The structure of Brazilian PHC units: what has changed between 2012 and 2024?Abstract
The structural typology of PHC units was drawn up based on the results of the 2024 National Census of PHC units, and the results were compared with those of 2012. Types of teams, diversity of professionals, shifts, available services, and facilities and supplies were used as the sub-dimension categories. A reference standard was set for each sub-dimension and a standardized score was calculated, with 1 being the best. Of the 44,938 PHC units that took part in the Census, 43,209 presented complete information on the variables and were analyzed. The final average score was 0.878, which proved to be 20% higher than in 2012. The sub-dimension with the worst score was “types of teams”, and the best was “shifts”. The units were grouped according to their final score from best to worst: A, B, C, D, E. All regions increased the percentage of PHC units in groups A and B, especially the North and Northeast. Type A was observed in 21.3% of the PHC units, a 4.4-fold increase, when compared to 2012. Advances in infrastructure conditions, shifts, and the increased presence of doctors indicate the effects of policies aimed at expanding access to PHC. However, essential components for comprehensive PHC still deserve attention, such as the presence of a sufficient number of Community Health Workers (CHWs), universal dispensing of medicines, and equalization between oral health teams and family health strategy (FHS) teams.
Key words:
Primary Health Care; Health Services Evaluation; Health Centers; Structure of Services
Resumo
A tipologia da estrutura das UBS foi elaborada com base nos resultados do Censo Nacional das UBS de 2024, os resultados foram comparados com os de 2012. Tipo de equipe, diversidade de profissionais, turnos de funcionamento, serviços disponíveis e instalações e insumos foram as subdimensões utilizadas. Para cada subdimensão foi definido padrão de referência e calculado escore padronizado, sendo 1 o melhor. Das 44.938 UBS que participaram do Censo, 43.209 apresentavam informações completas das variáveis e foram analisadas. O escore médio final foi de 0,878, 20% maior que o de 2012. A subdimensão com pior escore foi “tipos de equipes” e a melhor “turnos de funcionamento”. As unidades foram agrupadas de acordo com o seu escore final da melhor para a pior: A, B, C, D, E. Todas as regiões aumentaram os percentuais de UBS nos grupos A e B, especialmente Norte e Nordeste. O tipo A foi observado em 21,3 % das UBS, crescimento de 4,4 vezes comparando com 2012. Avanços nas condições de infraestrutura, nos turnos de funcionamento, bem como no aumento da presença de médicos indicam efeitos de políticas destinadas à ampliação do acesso à APS. No entanto, ainda merecem atenção componentes essenciais para a oferta de APS abrangente, como a presença de ACS em número suficiente, dispensação universal de medicamentos e equiparação entre equipes de saúde bucal e equipes de saúde da família.
Palavras-chave:
Atenção Primária à Saúde; Avaliação de Serviços de Saúde; Unidade Básicas de Saúde; Estrutura dos Serviços
Resumen
La tipología de la estructura de las UBS se elaboró a partir de los resultados del Censo Nacional de UBS, 2024, cuyos resultados se compararon con los de 2012. El tipo de equipo, la diversidad de profesionales, los turnos, los servicios disponibles y las instalaciones y suministros fueron las subdimensiones utilizadas. Se estableció un estándar de referencia a cada subdimensión y se calculó una puntuación estandarizada, siendo 1 la mejor. De las 44.938 UBS que participaron en el Censo, 43.209 tenían información completa sobre las variables y fueron analizadas. La puntuación media final, de 0,878, fue 20% más que en 2012. La subdimensión con peor puntuación fue “tipos de equipos” y la mejor, “turnos operativos”. Las unidades se agruparon según su puntuación final, de la mejor a la peor: A, B, C, D, E. Todas las regiones aumentaron el % de UBS en los grupos A/B, especialmente el Norte/Nordeste. El tipo A se observó en el 21,3% de los UBS, un aumento de 4,4 veces. Los avances en las condiciones de infraestructura, los turnos y la mayor presencia de médicos indican los efectos de las políticas destinadas a ampliar el acceso a la APS. Sin embargo, aún merecen atención componentes esenciales para una APS integral, como la presencia de un número suficiente de ACS, la dispensación universal de medicamentos y la equiparación entre los equipos de salud bucodental y los equipos de salud familiar.
