Strengthening Of Primary Health Care Research Articles

Twenty-first-century demographic and social inequalities of heat-related deaths in Brazilian urban areas.

Population exposure to heat waves (HWs) is increasing worldwide due to climate change, significantly affecting society, including public health. Despite its significant vulnerabilities and limited adaptation resources to rising temperatures, South America, particularly Brazil, lacks research on the health impacts of temperature extremes, especially on the role played by socioeconomic factors in the risk of heat-related illness. Here, we present a comprehensive analysis of the effects of HWs on mortality rates in the 14 most populous urban areas, comprising approximately 35% of the country's population. Excess mortality during HWs was estimated through the observed-to-expected ratio (O/E) for total deaths during the events identified. Moreover, the interplay of intersectionality and vulnerability to heat considering demographics and socioeconomic heterogeneities, using gender, age, race, and educational level as proxies, as well as the leading causes of heat-related excess death, were assessed. A significant increase in the frequency was observed from the 1970s (0-3 HWs year-1) to the 2010s (3-11 HWs year-1), with higher tendencies in the northern, northeastern, and central-western regions. Over the 2000-2018 period, 48,075 (40,448-55,279) excessive deaths were attributed to the growing number of HWs (>20 times the number of landslides-related deaths for the same period). Nevertheless, our event-based surveillance analysis did not detect the HW-mortality nexus, reinforcing that extreme heat events are a neglected disaster in Brazil. Among the leading causes of death, diseases of the circulatory and respiratory systems and neoplasms were the most frequent. Critical regional differences were observed, which can be linked to the sharp North-South inequalities in terms of socioeconomic and health indicators, such as life expectancy. Higher heat-related excess mortality was observed for low-educational level people, blacks and browns, older adults, and females. Such findings highlight that the strengthening of primary health care combined with reducing socioeconomic, racial, and gender inequalities represents a crucial step to reducing heat-related deaths.

Structural capacity and continuum of snakebite care in the primary health care system in India: a cross-sectional assessment

BackgroundIn 2019, the World Health Organization, set a target to halve the burden of snakebite, by 2030, and identified ‘health systems strengthening’ as a key pillar of action. In India, the country with most snakebite deaths, the Union Government identified (in September 2022) training of health workers as a priority action area. In this policy context, we provide empirical evidence by analysing the most recent nationwide survey data (District Level Household and Facility Survey − 4), to assess structural capacity and continuum of snakebite care in primary health care system in India.MethodologyWe evaluated structural capacity for snakebite care under six domains: medicines, equipment, infrastructure, human resources, governance and finance, and health management information systems (HMIS). We categorised states (aspirant, performer, front-runner, achiever) based on the proportion of primary health centres (PHC) and community health centres (CHC), attaining highest possible domain score. We assessed continuum of snakebite care, district-wise, under five domains (connectivity to PHC, structural capacity of PHC, referral from PHC to higher facility, structural capacity of CHC, referral from CHC to higher facility) as adequate or not.ResultsNo state excelled ( front-runner or achiever) in all six domains of structural capacity in PHCs or CHCs. The broader domains (physical infrastructure, human resources for health, HMIS) were weaker compared to snakebite care medicines in most states/UTs, at both PHC and CHC levels. CHCs faced greater concerns regarding human resources and equipment availability than PHCs in many states. Among PHCs, physical infrastructure and HMIS were aspirational in all 29 assessed states, while medicines, equipment, human resources, and governance and finance were aspirational in 8 (27.6%), 2 (6.9%), 17 (58.6%), and 12 (41.4%) states respectively. For CHCs, physical infrastructure was aspirational in all 30 assessed states/UTs, whereas HMIS, medicines, equipment, human resources, and governance and finance were aspirational in 29 (96.7%), 11 (36.7%), 27 (90%), 26 (86.7%), and 3 (10%) states respectively. No district had adequate continuum of snakebite care in all domains. Except for transport availability from CHC to higher facilities (48% of districts adequate) and transport availability from PHC to higher facilities (11% of districts adequate), fewer than 2% of districts were adequate in all other domains.ConclusionComprehensive strengthening of primary health care, across all domains, and throughout the continuum of care, instead of a piece-meal approach towards health systems strengthening, is necessitated to reduce snakebite burden in India, and possibly other high-burden nations with weak health systems. Health facility surveys are necessitated for this purpose.

