ESF ECRM made a substantial contribution to the original idea, design and data and health promotion. collection, analysis and interpretation, and wrote the manuscript. GO made a A limitation of this study is the acknowledgment that substantial contribution to the original idea, design, and data analysis and interpretation, and wrote the manuscript. All the authors have read and the municipality of Belford Roxo does not necessarily approved the final manuscript. provide a fair representation of the experiences throughout Brazil, given the heterogeneous nature of the country and Authors’ information GO is a researcher belonging to the research group that investigates the of the implementation of the policy in local contexts. “Formulation and implementation of public policies and management of However, problems such as patronage, political manipula- health systems – theoretical and methodological approaches in public policy tion, poverty and incipient cross-sectorial actions are analysis”. ECRM is a Master’s degree student in Public Health at the National School of Public Health / Oswaldo Cruz Foundation. common to other Brazilian towns and cities. Another limiting factor was the choice to interview the nurses, but Acknowledgements not the rest of the team members to understand the We thank ENSP’s Vice-Directorate for Research for its support for translation teamwork proposed for primary care. of the manuscript as well as our financial supporters. dos Reis Moreira and O’Dwyer BMC Family Practice 2013, 14:80 Page 11 of 11 http://www.biomedcentral.com/1471-2296/14/80 Received: 25 January 2013 Accepted: 6 June 2013 23. Mattos RA: Comprehensiveness, work, health and professional training. In Published: 13 June 2013 Government, society and professional health training: contradictions and challenges in 20 years of the SUS. Edited by Matta GC, Lima JCF. Rio de Janeiro: Fiocruz; 2008:313–352. References 24. Beato MSF, Stralen CJ, Passos ICF: A discursive analysis of health 1. Paim J, Travassos C, Bahia L, Almeida C, Macinko J: The health system in promotion meanings incorporated into the Family Health Strategy. 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BMC Family Practice – Springer Journals
Published: Jun 13, 2013
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