Access to government social programs and the tuberculosis control program: a multicenter study

Acceso a los programas sociales gubernamentales y al programa de control de la tuberculosis: un estudio multicéntrico

ABSTRACT

Objectives:

to analyze government social initiatives aimed at people with tuberculosis and the possibilities of access to government social programs and income transfers through the perception of tuberculosis program managers.

Methods:

descriptive, qualitative study with 19 managers from Belém, Recife, Campo Grande, and Rio de Janeiro, Brazil. Thematic content analysis was used.

Results:

there is no specific government social support for people with tuberculosis; the benefits are intended for people in social vulnerability. There are partnerships between the institutions of the secondary social healthcare network, social assistance, and community institutions.

Final Considerations:

the support of official bodies is important for the control of tuberculosis; however, the profile of people’s vulnerability is a determining factor for access to/destination of resources from these government social support programs.

Descriptors:
Health Management; Tuberculosis; Public Policy; Social Programs; Government Programs

RESUMEN

Objetivos:

analizar las iniciativas sociales gubernamentales dirigidas a las personas con tuberculosis y las posibilidades de acceso a los programas sociales gubernamentales y de transferencia de renta, en la percepción de los gestores de programas de tuberculosis.

Métodos:

estudio descriptivo, cualitativo, con 19 gestores de Belém, Recife, Campo Grande y Rio de Janeiro. Se utilizó el análisis de contenido temático.

Resultados:

no hay soporte social gubernamental específico para personas con tuberculosis; los beneficios son destinados a las personas en vulnerabilidad social. Hay colaboraciones entre las instituciones de la red social secundaria de salud, asistencia social e instituciones comunitarias.

Consideraciones Finales:

el apoyo de las instancias oficiales es importante para el control de la tuberculosis, con todo el perfil de vulnerabilidad de las personas es factor determinante para el acceso al/destinación de los recursos de esos programas gubernamentales de apoyo social.

Descriptores:
Gestión en Salud; Tuberculosis; Política Pública; Programas Sociales; Programas de Gobierno

RESUMO

Objetivos:

analisar as iniciativas sociais governamentais voltadas para as pessoas com tuberculose e as possibilidades de acesso aos programas sociais governamentais e de transferência de renda, na percepção dos gestores de programas de tuberculose.

Métodos:

estudo descritivo, qualitativo, com 19 gestores de Belém, Recife, Campo Grande e Rio de Janeiro. Utilizou-se a análise de conteúdo temática.

Resultados:

não há suporte social governamental específico para pessoas com tuberculose; os benefícios são destinados às pessoas em vulnerabilidade social. Existem parcerias entre as instituições da rede social secundária da saúde, assistência social e instituições comunitárias.

Considerações Finais:

o apoio das instâncias oficiais é importante para o controle da tuberculose, contudo o perfil de vulnerabilidade das pessoas é fator determinante para o acesso ao/destinação dos recursos desses programas governamentais de apoio social.

Descritores:
Gestão em Saúde; Tuberculose; Política Pública; Programas Sociais; Programas Governamentais

INTRODUCTION

Tuberculosis (TB) is an infectious disease that can be cured, but which persists as a public health problem(¹). Annually, more than 10 million people in the world become ill with tuberculosis and 1.5 million dies from the disease, making it one of the main causes of death from infection in the world, before the COVID-19 pandemic(²).

In Brazil, it is considered a latent public health problem, influenced by the social characteristics of the country, with an incidence of 73,864 cases in 2018 and 4,490 deaths from the disease in 2019(³). Such data demonstrate the relevance of global goals aimed at control and prevention, with the objective of reducing illnesses and deaths(²).

Faced with this problem, the implementation of political actions with a focus on expanding the coverage of care and monitoring of cases is discussed, with a view to providing quality care(²). This action took place in different Brazilian municipalities, as part of the Family Health Strategy; however, despite the numerous efforts of governments and health professionals, there is a high prevalence of tuberculosis in all regions of Brazil, especially in Rio de Janeiro and Amazonas(⁴).