The health and health system impacts of China's comprehensive primary health care reforms: a systematic review.

China's comprehensive primary health care (PHC) reforms since 2009 aimed to deliver accessible, efficient, equitable and high-quality health care services. However, knowledge on the system-wide effectiveness of these reforms is limited. This systematic review synthesizes evidence on the reforms' health and health system impacts. In August 2022, 13 international databases and three Chinese databases were searched for randomised controlled trials, quasi-experimental studies and controlled before-after studies. Included studies assessed large-scale PHC policies since 2009; had a temporal comparator and a control group; and assessed impacts on expenditures, utilisation, care quality, and health outcomes. Study quality was assessed using ROBINS-I and results were synthesized narratively. From 49,174 identified records, 42 studies were included - all with quasi-experimental designs, except for one randomised control trial. Nine studies assessed as at low risk of bias. Only five low to moderate quality studies assessed the comprehensive reforms as a whole and found associated increases in health service utilisation, whilst the other 37 studies examined single-component policies. The National Essential Medicine Policy (N=15) and financing reforms (N=11) were the most studied policies, whilst policies on primary care provision (i.e., family physician policy and the National Essential Public Health Services) were poorly evaluated. The PHC reforms were associated with increased primary care utilisation (N=17) and improved health outcomes in people with non-communicable diseases (N=8). Evidence on healthcare costs was unclear and impacts on patients' financial burden and care quality were understudied. Some studies showed disadvantaged regions and groups accrued greater benefits (N=8). China's comprehensive PHC reforms have made some progress in achieving their policy objectives including increasing primary care utilisation, improving some health outcomes, and reducing health inequalities. However, China's health system remains largely hospital-centric and further PHC strengthening is needed to advance Universal Health Coverage.

Primary health care strengthening in India: Imperative to providing inclusive health care

The primary contributors to poor health are inequality and poverty. Access to adequate health care on an affordable and fair basis in many sections of the country remains an unfulfilled desire. Health care disparity is seen as a compromise. "Right to Life" To promote inclusion in health care, it is vital to define "essential health care," which should be made available to all residents. The best use of public resources and more public investment on healthcare are recommended solutions. It is suggested that strengthening capacity through training, particularly training paramedical staff, is a crucial component of cost reduction, particularly in tertiary care. Another component which is deemed highly significant is improvement in delivery system of health care. The improvement of preventive care and decrease in tertiary care costs will result from expanding the role of "family physicians" in the health care delivery system. These findings support the importance of primary healthcare and its function in providing inclusive healthcare. More access to necessary treatments, higher care quality, an emphasis on prevention, early management of health issues, and overall health gains and decreased morbidity as a consequence of primary health care delivery are all benefits of the primary health care paradigm for the delivery of health services.

Towards applying the essential public health functions for building health systems resilience: A renewed list and key enablers for operationalization.