Palabras clave:
Atención Primaria en Salud; Investigación sobre Servicios de Salud; Centros de Salud; Estructura de los Servicios
Introduction
Countries with health systems based on strong Primary Health Care (PHC) perform better across several indicators of access, equity, and health outcomes. However, the mechanisms and how they contribute to the observed results require further exploration1. Among the many possibilities for analysis, we highlight the structure, understood as the material resources, physical and organizational contexts, and workforce, which together reflect relatively stable conditions for health services2. Assessing the structure is especially important in middle- and low-income countries, which face challenges related to their adequacy.
The provision of adequate infrastructure in Primary Health Care units (PHC units), including the environment, availability of space, equipment, and supplies, constitutes basic and essential conditions for the provision of the various individual and collective actions recommended for PHC. These are key issues to making health services accessible and providing appropriate working conditions for professionals to deliver quality care. In this sense, analyzing the structural conditions of Brazilian primary care units (PHC units) is essential in order to guide policies that contribute to improving the quality of care and the satisfaction of both users and professionals.
Since the 1970s, the structure of healthcare facilities has been studied, beginning with medical and healthcare surveys conducted by the Brazilian Institute of Geography and Statistics (IBGE), with the aim of supporting the planning of healthcare initiatives and regional demands.
In 2011, the National Primary Care Policy (Política Nacional de Atenção Básica - PNAB) strengthened the institutionalization of PHC assessment with the creation of the Primary Care Access and Quality Improvement Program (Programa de Acesso e Melhoria da Qualidade da Atenção Básica - PMAQ-AB), which established a routine external assessment of teams. In its first cycle, a census of the 38,000 existing PHC units across the country was conducted3.
The results of this assessment informed a set of policies, notably the Requalification of PHC units, which subsidized the construction, renovation, or expansion of PHC units throughout the country, as well as the More Doctors Program (Programa Mais Médicos), with its emergency provision component4.
After three cycles of the PMAQ-AB, the process of institutionalizing PHC assessment within the SUS was interrupted. In 2019, the Previne Brasil program was established, defining seven indicators for monitoring, but it was only partially implemented due to the health and humanitarian crisis resulting from the COVID-19 pandemic. Furthermore, a series of measures were adopted that jeopardized the Family Health Strategy (FHS)’s multidisciplinary and community-oriented care model5.
Additionally, in 2019, Pinto et al.6 indirectly assessed the structure and process of PHC based on its attributes in a small subsample of the National Health Survey (Pesquisa Nacional de Saúde - PNS). This was a shortened version of the Primary Care Assessment (PCA) tool, without individualized assessment of attributes, administered to 9,677 adults out of 88,531 eligible individuals (11%), as it was necessary to have seen the same physician more than once in a PHC unit no less than six months prior6.
In 2024, the national assessment of primary care was resumed, including a National Census of PHC units. This survey provides an inventory of the structural and service conditions of PHC units. This provides important information that can, on the one hand, guide investment strategies and policies needed to improve quality and access in primary care, and, on the other, contribute to the analysis of the effects of the policies implemented over this 13-year period.
This article, therefore, sought to identify and analyze the changes in the structure of Brazilian PHC units between 2012 and 2024.
Methodology
The structural typology of Brazilian PHC units was developed based on the results of the 2024 National Census of Primary Health Care Units. This National Census was conducted based on two complementary and inseparable approaches. The first was to ensure a process that aligned with the Brazilian federative structure; and the second, to define the objective image of Brazilian PHC, understood as comprehensive, problem-solving, community-based, territorial, and integrated into the service network, as advocated by the FHS care model.
Initially, a proposed data collection instrument was developed based on a set of dimensions considered essential to evaluate PHC, recognizing the need for a robust and comprehensive instrument, following the principles of fourth-generation health evaluation, which emphasizes the active participation of stakeholders in the evaluation process7,8.
The questionnaire was refined to cover multiple dimensions of analysis, such as infrastructure and physical resources, workforce, work and management processes, service supply, information and communication technologies, among others, and was discussed with the actors involved in the process.
The National Census of PHC Units was launched in May 2024, with municipal administrators participating. All Brazilian municipalities actively participated in the process. The entire process was conducted electronically through the e-Gestor system, which is accessed daily by administrators and healthcare professionals.
This article analyzes selected data on the structure of PHC units in order to assess their evolution over time. To this end, these results were compared with those of the PMAQ-AB, in its first cycle in 2012, based on the typology of Brazilian PHCs, as developed by Bousquat et al.3. The development of the analytical framework in 2012 dialogued with the dimensions of governance and workforce development proposed by Kringos et al.9 in order to assess the structure of PHC. Type of team, diversity of professionals, shifts open to the public, available services, and facilities and supplies were the sub-dimensions used in 2012 and were revisited in 2024 (Chart 1). These sub-dimensions can be considered essential for providing accessible, effective, and high-quality care in Brazilian PHC.
