Integration of Primary Health Care of a small Brazilian city in the health care network

Abstract

Introduction: integration of health care has been an important challenge in the provision of health care. Brazilian studies, however, have yet to evaluate it objectively and only large cities have been addressed. Therefore, this study’s objective was to objectively measure the degree of integration of Primary Health Care PHC in a small Brazilian city in the health care network. Methods: initially, to quantitatively operationalize the concept of integration, a structured evaluation matrix with 25 indicators was developed based on the scientific literature and technical recommendations, with evaluation parameters scored from 0 to 3. All the physicians and nurses of the public health facilities of a small city in the State of Minas Gerais, Brazil were invited to answer a structured questionnaire based on this evaluation matrix. Additionally, all the cases of individuals who had been referred for specialized exams and to medical specialists waiting to get an appointment during the study period, were analyzed. After data collection, each indicator was scored based on the parameters established in the matrix. The ratio between the total score obtained and the total score expected 75 points multiplied by 10 was considered to determine the degree of integration of the PHC in the health care network. The degree of integration was classified and analyzed on a continuous scale, from very little integration score 0.00-1.24 to perfect integration 8.75-10.00. Results: the results reveal there is poor coordination of care, along with problems concerning the organization of the flow of patients to provide appropriate health care, with weak instruments to promote integration and important barriers to the access of specialized care, limiting the integration of PHC within the health care network. The average score per indicator was very low 1.16 and the total score obtained for the matrix was only 28, meaning there was a degree of integration of 3.73, which is evidence of a poor level of integration of PHC into the health care network. Discussion: the limited integration of PHC into the health care network exposes the fragmentation of the care provided to the population of a small city that is linked to the Brazilian Public Health System Sistema Unico de Saude - SUS. In Brazil, there are more than 5,000 small towns with approximately 70 million total inhabitants. Most of these towns face political, geographical and socioeconomic conditions, which, along with the insufficient supply of specialized services, impose additional barriers to the integration of care, worsening a situation of already poor integration. Limitations: this study’s external validity represents a limitation, though the evaluation matrix developed here may contribute to the improvement of integration in many other cities with similar characteristics. Suggestions for future research: by listing several indicators that indicate actions for better integration in a single instrument, the evaluation matrix makes it possible to carry out systematic assessments of integration in municipal health systems. This methodology needs to be replicated in the future in cities of different sizes and contexts, and the level of relative importance of each indicator should be verified.