The COVID-19 pandemic, climate change-related events, protracted conflicts, economic stressors and other health challenges, call for strong public health orientation and leadership in health system strengthening and policies. Applying the essential public health functions (EPHFs) represents a holistic operational approach to public health, which is considered to be an integrated, sustainable, and cost-effective means for supporting universal health coverage, health security and improved population health and wellbeing. As a core component of the Primary Health Care (PHC) Operational Framework, EPHFs also support the continuum of health services from health promotion and protection, disease prevention to treatment, rehabilitation, and palliative services. Comprehensive delivery of EPHFs through PHC-oriented health systems with multisectoral participation is therefore vital to meet population health needs, tackle public health threats and build resilience. In this perspective, we present a renewed EPHF list consisting of twelve functions as a reference to foster country-level operationalisation, based on available authoritative lists and global practices. EPHFs are presented as a conceptual bridge between prevailing siloed efforts in health systems and allied sectors. We also highlight key enablers to support effective implementation of EPHFs, including high-level political commitment, clear national structures for institutional stewardship on EPHFs, multisectoral accountability and systematic assessment. As countries seek to transform health systems in the context of recovery from COVID-19 and other public health emergencies, the renewed EPHF list and enablers can inform public health reform, PHC strengthening, and more integrated recovery efforts to build resilient health systems capable of managing complex health challenges for all people.

Human security and universal health coverage: Japan's vision for the G7 Hiroshima Summit

Human security and universal health coverage: Japan's vision for the G7 Hiroshima Summit

PS-P06-1: REDUCED HEALTHCARE UTILIZATION AMONG PATIENTS WITH CHRONIC DISEASES DURING THE PANDEMIC

Objective: Public-health strategies resorted to world-wide, to reduce the transmission of COVID-19 impacted the healthcare-utilization of people with pre-existing chronic diseases. We aimed to assess the healthcare utilization, patient-experiences and economic impacts among people with chronic diseases due to COVID-19 pandemic. Design and Methods: An online survey was conducted in 2021 involving 449 adults living in the Western-Province of Sri Lanka. Data on participants socio-demographic and economic status, co-morbidities, healthcare utilization, and healthcare-seeking behaviours were collected using a pre-tested questionnaire. The questionnaire link was distributed through social media and by emails. Categorical data were expressed as proportions/percentages with 95% confidence intervals where relevant. Quantitative data, normally distributed, were summarized in terms of mean and standard deviation (SD) and non-normally distributed as the median and interquartile-range (IQR). Results: 449 respondents completed the survey. Majority (55%) responded that they experienced a negative impact on their main income. 26%(n = 115) mentioned that they had a doctor-diagnosed chronic disease or a disability and of them 72% (n = 83) were on regular medication. Nearly half (n = 55;48%) mentioned that there was a delay in seeking healthcare during the pandemic and 27% (n = 30)reported not having sought treatment during the lockdown period. Of the people with delayed healthcare seeking 25% had hypertension, 16% diabetes, and 12.2% asthma. Considering care seeking pattern among people with chronic illness, it declined in all institutions during the lockdown period. However careseeking in the private sector, only margially declined during the pandemic. Considering care seeking at a government hospital, a drastic drop was observed during the lockdown period (n = 13; = 11.3%). Of the respondents who sought healthcare for chronic illness during the pandemic in lockdown (n = 85; 74%) and no-lock down (n = 107; 93%), a considerable proportion mentioned that clinics were either not functioning on time or not functioning at all. Although the majority agreed that their perceived health despite the chronic illness was good, very good, or excellent, around 38% reported it as fair or poor. Conclusion: Health-care utilization among people with a chronic disease reduced due to supply and demand driven factors in healthcare. Efforts are necessary to ensure continuity of care for people with chronic disease to prevent complications. The government needs to invest in resilient health systems to be better equipped to provide uninterrupted care for NCDs in any circumstances. To support this, primary healthcare strengthening and tele-health options should be explored.

The effect of health insurance and socioeconomic status on women’s choice in birth attendant and place of delivery across regions in Indonesia: a multinomial logit analysis

BackgroundEvidence suggests that women gave birth in diverse types of health facilities and were assisted by various types of health providers. This study examines how these choices are influenced by...

Linkage to HIV care and hypertension and diabetes control in rural South Africa: Results from the population-based Vukuzazi Study.