The type of team is a proxy for the care model. The number of available professionals is a proxy for the services offered and their resolution. Operating shifts correspond to an access component. The list of available services, facilities, and supplies, with its three components of physical structure, supplies, and information and communication technology (ICT) devices, correspond to the minimum elements necessary to provide quality care. Information on the availability of the tetravalent vaccine was not collected in 2024, as it was replaced by data on the monitoring of vaccination status by Community Health Workers (CHWs). Further details on the choice of variables for the 2012 PHC unit typology can be found in Bousquat et al.3.
The PHC Census had 100% participation by municipal administrators and included a list of 49,738 PHC units registered with the National Registry of Health Establishments (CNES) in April 2024. Of this total, 4,113 facilities were deactivated by municipal administrators, citing either that they were not operating at the time of the Census response or that they were facilities of a different level of care. After analyzing the database for completeness and consistency, data from 44,938 Brazilian PHC units were included. Of these, 43,209 (96.2%) presented complete information on the model’s component variables and will be analyzed here.
A reference standard was defined for each sub-dimension (Chart 1). Based on the definition of the “reference standard,” a differentiated score was established according to the response type for each variable, and scores were generated for each of the sub-dimensions by adding the scores obtained for each of the variables. The scores per sub-dimension were standardized, regardless of the number of items, from 0 to 1. A score of 1 corresponds to meeting the “reference standard” criteria. For the facilities and supplies sub-dimension, the scores were initially calculated in each of the three parts, and then an average score was calculated. Thus, the methodology used aims to assess how different the evaluated PHC units are in relation to a minimum and elementary structural reference standard. Finally, a standardized score was calculated for each sub-dimension, relative to a reference standard (Chart 1).
The correlation between the sub-dimensions, analyzed using Spearman’s nonparametric correlation coefficient, as in 2012, demonstrated that they assess distinct phenomena, with the exception of the relationship between “team types” and “staff of professionals” (r=0.68) (Table 1). The decision to maintain team type and staff of professionals is based on extensive literature indicating that work processes performed by FHS teams have greater impacts than do those provided by isolated professionals alone10,11.
Factor analysis was performed to determine the weight of each sub-dimension in calculating the final score. The standardized coefficients used were: 27.1% for team type; 29.4% for staff of professionals; 1.6% for operating shifts; 20.6% for available services; and 21.2% for general infrastructure.
After determining the weights of each sub-dimension based on the results of the factor analysis, the final score of each PHC unit was calculated by multiplying the score obtained by the standardized coefficient of the sub-dimension, according to the following formula:
Based on the final score, the PHC units were grouped into five types: A - a final score of 1.000 corresponds to the reference standard reaching the maximum value in all variables and sub-dimensions analyzed in this study; B - a score from 0.750 to 0.999; C - a score from 0.500 to 0.749; D - a score from 0.250 to 0.499; and E - a score of less than 0.250. The decision to classify the PHC units by score ranges, rather than by quartiles or even quintiles, stems from the logic of the analysis adopted here, which is to identify how close a PHC unit is to a previously defined elementary reference standard.
Depending on their proximity to the structure’s quality reference standard, the types were designated by the “5 Rs”: PHC unit Type E - Failed; PHC unit Type D - Rudimentary; PHC unit Type C - Restricted; Type B PHC unit - Regular; and Type A PHC unit - Reference3.
The results are presented for Brazil as a whole and by major geographic regions. The census study was approved by the Research Ethics Committee of the University of São Paulo (USP) School of Public Health, logged under CAAE 78767024.2.0000.5421 and opinion no. 6.779.222.
Results
The final average score for Brazilian PHC in 2024 was 0.878, which proved to be 20% higher than in 2012, reflecting the increase in scores across all sub-dimensions assessed. The sub-dimension with the lowest score was “team types”, while the best was “operating shifts”. In the previous survey, the sub-dimension “facilities and supplies” had the lowest score, whereas in 2024, it showed a significant 70% increase, reaching a score of 0.884 (Table 2). Thus, on the one hand, we observed an increase in Type A and B PHC units, and on the other, a decrease in the remaining units (Table 3).
