We present to the scientific community the pioneering of Brazilian National Institute of Geography and Statistics (IBGE, the Brazilian Census Bureau) in partnership with the Ministry of Health, the largest fieldwork ever conducted in a single country in the world, using the PCAT in a national household sample survey, visiting more than 100,000 households and 40% of the country’s municipalities. In Brazil, PCAT is being consolidated as an instrument to support public policy for the evaluation of primary health care. We believe that it represents a virtuous example of dialogue between scientific community and health management, following the legacy of Professors Barbara Starfield and Leiyu Shi

D'Avila, Otávio Pereira

Harzheim, Erno

Hauser, Lisiane

Pinto, Luiz Felipe da Silva

International Journal for Equity in Health

English

Lume 5.8

LETTER TO THE EDITOR Open AccessFollowing the legacy of professors BarbaraStarfield and Leiyu Shi in Brazil as healthpolicy: the National Health Survey (PNS),led by the Brazilian National Institute ofGeography and Statistics (IBGE) and thePrimary Care Assessment Tool (PCAT)Erno Harzheim1 , Luiz Felipe Pinto2,3* , Otavio Pereira D’Avila4 and Lisiane Hauser5AbstractWe present to the scientific community the pioneering of Brazilian National Institute of Geography and Statistics(IBGE, the Brazilian Census Bureau) in partnership with the Ministry of Health, the largest fieldwork ever conductedin a single country in the world, using the PCAT in a national household sample survey, visiting more than 100,000households and 40% of the country’s municipalities. In Brazil, PCAT is being consolidated as an instrument tosupport public policy for the evaluation of primary health care. We believe that it represents a virtuous example ofdialogue between scientific community and health management, following the legacy of Professors BarbaraStarfield and Leiyu Shi.Keywords: Primary health care, PCAT, Survey, BrazilSince the early 2000s, when the team led by professors Bar-bara Starfield and Leiyu Shi of the Johns Hopkins Bloom-berg School of Public Health proposed to the scientificcommunity the Primary Care Assessment Tools (PCAT)[1–3] to the evaluation of Primary Health Care (PHC) inthe United States, dozens of other studies have been devel-oped over the 20 last years on all continents, using validatedversions adapted to the reality of each country, especially inNorth America, Latin America and most recently with theleadership of Professor Leiyu Shi in Asia [4, 5]. In low andmiddle-income countries, the access / first contact attributeremains the most difficult to reach when its PCAT score iscalculated. Comprehensiveness is what most differentiatescities in each country in which the instrument has beenused across continents [6].But who could imagine that in almost 20 years later, acountry of continental dimensions like Brazil, with hugesocial inequality, would adopt this instrument as an im-portant part of a public policy, evaluating the FamilyHealth Teams that work in primary health care and, tothis end, would initiate the major household sample sur-vey to create a national, regional and local baseline foreach of the 27 federation units? Who would havethought that from Oiapoque to Chuí (from north tosouth of Brazil) the enormous challenge of collectingdata with probabilistic household samples could be ac-complished across the nation?In Brazil, PCAT questionnaires using the sameStarfield-Shi four-point Likert scale was validated andpublished in 2006 by Harzheim, Starfield, Rajmil, Álva-rez-Dardet and Stein [7]. In 2010, Ministry of Health,with the technical support of Professor Starfield herselfpublished PCAT expanded questionnaires [8]. To adapt© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.* Correspondence: felipepinto.rio@medicina.ufrj.br2Departamento de Medicina em Atenção Primária à Saúde, Faculdade deMedicina, Universidade Federal do Rio Janeiro (UFRJ), Rio de Janeiro, RuaLaura de Araújo, 36 – 2º andar – parte, Cidade Nova, Rio de JaneiroCEP.21250-540, Brasil3IHMT/Universidade Nova de Lisboa, Lisboa, PortugalFull list of author information is available at the end of the articleHarzheim et al. International Journal for Equity in Health          (2019) 18:176 https://doi.org/10.1186/s12939-019-1083-2it to the Brazilian reality, each original version of the in-strument was transformed into an applicable tool by in-terviewers and went through a process of translationand reverse translation, adaptation, debriefing and valid-ation of content and construct, as well as reliability ana-lysis. From a scientific point of view, PCAT remains theone in which the techniques recommended by the Statis-tical Sciences for questionnaire validation are followed(multivariate / factorial analysis, correlation analysis, useof item-response theory, validity and reliability by Cron-bach’s alpha coefficient) [9].Until 2016, the largest sample in the