Evaluation of the Local Implementation of the Brazilian National Tuberculosis Control Program in the Municipality of Niterói, State of Rio de Janeiro, Brazil Luísa Gonçalves Dutra de Oliveira, Universidade Federal Fluminense Sônia Natal, Instituto Materno Infantil Prof. Fernando Figueira (GEAS/IMIP) Objectives: To assess the local integration between the Brazilian Family Health Strategy (BFHS) with some actions for endemics control, and to estimate the level at which that integration was accomplished in a Brazilian municipality. Methods: This work is a case study employing qualitative and quantitative approaches. Among the endemics control actions, those related with the local implementation of the National Tuberculosis Control Program (NTCP) were selected as a tracer, due to omnipresence of tuberculosis in Brazilian inner cities, especially in the Rio de Janeiro State. We studied two of the eight polyclinics caring for TB cases and one of the 31 units of the BFHS in the Municipality of Niterói, State of Rio de Janeiro, Brazil. The chosen polyclinics were those caring for the greatest number of TB cases in treatment in the town. The selected BFHS unit also cared for TB cases and was part of the working area of one of the polyclinics studied. In each of these healthcare units different aspects of cases were collected and analyzed: quantitative and qualitative resources needed to diagnosis and treatment of TB; expertise of the health care workers involved; service structure and organization; and the quality of the information system. Each unit was analyzed separately. A crossed case analysis was done afterwards, in order to find common features that could have contributed to more (or less) successful implantation of the NTCP. Sources and tools for gathering: Primary: interviews with patients, healthcare workers and managers; direct observation (through structured -gathering tools) Secondary: patient registry and follow-up books, medical records, municipal SINAN (Sistema Nacional de Agravos tificáveis, or National System of Reportable Injuries and Diseases), reporting forms and the general registry books in each unit. 1
The merits of the local health services were judged in this study according to the degree of fulfillment of what was established by the NTCP. The successful integration between NTCP and BFHS was measured by the development of more effective diagnostic actions and wider use of supervised treatment. The integration between the NTCP and the BFHS was studied by means of a Theoretical Model of the insertion of NTCP in BFHS, according to several contexts, namely, the Community Context, the local Political-Organizational Context, the Implementation Context, and the Effect Context. Theoretical Model of the integration of the National Tuberculosis Control Program in the Brazilian Family Health Strategy Community Context Political and organizational Context Logic Model of the Program Implementation Effects Local Board of BFHS Local Board of NTCP BFHS Units General Healthcare Units Hierarchized system Integral actions Problem-solving actions Patient satisfaction Secondary and tertiary: Polyclinics and hospitals 2
A Logical Model of the integration between the BFHS and the NTCP was also employed in this study. Logic Model of the National Tuberculosis Control Program (NTCP) integrated with the Brazilian Family Health Strategy (BFHS) Inputs Building Facilities Financial Resources Human Resources Protocol Activities Educaticional activities and improvement of knowledge about tuberculosis Detection of cases and situations implying in risk for transmission and becoming ill Early diagnosis and Supervised Treatment Scheduled household Visiting and search for absentees Cases reporting and registering Short Term Outputs Implementation of educational activities Exam of patients with respiratory symptoms Diagnosis and treatment of cases Rescued cases Registering of reported cases Medium Term Outcomes Better access to the health services network More diagnosed cases Better standard of care More healed cases Lowering of Mortality and abandoning rates Better information systems Long Term Impact Prevention of disease and sequels Reduction of risk factors Lowering of TB incidence and mortality 3