Non-communicable diseases (NCDs) account for half of all deaths in South Africa, partly reflecting unmet NCDs healthcare needs. Leveraging existing HIV infrastructure is touted as a strategy to alleviate this chronic care gap. We evaluated whether HIV care platforms are associated with improved NCDs care. We conducted a community-based screening of adults in rural KwaZulu-Natal, collecting BP, HbA1c, and health services utilization data. Care cascade indicators for hypertension and diabetes mellitus were defined as: 1) aware, if previously diagnosed, 2) in care, if seeing a provider within last 6 months; 3) treated, if reporting medication use within preceding 2 weeks; and 4) controlled, if BP<140/90mmHg or HbA1c<6.5%. We fit multivariable adjusted logistic regression models to compare successful completion of each step of the care cascade for hypertension and diabetes between people with virally suppressed HIV and HIV-negative comparators. Inverse probability sampling weights were applied to derive population-level estimates. The analytic sample included 4,933 individuals [mean age 58.4 years; 77% female]. Compared to being HIV-negative, having suppressed HIV was associated with lower adjusted prevalence of being aware (-6.0% [95% CI: -11.0, -1.1%]), in care (-5.7% [-10.6, -0.8%]), and in treatment (-4.8% [-9.7, 0.1%]) for diabetes; but higher adjusted prevalence of controlled diabetes (3.2% [0.2-6.2%]). In contrast, having suppressed HIV was associated with higher adjusted prevalence of being aware (7.4% [5.3-9.6%]), in care (8.0% [5.9-10.2%]), in treatment (8.4% [6.1-10.6%]) and controlled (9.0% [6.2-11.8%]), for hypertension. Overall, disease control was achieved for 40.0% (38.6-40.8%) and 6.8% (5.9-7.8%) of individuals with hypertension and diabetes, respectively. Engagement in HIV care in rural KwaZulu-Natal was generally associated with worse diabetes care and improved hypertension care. While further work should explore how success of HIV programs can be translated to NCD care, strengthening of primary healthcare will also be needed to respond to the growing NCDs epidemic.

Sub-district costs and efficiency of a combination HIV/AIDS prevention-intervention in the Northwest Province of South Africa.

BackgroundWe reviewed a combination prevention program to strengthen HIV prevention programming, community support mechanisms, community-based HIV testing, referral systems, and HIV prevention integration at the primary care level. The intervention included situational analysis to inform programming, community engagement and mobilization, and community-based biomedical and behavioral prevention. In support of PEPFAR’s country-ownership paradigm, we costed the combination HIV prevention program to determine data needed for local ownership. This research used costing and health system perspectives.ResultsCost per person reached with individual or small group prevention interventions ranged from $63.93 to $4,344.88. (cost per health facility strengthened). Personnel costs drove the intervention. This was true regardless of year or activity (i.e. wellness days or events, primary health care strengthening, community engagement, and wellness clubs).ConclusionsLabor-intensive rather than capital-intensive interventions for low-income settings, like this one, are important for treating and preventing HIV/AIDS and other health conditions sustainably. Over time, costs shifted from international cost centers to in-country headquarters offices, as required for sustainable PEPFAR initiatives. Such costing center evolution reflected changes in the intervention’s composition, including (1) the redesign and re-deployment of service delivery sites according to local needs, uptake, and implementation success and (2) the flexible and adaptable restructuring of intervention components in response to community needs.

Sub-district costs and efficiency of a combination HIV/AIDS prevention-intervention in the Northwest Province of South Africa

Background: We reviewed a combination prevention program tostrengthen HIV prevention programming, community support mechanisms, community-based HIV testing, referral systems, and HIV prevention integration at the primary care level. The intervention included situational analysis to inform programming, community engagement and mobilization, and community-based biomedical and behavioral prevention. In support of PEPFAR’s country-ownership paradigm, we costed the combination HIV prevention program to determine data needed for local ownership. This research used costing and health system perspectives. Results: Cost per person reached with individual or small group prevention interventions ranged from $63.93 to $4,344.88. (cost per health facility strengthened). Personnel costs drove the intervention. This was true regardless of year or activity (i.e. wellness days or events, primary health care strengthening, community engagement, and wellness clubs). Conclusions: Labor-intensive rather than capital-intensive interventions for low-income settings, like this one, are important for treating and preventing HIV/AIDS and other health conditions sustainably. Over time, costs shifted from international cost centers to in-country headquarters offices, as required for sustainable PEPFAR initiatives. Such costing center evolution reflected changes in the intervention’s composition, including (1) the redesign and re-deployment of service delivery sites according to local needs, uptake, and implementation success and (2) the flexible and adaptable restructuring of intervention components in response to community needs.