Despite the tuberculosis challenges to be faced, regional differences in terms of the number of inhabitants, the Human Development Index, availability of health facilities and ease-of-access to them, the country was considered a reference in the control of the disease, presenting effective actions related to social protection, guaranteed by the Sistema Único de Saúde (SUS) [Brazil’s Unified Health System] from diagnosis to treatment, and the implementation of support and income transfer programs(⁵).

In this perspective, in Brazil, through the Cadastro Único (CadÚnico), which is an action of the federal government, but with shared and decentralized management between the Union, the states, the Federal District, and the municipalities, it is possible to identify vulnerable people and families, exposed or not to tuberculosis, to whom various programs and social benefits are offered(⁶).

In this scenario, the process of putting policies and programs into effect requires that health units’ management be aware of the aforementioned programs and implement them with innovative actions in order to meet worldwide established goals. Among these goals, we highlight the guarantee of treatment for 40 million people and the achievement of at least 30 million in the prevention of latent tuberculosis between the years 2018 and 2022(²). That said, it is up to the manager - alongside units’ management -, to monitor the implementation of the program through actions, in order to discover the facilitating and impeding factors and seek a solution which enables the achievement of the objectives of the government programs for every user.

The present study is relevant as there are national and international gaps in the production of scientific evidence on the conditions of people with tuberculosis pertaining to their access to government social programs with a view to mitigating social determinants and social protection of those most vulnerable(²,⁵), from a tuberculosis control program managerial perspective.

OBJECTIVES

To analyze government social initiatives aimed at people with tuberculosis and the possibilities of access to government social programs and income transfers through the perception of tuberculosis program managers.

METHODS

This research had as ethical direction, the Resolution nº 466/2012 of the National Health Council. Participants were presented with the Free and Informed Consent Terms (FICT) for clarity pertaining to research objectives and methods and, subsequently, their signature. All participants’ questions were clarified.

To ensure identity secrecy, professionals were identified using the letter M (for “manager”), followed by the numerical order of the interviews and the acronym of the city where the data was collected. The project was approved by the Research Ethics Committees of the Federal University of Espítito Santo, Anna Nery School of Nursing of Federal University of Rio de Janeiro, and the Municipal Secretariat of Rio de Janeiro/RJ.

Study design

Exploratory qualitative study, the first phase of the multicenter project entitled: “Longitudinal Study of the Impacts of Social Protection Operational Indicators of Tuberculosis- ELISIOS-TB”, coordinated by the Federal Universities of Espírito Santo. The Consolidated Criteria for Reporting Qualitative Research (COREQ) instrument was adopted to guide the study’s methodology.

Study location

The study was carried out in the cities of Belém (state of Pará - PA), Recife (state of Pernambuco - PE), Campo Grande (state of Mato Grosso do Sul - MS), and Rio de Janeiro (state of Rio de Janeiro - RJ) — in the municipal and state Coordination of the Programa Nacional de Controle da Tuberculose (PNCT) [National Tuberculosis Control Program], considering the criterion for the highest number of reported cases in 2019.

Study participants

Nineteen managers of the Tuberculosis Assistance and Control Program coordination staff of the municipal and/or state health secretariat of the aforementioned cities participated in the study. Participant selection was carried out by convenience. The inclusion criterion was to carry out the role of a tuberculosis care and control service manager for a minimum period of six months. Managers who were away from their work activities, either on leave or vacation, during the data collection period, were excluded.

Data Collection Tool

The construction of the data collection instrument was done by the researchers and consisted of sociodemographic and occupational data and three semi-structured interview guiding questions, namely: “1) Tell me what are the initiatives in the area under your management to support people being treated for tuberculosis; 2) What possibilities does a person with tuberculosis have to access government social and income transfer programs?; and 3) What kind of support does this person receive?”. This instrument had been previously tested without any need for changes.

Data collection was carried out from November 2019 to February 2020. The managers’ invitations to participate in the research were carried out through; there were no participation refusals. The interviews were carried out at the managers’ workplace in a previously reserved room in order to ensure privacy; had an average duration of 15 minutes; were recorded using mobile devices and transcribed in full for analysis. In order to ensure technique uniformity in conducting the interviews, training was carried out in a Data Collection Workshop, with the participation of researchers from each university. The participation of UFES (ES) in this workshop is highlighted as it was the site for the data collection instrument pilot test. As a result, the “Interviewer’s Manual” was created to guide the researchers’ teams through the data collection process.

