Inequalities in the work process of Brazilian primary health care teams: a rural-urban analysis based on PMAQ-AB data
DOI:
https://doi.org/10.15517/b0tt4464Keywords:
Primary Health Care, Public Health, Community Health Planning, Health Care Process Assessmen, Rural Health ServicesAbstract
Objective: To evaluate the work process of Primary Health Care teams in Brazil, based on the rural/urban typology defined by the Brazilian Institute of Geography and Statistics. Method: This is a cross-sectional evaluative study with a quantitative and analytical approach, based on secondary data from the third cycle of the National Program for Improving Access and Quality of Primary Care (PMAQ-AB), conducted between 2017 and 2018. A total of 37,350 Primary Health Care (PHC) teams (96.1% of those approved for participation) were analyzed. The study focused on two analytical axes: (1) territorialization and (2) team planning. Data were processed using Multiple Correspondence Analysis (MCA), which enabled the identification of patterns in the organization of work processes based on municipal typology. Results: The study revealed important disparities across municipal strata. Adjacent rural municipalities had the lowest percentage of teams with uncovered populations (21.0%), while urban and remote intermediate municipalities showed the highest rates (42.0% and 43.6%, respectively). Regarding planning, 15.1% of teams reported not conducting planning activities, with the lowest proportions found in remote municipalities. The MCA perceptual maps identified three main clusters, showing the concentration of positive organizational attributes in intermediate adjacent municipalities and weaker work processes in remote areas. Conclusion: The organization of PHC teams' work processes varies significantly according to the rural/urban classification of municipalities. These findings reinforce the need for territorialized policies and differentiated support strategies to strengthen PHC performance in diverse Brazilian contexts.
Downloads
References
Agresti, A. (2013). Categorical data analysis (3rd ed.). Wiley.
Baratieri, T., Lentsck, M. H., Falavina, L. P., Soares, L. G., Prezotto, K. H., & Pitilin, É. de B. (2022). Longitudinal care: Factors associated with adherence to postpartum follow-up according to data from PMAQ-AB. Cadernos de Saúde Pública, 38, e00103221. https://doi.org/10.1590/0102-311X00103221 DOI: https://doi.org/10.1590/0102-311x00103221
Barros, R. D., Aquino, R., & Souza, L. E. P. F. (2022). Evolution of the structure and results of primary health care in Brazil between 2008 and 2019. Ciência & Saúde Coletiva, 27(11), 4289-4301. https://doi.org/10.1590/1413-812320222711.02272022EN DOI: https://doi.org/10.1590/1413-812320222711.02272022en
Brasil, Ministério da Saúde. (2015). Portaria nº 1.645, de 2 de outubro de 2015. Dispõe sobre o Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ-AB). https://bvsms.saude.gov.br/bvs/saudelegis/gm/2015/prt1645_01_10_2015.html
Brasil, Ministério da Saúde. (2017). Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica. https://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/prt2436_22_09_2017.html
Brasil, Ministério da Saúde. (2019). Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ). https://aps.saude.gov.br/ape/pmaq/ciclo3/
Brasil, Ministério da Saúde. (2022). Histórico do quantitativo de equipes e serviços custeados. https://egestorab.saude.gov.br/paginas/acessoPublico/relatorios/relHistoricoPagamentoEsf.xhtml
Cordioli, D. F. C., Cordioli, J. R., Gazetta, C. E., Silva, A. G. da., & Lourenção, L. G. (2019). Occupational stress and work engagement in primary health care workers. Revista Brasileira de Enfermagem, 72(6), 1580-1587. https://doi.org/10.1590/0034-7167-2018-0681 DOI: https://doi.org/10.1590/0034-7167-2018-0681