Interprofessional Education and Integration with Primary Care: A Systematic Review

Interprofessionalism encompasses teamwork, knowledge construction, open dialogue, and respect among the peculiarities related to professional practice. This study consists of a systematic review, structured by the P.V.O. is does Primary Health Care (V - variable), favor the development of interprofessionalism (O - outcomes), during the training of higher education health students (P - population). We used searches of the PubMed (United States National Library of Medicine Service) and SciELO (Scientific Electronic Library Online) databases with descriptors from the DeCS (Descriptors in Health Sciences) and MeSH (Medical Subject Headings) platforms. The Medical Education Research Study Quality Instrument (MERSQI) was used to assess risk of bias and quality. After reading and analyzing the 15 selected articles, three categories emerged: "The dimensions of interprofessionalism in the strengthening of Primary Health Care"; "Interprofessionalism and the teaching-learning process in health"; "Perspectives for interprofessional training in higher education: challenges in implementation and possible solutions". Primary Health Care favors the development of interprofessionalism in many countries, especially in Brazil. However, it is up to the academic staff to use this strategy to advance interprofessional competencies in health education. It is indicated that more didactic-pedagogical resources on interprofessional education be developed and implemented, in such a way that Primary Care is the focal point for the development of interprofessionalism.

Acesso à contracepção durante a pandemia de Covid-19: barreiras e perspectivas

Abstract Background The SARS-CoV-2 pandemic, which started in December 2019, was declared by the World Health Organization (WHO) as an international public health emergency in January 2020, with an impact on access to sexual and reproductive health services for women. Objective To discuss contraception in the pandemic context, based on current public policies and the world and Brazilian scenario. Method This is an opinion article, which describes the barriers and possible solutions for access to qualified sexual and reproductive health care for women. Results Relevant topics were explored, such as: the change in the logistics of services, the reduction in the number of consultations, the difficulty in importing contraceptives, the lack of trained professionals, and the bureaucratization of access to contraceptives methods. The use of telemedicine and the strengthening of Primary Health Care are considered strategies to guarantee access and change the reality of women. Conclusion In this context, it is necessary to maintain the actions of sexual and reproductive planning services to prevent injuries from unplanned pregnancies and increase maternal morbidity and mortality.

Development trend of primary healthcare after health reform in China: a longitudinal observational study

ObjectivesReconstructing the primary healthcare system is the focus of the new round of Chinese health reform. Nevertheless, there have been few studies focusing on the strengthening of primary healthcare in...

Universal health coverage: opportunities and challenges (on the materials of the International conference on December 10, 2021 in Almaty, dedicated to the Universal Health Coverage Day)

On December 10, 2021, an International conference dedicated to the Universal Health Coverage (UHC) Day was held at the Al Farabi Kazakh National University. The purpose of the conference was to support and develop the main ideas of the UHC. The conference was attended by more than 100 representatives of universities and the medical community from Kazakhstan and other countries of the Commonwealth of Independent States (Russia, Ukraine, Belarus, Kyrgyzstan, Uzbekistan, Tajikistan, Azerbaijan). The reports of the conference participants were devoted to the discussion of global problems of the development and strengthening of primary health care and the achievements of UHC both at the level of the WHO European Region and in individual CIS countries. The issues of training doctors for primary health care, the successes, and prospects of the development of the primary health care system, issues of assessing and improving the quality of medical care, approaches to providing HEU during the COVID-19 pandemic were highlighted.&#x0D; The conference resolution noted the need to consider the principles of the UHC when developing and making proposals to regulatory documents, initiate scientific research in the field of development and effectiveness of PHC models in the CIS countries, review educational programs for the training of PHC specialists taking into account the ideas and principles of HEU. It was also decided to hold an annual International conference UHC: Opportunities and challenges, to carry out joint publications on HEU at the country and regional levels.