Across the country, 21.3% of the PHC units met all criteria across the five dimensions of the benchmark and achieved the maximum score of 1,000. Type A consisted of 9,207 PHC units, which have an FHS team with oral health services and a full staff, offer all services, and have the selected equipment (Table 2). In the 2024 Census, these PHC units were most prevalent in the Northeast region (4,412 establishments; 26.1%), while in 2012, they were concentrated in regions with greater socioeconomic development (Southeast and South). The North region saw the largest increase (8 to 9-fold) in Type A units (Table 3).
The majority of Brazilian PHC units (59.8%), with an average score of 0.924, were classified as Type B (Table 2). There was both an increase in the percentage of these units and an increase in the final score. The sub-dimension with the lowest score in this category of PHC units is facilities and supplies, which increased from 0.645 in 2012 to 0.890. In 2012, the availability of equipment, mainly glucometers, nebulizers, and Internet access, increased 2.8, 2.2, and 2.7-fold, respectively (Table 4). Their scope of action, although improved, is still limited: only 57.8% of type B PHC units offer the five services of the minimum reference standard, with deficiencies found particularly in vaccination and medication dispensing (Table 4).
Approximately 60% of the Brazilian PHC units (25,860) can be found in category B, the majority of which are located in small municipalities (less than 50,000 inhabitants), with 15,591 PHC units (60.3%). Among small municipalities, 34.5% of the PHC units are located in municipalities with less than 20,000 inhabitants and 25.8% between 20,000 and 50,000 inhabitants, followed by 21.9% of the PHC units located in large municipalities. Of the total of small PHC units (<20,000), 61.1% of the PHC units were classified in category B. Figure 1 allows for the visualization of the results, according to the classification categories, in Brazilian municipalities.
Average ordinal rank by municipality, according to the 5R typology (A=1; B=2; C=3; D=4; E=5). Brazil, 2024.
Type C, with an average score of 0.663, aggregates 6,519 PHC units (15.1%) with low oral health provision (only 2.6% have an FHS team with oral health and 16.9% have a dentist; 12.6% have an oral health assistant/technician). Slightly more than half of these PHC units have four or more community health agents, in addition to a limited scope of actions offered (25.5% offer all five services listed). Although improvements have been made, when compared to 2012, there is still a lack of basic equipment: 53.3% have a nebulizer and 53.2% have a refrigerator or cold room exclusively for vaccines. On the other hand, 95.1% offer medical consultations and 96.2% nursing consultations (Table 4). Compared to the 2012 survey, most items increased, but the dispensing of medicines decreased by 20%, and a reduction was also found in the oral health team (dentists and assistants/technicians).
Type D, with 1,207 PHC units (2.8%) and an average score of 0.397, presents serious deficiencies in all components, with the worst results for teams (score 0.128) and professionals (score 0.346), despite a 3.3-fold increase in facilities and supplies and a 1.5-fold increase in work shifts (Table 2). Only 14.2% provide the five selected types of services; 50.0% monitor vaccination, and 36.3% report vaccinating, albeit precariously, as only 18.9% of these PHC units have exclusive refrigerators/cold storage for vaccines. Only 53.9% distribute medicines, and they do not offer oral health care (61.7% do not have dental appointments and only 6.6% have a dentist). Approximately 54% do not have a doctor, and 46% do not have a nurse (Table 4). The most common service in these PHC units is nursing consultation (Table 4). Proportionally, these services are more common in the North region (6.2%), although they decreased by 60% over the 12-year period (Table 3).
Type E encompasses only 416 PHC units (1.0%), with an average score of 0.141 due to the absence of almost all the elements analyzed in four sub-dimensions, with the exception of work shifts, which increased 2.6-fold (Tables 2 and 3). These services are concentrated primarily in the North region, both in absolute numbers and proportionally, while the Northeast region saw a decrease in the number of units, proportionally to the South and Southeast regions (Table 2).
Theistributeon of PHC units across Brazil’s major regions (Table 2) shows progress in the Northeast and North regions. Nevertheless, the North region, with 3,043 units (7.0% of the country’s PHC units), has the highest proportions of E (6.1%) and D (6.2%). The Southeast region has the lowest proportion of type E PHC units (0.4%) and the highest proportion of type C PHC units (19.4%), together with the North region (20.2%) (Table 2).
The largest number of PHC units (16,914) is located in the Northeast Region (Table 2). The distribution of PHC units by type A and B in this region is higher than the national average, representing 26.1% and 60.4%, respectively, of its PHC units. This is the region with the largest number of type B PHC units (10,214) (Table 2). In the Midwest Region, the PHC units grouped as type B (69.6%) have the highest proportion, but with a lower distribution of type A (14.7%), lower than the national average (Table 2). However, the absolute number of type A PHC units is small (448), as this is the region of the country with the smallest number of PHC units (3,043 or 6.9% of the total), although its population is larger than that of the North Region (Table 2).
