Changes in the primary care policy and the (un)sustainability of the Family Health Strategy

Mendonça, Fernanda de Freitas; Lima, Luciana Dias de; Pereira, Adelyne Maria Mendes; Martins, Caroline Pagani

doi:10.1590/0103-1104202313701I

Fernanda de Freitas Mendonça

contributed to the design

data collection

data analysis

writing and final revision of the manuscript

Universidade Estadual de Londrina (UEL) – Londrina (PR), Brasil. fernandamendonca@uel.br

https://orcid.org/0000-0002-6490-1815

Luciana Dias de Lima

contributed to the conception

writing and final review

Fundação Oswaldo Cruz (Fiocruz), Escola Nacional de Saúde Pública Sergio Arouca (Ensp) – Rio de Janeiro (RJ), Brasil

https://orcid.org/0000-0002-0640-8387

Adelyne Maria Mendes Pereira

contributed to writing the final review

Fundação Oswaldo Cruz (Fiocruz), Escola Nacional de Saúde Pública Sergio Arouca (Ensp) – Rio de Janeiro (RJ), Brasil

https://orcid.org/0000-0002-2497-9861

Caroline Pagani Martins

contributed to data collection and final review

Universidade Estadual de Londrina (UEL) – Londrina (PR), Brasil. fernandamendonca@uel.br

