Process monitoring (NPHV)
Agreement between the instances (state and municipal) |
- Federal scope:
- Brazilian Ministry of Health acted as a policy inducer that favored the decentralization and implementation of services and increased testing offer. |
“The Ministry encouraged the implementation of TCC. It was important to have this service here”. P4
“It seems that the Ministry has been providing opportunities for the decentralization of services”. P8
“The Kits are just ask and they come from the Ministry of Health, this has no cost to the municipality”. P3 |
- Inter-municipal agreement:
- The health consortium has been the management instrument for agreement favoring access. |
“The consortium was the right strategy. In logistics, the physician attends here at the SAE twice a month for the references of the municipalities. They don’t have a hard time buying the consultation; it’s not an expensive consultation.” P6
“With the consortium we were able to hire the specialist.” P5 |
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ANALYSIS DIMENSION: ECONOMIC-SOCIAL
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Investments in the public network by sphere of power and level of complexity.
Social, economic, cultural, and physical barriers |
Investment in the health sector has aligned improvements in infrastructure and resources to reduce barriers:
- Recognition of the epidemiological scenario by management, given the increase in reported cases of human immunodeficiency virus infection and sexually transmitted infections, motivated the creation of reference services such as TCC and SAS.
- The infrastructure and human resources framework in the SAE that is used as a reference for attention to hepatitis in the health region was considered satisfactory in relation to the other services in the state. |
“The number of people being treated for HIV has increased. So it was proposed to create the TCC to advance testing”. P4
“Last year (2020) we started a conversation to implement an SAE in the municipality. With the project we moved to a better physical space ”. P7
“Look, if you are going to make a comparison with other municipalities, we are fine. For a while I got a room for myself”. P3
“The SAE infrastructure, the multi-professional team is a differential in care. The ease of collecting the material is what gives us strength, we have the laboratory and we collect almost weekly viral load. We reduce the waiting time of the patients, at the latest it is ten days. We also collect for genotyping. The result today is a quick result, before it was 30 or more today from ten to fifteen days”. P6 |
Ensuring attention from the perspective of user needs:
- The attitude of the municipal manager and the local economy contributes to the displacement of the users to the consultation, covering medications outside the REMUNE (Municipal List of Essential Medicines) and examinations that are not included in the agreement list. |
“Even if the patient has to move from the municipality, transportation is provided and in some cases OHT (Out-of-Home Treatment) has already been offered. The patient has the facility of the examination, of the medication, including those that are out of REMUNE, because sometimes the infectious disease physician passes another medication and the secretary provides it. We had a hepatitis C patient who was given a OHT for her to have tests, which were not in the agreed list in the consortium, she did it in a private service. ” P8 |
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ANALYSIS DIMENSION: ORGANIZATIONAL
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Entry Door
Attendance flow
Geographical barriers,
Regulation
Reference
Counter-reference
Evaluation |
User flow in the regulation system:
- There are no limitations to the offer of testing in TCC and SAE services.
- There is a defined flow to the users as soon as they receive the diagnosis.
- The expansion of the offer of testing through Primary Health Care and the organization of flows in the municipality is a favorable point.
- It is easy to schedule appointments through the consortium.
- Female population deprived of liberty has partnerships for actions with the SAE of Rondonópolis.
- The care protocol for pregnant women with a flowchart that guides professionals favors the organization of care and access to prevention of vertical transmission. |
“If the user arrives here, there is a test, if he goes to a basic unit and there is no test there, just forward him here and I will attend him.” P4
“Once this patient is diagnosed, he has a right way.” P5
“Quick test that gave reagent already has a right way”. P8
“We have five basic health units here, the rapid test is offered in the units and in the municipal hospital”. P9
“All FHS (Family Health Strategy) can perform the test, the nurse is trained. This goes a long way in increasing access to testing”. P4
“The consortium calls and says that there is a patient who is sick; we tell the patient that we can manage to put him in the consultation here. Sometimes it puts this user on the agenda of Rondonópolis, but our concern is that this patient suffers as little as possible and that he has access to medication as soon as possible”. P6
“For pregnant women, the flow is easier because there is a protocol and all professionals already follow. The quick test is done on the unit, this makes it easier to guide the attention network, it doesn’t get so loose”. P5
“In the SAE we have a partnership with the female penitentiary, with actions there for screening and diagnosis and treatment. Already the male penitentiary they have a team of physicians and nurses there, they seek the SAE more to seek the test and also the medications”. P5 |
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ANALYSIS DIMENSION: TECHNICAL
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Welcoming
Bond
Competence
Ability
Autonomy
Commitment
Shared therapeutic project
Team and user
Quality of care |
Strategies to promote welcoming in the reference service:
- Scheduling various time slots at the CTA/SAE is a strategic approach.