The contribution of family medicine to community-orientated health services in Mali: A short report.

Family medicine has not received appropriate attention in the sub-Saharan African context. In particular, family medicine is rarely recognised as a medical speciality and most African countries are silent on the role of family medicine in their health systems. There is, however, an emerging interest in developing family medicine as a key component of primary healthcare. Postgraduate training in family medicine is progressing and many countries have already established specific training programmes. In addition, there have been attempts to define the importance of family medicine, which, we expect, this short report contributes to. Interviews were conducted with physicians, partners and beneficiaries of two international development projects funded by the Canadian government. The one project supports training of health professionals and the other education of healthy women and girls in the community. The objective was to document the strengthening of primary healthcare through the creation and adaptation of a new family and community medicine postgraduate medical programme (which includes both family and community medicine) emphasising field training, immersion in local communities and interdisciplinary collaboration. This article underlines the importance of family medicine in Mali by documenting how what is now termed family and community medicine can promote community-orientated health services. To do so, we use the examples of initiatives and actions done through two international health development projects.

Factors associated with career intention in primary health care among medical students

Abstract: Introduction: Health assistance reorganization has been oriented, since the Unified Health System (SUS) creation, by a proposal of expansion and strengthening of Primary Health Care (PHC). In this context, the scarcity of trained professionals is considered one of the main challenges for PHC consolidation. Among the career options after graduation, most physicians choose to seek focal specializations to work in other health care levels. Objective: Therefore, this quantitative study aims to analyze the prevalence and associated factors of medical students’ interest in following a career in PHC. Method: A cross-sectional study was conducted with medical students attending the last two years in four medical schools in the state of Minas Gerais, Brazil. A total of 524 students participated by answering a self-administered questionnaire, which was prepared by the authors, including questions regarding sociodemographic and economic profile, interaction with PHC during undergraduate school, career intention and intention to attend the Family and Community Medicine Residency (FCMR) program. Results: The results showed that 26.3% of the respondents indicated interest in following a career in PHC, a higher percentage when compared to previous studies. Regarding PHC being a temporary work choice, 79,3% of the participants indicated that they intend to work in this field after graduation. Ten percent of the students informed they intend to attend the FCMR program. Among the factors associated with the intention to work in PHC, a successful PHC experience during undergraduate school stands out. Conclusion: The results should be taken into consideration by health and medical education managers, fostering strategies that promote successful PHC experiences, encouraging learning-service integration and including students in a consolidated PHC network during undergraduate school. Initiatives such as increasing the workload in PHC during undergraduate school, increasing the number of FMC specialized teachers and health network improvement in the municipalities where these Higher Education Institutions are located can be powerful actions toward increasing the graduating students’ interest to work in PHC.

Factors associated with career intention in primary health care among medical students