https://orcid.org/0000-0001-6217-4944

Conflict of interests: non-existent

Family Health Team	Normative acts
Composition	Ordinance 2436/2017 (not in force, but with part of its content incorporated on PC 2) Physician, preferably family and community medicine specialist; Nurse, preferably Family Health Specialist; Assistant and/or Nursing Technician and Community Health Agent (ACS). The team of Endemic Fighting Agent (ACE) and Oral Health professionals: Dental surgeon, preferably specialist in family health, and assistant or oral health technician may be part of the team.
Coverage parameter	Ordinance 2436/2017 (not in force, but with part of its content incorporated on PC 2) A team for 2,000 to 3,500 people Ordinance 2979/2019 (current) In urban municipality, one team for every 4000 people In adjacent municipality, one team for every 2750 people In remote municipality, one team for every 2000 people
Workload	Ordinance 2436/2017 (not in force, but with part of its content incorporated in PC 2) 40 hours a week for all team members Ordinance 2979/2019 (current) 40 hours a week for all team members Ordinance 60/2020 (not in effect, revoked by Ordinance 32) In units that adhere to Saúde na Hora, they can have flexible workload (min 20h) for nurses, doctors and dentists
Community Health Agents	Normative Acts
Coverage parameter	Ordinance 2436/2017 (not in force, but with part of its content incorporated in PC 2) One ACS for every 750 people in areas of great territorial dispersion, areas of risk and social vulnerability
Workload	Ordinance 2436/2017 (not in force, but with part of its content incorporated in PC 2) 40 hours a week
Basic/primary care team	Normative Acts
Composition	Ordinance 2436/2017 (not in force, but with part of its content incorporated in PC 2) eAB – physicians, preferably in the specialty of family and community medicine; nurse, preferably specialist in family health; nursing assistants and/or nursing technicians. They may add other professionals, such as dentists, oral health assistants and/or oral health technicians, community health agents and agents to combat endemic diseases. Ordinance 18/2019 (not in effect, revoked by Ordinance 37) Reaffirms the composition of the PNAB for eAB Ordinance 2539/2019 (current) Establishes the eAP, its composition being: Physicians, preferably specialists in family and community medicine; and nurses, preferably specialists in family health registered in the same Health unit.
Coverage parameter	Ordinance 2436/2017 (not in force, but with part of its content incorporated in PC 2) A team for 2,000 to 3,500 people Ordinance 2539/2019 (current) eAP Modality 1 (20h) – must cover 50% of the population covered by the eSF eAP Modality 2 (30h) – must cover 75% of the population covered by the eSF Ordinance 2979/2019 (current) For eAP modality 1 (20h), coverage in: Urban municipality – one team for every 2000 people Adjacent municipality – is one team for every 1375 people Remote municipality – one team for every 1000 people For eAP modality 2 (30h), coverage in: Urban municipality – one team for every 3000 people Adjacent municipality – is one team for every 2063 people Remote municipality – one team for every 1500 people
Workload	Ordinance 2436/2017 (not in force, but with part of its content incorporated in PC 2) Ten hours, with a maximum of 3 (three) professionals per category, with a minimum of 40 hours/week Ordinance 18/2019 (not in effect, revoked by Ordinance 37) Reaffirms the workload of the PNAB Ordinance 2539/2019 (current) Modality 1 - the minimum individual workload of professionals must be 20 (twenty) hours per week Modality 2 - the minimum individual workload of professionals must be 30 (thirty) hours per week Ordinance 2979/2019 (current) Type 1 – 20 hours a week Type 2 – 30 hours a week
Oral Health Team	Normative Acts
Composition	Ordinance 2437/2017 (not in force, but with part of its content incorporated in PC 2) Modality I: Dental surgeon and oral health assistant (ASB) or oral health technician (TSB) Modality II: Dental Surgeon, TSB and ASB, or other TSB Ordinance 18/2019 (not in effect, revoked by Ordinance 37) Reaffirms the composition of the PNAB
Coverage parameter	Ordinance 2436/2017 (not in force, but with part of its content incorporated in PC 2) One team for every 2,000 to 3,500 people Ordinance 18/2019 (not in effect, revoked by Ordinance 37) 40h modality – a team must cover 100% of the population assigned to an eSF Ordinance 2539/2019 (current) 30h modality – must cover 75% of the population enrolled for an eSF 20h modality – must cover 50% of the population enrolled for an eSF
Workload	Ordinance 2436/2017 (not in force, but with part of its content incorporated in PC 2) 40 hours a week Ordinance 18/2019 (not in effect, revoked by Ordinance 37) 40 hours a week Ordinance 2539/2019 (current) Modality 1 – 20h Modality 2 – 30h
NASF-AB team	Normative Acts
Composition	Ordinance 2436/2017 (not in force, but with part of its content incorporated in PC 2) Acupuncturist Doctor; Social Worker; Physical Education Professional/Teacher; Pharmaceutical; Physiotherapist; speech therapist; Gynecologist/Obstetrician; Homeopathic Doctor; Nutritionist; Pediatrician; Psychologist; Psychiatric doctor; Occupational Therapist; Geriatrician Doctor; Internist (medical clinic), Occupational Physician, Veterinarian, professional with training in art and education (art educator); and sanitary health professional, that is, a professional graduated in the health area with a post-graduate degree in public or collective health or graduated directly in one of these areas according to current regulations.
Coverage parameter	Ordinance 3124/2012 (not in force, but with part of its content incorporated into PC2) Modality 1 – at least five and at most nine eSF or Primary Care teams for specific populations (Street Clinics, riverside and riverside teams). Modality 2 – at least three and at most four eSF and/or Primary Care teams for specific populations (Street Clinics, riverside and riverside teams). Modality 3 – at least one and at most two eSF and/or Primary Care teams for specific populations (Street Clinics, riverside and riverside teams), specifically adding to their work process, setting up as an expanded team.
Workload	Ordinance 3124/2012 (not in force, but with part of its content incorporated into PC2) Modality 1 - the sum of the weekly workloads of the team members must accumulate, at least, 200 (two hundred) weekly hours; no professional should have a weekly workload of less than 20 hours; each occupation, considered separately, must have a minimum of 20 hours and a maximum of 80 hours of weekly workload. Modality 2 – the sum of weekly workloads of team members must accumulate at least 120 hours per week; no professional should have a weekly workload of less than 20 hours; each occupation, considered separately, must have a minimum of 20 hours and a maximum of 40 hours of weekly workload. Modality 3 – the sum of weekly workloads of team members must accumulate at least 80 hours per week; no professional should have a weekly workload of less than 20 hours; each occupation, considered separately, must have a minimum of 20 hours and a maximum of 40 hours of weekly workload.