Discussion
The adequate structure of a PHC unit is a necessary, but insufficient, condition for guaranteeing high-quality care12. On the other hand, a quality structure contributes to user satisfaction13 and professional retention, facilitating teamwork and communication between managers, professionals, and users14. In the case of the present study, the results observed indicate that there was a significant improvement in the structure of Brazilian PHC units between 2012 and 2024. However, it should be noted that the reference standard that could be used in 2012 is quite elementary and certainly insufficient to guarantee a structure capable of enabling the provision of robust and comprehensive PHC, which articulates strong components of individual and collective care.
It should be noted that, in Brazil, the expansion of population coverage by FHS teams, with the strengthening of PHC within the Unified Health System (SUS), has occurred at different paces and with distinct political approaches over the past two decades, showing both advances and setbacks. This approach has also been impacted by the devastating health and humanitarian crisis resulting from the COVID-19 pandemic5. One of the greatest limitations of this study lies in the methodological impossibility of observing the impact of these changes on the structure of all of the PHC units as a whole. Between 2012 and 2024, the country experienced very distinct cycles in health policies in general and specifically in the political and institutional weight given to the FHS.
It is important to note that all regions increased the percentages of PHC units in groups A and B during the analyzed period. Type A showed a 4.4-fold increase, which was greater in the North (8.9) and Northeast (9.3) regions, but it was also present in the Southeast (3.0) and South/Midwest (2.4) regions. As for type B PHC units, the improvement was 1.2 overall, ranging from 1.1 (North) to 1.3 (Northeast). Types C-E registered a significant decrease (50% for type C, 70% for type D, and 80% for type E), with the Northeast region standing out for type C (60% decrease) and for type E (90%), reflecting the impact of various policies implemented during the period. However, given the elements analyzed in this typology, it would be desirable for the majority of Brazilian PHC units to have achieved a score of 1.00.
The Census moves toward the institutionalization of the necessary PHC assessment in the country and enables, despite methodological differences, a dialogue with the results obtained in the assessments of the infrastructure conditions of PHC units in the PMAQ-AB quality assessment cycles. Tomasi et al.15 identify the effects of improvements in infrastructure and in the provision and performance of services. Facchini et al.16 draw attention to physical infrastructure conditions that facilitate accessibility for a variety of users at the architectural level, such as visual signage and sound waves. In the same vein, comparative analyses between the 1st and 3rd cycles of the PMAQ-AB demonstrate significant improvements in the structural conditions of the PHC units, facilitating access for people with mobility difficulties17. Regarding the days and hours of operation of the PHC units, improvements were also observed17, as in this study.
One of the most significant advances observed in the comparison between 2012 and 2024 was the improvement in the arrangement of teams with physicians. Indeed, the More Doctors Program (PMM), established in 2013, provided doctors to underserved regions18,19 and reduced intermittent staffing4. The withdrawal of Cuban doctors at the end of 2018 had negative impacts, especially in municipalities with greater difficulties in attracting and retaining doctors, such as rural and remote areas20. These positions were subsequently filled by Brazilian doctors registered abroad.
The PMM was revived early in Minister Nisia Trindade’s administration, with improvements to the previous version’s guidelines, prioritizing medical training and professional qualifications. The tenure in the PMM was extended to up to eight years, and incentives were introduced to reduce turnover. By 2023, the PMM had 21,000 professionals working nationwide, and by 2024, it had 25,000 physicians working in 80% of the municipalities. As the 2024 Census results show, advances in the professional component have been able to address professional shortages and reduce areas of underserved care. They have certainly contributed to the increased presence of Type A units in the North and Northeast regions. The fact that 96.5% of the PHC units have female and male physicians, and 97.1% have female and male nurses, is a significant achievement for SUS.
The Census results show a significant increase in operating hours and the availability of medical appointments around the country, indicating greater access to health services for the population. However, although most PHC units operate at the minimum recommended operating hours, analysis of data from the 3rd cycle of the PMAQ-AB revealed that half of them were closed during lunch hours, compromising the availability of services for the population, who often find this time to be the best or only alternative for accessing health services17.