Cozma, I., Potorac, A., Cojocaru, D., Furtunescu, F., Mursa, G., & Gogu, C. (2022). Barriers to health services in rural Romania: A qualitative study. International Journal of Environmental Research and Public Health, 19(12), 7110. https://doi.org/10.3390/ijerph19127110 DOI: https://doi.org/10.3390/ijerph19127110
Endalamaw, A., Khatri, R. B., Erku, D., Nigatu, F., Zewdie, Wolka, E., & Assefa Y. (2023). Successes and challenges towards improving quality of primary health care services: A scoping review. BMC Health Services Research, 23, 893. https://doi.org/10.1186/s12913-023-09917-3 DOI: https://doi.org/10.1186/s12913-023-09917-3
Fernandes, W. R. (2014). Gestão do trabalho em saúde. Tempus – Actas de Saúde Coletiva, 8(1), 115. https://doi.org/10.18569/tempus.v8i1.1462 DOI: https://doi.org/10.18569/tempus.v8i1.1462
Ferreira, A. J. F., Pescarini, J., Sanchez, M., Flores-Ortiz, R. J., Teixeira, C. S., Fiaccone, R., Ichihara, M. Y., Oliveira, R., Aquino, E. M. L., Smeeth, L., Craig, P., Ali, S., Leyland, A. H., Barreto, M. L., Ribeiro, R. C., & Katikireddi, S. V. (2021). Evaluating the health effect of a social housing programme, Minha Casa Minha Vida, using the 100 million Brazilian cohort: A natural experiment study protocol. BMJ Open, 11, e041722. https://doi.org/10.1136/bmjopen-2020-041722 DOI: https://doi.org/10.1136/bmjopen-2020-041722
Ferreira, G. R. O. N., Miranda, A. L. C., Farias, V. A., Martins, M. B., Neri, D. T., Borges, W. D., Cunha, C. L. F., Dias, G. A. R., Santos, D. C., & Sousa, F. J. D. (2023). Leprosy and tuberculosis control scenario of the national program for the improvement of access and quality of primary care in Brazil. BMC Health Services Research, 23, 825. https://doi.org/10.1186/s12913-023-09842-5 DOI: https://doi.org/10.1186/s12913-023-09842-5
Ferreira-Batista, N. N., Postali, F. A. S., Diaz, M. D. M., Teixeira, A. D., & Moreno-Serra, R. (2022). The Brazilian Family Health Strategy and adult health: Evidence from individual and local data for metropolitan areas. Economics & Human Biology, 46, 101143. https://doi.org/10.1016/j.ehb.2022.101143 DOI: https://doi.org/10.1016/j.ehb.2022.101143
Franco, C. M., Giovanella, L., & Bousquat, A. (2023). Doctors’ work in primary health care in remote rural municipalities: Where is the territory? Ciência & Saúde Coletiva, 28(3), 821-836. https://doi.org/10.1590/1413-81232023283.12992022 DOI: https://doi.org/10.1590/1413-81232023283.12992022
Franco, C. M., Lima, J. G., & Giovanella, L. (2021). Primary healthcare in rural areas: Access, organization, and health workforce in an integrative literature review. Cadernos de Saúde Pública, 37, e00310520. https://doi.org/10.1590/0102-311X00310520 DOI: https://doi.org/10.1590/0102-311x00310520
Ghimiray, B., Wangmo, D., & Yaya, S. (2024). Rural–urban inequalities in health care utilization in Bhutan: Decomposition analysis. International Journal for Equity in Health, 23(1), 58. https://doi.org/10.1186/s12939-024-02183-7 DOI: https://doi.org/10.1186/s12939-024-02178-4
Giovanella, L., Bousquat, A., Schenkman, S., Almeida, P. F. de., Sardinha, L. M. V., & Vieira, M. L. F. P. (2021). The Family Health Strategy coverage in Brazil: What reveal the 2013 and 2019 National Health Surveys. Ciência & Saúde Coletiva, 26(6), 2543-2556. https://doi.org/10.1590/1413-81232021266.1.43952020 DOI: https://doi.org/10.1590/1413-81232021266.1.43952020
Giovanella, L., Escorel, S., Lobato, L. V. C., Noronha, J. C., & Carvalho, A. I. (Eds.). (2012). Políticas e sistemas de saúde no Brasil (2ª ed., rev. e ampl.). Editora Fiocruz. https://doi.org/10.7476/9788575413494 DOI: https://doi.org/10.7476/9788575413494
