Accessibility to primary healthcare in the capital city of

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Aug 18, 2010 - para melhoria da acessibilidade e humanizaça˜o do acolhimento. Salvador: Secretaria. Municipal de Saúde de Salvador, Bahia, Brazil, 2005.
Evidence-based public health, policy and practice

Accessibility to primary healthcare in the capital city of a northeastern state of Brazil: an evaluation of the results of a programme Ligia Maria Vieira-da-Silva,1 Sonia Cristina Lima Chaves,2 Monique Azevedo Esperidia˜o,3 Rosana Machado Lopes-Martinho3 1

Institute of Collective Health, Federal University of Bahia, Bahia, Brazil 2 School of Dentistry, Federal University of Bahia, Bahia, Brazil 3 Institute of Collective Health, Federal University of Bahia, Bahia, Brazil Correspondence to Professor Ligia Maria Vieira-da-Silva, Rua Bası´lio da Gama s/no., Campus da UFBa, Canela 40.110-040 Salvador, Bahia, Brazil; [email protected] Accepted 31 May 2010 Published Online First 18 August 2010

ABSTRACT Background Organisational barriers to primary healthcare are still relevant in developing countries. Although descriptive reports of some experiences focusing on improving accessibility have been published, few studies have evaluated specific interventions aimed at overcoming the organisational obstacles. Objective To evaluate the results of a project designed to improve accessibility to healthcare services in Salvador, Bahia, Brazil. Methodology An evaluative, cross-sectional, ex post facto study that included a control group was carried out in a random sample of 710 users of 25 healthcare units of the primary municipal healthcare network. The association between the project implementation degree and outcome variables was measured by prevalence ratios (PR) and statistical inference was based on Taylor series 95% CIs. Results Better access to primary healthcare was found in units in which the intervention had been implemented than in those in which it had not been implemented, particularly with respect to reducing avoidable queues, the waiting time for scheduling a consultation (PR¼0.23; 95% CI 0.15 to 0.34); the time of arrival in the queue (PR¼0.16; 95% CI 0.09 to 0.31) and the introduction of a system for scheduling appointments by telephone (PR¼0.76; 95% CI 0.70 to 0.83). Conclusion Owing to the simplicity of the programme and the impact it achieved, it may be reproduced in other underdeveloped countries to improve access to healthcare services. In addition, some of the instruments may be used in routine programme evaluation.

INTRODUCTION Accessibility, in the sense described by Donabedian1 as the ease with which people can obtain care, may be analysed as the relationship between the barriers resulting from the organisational characteristics of the healthcare services and the users’ resources to overcome these obstacles. Therefore, although many barriers to the use of services are structural2 or cultural,3 many of the problems of access are also organisational, hence susceptible to intervention by healthcare system managers.4 The weight of the components of this equation depends on the characteristics of the healthcare system of each country. For example, in some countries open demand has been studied as an organisational measure to facilitate access.5 6 Other authors have proposed 1100

intervening in the so-called demand-related factors.3 7 Different forms of organising the way in which patients are received have been tested in various countries, including the association of open offer and appointment scheduling.6 8 Ever since the Brazilian Unified Health System (Sistema Único de Saúde (SUS)) was legally defined in 1988,9 its primary healthcare coverage has been continually increasing. Nevertheless, inequalities persist with respect to access despite a slight decrease registered between 1998 and 2003.10 Concern with reorganising the flow of patients and work processes in healthcare centres to improve access is mentioned in the National Humanisation Policy11 and in local experiences.12 The National Humanisation Policy was conceived to encompass all the actions and services of the Brazilian Unified Health System. The concept of ‘humanisation’ was defined as ‘respecting the different subjects involved in the process of providing healthcare: users, workers and managers’. This preoccupation with the dimension of interpersonal relations should be articulated with the reorganisation and quality of the healthcare model, the objective of which is to care for the health needs of the population. Increasing access to healthcare by reducing queues and delays was one of the principal objectives related to the way in which users are received into the healthcare system.11 13 Although descriptive reports of some of these experiences focusing on improving accessibility have been published,12 few studies have evaluated interventions aimed at overcoming the organisational obstacles that result in queues and long delays. In this situation, the existence of an opendemand system without the corresponding guarantee of same-day consultation hampers access instead of facilitating it. In-depth evaluations of specific components of primary healthcare are rare; however, they are important, since such assessments serve to identify obstacles to improving care that are hidden in the synthetic indexes and in the calculation of means. In Salvador, capital of the state of Bahia in the northeast of Brazil, the municipal health department drew up a project in May 2005 to improve the accessibility of users to healthcare services.14 This study sought to evaluate how changes made in the way consultations are scheduled facilitated the use of the services by the clients, eliminating queues, and reducing the waiting time involved in scheduling an appointment.