For doing the analysis, we established criteria for judging the successfulness of the implementation of NTCP and its integration with the BFHS. The criteria were arranged in four judgment arrays, one for each of the different contexts. The judgment arrays divided the gathered about its context into sub-dimensions, which, in their turn, were divided into criteria/indicators. These criteria/indicators were again subdivided in descriptors, to which maximal ranking points were assigned. For example, in the judgment array for the Community Context, the subdimension Social Vulnerability included only one criterion/indicator, which was Clustering of population groups. Three descriptors were included in that criterion/indicator, namely Demographic density greater than the State s demographic density (to which a maximal 1 point value was assigned); Presence of people dwelling in sub-standard house clusters (to which a maximal 2 points value was assigned); and Presence of asylums and prisons (to which a maximal 2 points value was assigned, summing up a maximal 5 points value assigned to the Social Vulnerability sub-dimension as a whole). The maximum of points attainable in the judgment array for the Community Context was 30; for the Political-Organizational Context, 40; for the Implementation Context, 105; and for the Effects Context, 35. For these values, cutoffs were drawn at the terciles, as follows: For the Community Context, the following limits were employed: 1. Satisfactory development 67% 2. Partial development, from 34% to 66% 3. Undeveloped, 34% For the Political-Organizational Context, the following limits were employed: 1. Satisfactory implementation 67% 2. Partial implementation, from 34% to 66% 3. Unimplemented, 34% For the Implementation Context: 1. Satisfactory implementation 67% 2. Partial implementation, from 34% to 66% 3. Unimplemented, 34% And as to the Effects Context: 4
1. Performance achieved, 67% 2. Performance partially achieved, from 34 to 66% 3. Performance unachieved, 34%. Dimension I : Community context (40 points) Social Vulnerability (05 points) 2,5 points Political engagement (15 points) 2,5 points Subdimension Socioeconomic conditions (20 points) 12,7 points Criteria/indicator Descriptors Points Sum 1 - Clustering of population groups 1 - Municipal health services coverage 2 NTCP and BHFS as part of the Municipal Health Council agenda 3 Financial resources for the NTCP 1 Age strata and sex 2 - School years of the population in the municipality 3 - Stable job contract 4 - Per capita income 5 - Household/sanitary conditions Demographic density Rio de Janeiro State s demographic density (1 point) Absence of sub-standard house clusters (2 points) Absence of asylums and prisons (2 points) % of coverage by Health Centers (Basic Attention) in the Municipality Full coverage (2 points) % of coverage of BHFS in the Municipality Full coverage (2 points) % of public hospital beds in the total number of hospital beds in the Municipality 100% = 1 point NTCP as a Municipal Health Council agenda item in the last year (5 points) Proportion of federal, state and municipal resources % of people with 8 school years 100% = 3 points % of literate people >90% = 2 points % of people with wage-earning jobs 100% = 5 points % of people with income >5 minimum wages 100% = 5 points % of households with piped water 100% = 2 points % of households with sanitized sewage 100% = 2 points % of households with garbage collecting service 100% = 1 point Total attained 17,7 points in 30 = 59% (Partial Development) 0 1.5 1.0 1.5 0.5 0.5 t seen 2.0 2.0 2.5 2.5 t seen 4.0 3.4 3.4 1.5 1.5 1.5 1.4 0.9 3.8 5
Subdimension Political and Financial Autonomy Intersectorial Actions Management (30 points) Dimension II : Political-Oganizational (40 points) Criteria/indicator Descriptors NTCP BHFS 1 - Politico-financial autonomy of the management programs over budget money assigned to TB control in the municipality 1 - Insertion of programs in the organizational structure 1 - Integration between NTCP and BHFS at the level of municipal managing 2 Coverage of services doing TB diagnosis, treatment and prophylaxis 3 - Training and supervision of human resources (05 points) 4 Reporting and surveillance system (05 points) 5 Technical and managing autonomy Participation in the management of resources Yes = 2 points; Partial = 1 point; = 0 point Participation in the assignment of money budget destined to programs Yes = 2 points; = 0 point Participation in the Municipal Health Council As a member = 1 point Sporadic = 0.5 point Never = 0 point Integration with epidemiologic Surveillance Yes = 2,5 points; = 0 point Connection with other programs and with other organized sectors of society Yes = 2.5 points; Partial = 1.5 point; Irregular = 0.5 point; = 0 point Conjoint planning for the TB control actions Formal = 10 points; Informal = 2 points % of Health Centers 100% = 2 points % of the BFHS modules 100 % = 2 points % of hospitals 100 % = 1 point Professionals received training on NTCP issues in the last year (3 points) Professionals received regular supervision by the program managers (2 points) Reporting by Local NTCP/BHFS (1 point) Reports issued conjointly (1 point) Conjoint evaluation or the reporting system (1 point) Information serves to conjoint decisionmaking process (2 points) Definition of strategies for abandoning and for drug administration modalities NTCP 19 points in 40 = 47.5% BHFS 24 points in 40 = 60% Both with Partial Implementation 1.5 1.5 3.0 4.0 2.0 2.0 4.0 5.0 3.0 5.0 2.5 2.5 3.0 4.0 6
