PHC Reform 2012-2016
Secretaria Municipal de Saúde de Florianópolis

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Florianópolis is a city in south of Brazil with 477,798 inhabitants (IBGE, 2017). The municipality Health Department is responsible for operating the primary health care (PHC) services as proposed by the national Ministry of Health, the Family Health Strategy (Ministério da Saúde, 2017). This strategy is designed nationaly in broad lines, with primary care teams responsible for providing care to the resident population of a set geographical territory. The fine tuning of the services structure and scope, however, is determined by the municipal management, with a broad range of organizing patterns throughout Brazil, from well rounded open accessed settings with a wide offer spectrum to situations with closed and bureaucratic organizations with narrow clinical offering variety. Already in 2012 Florianópolis’ primary health care system was widely recognized nationally, with 110 PHC teams spread in 49 practices integrated by a common electronic health record system. Back then, population coverage of the PHC system was 90%, as for the National Ministry of Health criteria of 3,450 inhabitants per PHC team (Diretoria de Atenção Básica - Ministério da Saúde, 2017), and the accessibility and clinical offer patterns were, however, still very heterogeneous with sharp differences regarding the PHC attributes of accessibility, coordination of care, and integrality (Oliveira & Pereira, 2013) between different practices. This meant that a significant portion of the population in need of PHC services was left without proper care, be it because of inability to access it or because of a clinical offer limited in both spectrum and quality. In that year, 49822 people got to access medical appointments (11.5% of the population), according to the local electronic health record. Still, no clinical guidelines where set up to drive clinical quality by the best evidence available. The child mortality was 9,15 per 1000 and the rate of hospitalization for causes that are sensitive to primary care was 513,7. Finally, it is known that more vulnerable people has less access to health services than people in better income and schooling condition, as stated by the Inverse Care Law (Hart, 1971), so it would be expected that a high proportion of morbidity and mortality could be avoided by an equitable provision of PHC services to these populations.

B. Strategic Approach

 2. What was the solution?
A comprehensive strategy aiming qualification of PHC services in both the structural and clinical scopes, as well as actions to increase the number of qualified PHC teams by applying to more federal resources and the implementation of health residency programs.