Data analysis

The treatment of the data involving the phases of organization, processing and analysis was applied to the characterization information of the participants was conducted using the program IBM Statistical Package for Social Sciences (IBM SPSS Statistics, version 21.0).

The testimonies were submitted to Bardin’s content analysis technique(⁷), considering two phases: the first, named “pre-analysis”, consisted of reading and rereading the collected data, seeking to acquire an overall view and apprehend the particularities expressed in the statements. The second, called “material exploration”, aimed at transforming the information into thematic content of text comprehension, in which the fragments of the participants’ speeches were grouped and categorized. By condensing the thematic units into categories, it was decided to organize them into pre-defined categories, articulating them with the research objectives. In the third phase, the elaboration of an “interpretive summary of the results”, the objective was to understand the meaning of the reports evidenced in each category through the inference and interpretation of the results considering the theoretical foundation relevant to the subject of the study.

Based on the steps described, three categories were organized, namely: Existing initiatives to support people undergoing tuberculosis treatment; Access possibilities to Government Social Programs for people diagnosed with tuberculosis; Social support received by people diagnosed with tuberculosis.

RESULTS

Nineteen tuberculosis control program managers participated in the study, 16 of whom coordinated the tuberculosis control program at the municipal level and three at the state level. As for gender, 16 were female and three were male. Regarding the city of origin, eight were from Rio de Janeiro/RJ; four, from Campo Grande/MS; four, from Recife/PE; and three, from Belém/PA. As per professional category: 11 nurses, four doctors, three social workers, and one physiotherapist. The median age was 45 years, ranging between 32 and 65 years. All reported postgraduate degrees, most in the areas of health surveillance, public health, and pulmonology. However, nine took a training course in the management and care of people with tuberculosis. Regarding the experience in caring for people with tuberculosis, seven managers did not have any; and, among those who had already worked in this care assistance, the average time was of ten years. The median time of experience in management was 4.5 years.

Existing initiatives to support people undergoing tuberculosis treatment

An absence of specific initiatives for people with tuberculosis was identified in the managers’ communication. There are partnership initiatives on the part of management with official and community bodies to meet the needs of people in a vulnerable state.

Currently, the Campo Grande Tuberculosis Municipal Program has no specific benefit for tuberculosis patients. [...] they used to get a “cesta básica” [“Food Basket”: Brazilian benefit in the form of a box with essential food products] and transportation vouchers. [...] In 2013, they moved the assistance part and put it alongside with surveillance. We were told that the Secretary of Health could no longer use the resources for food and transportation. And it was said that we needed to work alongside the Social Assistance Secretariat for our patient to have this benefit. (M2_MS)

We observed that for patients of great social vulnerability, we have implemented working groups in areas where they have the highest number of abandonment and with a social vulnerability profile. [...] this working group looks at and discusses the cases in a multidisciplinary and intersectoral manner, one by one. [...] The Residents’ Association are in it together, the school is together, the CRAS, which is the social assistance, is together, community leaders are together, technical staff of the family clinic are together, and management, the responsible medical technician, nursing technician, everyone is together in this discussion. (M1_RJ)

[...] We have a partnership with the Fundação Papa João Paulo, referred to as FUNPAPA. [...] there is a partnership with these health units, making bacilloscopy and treatment through this partnership, which would be the treatment observed within these units, the POPs centers. They receive medication and orientation to make this supervised treatment within these reference units that would be part of social assistance. (M1_PA)

[...] we have within the territory the presence of the CRASs for patients to be referred when in a situation of social vulnerability and with a certain prioritization when he has any illness - in this case, tuberculosis, but this is also available for other illnesses. (M2_PE)

However, to ensure that people’s access to social programs, managers emphasized the importance to articulate with the Social Assistance Secretariat or other services:

[...] we need to articulate with the Social Assistance Secretariat to get our patients to have this benefit. (M3_MS)

[...] we have been able to institute a partnership with the Municipality’s Social Assistance Secretariat so that patients under social vulnerability are referred to the social assistance reference centers, called CRASs. (M1_PE)

[...] we need to articulate with other public policies to try and minimize this tuberculosis issue. [...] We partnered with popular restaurants so that when the patient does the DOTs in the unit, he can get a ticket to eat at the restaurant. (M2_RJ)

Although most participants have mentioned a lack of knowledge of specific social programs that support people with tuberculosis, the conditions for which a health care network user can have access to existing governmental social programs within the studied municipalities were pointed out.

Access possibilities to government social programs for people diagnosed with tuberculosis

In this category, it was pointed out: the vulnerability of people diagnosed with tuberculosis, vulnerable peoples’ access to governmental social programs and manager’s performance in this context of patient vulnerability.

[...] Tuberculosis presents a higher incidence within the vulnerable population, [...] thus, it is a concern of ours to provide people with access to the health system. (M4_RJ)

Actually, the person enters as an individual or person in vulnerability, which has access to existing programs in his municipality... he will be directed to CRAS, [...] where he can be oriented and referred to existing programs and projects in the municipality. (M1_MS)

[...] The person with tuberculosis has access to this service like anyone else. If he did not have tuberculosis, but he was in a situation of social vulnerability or at risk, he would have access to all programs. He is not discriminated by tuberculosis. (M2_PA)

[...] we have to put into perspective that tuberculosis will pass, but hunger will continue, the situation of vulnerability will continue. And social assistance, it comes with this proposal to reduce this vulnerability and try to remove this individual from vulnerability, because we may treat the tuberculosis, but the vulnerability remains, then they get sick again. [...] then, we understand that social assistance, in fact, is very important in this aspect of not only treating tuberculosis today: if the vulnerability remains, the person gets sick afterwards. (M1_PE)

Social support received by people diagnosed with tuberculosis

In this category, existing social supports and those of which people benefit from were referenced, as well as the availability and continuity of programs:

[...] people who live in the street have a differentiated health team, which accompanies people living in their situation. We have a snack kit to encourage and keep people interested also in the use of medication, which is a difficult task, especially in this population. (M4_RJ)

[...] until mid-2015, you had the “Food Basket” and the transportation vouchers. We still have transportation voucher credit. We received a donation from the immunization program, which had some, did not use it, and gave it to us. So, we are still using this transportation voucher. (M3_MS)

[...] to be eligible for continuous benefit, they must be over 65 and have an income of up to a quarter of a minimum wage salary. Then the person is eligible, but only if he meets these criteria. (M1_PA)

[...] in relation to the Bolsa Família [Brazilian income transfer program], we crossed checked the people who were notified with those who were receiving the Bolsa Família benefit. We were even surprised at the quantitative of people who received it, but this initiative is not ours, it is [...] it was an information, and for us to provide feedback from the result. (M3_PA)

[...] professionals, as a whole, know that there is this support of the CRAS, they always speak of that “Food Basket”. They write a social report and deliver it to the patient or to whomever is responsible, in case the patient is very weak and not able to go to the CRAS at the health unit. And CRAS makes a social visit in a timely manner, [...] there is usually a home visit from Social Services and Psychologists and these patients are included in programs, or Bolsa Família, or verifies the BPC issue [...] they have sought vocational courses for family members, for the contacts of this patient. [...] and when you ask what kind of support this person receives, I’m aware of: Bolsa Família, BPC, elderly benefit, low-income person retirement, social fare of electric energy, the free transportation voucher pass for people with disabilities, and temporary shelter care. (M3_PE)

Although it is recognized the importance of public policies to support people with tuberculosis, the granting of governmental social benefits in accordance with the criterion of social vulnerability, as well as intersectoral articulation, managers of some states also mentioned the existence of weaknesses in peoples’ access to such benefits due to the decentralization of basic health units, bureaucracy, and discontinuity of public policy, beneficiary selection criteria:

[...] we have here in the municipality the transportation voucher, [...], but with the decentralization of Basic Care and the health unit being close to the user’s residence, many do not have access to this benefit, because, as he lives close by, he ends up not fitting the profile to acquire this benefit. [...] the popular restaurant [where patients receiving DOTs ate at], were state owned; due to the state’s crisis, this partnership ended. (M2_RJ)

[...] Sometimes it takes a while, there is a relatively large bureaucracy, [...] there are patients who need to go to the tertiary reference unit, which are federal hospitals, to take the treatment with the specialist in resistant tuberculosis. [...] There’s a gap between beginning treatment and when they begin to receive this transport voucher benefit [...]. (M3_RJ)

[...] until the year 2012, the Secretariat provided the “Food Basket” for patients in TB [tuberculosis] treatment. From 2013 forward, we can no longer acquire the “Food Basket” with Secretariat resources, [...] so, today we do not provide any financial support. (M4_MS)

[...] the benefit is not necessarily only for tuberculosis patients. [...] their life conditions will be evaluated, the state of vulnerability they live in and what specific aid they need. (M2_MS)

DISCUSSION

In view of the absence of specific support initiatives for tuberculosis treatment, Brazilian states management establishes partnerships with official and community bodies to achieve their needs. These people also resent the extinction of initiatives and municipal actions that helped minimize identified needs.

Brazilian states are marked by social inequalities, with greater concentration in urban areas with greater population density, factors that influence the outcome of tuberculosis treatment. Therefore, it is important to develop short-term interventionist behaviors to guarantee universal access to health and social protection services, in order to allow changes in social and economic determinants(⁸).

A study(⁹) held in Kazakhstan showed that the burden of tuberculosis is influenced by populations’ socioeconomic factors, affecting those who are economically disadvantaged, that is, those suffering from high unemployment rates, alcohol dependence, a history of seclusion or a lack of housing in comparison with the general population. This set of factors helps explain the underlying association between low socioeconomic level, risk of tuberculosis (TB), and positivity of cases, reiterating the need for countries’ public policies to consider such factors.

Studies(¹⁰-¹²) reported that impacts generated by illness due to TB can accentuate poverty due to economic costs generated by treatment, thus feeding the poverty cycle. It is substantial that, associated with the strengthening of health actions, should have development of inclusion policies for the protection of rights, such as social programs, to maintain the downward trend in tuberculosis incidence and mortality, in addition to containing the progression of abandonment. of treatment mainly by the poor population(¹¹-¹²).

A research(¹³) along this line was held in Thailand demonstrating the lack of sustainable financing for the treatment of tuberculosis within the populations of migrants and refugees. For this group, support and treatment care were linked to the financing of donors and collaborators, through local and international non-governmental organizations (NGOs). These would develop free residential and support care programs to reduce abandonment rates, providing food and accommodation as well as actively collaborating for patient care and general disease control. Without these services, the country’s public policies would be unable to meet this groups’ social demands.

It is understood that this investment should be primarily carried out by both health and social assistance government bodies, although with the support of volunteers of civil society and NGOs. When there is government initiative, there is a greater perspective of guaranteed insertion of people affected by TB and continuity of service(¹³).

According to Resolution No. 444/2011 of the National Health Council, the creation of tuberculosis control strategies is recommended, which must be articulated with other public policies, for the development of actions with a relevant approach to specific needs, especially populations in a situation of vulnerability(¹⁴).

Therefore, the importance of the development of intersectoral actions and the strengthening of partnerships to broaden access to health and social rights, especially among the most vulnerable populations should be highlighted(¹²).

In many countries, income transfer programs are the basis of social security policy as a form of social assistance to improve acceptance of health interventions. In the case of TB, these programs support people in treatment mainly to reduce low adhesion and risk of drug resistance. Although such programs are recognized as a potentially powerful tool to promote healthy behaviors, the formal impact assessment of these strategies has been very limited in TB control, particularly in Latin America and the Caribbean(¹⁵).

