Analyzed Aspects
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Main results
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Main speech extracts from the key informants
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Process Monitoring (PNVH) |
Federal level:
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"It has political instigation, and that the Ministry has its disease flagships. We have many hepatitis protocols, to guarantee treatment, but not to organize care." P7 |
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- Ministry of Health fragile to the formulation of guidelines for the organization of the care network. |
"Hepatitis has never been a priority in the Ministry's speeches". P8 |
Pacts between the instances (State and Municipal) |
- Hepatitis is not a relevant issue on the agenda of public health policies. |
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- The PNVH has not yet promoted universalization and equity of access.
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State and regional level:
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"There is no presence of the SDH accompanying our work, not even that of the RHO." P3 |
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- Absence of monitoring of the state coordination and the Regional Health Office (RHO) in the pact of the care network and organization of care flows. |
"I don't participate in the management articulations in the Municipal Health Secretariat or in the RHO, they just check if there is a vacancy". P6 |
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- The Intermunicipal Health Consortium (IHC) did not show monitoring potentiality to qualify the care network. |
"The doctor is paid by production, they are hired as a legal entity. We had to suspend consultations for some days, because of contract or payment". P5 |
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- The hiring of the physician by the IHC showed, in some moments, discontinuity due to lack of payment. |
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Municipal level:
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"The change of mayor hinders or helps because each manager comes with an understanding (of the situation)." P3 |
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- Rotation of managers, in the municipal sphere, and in health services, showed influence on the direction of actions for hepatitis care. |
"During the changes of managers, I saw that we lost what we had". P4 |
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"Mayors change and the coordination change. Each one comes with his or her particular way". P8 |
DIMENSION OF ANALYSIS: ECONOMIC AND SOCIAL
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Analyzed Aspects
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Main results
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Main speech extracts from the key informants
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Investments in the public network by a sphere of power and level of complexity |
- Only one specialist physician attends the network of nineteen municipalities. |
"Two SAEs were decentralized, but I couldn't get a doctor to cover hepatitis." P9 |
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-No policy was designed to attract and retain specialized doctors to attend hepatitis, even with the decentralization of SAE in the region. |
"We have not moved forward to be microregional because we need doctors who stay in the program." P7 |
Social, economic, cultural, and physical barriers |
- Low quantity of human resources, especially in TCC. |
"It is one infectologist to serve the network of nineteen municipalities". P6 |
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- Most municipalities in the HR do not have testing services |
"It is only me who does the testing here. If I go out on extramural activity the patients are left without testing". P7 |
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"Here we have a TCC and we still can't test everyone, imagine where there isn't one". P3 |
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"There are few municipalities in the HR that have testing". P5 |
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- Testing actions have not kept up with the population expansion of the municipalities. |
"The population grew and the amount of testing performed, is still little if it is to be compared." P7 |
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- Municipal support for patient transportation depends on the municipal budget and vehicle availability. |
"There are difficulties with transportation, sometimes you miss an appointment due to lack of transportation or financial reasons. P5 |
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- The physical structure of the TCCs limits group actions and restricts services. |
"The TCC is a room next to the health unit". P9 |
DIMENSION OF ANALYSIS: ORGANIZATIONAL
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Analyzed Aspects
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Main results
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Main speech extracts from the key informants
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Entrance |
- Resistance of Primary Health Care units (PHC) in the decentralization of testing. |
“We are supposed to have quick tests in family health, but it's a stalemate. A lot of resistance from the nurses. P4 |
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- The reference service, TCC, refers the user with a confirmed diagnosis more quickly than the PHC. |
"The orientation for patients is that every time the doctor asks for an exam, he/she has to schedule it here with us because if he/she goes to the PHC, it takes 30 to 40 days". P7 |
Flow of care |
- Multiple flows in the municipalities until the user receives the diagnosis. |
"The viral load is done at six o'clock in the morning. It's exhausting for the patient who needs to leave his municipality to be here on time. The same happens with consultations and follow-ups. P6 |