Giovanella, L., Franco, C. M., & Almeida, P. F. (2020). National Primary Health Care Policy: Where are we headed to? Ciência & Saúde Coletiva, 25(4), 1475-1482. https://doi.org/10.1590/1413-81232020254.01842020 DOI: https://doi.org/10.1590/1413-81232020254.01842020
Hone, T., Powell-Jackson, T., Santos, L. M. P., Soares, R. S., Oliveira, F. P., Sanchez, M. N., Harris, M., Santos F. O. S., & Millett, C. (2020). Impact of the Programa Mais médicos (more doctors Programme) on primary care doctor supply and amenable mortality: quasi-experimental study of 5565 Brazilian municipalities. BMC Health Services Research, 20, 873. https://doi.org/10.1186/s12913-020-05716-2 DOI: https://doi.org/10.1186/s12913-020-05716-2
Infantosi, A. F. C., Costa, J. C. G. D., & Almeida, R. M. V. R. (2014). Análise de Correspondência: bases teóricas na interpretação de dados categóricos em Ciências da Saúde. Cadernos de Saúde Pública, 30(3), 473-486. https://doi.org/10.1590/0102-311X00128513 DOI: https://doi.org/10.1590/0102-311X00128513
Instituto Brasileiro de Geografia e Estatística. (2017). Classificação e caracterização dos espaços rurais e urbanos do Brasil. https://www.ibge.gov.br/apps/rural_urbano/
Julio, R. de S., Lourenção, L. G., Penha, J. G. M., Oliveira, A. M. N. de, Nascimento, V. F. do, Oliveira, S. M. de, & Gazetta, C. E. (2021). Anxiety, depression, and work engagement in primary health care nursing professionals. Rev Rene, 22, e70762. https://doi.org/10.15253/2175-6783.20212270762 DOI: https://doi.org/10.15253/2175-6783.20212270762
Kovacs, R., Maia Barreto, J. O., da Silva, E. N., Borghi, J., Kristensen, S. R., Costa, D. R. T., Bezerra Gomes, L., Gurgel, G. D., Sampaio Júnior, J., & Powell-Jackson, T. (2021). Socioeconomic inequalities in the quality of primary care under Brazil’s national pay-for-performance programme: A longitudinal study of family health teams. The Lancet Global Health, 9(3), e331–e339. https://doi.org/10.1016/S2214-109X(20)30480-0 DOI: https://doi.org/10.1016/S2214-109X(20)30480-0
Lima, J. G., Giovanella, L., & Bousquat, A. (2022). Access barriers to primary health care in remote rural municipalities of Western Pará state, Brazil. Trabalho, Educação e Saúde, 20, e00616190. https://doi.org/10.1590/1981-7746-ojs616 DOI: https://doi.org/10.1590/1981-7746-ojs616
Lourenção, L. G., Oliveira, J. F., Ximenes Neto, F. R. G., Cunha, C. L. F., Valenzuela-Suazo, S. V., Borges, M. A., & Gazetta, C. E. (2022). Career commitment and career entrenchment among Primary Health Care workers. Revista Brasileira de Enfermagem, 75(1), e20210144. https://doi.org/10.1590/0034-7167-2021-0144 DOI: https://doi.org/10.1590/0034-7167-2021-0144
Massuda, A., Dall'Alba, R., Chioro, A., Temporão, J. G., & Castro, M. C. (2023). After a far-right government: Challenges for Brazil's Unified Health System. The Lancet, 401(10385), 886-888. https://doi.org/10.1016/S0140-6736(23)00352-5 DOI: https://doi.org/10.1016/S0140-6736(23)00352-5
Mendes, E. V. (2015). A construção social da atenção primária à saúde. Conass.
Merhy, E. E. (2007). Saúde: A cartografia do trabalho vivo. Hucitec.
Merhy, E. E., Franco, T. B., Baduy, R. S., & Santos, M. F. P. S. (Eds.). (2004). O trabalho em saúde: Olhando e experienciando o SUS no cotidiano (2ª ed.). Hucitec. DOI: https://doi.org/10.1590/S1981-77462004000200014
Otieno, P. O., Wambiya, E. O. A., Mohamed, S. M., Mutua, M. K., Kibe, P. M., Mwangi, B., & Donfouet, H. P. P. (2020). Access to primary healthcare services and associated factors in urban slums in Nairobi, Kenya. BMC Public Health, 20, 981. https://doi.org/10.1186/s12889-020-09106-5 DOI: https://doi.org/10.1186/s12889-020-09106-5
Peduzzi, M., Ciampone, M. H. T., & Leonello, V. M. (2016). Trabalho em equipe e prática colaborativa. In P. Kurcgant (Org.), Gerenciamento em enfermagem (3ª ed., pp. 103–114). Guanabara Koogan.