J Epidemiol Community Health 2010;64:1100e1105. doi:10.1136/jech.2009.097220

Evidence-based public health, policy and practice METHODOLOGY Study design An evaluative, cross-sectional, ex post facto study15 that included a control group was carried out. The study group comprised primary healthcare units that were part of the city of Salvador ’s municipal network in which the project to improve accessibility was considered to be at an advanced stage of implementation. The control group comprised units in which the project had either not been implemented or had already been implemented but was still at an incipient stage.

The intervention The intervention consisted of a project aimed at improving the accessibility and humanisation of patient reception.14 At that time, various obstacles to the use of the primary healthcare network had been identified. Queues were usual at almost all the units and scheduling appointments involved long delays. One of the principal objectives of the project was the extinction of avoidable queuesdthat is, those queues that exist because of a lack of any other option for the user to schedule an appointment and that incur a wait of more than 15 min. To achieve this purpose, the following activities were developed: (a) implementation of a permanent system for scheduling appointments (score 45); (b) creation of a telephone appointment scheduling system (score 20); (c) creation of a waiting list for elective appointments to aid the process of redefining flow (score 20) and (d) creation of a work group on humanisation to support implementation of the project in the health unit (score 15).14 The selection of dimensions and criteria for the evaluation of the degree to which the project had been implemented followed a methodology previously used elsewhere.16 For each activity considered to be a criterion for evaluation, a goal was defined corresponding to the ideal status of implementation for which a maximum score was awarded as indicated above. Next, the unit was classified in accordance with whether or not the project had been implemented depending on the percentage of points obtained in the evaluation compared with the maximum possible score for that criterion. In the units that achieved more than 66.6% of the maximum proposed score, the intervention was considered to have been implemented.

Sample population and calculation of sample size To calculate sample size, the population was considered to comprise all the users of the Brazilian Unified Health System within Salvador ’s primary healthcare network during 2005.17 The health units belonged to the 12 sanitary districts of Salvador. Stratified sampling was carried out in accordance with the type of unit and the level of implementation of the intervention. According to these criteria, the 86 units were therefore stratified into four groups for each one of the 12 sanitary districts, making a total of 48 groups: (a) a traditional basic healthcare unit (THU)18 in which the intervention had been implemented; (b) a traditional basic healthcare unit in which the intervention had not been implemented; (c) a family health unit (FHU) in which the intervention had been implemented; or (d) an FHU in which the intervention had not been implemented. Two healthcare units were randomly selected for each sanitary district and classified according to the type of unit and the degree of implementation, making a total of 24 healthcare units. Since there were no FHUs in two of the districts, two traditional units were selected. It was later found that one FHU was in fact operating as a THU. For this reason, another FHU was randomly selected in the same district, thus making a total of 25 units: 11 FHUs and 14 THUs. J Epidemiol Community Health 2010;64:1100e1105. doi:10.1136/jech.2009.097220

Next, sample size was calculated by simple random sampling without replacement of users based on the number of consultations per healthcare unit in 2005, with an allocation proportional to the capacity of the healthcare unit. Subjects were selected for interview in each unit based on the order of scheduled appointments and/or arrivals, the first on the list followed by the remainder on the listdin consecutive order, with an interval represented by the total number of users present divided by the fraction of the corresponding sample. In choosing the subsequent patients, in addition to maintaining the same interval, care was taken to ensure representation of women