Also noteworthy is the reduction in the number of four or more CHWs in the PHC units during this period, a finding already identified in a previous study comparing the results of the 2013 and 2019 National Health Surveys (PNS). This study found a reduction in the frequency of CHW home visits received by families. This may be related to the 2017 PNAB guidelines, which prioritized individual care21. This is a crucial issue, as the unequivocal success of Brazilian PHC in improving several indicators and rapidly expanding access certainly lies in the FHS model, in which the CHW is a key player, proving that the CHWs working in the territory are indeed essential, as evidenced by the COVID-19 pandemic22.
Infrastructure was the sub-dimension that showed the greatest progress over the years, even though the set evaluated is only basic for the functioning of a PHC unit. Conversely, medication distribution and vaccination provisions require greater attention in the coming years. The average medication availability found in the 2nd cycle of the PMAQ-AB (60%) was similar to that observed in the 2015 National Survey on Access, Use, and Promotion of the Rational Use of Medication in Brazil (62.5%), showing a significant improvement in the 3rd cycle (69.2%), although still well below the WHO recommendations for PHC (≥80%)23. In this sense, low availability of medicines in PHC units continues to compromise the comprehensiveness, equity, and resolution of care24.
Regarding the National Oral Health Policy (Política Nacional de Saúde Bucal - PNSB), significant setbacks were observed between 2018 and 2021 in a context marked by economic, political, and health crises24. Indicators, such as coverage of initial dental appointments and collective supervised toothbrushing showed a significant reduction between 2020 and 2021, as did federal funding between 2018 and 2019 (8.45%), with growth observed in 2020 (59.53%) and a further decrease in 2021 (5.18%)25. The data found here suggest improvements in the supply of Oral Health Teams (OHT) professionals, which may have contributed to changing this situation, which deserves investigation with further studies.
The comparison between the two time points, 2012 and 2024, does not allow for an understanding of the pace of structural evolution during the period. Between 2011 and 2015, the PHC Unit Requalification Program (Requalifica UBS) directed financial investments toward the renovation, construction, and expansion of PHC Units, constituting a significant intervention in the SUS service infrastructure. Twenty-six thousand projects were funded, 18,000 for renovation or expansion and 7,700 for the construction of new PHC units, which contributed to the improvement in PHC unit infrastructure observed here4. Comparative studies across the three PMAQ-AB cycles showed improvements in several components through 2018, suggesting different paces of improvement in PHC unit infrastructure over the past two decades16.
A systemic perspective suggests that the performance of a PHC-based health system cannot be viewed solely in terms of its eventual outputs and outcomes (equitable access, effective services, and quality care), but rather it must also be understood in terms of the underlying structures and processes that explain these outcomes and their interrelationships26.
Evidence from high-income countries, replicated in low-to-middle-income countries, indicates that the structural elements of a health system, such as governance, financing, human resources, and the organization of services, as well as key processes (such as policy implementation, regulation, supervision, and information flow), are key to shaping outcomes27. One study conducted in Brazil showed that expenditure variables are positively related to the infrastructure of PHC units28. However, this relationship is significantly affected by regional and social inequalities29. Regions with the worst socioeconomic indicators, such as GDP per capita and HDI-M, especially the North and Northeast, concentrated infrastructure types classified as failed, rudimentary, and restricted, highlighting the urgent need to continue improving health resource governance structures so as to achieve increased investment results in reduced inequities and improved PHC infrastructure in vulnerable territories28.
Recent years have led to an increased use of digital information and communication tools, whether due to the encouragement of health data collection for monitoring and evaluating services and programs, or due to the increased use of telemedicine and telediagnosis tools. Although the presence of computers and internet access has increased substantially, it is mainly in Type D and Type E units that still have minimal computer availability and internet access. Recent policies, such as Informatiza SUS and the SUS Digital Program, aim to overcome these challenges, although the availability of technology is the first step in a process that involves the availability, training, and qualification of staff in its use, as well as financial resources for its maintenance.
Final considerations
In commemorating the thirtieth anniversary of the FHS, advances in infrastructure, PHC unit operating hours, and the increased presence of physicians, driven by the expansion of the PMM, demonstrate the synergy between public policies aimed at expanding access to PHC and reducing regional inequalities. However, essential components for providing comprehensive PHC still deserve attention, such as the presence of enough CHWs to serve all families covered by the FHS, universal medication distribution, and equalization between oral health teams and family health teams.