The lack of specific legislation that collaborates for the social protection of people with TB is highlighted by the National Plan for the End of Tuberculosis as a Public Health Problem in Brazil. However, since 2013, a law project No. 6,991/13(¹⁶) has been pending in the Chamber of Deputies to offer a benefit in the amount of half a minimum wage to families registered in CadÚnico and affected by tuberculosis or leprosy.

The treatment of the person with tuberculosis goes beyond the medicines, since, when understanding the complexity of the scenario of individuals, it is realized that it is necessary to confront the social determinants involving illness. However, it is still a challenge for tuberculosis program coordinators to guarantee the completion of treatment in the face of the adversities involved(¹²).

An experience(¹⁷) in Peru with social support and income transfer programs showed an impact on prevention and treatment success in slums, with successful treatment in 64% of patients who received socioeconomic support. This supports the idea that incorporating these interventions as established policies can have a considerable effect on TB control.

Through a research review(¹⁸), the impacts of social protection on TB treatment outcomes in low- and middle-income nations were evaluated. It was evident that this protection was associated with treatment success and reduced risk of noncompliance. However, it was shown that most evaluated interventions were isolated incentives and not a formal social protection policy program.

The Brazilian Plan for the End of Tuberculosis(¹⁹), based on the WHO strategy, was developed considering the goal of reducing incidence and mortality by the year 2035. This plan was divided into three pillars, with the necessary maneuvers being indicated according to their objectives. Among them, two aim to strengthen the participation of civil society in fighting the disease through strategies such as: establishing spaces of articulation between management and civil society for tuberculosis control; foster community actions for social mobilization to fight the disease; support communication, advocacy, and social mobilization actions developed by civil society; and include their participation in the planning, monitoring, and evaluation of actions to fight tuberculosis in the three spheres of management(²⁰). Therefore, efforts should be made to fight poverty and social inequality, implementing income transfer and social mobility policies(²¹).

It is essential for municipal managers to promote intersectorial and intrasectorial articulations with the executing units, such as the Primary Care teams and the organized segments of the community, improving tuberculosis control actions at all stages, including the participation of civil society in health promotion and social control of implemented actions(¹²,²⁰).

In this context, specifically in the municipalities, there is a need to strengthen social protection actions within the municipality, mainly through the expansion of the offer of direct benefits(²²). It is understood that in order to achieve favorable outcomes in the control of this disease, it is important to implement different types of benefits such as training for work, providing opportunities for microfinance and microcredit, access to food and nutrition security programs added to social protection measures.

Therefore, it is essential that tuberculosis be included in the agendas of municipal secretaries in the areas of social assistance, education, justice and human rights, favoring intersectoral articulations and expanding the link between public management and civil society(²⁰).

This strategic articulation was identified as critical by the Vietnam national tuberculosis program in 2016(²³), which carried out a national TB patient survey in order to identify the main drivers of expenditure to help guide cost and cost reduction policies and financial barriers to treatment. The results pointed to a roadmap whose main components included: advocating social health insurance coverage and creating a fund for tuberculosis patients; strengthen collaboration between the Ministries of Health, Labor and Social Affairs.

Regarding to the possibilities of access for people diagnosed with tuberculosis to governmental social programs, the situation of social vulnerability was a factor that facilitated the acquisition of benefits.

The little chance of citizens exercising their citizenship is enhanced, as their needs and demands have been expressed in a restricted way due to their constant silence in front of them(²⁴).

In order to have effective health actions, the repercussions of the health vulnerability process need to be addressed by expanding the perspective of human rights.

Vulnerability and human rights (V&DH) guides on the recognition of the individual’s way of being, his subjectivity and sociability, making it viable to exercise his rights as subjects and not just as a collectivity based on epidemiological indicators. In a world of inequalities, it is essential to give visibility to the person in its essence and complexity(²⁴).

It is worth mentioning that tuberculosis is linked to low income and socioeconomic vulnerability, and that the treatment generates financial expenses for the patient and their families. Even though the Brazilian Health System is free and universal, reducing weaknesses and inequalities in access, it is still inefficient in reducing catastrophic health expenditures during the treatment of a disease such as tuberculosis. However, the more strategies that affect the expansion of access, comprehensiveness and resolution in the SUS are provided, they are welcome to contain these expenses, and consequently reduce the demand for private services(²⁵).