Abstract: Introduction: Health assistance reorganization has been oriented, since the Unified Health System (SUS) creation, by a proposal of expansion and strengthening of Primary Health Care (PHC). In this context, the scarcity of trained professionals is considered one of the main challenges for PHC consolidation. Among the career options after graduation, most physicians choose to seek focal specializations to work in other health care levels. Objective: Therefore, this quantitative study aims to analyze the prevalence and associated factors of medical students’ interest in following a career in PHC. Method: A cross-sectional study was conducted with medical students attending the last two years in four medical schools in the state of Minas Gerais, Brazil. A total of 524 students participated by answering a self-administered questionnaire, which was prepared by the authors, including questions regarding sociodemographic and economic profile, interaction with PHC during undergraduate school, career intention and intention to attend the Family and Community Medicine Residency (FCMR) program. Results: The results showed that 26.3% of the respondents indicated interest in following a career in PHC, a higher percentage when compared to previous studies. Regarding PHC being a temporary work choice, 79,3% of the participants indicated that they intend to work in this field after graduation. Ten percent of the students informed they intend to attend the FCMR program. Among the factors associated with the intention to work in PHC, a successful PHC experience during undergraduate school stands out. Conclusion: The results should be taken into consideration by health and medical education managers, fostering strategies that promote successful PHC experiences, encouraging learning-service integration and including students in a consolidated PHC network during undergraduate school. Initiatives such as increasing the workload in PHC during undergraduate school, increasing the number of FMC specialized teachers and health network improvement in the municipalities where these Higher Education Institutions are located can be powerful actions toward increasing the graduating students’ interest to work in PHC.

Primary Healthcare Strengthening through Distance Education for Health Professionals

Introduction: Primary Health Care is proven to be a highly effective and efficient way to address poor health and well-being. Despite its achievements Sri Lanka’s PHC System, specialized for preventive and curative actions, is increasingly under pressure due to chronic and non-communicable diseases. Developing the broad range of skills necessary for medical practice in the existing PHC settings should be achieved through continuous professional development. A distant learning programme through eLearning is a model solution to expand the existing boundaries for CPD. Methods: Sri Lanka Medical Association, Ministry of Health, Primary Healthcare System Strengthening Project and World Bank have collaboratively worked as key stakeholders to develop and implement a course for capacity building among the medical professionals. The first phase of the course was developed with 6 priority modules consisting of Ministry of Health approved content conjoined with digital material. Participants were provided with additional resources. The course was evaluated by assessing user involvement and users’ perception towards the course. The course reflected a positive involvement for majority of modules and a generally positive feedback despite the response rate being considerably low. Discussion: Vulnerabilities in the system could be identified including shortcomings of the system, instructors and learning material, and administration issues. Including diverse course materials, provision of incentives for participation, training resource persons and other recommendations may allow better distance learning experience with desired outcomes. Conclusion: Distance learning through an eLearning platform is an ideal way to address CPD in PHC through timely modules, appropriate learning material, user friendly interface, efficient evaluation methods, and an effective system improving procedure. This course has enabled medical professional to develop their insights in PHC, however the shortcomings should not be neglected.

Nurses' production of meaning about National Program for Access and Quality Improvement Primary Care

Abstract Introduction The Brazil's Family Health Strategy (ESF) is one of the initiatives for the strengthening of primary health care (PHC) in Brazil. The ESF is composed of a team of professionals, with the nurse usually adding care and administrative functions. In regard to the National Program for Improving Access and Quality in Primary Care (PMAQ-AB), the nurses have played a prominent role, especially in the external evaluation phase. Aim Analyze the meanings produced by nurses about the PMAQ-AB in a state in the northeastern of Brazil. Methods A qualitative research was carried out with twenty-five nurses from the health macro-regions of the State of Piauí. Data were collected from four focus groups, with one group in each macro-region, containing at least six and at most seven participants. The meetings were held from September to October 2018, in which semi-structured interview script was used. For the analysis of information, the maps of association of ideas proposed by Spink and Gimenes (1994) were used. Conclusions Despite the difficulties and conflicts felt by nurses with the implementation of PMAQ-AB, the program was understood as an agent for transforming in the work process of family health teams. In addition, the realization of this study allowed another space for reflection to the nurses about the program, qualification and financing of PHC, which can contribute to the institutionalization of the culture of monitoring and evaluation and also the consequent strengthening of these services. Key messages Based on the expected impacts, we seek collaborate with reflection on the experience and generate consistent and useful information to contribute to the decision-making processes of health policies. The PMAQ-AB was considered a program that was able to induce substantial changes in work processes because it was a way to finance the workforce.