In any case, the presence of an adequate structure is not in itself sufficient to guarantee quality health care. Therefore, we highlight the need to develop new analytical models that incorporate aspects of governance, equitable resource allocation, and service organization. Furthermore, new typologies of PHC unit structures could benefit from the inclusion of new components, such as professional qualifications; a community and territorial approach (health promotion and surveillance); the organization of care and integration with the network; and social participation, accessibility, and use of electronic medical records, elements that are necessary to achieve the objective image of Brazilian PHC, a comprehensive, problem-solving, territorial, and community-based PHC.
Acknowledgments
We thank all the health professionals, managers, supporters, and facilitators who worked immensely to carry out the 2024 Primary Health Care Unit Census.
References
- 1 Schäfer WLA, Boerma WGW, van den Berg MJ, De Maeseneer J, De Rosis S, Detollenaere J, Greß S, Heinemann S, van Loenen T, Murante AM, Pavlic DR, Seghieri C, Vainieri M, Willems S, Groenewegen PP. Are people's health care needs better met when primary care is strong? A synthesis of the results of the QUALICOPC study in 34 countries. Prim Health Care Res Dev 2019; 20:e104.
- 2 Donabedian A. The quality of care. How can it be assessed? JAMA 1988; 260:1743-1748.
- 3 Bousquat A, Giovanella L, Fausto MCR, Fusaro ER, Mendonça MHM, Gagno J, Viana ALÁ. Tipologia da estrutura das unidades básicas de saúde brasileiras: os 5 R. Cad Saude Publica 2017; 33(8):e00037316.
- 4 Giovanella L, Mendonça MHM, Fausto MCR, Almeida PF, Bousquat A, Lima JG, Seidl H, Franco CM, Fusaro ER, Almeida SZF. A provisão emergencial de médicos pelo Programa Mais Médicos e a qualidade da estrutura das unidades básicas de saúde. Cienc Saude Colet 2016; 21(9):2697-2708.
- 5 Giovanella L, Franco CM, Almeida PF. Política Nacional de Atenção Básica: para onde vamos? Cien Saude Colet 2020; 25(4):1475-1482.
- 6 Pinto LF, Quesada LA, D'Avila OP, Hauser L, Gonçalves MR, Harzheim E. Primary Care Asssement Tool: diferenças regionais a partir da Pesquisa Nacional de Saúde do Instituto Brasileiro de Geografia e Estatística. Cien Saude Colet 2021; 26(9):3965-3979.
- 7 Guba EG, Lincoln YS. Fourth generation evaluation. Thousand Oaks: Sage Publications, Inc; 1989.
- 8 Furtado JP. Um método construtivista para a avaliação em saúde. Cien Saude Colet 2001; 6(1):165-181.
- 9 Kringos DS, Boerma WGW, Bourgueil Y, Cartier T, Hasvold T, Hutchinson A, Lember M, Oleszczyk M, Pavlic DR, Svab I, Tedeschi P, Wilson A, Windak A, Dedeu T, Wilm S. The European primary care monitor: structure, process and outcome indicators. BMC Fam Pract 2010; 11:81.
- 10 Macinko J, Harris M. Brazil's Family Health Strategy: Delivering community based primary care in a universal health system. N Engl J Med 2015; 372(23):2177-2181.
- 11 Macinko J, Mendonça CS. Estratégia Saúde da Família, um forte modelo de Atenção Primária à Saúde que traz resultados. Saude Debate 2018; 42(n. esp. 1):18-37.
- 12 Leslie HH, Sun Z, Kruk ME. Association between infrastructure and observed quality of care in 4 healthcare services: A cross-sectional study of 4,300 facilities in 8 countries. PLoS Med 2017; 14:e1002464.
- 13 Rajan D, Rouleau K, Winkelmann J, Kringos D, Jakab M, Khalid F, editors. Implementing the Primary Health Care approach: a primer. Geneva: WHO; 2024.
- 14 Karp Z, Kamnetz S, Wietfeldt N, Sinsky C, Molfenter T, Pandhi N. Influence of Environmental Design on Team Interactions Across Three Family Medicine Clinics: Perceptions of Communication, Efficiency, and Privacy. HERD 2019; 12(4):159-173.
- 15 Tomasi E, Duro SMS, Saes MO, Volz PM, Machado KP, Quispe MPF, Soares UM, Neves RG, Kessler M, Silveira DS, Siqueira FCV, Thumé E, Facchini LA. Características gerais das UBS e equipes de saúde na APS brasileira de 2012 a 2018: infraestrutura e oferta de serviços. In: Facchini LA, Tomase E, Thumé E, organizadores. Acesso e qualidade na atenção básica brasileira: análise comparativa dos três ciclos da avaliação externa do PMAQ-AB, 2012-2018. São Leopoldo: Oikos; 2021. p. 110-130.