Thus, social protection is the place where health and social interventions are transversal so that tuberculosis control is achieved. Social support for tuberculosis patients with the availability of resources reduces financial difficulties due to the disease, mitigating direct and indirect costs and consequently reducing poverty and social vulnerability(¹⁸,²²,²⁶).

In Brazil, studies confirm that social protection positively influences the outcome of tuberculosis treatment. The Bolsa Família Program (PBF) stands out for transferring income to poor or extremely poor families, with monthly per capita income that does not exceed BRL $178.00(²⁷).

The first evidence in Brazil of a statistically significant association between the increased coverage of cash transfer programs and the reduction in the incidence rate of TB was pointed out in a study in which the authors(²⁸) found that municipalities with high coverage of the BFP presented reduction in TB incidence rates compared to municipalities with low or intermediate coverage.

Regarding the results on the social support received by people diagnosed with tuberculosis, these allow us to say that the search for TB treatment represents an important burden for patients and families, due to the direct costs of transportation, food, and other expenses(²⁹).

In Argentina, a study(³⁰) concluded that inequalities in the spatial distribution of tuberculosis are related to the main social determinants. Its incidence is linked to social conditions such as overcrowding in homes with few rooms and a precarious sewage network.

In Brazil, there is a similar reality, even though the country is considered a world reference for offering free diagnostic technology and treatment for tuberculosis to the population. The morbidity and mortality caused by the disease, generated by social inequality existing in different regions of the country, are still significant, as shown in the study results.

Considering the complexity of tuberculosis as a socially produced disease, there is a need to implement investigative and operational measures, essential for understanding its social determinants of the health-disease process, requiring greater involvement of health professionals, managers and the scientific community. However, in order to eliminate this disease, the importance of public social protection policies as a fundamental and promising strategy for improving tuberculosis indicators is reinforced, along with scientific evidence(³¹).

Study limitations

Data collection with TB control program managers in only four municipalities is a limitation, as it is not possible to ensure the generalization of the results to the reality of the country. However, the research has broadened the understanding of the factors involved in the access of people with tuberculosis to government social programs.

Contributions to the professional Nursing practice, Health, and Public Policy

This study contributes to a reflection on the realization of newer and deeper research that highlights the need for government and social support strategies for people with tuberculosis. The results draw the professionals’ attention to the vulnerabilities of these individuals and to the recognition that treatment cannot be focused solely on epidemiological aspects. However, these aspects are relevant because tuberculosis is an important endemic in Brazil and that requires, via a policy definition at the federal, state, and municipal level, the involvement of health professionals, especially nurses, who are in the front-line monitoring of people and care management. Only by knowing the needs of people with tuberculosis and having institutional conditions to meet these needs will it be possible to face this serious public health problem.

FINAL CONSIDERATIONS

The study made it clear that, in the perception of managers, there are no specific government social support programs for people with tuberculosis and that government benefits are intended for people with socioeconomic vulnerability.

The support of official bodies is essential, but other partnerships are relevant to guaranteeing access and continuity in the provision of social actions and programs aimed at people with tuberculosis. From this perspective, the importance of strengthening intersectionality between the areas of health and social care is highlighted through the joint creation of protocols, training courses, and professional training, to enable the recognition of the needs of people affected by tuberculosis and the establishment of partnerships to be carried out by the managers of these areas of activity.

With this study, it is seen that future investigations are still needed to deepen and broaden the understanding of the participation of government program managers in the prevention, treatment, and control of tuberculosis, at the national level.

• FUNDING
  The “Longitudinal Study of social support impacts, operational indicators of tuberculosis - ELISIOS - TB” was financed by the Ministry of Health through the commitment note 2018NE803480 of CGDR/DEVIT/SVS/MS.

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Edited by

EDITOR IN CHIEF: Dulce Barbosa

ASSOCIATE EDITOR: Álvaro Sousa

Publication Dates

• Publication in this collection
  22 Apr 2022
• Date of issue
  2022

History

• Received
  17 June 2021
• Accepted
  14 Aug 2021