 3. How did the initiative solve the problem and improve people’s lives?
The strategy was implemented through a series of management actions that sought to consolidate the know-how acquired by many of the teams of the primary care network in the accessibility to health care services and also in the scope of the care provided. Two PHC Accessibility Workshops were held and aimed to spread best workflow practices aiming debureaucratization of that aspect, aiming the maximization of availability to the general population. Also, three Municipal Health Forums developed in workgroups aiming to systematize the general organization and scope of offerings of PHC in Florianópolis. As a result, the PHC Services Portfolio was published with the expected scope of actions in the services, as well as regulations concerning their organization. Some highlighted points of regulation were the determination that 50% of the clinical capacity of the teams would be devoted to tending to same-day appointments, and the opening of non-presential forms of scheduling appointments, such as phone calls and e-mail. This last action demanded that all teams formalized their electronic addresses and resulted in the use of shared instruments for the coordination of care between professionals, teams, and levels of care. In 2014 a federal program aimed to encourage the development of medical residency programs and the Health Department implemented a program in Family and Community Medicine in twenty PHC facilities, an action that has boosted the expansion of the number of family health teams as well as the qualification of the services provided. In 2015 florianopolis achieved 100% coverage for the family health strategy according to the Ministry of Health (Diretoria de Atenção Básica - Ministério da Saúde, 2017). In 2016 the municipal network conducts the postgraduate training in the modality of residency in health of 122 professionals including Family Doctors, Nurses, Dentists and other allied health categories. In 2015 a partnership with the University of Cape Town and the British Medical Journal allowed for the localization of the PACK (Practical Approach to Care Kit) from the original South African material to Brazil, being offered to the entire municipal health system. This allowed introducing the concept of using the best available evidence in the clinical routine, potentially increasing the overall quality of care in the system. From 2015 on, five Nursing Protocols were published, aimed at increasing the clinical share of nurses in the overall clinical capacity for the family health teams. In 2016, 113066 people underwent 293293 appointments with doctors, an increment of 126% patients and 164% of the 2012 results. In the same period, total population increased an estimate 10%. 79.5% of the visits were same-day appointments, in contrast to 71.6% in 2012, and the average waiting time from scheduling to appointment has decreased from 11 days to 4 days. The proportion of referrals in medical appointments went from 9.5% to 9.1%. The infant mortality went from 9.2 to 5.4 per 1,000 births.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
Since 2012, the Primary Care Department of the Municipal Secretary of Health of Florianópolis has been developing a PHC strengthening intervention based on the implementation of a PHC Services Portfolio, which have been used as quality improvement and management tool in some provinces of Spain and, more recently, some Brazilian capitals. It is a framework for reorganization of care, monitoring services and supporting practices, and in Florianópolis it covers organization of PHC practices, human resources management and clinical scope of the care. Beyond a reference document, it can be considered as the starting point of a broader reforming process embedded in current primary care management routines, to be complemented by other initiatives as clinical guidelines in strategic themes, nursing protocols and team-based monitoring tools. The Services Portfolio implementation is a complex intervention with interrelated key components expected to unfold in an iterative way: a) Dissemination and discussion of the document (Services Portfolio) in working groups with PHC professionals; b) Systematic inquiry of the PHC practices functioning, based on the Services Portfolio general framework (normative evaluation and routinary monitoring); c) Definition of priorities for change and quality indicators for PHC practices based on the framework of the Services Portfolio; d) Implementation of clinical practice guidelines on the most frequent reasons for consultation (Project PACK Brazil); e) Induction of practices-based educational strategies based on these guidelines and targeted to priority conditions and quality gaps; f) Continuing monitoring, with feedback to the PC teams, of the implementation of the Services Portfolio and clincal guidelines. These actions were all implemented at a minimal or no financial cost to the institution, with the use of opinion leaders raised from the professionals themselves for spreading and implementing of the strategies. Actually, the implementation of the residency programs are superavitary for the municipality by adhering to the many federal financing strategies. Furthermore, the strategies are a strong step in the field of evidence-based management, still an incipient practice in Brazilian public sector.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The initiative was led by PHC professionals who, during the period from 2012 to 2016, held positions of management, coordination and practice of PHC services within the municipal Health Department of Florianópolis. The board of Primary Care managed the residency programs in family medicine and multiprofessional health teams, the elaboration, publication and training of the nursing protocols, the actions of the PACK BRASIL project as well as the hiring and rational distribution of professionals in the primary care network. The implementation actions were held in partnership between the management system and some end-user professionals identified as leaders between their peers. As already mentioned, the municipal PHC network is the coordinator of the care to 113066 people or 23.7% of the population of Florianópolis, offering overall health services to 278901 people considering all services at all levels, 58.37% in 2016. The clinical guidelines as well as the nursing protocols are available to all 280 professionals working in the primary care teams in the city, and all physicians and nurses received their own printed copy of the PACK BRASIL and 50% of them will receive specific training for the use of the tool.
 6. How was the strategy implemented and what resources were mobilized?