- 16 Facchini LA, Tomasi E, Silveira DS, Fassa AG, Thumé E. Acesso e qualidade da atenção primária à saúde: desafios teóricos e políticos da avaliação da atenção básica. In: Facchini LA, Tomase E, Thumé E, organizadores. Acesso e qualidade na atenção básica brasileira: análise comparativa dos três ciclos da avaliação externa do PMAQ-AB, 2012-2018. São Leopoldo: Oikos; 2021. p. 22-66.
- 17 Sousa ANA, Shimizu HE. Como os brasileiros acessam a Atenção Básica em Saúde: evolução e adversidades no período recente (2012-2018). Cien Saude Colet 2021; 26(8):2981-2995.
- 18 Oliveira JPA, Pacheco C, Taves FAQ, Barbosa JMV, Santos LMP. Efeitos do Programa Mais Médicos na Atenção Primária e seus impactos na saúde: uma revisão sistemática. Trab Educ Saude 2024; 22:e02635249.
- 19 Girardi SN, Stralen ACS, Cella JN, Wan Der Maas L, Carvalho CL, Faria EO. Impacto do Programa Mais Médicos na redução da escassez de médicos em Atenção Primária à Saúde. Cien Saude Colet 2016; 21(9):2675-2684.
- 20 Almeida PF, Franco CM, Pereira AG, Giovanella L. Força de Trabalho em saúde em municípios rurais remotos: desafios e estratégias para atração e fixação de profissionais na Atenção Primária à Saúde. In: Fausto MCR, Almeida PF, Santos AM, Bousquat A, Giovanella, L, organizadores Atenção Primária à Saúde em Municípios Rurais Remotos no Brasil. Rio de Janeiro: Editora Fiocruz; 2023. p. 285-309.
- 21 Giovanella L, Bousquat A, Schenkman S, Almeida PF, Sardinha LMV, Vieira MLFP. Cobertura da Estratégia Saúde da Família no Brasil: o que nos mostram as Pesquisas Nacionais de Saúde 2013 e 2019. Cien Saude Colet 2021; 26(Supl. 1):2543-2556.
- 22 Schenkman S, Bousquat AEM, Facchini LA, Gil CRR, Giovanella L. Padrões de desempenho da atenção primária à saúde diante da COVID-19 no Brasil: características e contrastes. Cad Saude Publica 2023; 39(8):e00009123.
- 23 Peixoto RT, Campos MR, Luiza VL, Mendes LV. O farmacêutico na Atenção Primária à Saúde no Brasil: análise comparativa 2014-2017. Saude Debate 2022; 46(133):358-375.
- 24 Álvares J, Guerra Junior AA, Araújo VE, Almeida AM, Dias CZ, Ascef BO, Costa EA, Guibu IA, Soeiro OM, Leite SN, Karnikowski MGO, Costa KS, Acurcio FA. Access to medicines by patients of the primary health care in the Brazilian Unified Health System. Rev Saude Publica 2017; 51(Supl. 2):20s.
- 25 Santos LPS, Lima AMFS, Chaves SCL, Vilela DMOC, Valente APPC, Rossi TRA. Política de Saúde Bucal no Brasil: transformações e rupturas entre 2018-2021. Cien Saude Colet 2023; 28(5):1575-1587.
- 26 Espinosa-González AB, Delaney BC, Marti J, Darzi A. The impact of governance in primary health care delivery: a systems thinking approach with a European panel. Health Res Policy Sys 2019; 17(1):65.
- 27 Kringos DS, Boerma WG, Hutchinson A, van der Zee J, Groenewegen PP. The breadth of primary care: a systematic literature review of its core dimensions. BMC Health Serv Res 2010; 10(1):65.
- 28 Kashiwakura HK, Gonçalves AO, Azevedo RR, Nunes A, Silva CAT. Retrato da atenção básica no Brasil: gastos e infraestrutura em municípios brasileiros. Cien Saude Colet 2021; 26(Supl. 2):3397-3408.
- 29 Kessler M, Thumé E, Marmot M, Macinko J, Facchini LA, Nedel FB, Wachs LS, Volz PM, Oliveira C. Family Health Strategy, Primary Health Care, and Social Inequalities in Mortality Among Older Adults in Bagé, Southern Brazil. Am J Public Health 2021; 111(5):927-936.
The data sources adopted in the research are indicated in the article’s body.
Source: National Census of PHC units, 2024.