- Expanding extramural actions enhances testing.
- Having an infectious disease physician in the network was recognized as favorable for facilitating diagnosis and treatment.
- Professional training within the care network was considered an opportunity to advance in providing testing. |
“I give priority to attending in the morning, but if the patient comes in the afternoon, I attend. You have to consider who works, the sex workers who sleep in the morning”. P3
“We do a lot of lectures, this region is a farm, so in SIPAT (Internal Week for the Prevention of Accidents at Work) weeks one of the themes is HIV and viral hepatitis, and in addition, lectures go to schools. The lecture is the key car in the municipality, because when we go it is clear that people do not know about hepatitis”. P4
“We have an infectious disease physician in the unit, this is a gain; many SAE do not have. In the past he attended once a week, today he attends twice. He attended 15 patients; today he attends 20 each day, so there are 40 vacancies weekly. His schedule for other municipalities is 30 vacancies. The chance of treatment being faster and also right is higher with a specialist”. P6
“There are few capacities, but they help to stay on top of the new protocols”. P5 |
Cross-sector alliances:
- - Partnerships between health services and social media, communication channels, and third-sector institutions have helped promote the prevention of hepatitis in society. |
“We have partners like the Catholic Church, AIDS pastoral, partnerships with higher education institutions, with television and radio media. We do interviews talking about epidemiological situation, talking about the importance of prevention and testing. Partnership with Non-governmental organizations that represent LGBT (Lesbian, Gay, Bisexual and Transgender groups and sex workers are intermediaries to get us there”. P7
“We partner with Rotary for campaigns, especially for hepatitis C. When you do actions with partnerships you can even reach a target audience”. P8 |
Professional commitment:
- The proactive attitude of the professionals and their commitment to work result in greater benefit to access.
- Efforts by professionals to assist the users in their demands increases adherence to treatment. |
“A couple of years ago I started talking to managers about the importance of better structuring the operation and creating a SAE, equipping and putting more professionals”. P7
“Our social worker does a very detailed job. It is a facilitator for hepatitis patients, especially in scheduling appointments and exams, in medication processes, with documentation and checking so that it works there in the removal of high-cost medications of the pharmacy”. P5
“The physician gives us a lot of access, we talk to him to solve a problem of a patient that appears, he opens a schedule and we manage to fit in”. P6
“Sometimes we have leftover HIV medication, because the patient dies and the medication is returned here, so if you have Tenofovir it stays as leftover in the pharmacy and we deliver it. So we stood between the cross and the sword, between doing right or doing wrong, but at that moment if we have leftovers here we will offer, the physician prescribes and we release, it is not the ideal way, but it is also not ideal to leave him in this situation if I have medication here”. P5 |
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ANALYSIS DIMENSION: SYMBOLIC
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Culture
Beliefs
Values
Subjectivity |
The voice of the user after accessing the service mobilizes to qualify the assistance:
- The users’ experience in the utilization of the health service and the manner in which they communicate their management and professional interactions have contributed to the expansion of specialized reference services. |
“The patient has a voice, he talks about his difficulties. Although we are close to Rondonópolis, moving there and here is not easy. So he comes and says, when he has an opportunity, he takes it to the board or to the secretary; it helps us to show the manager the need to qualify the service”. P7
“The idea of bringing an SAE was due to complaints from patients about the times they had to go beyond the conditions of our roads and the wear and tear with the trip”. P9 |
- Profile of the professional to favor access:
- The professional’s ability to empathize in serving the vulnerable population is an essential factor in understanding the approach to hepatitis in different territories. |
“For the service to walk, you need to identify yourself a lot with work, you have to like it, you have to break down prejudices, taboos. Example: we have a very large flow of homosexuals, sex workers and if suddenly you are a very closed professional, you may not be able to do the actions that are viable”. P4
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