The first Accessibility Workshop aimed at showcasing the best practices in accessibility organization already implemented in Florianópolis, and after that workgroups defined what would be the regulatory cornerstones for the next steps in the strategy. The second Workshop aimed at updating the teams on the degree of implementation and pragmatic revision of the standards developed in the first one. The first Municipal Health Forum aimed at sharing data about the state of the health care in Florianópolis with the teams and defining strategies for future development. Working groups in Information Technology, the Services Portfolio, Social Communication, and People Management were created and the next two forums aimed at updating on the workgroup developments and, finally, validation of the products. The most significant product of those movements was the PHC Services Portfolio, that set the regulatory framework that later would be formalized as the PHC Municipal Act. With the formal declaration of expected clinical scope to be offered by the teams, the necessity of clinical guidelines aimed at bringing the best scientifical evidence to the daily routine was detected. A partnership with the University of Cape Town and the British Medical Journey was then estabilished and one family doctor was designated to lead the localization efforts with part-time help of other doctors and nurses from the different clinical settings. After one year the first edition of PACK Florianópolis was published and distributed to all health staff of the municipality. Half the PHC teams also underwent a training processes and a clinical trial is being held to try to determine the efficacy of the training process as part of the implementation strategy. The only explicit cost in this strategy was the removal of a doctor from the clinical setting. All the training process is done with local staff at their own facilities. Also, Nursing Protocols are being published aiming to increase the nursing staff clinical share on the family health teams. Until now four Protocols were published and the impact on nursing care is currently being accessed, with empiric data pointing to an increase of clinical offer from this category. The medical residency in Family Medicine hosts 20 students a year in a two year program in the municipal facilities having the staff of family doctors as the tutors. Every student earns a R$ 2,700.00 municipal scholarship plus R$ 3,000.00 from the federal government and each tutor earns a R$ 1,000.00 municipal scholarship as a salarial complement. The multiprofessional hosts 20 nursing students and 24 students of the allied health categories and is also held at the facilities. The students earn federal scholarship only and the tutors also earn a R$ 1,000.00 municipal scholarship. Still, the residency programs end up being superavitary to the municipality due to the possibility of assembling family health teams with the resident professionals and receiving the correspondent federal incentives. The implementation of those strategies is based in the involvement of champions (practitioners, doctors and nurses) in the review, dissemination and training phases of the process. These reviewers and trainers will be recruited from stablished groups of clinical leaderships, namely doctors and nurses involved in the trainig of colleagues as specialist in Family Health and nurses of a Committee on Systematization of Nursing Care, that already work collaboratively with the management level in the design and implementation of other PC qualification strategies. These professionals are expected to work as local change agents, enhancing knowledge exchange processes and facilitating the implementation of the Services Portfolio guidelines. They present some attributes of the opinion leaders (Thompson, Estabrooks, & Degner , 2006): are internal to the organization, have long-term relationships with other staff members, are context-specific of primary care - and, in the case of the practitioners, also of the same medical specialty, family medicine -, and in a general way, they are respected sources of information for their groups, as well as informally well-connected individuals. These opinion leaders would be mainly front-line peer healthcare workers providing support to their fellow healthcare workers in a sort of ways: (i) during themes focused, intermittent, interactive sessions on-site in targeted PC practices; (ii) receiving fellow workers in their own practices for joint attendance and practical training sessions during routine care; and (iii) maintaining further informal communication by phone and email for additional support. The content of the initial educational sessions would be based on the Services Portfolio guidelines, but the additional communication and informal meetings, whenever established, could follow singular and unpredictable directions. This intervention is expected to be feasible and acceptable, since similar strategies have already been used in the research setting for continuous professional development processes covering topics like advanced access, antenatal care and mental health. It is also expected to work as a demonstrative experience to the reorientation of current professional training and development practices in the city. This intervention has some differential points, like the focus on practitioner-practitioner, horizontal collaboration pathways of knowledge exchange for promoting organizational change in PC practices; and the strong services-based character of the intervention, undertaken within the health organization management resources and routines.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
From 2007 on Primary Health Care gained the status of public health system coordinator and in the same period started a institutional culture of raising the management position from the highly qualified frontline staff. From 2012 to 2016 the position of Municipal Secretary of Health, the highest hierarchical position in the health department, was also occupied by a frontline doctor, who climbed the ranks in management since 2007. This culture of self governance and felling of ‘belonging’ is unusual in Brazil, where often all the managerial positions are occupied by partisan appointments and not always even in the technical know of the systems to be managed. Also, from 2014 on, a strong and fruitful partnership with the University of Cape Town and the British Medical Journal allowed for the development of the clinical guidelines in use today. This partnership also led to collateral benefits, with the strengthening of Florianópolis’ technical formulation capacity and the use of evidence and data not only in clinical settings but also in management actions. The bond with the Federal University of Santa Catarina and the University of the State of Santa Catarina also was strengthened and today more than 4,000 students of a vast array of graduation courses intern every year on the municipal health services. A group of opinion leaders formed by family physicians and nurses who had a practical experience in primary care leaded the implementation actions having a crucial role in managing the implmentations, inspiring their colleagues, coordinating the changes needed and overall encouraging and exercising self-governance. Some professional regulatory organs, as the Regional Nursing Council and the State’s Family Medicine Association, were crucial in legitimizing the strategies.