Family health team	Normative acts
Incentive value	Ordinance 978/2012 (not in force, but with part of its content incorporated in PC 2) Modality 1 teams: BRL 10,695.00/month. Modality 1 teams are all teams deployed in municipalities: a) with a population of up to 50,000 inhabitants in the states of the Legal Amazon, or b) with a population of up to 30,000 inhabitants and a Human Development Index (HDI) equal to or less than 0.7, in the other states of the country; or c) who are already entitled to receive a 50% increase in the value of the incentives referring to the total eSF and eSB they implement; It is The eSF implemented in municipalities not included in the provisions of paragraph I and that serve the remaining population of quilombos and/or residents in settlements of at least 70 (seventy) people, respecting the maximum number of teams per municipality, published in a specific ordinance. Type 2 teams: BRL 7,130.00/month Ordinance 2979/2019 (current) The value is included in the weighted capitation value Ordinance 169/2020 (current) Updates the per capita amount by BRL 50.50/month
Incentive source	Ordinance 2436/2017 (not in force, but with part of its content incorporated in PC 2) Variable basic care floor Ordinance 2979/2019 (current) Weighted capitation
Community Health Agent	Normative acts
Incentive value	Original Ordinance 1024 and 1962/2015 (not in force, but with part of its content incorporated in PC 6) Defines the transfer of funds from the union’s Supplementary Financial Assistance (AFC) to comply with the national professional salary floor for Community Health Agents (ACS) Ordinance 201/2019 (not in effect) Establishes the transfer of BRL 1,250.00 per ACS/month Ordinance 3317/2020 (current) Establishes the transfer of BRL 1,550.00 per ACS/month
Incentive source	Ordinance 2436/2017 (not in force, but with part of its content incorporated in PC 2) Variable basic care floor Ordinance 2979/2019 (current) If included in the eSF, incentive by weighted funding If included in the ACS strategy, incentive for adherence to strategic actions
Primary care team	Normative acts
Incentive value	Ordinance 1808/2018 (current) eAB – the amount corresponds to 30% of the monthly cost of the eSF (BRL 2,139.00/month) Ordinance 2539/2019 (current) Modality I (20h) – BRL 3,565.00/month Modality II (30h) – BRL 5,347.00/month Ordinance 2979/2019 (current) The value is included in the weighted capitation value as the eSF Ordinance 3883/2019 (current) Modality I (20h): monthly transfer equivalent to 50% of the financial incentive related to the eSF Modality II (30h): monthly transfer equivalent to 75% of the financial incentive related to the eSF. Ordinance 169/2020 (current) Updates the per capita amount to R$ 50.50/month
Incentive source	From Ordinance 2436/2017 (not in force, but with part of its content incorporated in PC 2) Variable basic care floor Ordinance 2979/2019 (current) Weighted capitation
Oral health team	Normative acts
Incentive value	Original Ordinance 978/2012 (not in force, but with part of its content incorporated in PC6) Modality I 40h (with two professionals) BRL 2,230.00/month Modality II 40h (with three professionals): BRL 2,980.01/month Ordinance 2539/2019 (current) It makes the workload of the teams more flexible to: Modality I (20h): BRL 1,115.00 per team; Modality I (30h): BRL 1,672.50 per team. Ordinance 2305/2020 (current) Modality I - BRL 2,453.00/month Modality II - BRL 3,278.00/month Modality I – (20h): BRL 1,226.50/month Modality I – (30h): BRL 1,839.75/month
Incentive source	Ordinance 2436/2017 (not in force, but with part of its content incorporated in PC 2) Variable basic care floor Ordinance 2979/2019 (current) Incentive for adherence to strategic actions
NASF-AB team	Normative acts
Valor do incentivo	Ordinance 548/2013 (not in force, but with part of its content incorporated into PC2) NASF Modality 1 – BRL 20,000.00/month NASF Modality 2 – BRL 12,000.00/month NASF Modality 3 – BRL 8,000.00/month Ordinance 2979/2019 (current) No funding
Fonte do incentivo	Ordinance 2436/2017 (not in force, but with part of its content incorporated into PC2) Variable basic care floor Ordinance 2979/2019 (current) No source of incentive