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- Lack of definition of regional governance. |
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Geographical barriers |
- Centrality to perform confirmatory tests and consultations indicates a geographical barrier. |
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Regulation/ |
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Referral/ |
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Counter-reference |
- State management is absent from the care regulation process. |
"The regulation is via IHC, I don't know anything about waiting demand". P5 |
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- The responsibility of the federal entities in care management is not clear for health services. |
"Since IHC took over TCC stopped following up on people with hepatitis". P4 |
Evaluation |
- The regional reference service does not participate in the analysis of the care network and follow-up/monitoring. |
"We don't do an integrated service with the network". P6 |
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- For transplantation, it is not clear the user flow in the HR care network. |
"The transplant is the first case. I can't tell how it happens yet". P6 |
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- Treatment access logistics is a major problem, especially for hepatitis C. |
The difficulty is the medication logistics. We have many cases of irregular patients, patients who discontinued the medication, because of bureaucratization. P6 |
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- There is no coordination of services to monitor user access to treatment. |
"After it is forwarded to the high-cost pharmacy, we the SCS do not perform the monitoring". P6 |
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- There are weaknesses in communication between the distribution of the medication in the municipalities, and the users waiting for the medication. |
"We had cases of patients whose medication was in the municipality, however, they didn't notify the patient". P6 |
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- There is no monitoring by the health services that referred users to the referral. |
"Monitoring has become loose. The patient is the one who goes there to complain about something or because they are passing out." P4 |
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- IHC management does not assess care coordination in the network. |
"The patient's follow-up is difficult. Some move to another city, and others stop the treatment". P8 |
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- It is not clear whether the PHC or the hepatitis care program assumes the user's follow-up in the municipality. |
"We participated in some network evaluations that were done by the Ministry, but you realize that it is more about infrastructure than quality." P6 |
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- Evaluation of the service, the work process, and the care provided is not carried out in health services. |
"I don't work here with evaluation, that is up to the SDH as is the goal planning". P5 |
DIMENSION OF ANALYSIS: TECHNICAL
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Analyzed Aspects
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Main results
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Main speech extracts from the key informants
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Welcoming |
- Need for trained teams to take on hepatitis care. |
"It would be our competence to assist hepatitis because we are an SCS, but we do not have trained staff." P9
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Connection |
"If you don't have a training and support team you won't decentralize. There are doctors in PHC and SCS who don't know how to read a marker in hepatitis results. P5
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Competence/ |
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Ability |
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Autonomy |
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Commitment |
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Shared therapeutic project - team and user |
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Quality of care |
- Confronting hepatitis is not routine in health services. |
"There is not a routine for hepatitis." P8
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- Late diagnosis is a reality. |
"Prevention is up to the municipality. About 80% of our diagnoses are late. P6
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- Little strategic action to identify users early and the key/vulnerable population. |
"It doesn't mean that where there is a TCC, there are not people with a late diagnosis". P5
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DIMENSION OF ANALYSIS: SYMBOLIC
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Analyzed Aspects
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Main results
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Main speech extracts from the key informants
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Culture |
- Culture, beliefs, values, and subjectivity contribute to reducing access to testing and influence treatment. |
"There are people who don't come here because they are afraid. It's a small town, they might see them (hepatitis patients) coming into my room. P3 |
Beliefs |
- The fact that the user has some symptoms makes him/her seek testing. |
"Hepatitis testing is more common when they come looking for HIV testing". P8 |
Values |
- Lack of knowledge about the actions that the services offer. |
"People usually don't know they have hepatitis; by the time they get here, it's already serious. P9 |
Subjectivity |
- Posture of the health professional. |
"There was one lady who had stopped her treatment because she started drinking tea. P5 |
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"Many patients don't know that this service exists, that it has free and affordable testing." P7 |