 8. What were the most successful outputs and why was the initiative effective?
113066 people went through medical consultations in the PHC system in 2016, in 2012 this number was 49822. This 127% increase was mostly seen on low income areas and in populations that before were neglected by PHC, eg working age adults. This improvement in delivering care didn’t reflect in less resolutivity by the clinicians, and the referral rate went from 9.5% of the appointments in 2012 to 9.1% in 2016. As for finalistic results, the populational coverage by family health teams went from 91.04% in 2012 to 100% in 2016, much of it as result of the professional influx due to the residency programs. The proportion of families detected as very vulnerable by a large national income income transfer, the Programa Bolsa Família, that were systematically followed by the PHC teams jumped from 53% in 2012 to 95% in 2016. Infant mortality fell from 9.2 per thousand births in 2012 to 5.34 (Secretaria de Vigilância em Saúde, 2017) in 2016.

 9. What were the main obstacles encountered and how were they overcome?
The political steering of public services brought three big obstacles for the strategies: • There’s a lack of understanding about the medium-term correlation of quality of care and health results, and lay politicians not versed in health care usually see the use of clinical hours for professional development as a waste of pontential. Populating the management with health professionals allowed for the priorization of qualification actions; • Brazil is ridden by extreme bureaucracy in the hiring and acquiring processes, and it meant that all of the events and strategies had to happen at minimal cost, both financial and administrative, using less-than-ideal venues and forcing the development of the culture of homegrown leaderships, that ended becoming one of the great strengths of the strategy; • Money, money and money. The municipal government investiment in health services has decreased proportionally to the total budget since 2012, from 19.62% to an estimated 17% in 2016. This, coupled with an increased influx of clientele that used private insurance plans before and and increase of the clinical scope of services ca be a recipe for a disaster. The qualification strategies, recognition of opinion leaderships, and proximity of management with the front line ended up meaning a solace of good work conditions through these arid times. Also, there’s a big debate in Brazil about the regulating of health acts that would be restricted to doctors, and the expansion of the clinical share of the nursing staff was met with hard criticism of the Regional Medical Council. These actions, however, tend to be motivated by market share worries and have no legal basis. As a matter of fact, a coalition between family doctors and nurses was formed and their ties grew stronger.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
In 2016, the municipal PHC services were more open, having offered medical care to 113066 persons, an increment of 127% since 2012. The number of clinical encounters went up 164% to 293293 appointments with a referral rate coming from 9.5% to 9.1%. It means that more people who had no access to a longitudinal and qualified care close to their homes now were included in the system without loss of resolutivity. The active vigilance of a studied population in socioeconomic vulnerability went from 53% to 95%, infant mortality went down from 9.2 to 5.34 per 1000 births, hospitalizations for Ambulatory Care Sensitive Conditions (Alfradique, et al., 2009) kept level at 20% of the total clinical hospitalizations. It means that the system was able to include people in need, keeping or improving overall results. And finally, the health system was able to grow leaderships from its ranks, exercising self-governance in the daily routine, capable of applying high concepts of technology and evidence even in the eye of the hurricane of underfinancing.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
Upon debureaucratizing access to its services and opening the doors to the entirety of the population, the system exposed its face and workings to the general scrutiny. The fact that the national media turned its attention to a smaller city far from the big populational hubs to showcase Florianópolis experience as an example to be followed shows the good will conquered through this time.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
Initially, Florianópolis PHC services were bureaucratic in the accessibility aspect and extremely narrow in the clinical scope. Not rare the vast majority of the clinical practice of the professionals would focus on pre-scheduled appointments for the care of mild to moderate cases of chronic non-transmitable diseases. Opening the accessibility and expanding the clinical scope allowed for the inclusion of all populations independently of clinical condition, age or gender, especially thos not included in the traditional Brazilian “public health markers”. For women specifically it meant health care in its whole, beyond the assembly line of “pap tests just because”. More pregnancies were detected earlier and taken care in a more qualified fashion, and the working young adult woman was finally able to have comprehensive care.

Contact Information

Institution Name:   Secretaria Municipal de Saúde de Florianópolis
Institution Type:   Government Department  
Contact Person:   Matheus Pacheco de Andrade
Title:   Manager for Integration of Care  
Telephone/ Fax:   +55-48-99135-1337
Institution's / Project's Website:  
Address:   Avenida Professor Henrique da Silva Fontes, 6100
Postal Code:   88036-700
City:   Florianópolis
State/Province:   Santa Catarina

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