Pereira, R. C. A., Rivera, F. J. U., & Artmann, E. (2013). The multidisciplinary work in the family health strategy: A study on ways of teams. Interface - Comunicação, Saúde, Educação, 17(45), 327–340. http://dx.doi.org/10.1590/S1414-32832013005000006 DOI: https://doi.org/10.1590/S1414-32832013005000006
Pinto, P. F. P. S., Santos, B. P. S. dos, Teixeira, C. S. S., Nery, J. S., Amorim, L. D. A. F., Sanchez, M. N., Barreto, M. L., & Pescarini, J. M. (2022). Performance evaluation of tuberculosis control in Brazilian municipalities. Revista de Saúde Pública, 56, 53. https://doi.org/10.11606/s1518-8787.2022056004020 DOI: https://doi.org/10.11606/s1518-8787.2022056004020
Rodrigues, K. V., Almeida, P. F., & Cabral, L. M. S. (2021). Organization of primary health care in a remote rural municipality in northern Brazil. Saúde em Debate, 45, 998-1016. https://doi.org/10.1590/0103-1104202113105 DOI: https://doi.org/10.1590/0103-1104202113105
Shimizu, H. E., & Carvalho Junior, D. A. (2012). O processo de trabalho na Estratégia Saúde da Família e suas repercussões no processo saúde-doença. Ciência & Saúde Coletiva, 17(9), 2405-2414. https://doi.org/10.1590/S1413-81232012000900021 DOI: https://doi.org/10.1590/S1413-81232012000900021
Silva, A. G., Cabrera, E. M. S., Gazetta, C. E., Sodré, P. C., Castro, J. R., Cordioli Jr, J. R., Cordioli, D. F. C., & Lourenção, L. G. (2020). Engagement in primary health care nurses: A cross-sectional study in a Brazilian city. Public Health Nursing, 37(2), 169-177. https://doi.org/10.1111/phn.12694 DOI: https://doi.org/10.1111/phn.12694
Silva, G. T., Carvalho, F. O., & Vieira-Meyer, A. P. G. F. (2021). Planning and support in the work process of PHC teams in the Northeast: Analysis of the PMAQ-AB (3rd cycle). Ciência & Saúde Coletiva, 26(5), 1749-1755. https://doi.org/10.1590/1413-81232021265.03722021 DOI: https://doi.org/10.1590/1413-81232021265.03722021
Starfield, B. (2002). Atenção primária: Equilíbrio entre necessidades de saúde, serviços e tecnologia. Unesco.
Tessema, G. A., Mahmood, M. A., Scott, A., & Melaku, Y. A. (2017). Structural quality of services in primary health care facilities in Ethiopia: A comparison between urban and rural areas. BMC Health Services Research, 17, 273. https://doi.org/10.1186/s12913-017-2745-7 DOI: https://doi.org/10.1186/s12913-017-2745-7
Wang, R., Xu, Y., Yu, L., Deng, F., & Li, J. (2024). Uneven primary healthcare supply of rural doctors and medical equipment in remote China: A spatial analysis. International Journal for Equity in Health, 23(1), 50. https://doi.org/10.1186/s12939-024-02178-4 DOI: https://doi.org/10.1186/s12939-024-02183-7
Downloads
Published
Issue
Section
License
Copyright (c) 2025 Lemos et al.
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Population and Health in Mesoamerica informs its authors and readers that all publications must be submitted with the Letter of Acceptance of Copyright Conditions where the authors are asked for authorization to submit the article to the Journal for consideration so that it may carry out any of the following activities:
- The graphic and style editing of the work or part of it.
The publication and reproduction of the work or part of it, both in print and electronic media, including the Internet and any other known or unknown technology.
The translation of the work or part of it into any language or dialect.
The adaptation of the work to reading, sound, voice and any other available technical representation or mechanism, which makes possible its access for partially or totally blind people, or with any other form of special abilities that prevent their access to the conventional reading of the article.
The distribution and availability of the work to the public, in such a way that the public may have access to them from the time and place that each person chooses, through the physical or electronic mechanisms available to them.
Any other form of use, process or system known or to be known that is related to the activities and editorial purposes to which the Journal is linked.
You can access the Letter by clicking HERE. If you have a question, please write to revista.ccp@ucr.ac.cr
In addition, the content of this site is protected under the Attribution - Noncommercial - Share Alike (by-nc-sa) license which permits commercial use of the original work or derivative works and distribution of which must be made under the same license that governs the original work. The graphic design, images and texts generated by the e-Information Science magazine are property of the Universidad de Costa Rica and are licensed under Creative Commons Attribution - NonCommercial - Attribution-ShareAlike 4.0 International.
Authors who publish in this journal accept the following conditions:
-The authors retain their moral rights over the publication and assign the patrimonial rights mentioned in the Letter of Assignment of Rights with the Creative Commons Attribution - NonCommercial - Compatitr Equal 4.0 International license, which allows third parties to use what is published as long as they mention the authorship of the work and to the first publication in this journal.
-Authors may make other independent and additional contractual arrangements for non-exclusive distribution of the version of the article published in this journal (e.g., inclusion in an institutional repository or publication in a book) as long as they clearly indicate that the work was first published in this journal.
This policy is established in accordance with Law 6638 on Copyright and Related Rights of the Republic of Costa Rica.