Coverage and Attending (24 points) Dimension III: Implementation Context (105 points) Criteria/indicator 1 Patient access to services (15 points) 2 Infrastructure - Premises, equipment and resources (9 points) Descriptors Subdimension Polyclinic A Polyclinic B BHFS unit Commuting time from home to unit 30 min. (2 points) 2.0 2.0 2.0 Waiting time till being received by receptionist <30 min (2 points) 2.0 2.0 2.0 Waiting time till being received by healthcare worker <60 min (2 points) 1.5 1.5 1.5 Expanded attending shift (2 points) 0 0 0 Attending without previous scheduling (2 points) 2.0 2.0 2.0 Return to the same healthcare work guaranteed (2 points) 2.0 2.0 2.0 Number of visits by patient 6 (2 points) 2.0 2.0 2.0 Average time with the doctor > 20 min (1 point) 0.8 0.8 1.0 Properly ventilated consulting rooms (2 points) 1.0 1.8 0 1 table with 3 chairs in each consulting room (1 point) 0 1.0 1.0 1 examining stretcher in the consulting room (1 point) 1.0 1.0 1.0 Weighing scale (1 point) 1.0 1.0 1.0 Clinical thermometer (1 point) 0 0 1.0 X ray viewer (1 point) 1.0 1.0 1.0 Consulting and waiting rooms that assure patient privacy (2 points) 1.0 1.0 1.0 Diagnostic, Clinical and Laboratory Assistance (16 points) 1 Availability of ABF smear microscopy (10 points ) 2 Case search (6 points) Proportion of cases with AFB smear microscopy among total cases (3 points) 2.0 2.5 2.0 Turnaround time (4 points) 2.5 4.0 1.0 Treatment onset vs. exam result (3 points) 1.0 3.0 1.0 Performed (2 points) 1.0 1.0 1.0 Scheduled as routine (3 points) 0 0 1.0 Proportion of diagnosed cases among patients with respiratory symptoms examined (1 point) 7
Dimension IV: Implementation Context (Continued) Sub-dimension Criteria/indicator Descriptors 1 Treatment modality 2 Availability of drugs Polyclinic A Polyclinic B BHFS unit % of supervised treatments among confirmed cases 0.5 0.5 3.0 100% = 3 points % of self-administered treatments among confirmed cases 0% = 2 points 0.2 0.2 2.0 Programmed ordering of drugs for General Healthcare Units, polyclinics and BHFS Units 3.0 3.0 1.0 (3 points) Drug storage (2 points) 2.0 1.0 0.5 Treatment and Pharmacy Assistance (45 points) Integrality (15 points) 3 Cure 4 Abandoning 5 Mortality rate 6 Cases without information 1 Home visiting 2 Counseling about contacts Proportion of healed patients among those treated 85% = 10 points Proportion of patients abandoning treatment among those treated 5% = 10 points; 6 to 8% = 8 points; 9 to 11% = 6 points; 12 to 15% = 4 points; and >16% = 0 point Proportion of patients died during treatment, among those treated 5% = 10 points; 6 to 8% = 8 points; 9 to 11% = 6 points; 12 to 15% = 4 points; and >16% = 0 point Proportion of patients without information about treatment conclusion 0 to 1 % = 5 points; 2 to 6% = 3 points; >7% = 0 point Home visits to registered patients Proportion of patient contacts examined among patients with TB 4 8.5 8.5 8.8 4.0 4.0 0 10.0 8.0 10.0 3.0 5.0 5.0 1.0 0 5.0 0 0 0 Epidemiologic surveillance/ Information System 1 Case reporting Reporting done by the health unit or by the FHP module where the patient was diagnosed (2 points) Proportion of reported cases among those diagnosed (3 points) Polyclinic A - 58/105 points ( 55.2%) Polyclinic B 61.8/105 points (58.8%) BHFS unit 61,8/105 points (58,8%) Partial Implementation in all studied units 2.0 2.0 2.0 8