THEMATIC AXES	NORMATIVE ACTS	VALIDITY
Accreditation Flow	Ordinance 2436/2017 Determines that the accreditation flow must go through the elaboration of the project by the municipality; be forwarded to the SES; be approved by the CIB, which resolution is forwarded to the MS, which publishes the accreditation ordinance. From then on, the municipality has up to four months to register with the CNES.	No, but part of its content is incorporated in consolidation ordinance n. 2
	Ordinance 1710/2019 Changes the previous stream. Reduces bureaucracy in the team accreditation process. The project comes from the municipality, which sends it directly to MS. A letter is sent to the other instances (CMS, SES, CIB), for knowledge.	Yes
Registration at CNES	Ordinance 18/2019 Creates the national team identifier (INE) for the eAB and eAB oral health modalities I and II.	No, revoked by ordinance 37/2021
	Ordinance 99/2020 Unification of several INEs. The following codes are included: 70 – eSF 71 – eSB 72 – eNasf-AB, 76 – eAP – Primary Care Team	No, revoked by ordinance 37/2021
	Ordinance 60/2020 Defines the criteria for the municipality to be able to validate the teams in the CNES.	No, revoked by ordinance 32/2021
	Ordinance 801/2020 Makes automatic accreditation in eAP for teams certified in the 3rd Cycle of PMAQ-Ab and those registered in SCNES under team type codes 16, 17, 18, 19, 20 and 21 at the time of certification.	Yes
	Ordinance 32/2021 Defines the criteria for the municipality to be able to validate the teams in the CNES, changing the text of Ordinance 60 in some aspects.	No, its content was incorporated into APS Consolidated Ordinance 1
	Ordinance 37/2021 Defines new INEs. It differs from Ordinance 99/2019 by proposing eSF (code 70) with and without oral health. The same applies to eAP (code 76).	Yes
	Ordinance 1037/2021 Defines the exclusion and priority criteria for analyzing team accreditation requests.	Yes
Team’s fixation	Ordinance 3566/2019 Sets the amount of eSF and eSB of municipalities. For the definition of the quantitative, the teams considered were those accredited, registered in the National Health Establishment Registration System (SCNES) and that received federal financial incentives until the financial competence of October 2019. Teams that are transitional can choose to migrate to eSF or eAP. If there is no relocation of the physician’s HC, the transitional teams will be automatically converted into eAP.	Yes
Follow-up, monitoring and evaluation	Ordinance 47/2019 Determines that this process will occur through codes referring to the National Team Identification (INE) and the National Health Establishment Register (CNES) of the Primary Health Care teams or services. The INE code will be considered for the following types of teams: I - Family Health team (eSF) and Riverside Family Health team (eSFR); II - Oral Health team (eSB); III - Street Office team (eCR); IV - Prison Primary Care team (eABP); and V - Primary Care team (eAP).	Yes

Region	Team Modalities	2017	2018	2019	2020	2021	Variation in the period
		N	N	N	N	N	%
Brazil	Family Health Team	42388	44190	44334	48850	49989	1 7.9 3
	Basic/primary care team	488	535	524	2704	4497	821.52
	Oral Health Team	26369	27817	28083	30597	34579	31.14
	Community Health Agent	270867	271982	269217	282917	283104	4.52
	Family Health Support Center/ Primary Care	4904	5665	5863	5652	5467	11.48
North	Family Health Team	3427	3628	3628	4391	4593	34.02
	Basic/primary care team	42	42	7	142	316	652.38
	Oral Health Team	2004	2150	2178	2577	2917	45.56
	Community Health Agent	32874	32586	32700	33099	33081	0.63
	Family Health Support Center/ Primary Care	365	464	493	473	443	21.37
North-east	Family Health Team	15619	16046	16045	17479	17710	13.39
	Basic/primary care team	11	12	13	139	331	2909.09
	Oral Health Team	11802	12397	12614	12988	14138	19.79
	Community Health Agent	106508	106336	105996	106651	107028	0.49
	Family Health Support Center/ Primary Care	2029	2235	2287	2201	2055	1.28
Center-West	Family Health Team	2970	3201	3371	3764	3856	29.83
	Basic/primary care team	9	6	5	66	141	1466.67
	Oral Health Team	2137	2331	2348	2454	2788	29.49
	Community Health Agent	20183	20209	19922	20047	19910	-1.35
	Family Health Support Center/ Primary Care	359	410	443	426	403	12.26
South-east	Family Health Team	14229	14872	14887	16217	16695	17.33
	Basic/primary care team	318	377	402	1637	2625	725.47
	Oral Health Team	7225	7681	7736	8464	10190	44.42
	Community Health Agent	87904	89041	88345	88734	89123	1.39
	Family Health Support Center/ Primary Care	1441	1726	1782	1757	1769	22.76
South	Family Health Team	6143	6443	6443	6999	7135	16.15
	Basic/primary care team	108	98	97	720	1084	903.70
	Oral Health Team	3321	3180	3338	4114	4546	35.54
	Community Health Agent	35874	35079	34216	34386	33962	-5.33
	Family Health Support Center/ Primary Care	710	830	858	795	797	12.25

[1] Conflict of interests: non-existent

Brasil

Brasil

Changes in the primary care policy and the (un)sustainability of the Family Health Strategy

ABSTRACT