Dimension IV: Effects Context (35 points) Subdimension Treatment results (15 points) Patient satisfaction Criteria/indicator Descriptors NTCP BHFS 1 Cure by treatment modality 2 Abandoning 3 Mortality rate 1 - Patient satisfaction Number of healed patients/number of patients submitted to supervised treatment >85% = 3 points Number of healed patients/number of patients submitted to self-administered treatment > 85% = 2 points 70 to 84 % = 1 point <70% = 0 point Number of patients who abandoned treatment/number of patients assisted in the program <5% = 05 points 6 to 8% = 03 points >8% = 0 point Number of patients died during treatment/number of patients assisted in the program <5% = 5 points 6 to 8% = 3 points >8% = points Patient satisfaction with services availability, access, suitability and reception NTCP 10/15 points (66.6%) Performance partially achieved. BHFS 15/15 points (100%) Performance achieved. 3.0 3.0 1.0 2.0 3.0 5.0 3.0 5.0 9.0 t seen RESULTS For the Community Context, the percentage result was 59%, which is compatible with a partial development. For the Political-Organizational Context, the percentage result was 47.5% for the NTCP, and 60% for the BFHS, which are both compatible with partial implementation. For the Implementation Context, the percentage result was 55.2% for the Polyclinic A, 58.8% for the Polyclinic B, and 58.8% for the BFHS unit, which are all compatible with partial implementation. 9
For the Effects Context, the percentage result was 66.6% for the NTCP, which is compatible with partial performance achievement and 100% for the BFHS, which is compatible with full performance achievement. Dimension I Community context 59% Partial development Pros Proportion of own resources assigned to healthcare High indexes of literacy and of people with 8 or more school years Proportion of people with income 5 minimum wages superior to the country s same proportion. FHS as a pioneer program lasting more than 15 years Cons High demographic density High number of persons dwelling in sub-standard house clusters Low BFHS coverage in the general population Dimension II Organization context NTCP and BFHS PCT 47.5% BFHS 60% Partial implementation Pros High proficiency and professional experience of managers Participation in the decisions related to the assignment of resources destined to the program Management shared with neighbors associations Training and qualifying teaching as routine activities, with an annual schedule Informing local level healthcare workers in quarterly-meetings Overseers present at the unit at least once a week Cons participation in the management of municipality resources destined to healthcare systematized planning or conjoint reports Irregularity of the financial incentives to supervised treatment BFHS not integrated to the Local Health Foundation structure Conflicts between healthcare workers and neighbors associations 10
Dimension III Implementation context Polyclinic and BFHS unit Polyclinic A 55.2% Polyclinic B 58.8% BFHS unit 58.8% Partial implementation Pros Patients are always followed by the same healthcare worker. Unscheduled consults can be arranged for. Distance from home and waiting for being let in are not mentioned as problems by the patients Sharing of technical information between healthcare professionals and specialists Proper waiting rooms. Drugs and equipment sufficient to the amount of patients followed Results of first AFB smear available in most cases Supervised treatment in all cases Cons Impossibility of expanding attending hours Small number of professionals in the team Cases search not systematized Cure rates 85% and abandon rates 10% Integration between polyclinics and BFHS units restricted to referring patients Supervised treatment in 10% of cases and an insufficient number of contacts examined Infrequent household visits during the follow-up of TB patients Poor waiting rooms and small and poorly aired attending rooms Dimension IV Effects context NTCP 66.6% Performance partially achieved BFHS 100% Performance achieved Pros Better cure and abandon rates in recent years/abandon rates 10% Excellent results in cases submitted to supervised treatment Most patients satisfied with the attending and counseling received Cons Cure rates 85% and death rates 5% (goals from the national program) Small proportion of supervised treatments Small proportion of patients followed in the BFHS units 11
CONCLUSIONS Integration between the NTCP and the BFHS yet incipient: local BFHS is only supplementary to the endemics control actions technical and administrative hierarchical ranks in different and distant positions in the organizational structure Scarcity of human resources and work overload. Similarly, the degree of the implementation of the NTCP with BFHS in the polyclinics and in the BFHS unit was only partial: Active cases search and patient contact examinations are insufficient and not integrated among the different units Supervised treatment had optimal results, but was offered to a small proportion of cases. The Logical Evaluation Model was capable to reach its goals. The results obtained in this work can be useful in the decision-making processes in public health. 12