world (n = 6675)performed in a single city occurred in Rio de Janeiro,Brazil, the second largest in the country, with the appli-cation of the instrument in expanded versions of adultand child users in family health units [10], including themost known poor community of Brazil, the neighbor-hood of Rocinha [11]. In Spain, the Catalonia region in-cluded a reduced PCAT version for both adult andchildren [12] in a national survey in 2006, with the par-ticipation of Professor Barbara Starfield.Like the United States Census Bureau, Brazilian Na-tional Institute of Geography and Statistics (IBGE) ishuge, and has a national structure with more than 500support offices in all five regions of the country. How-ever, the giant heterogeneity of each federation unityand the difficulty of connectivity and linkage of adminis-trative databases do not allow the use of interviews innational surveys by telephone or email. Therefore, a true“war operation” was planned in detail for the five-yearNational Health Survey (PNS), the main sample house-hold survey of the country that portrays the most diversefacets of Brazilian population.PNS emerged from breaking down the major growthof elements included in the National Household SampleSurvey (PNAD) Special Health Supplements, publishedevery 5 years since 1998 (1998, 2003, 2008, and then forthe first time in 2013 as PNS), maintaining the same re-search aspects (set of questions or Modules) so that datamay be compared to previous surveys. This survey ispart of the IBGE Integrated System of Household Sur-veys (SIPD), and uses the “Master Sample” infrastruc-ture. Sampling for PNS-2019 was designed to produceindicators for 80 geographic sections: the country, fiveregions, 27 states, 21 metropolitan regions and 27 statecapitals (this one the maximum level of granularityallowed). It is important to point out the need to dis-close estimates and their coefficients of variation.Encouraged by one of the authors of this text, in Au-gust 2019, IBGE in partnership with the Ministry ofHealth started the survey fieldwork visiting more than100,000 households in about 2000 municipalities (about40% of the country’s municipalities) from all over the 27states and regions of the country, interviewing an adultaged 18 or older in each household, and applying for thefirst time in its 20 years of Health Surveys, the reducedvalidated version of the PCAT, as a part of one of thePNS set of questions (Module H) [13].To the best of our knowledge, it will be the first timethat a country in the world applies the instrument on anationwide sample scale, albeit in a reduced version sothat it can draw a baseline for further comparisons in fu-ture national surveys.Following the legacy of Professors Barbara Starfieldand Leiyu Shi, we believe that strong primary careshould follow the essential and derivative attributesstated in the 1990s by Shi and Starfield, who later hadher work translated into Portuguese by United NationsEducational, Scientific, and Cultural Organization(UNESCO) and launched in Brazil in the same year 2002[14]. With Brazil’s pioneering health household nationalexperience in 2019, PCAT is being consolidated as aninstrument to support public policy for the evaluation ofprimary health care. It also considers a new federal fi-nancial model of pay for performance that will begin in2020 [15]. This match between scientific community andpublic health policy therefore represents a virtuous ex-ample of success in this partnership. So our tribute toProfessors Barbara Starfield and Leiyu Shi is a way tokeep the flame burning and the legacy built and underconstruction to demonstrate that yes, a nationwide sci-entific survey and primary care services integration ispossible with representative random samples, from astatistical point of view, that is, with external validity,and its results can be generalized to the population as awhole, disclosing the scores found and their respectivecoefficients of variation.AcknowledgementsWe would like to thank Brazilian National Institute of Geography andStatistics (IBGE) for the opportunity to adapt the former “Medical Care”Question Module (set of questions) which now contains the Adult PCATquestions in their reduced version validated in Brazil, by the same Likertscale used by Professor Barbara Starfield and Professor Leiyu Shi.Authors’ contributionsAll authors contributed equally to the writing of the text and the first authorreviewed the final text. All authors read and approved the final manuscript.FundingThe Brazilian Ministry of Health and Brazilian National Institute of Geographyand Statistics (IBGE) fund the National Survey of Health (PNS-2019) which hasone of its part, addressing questions about Adult PCAT.Availability of data and materialsNot applicable. The National Survey of Health (PNS-2019) has just started tocollect data from 100,000 household all over the 27 States of Brazil.The authors chose the section “Letter to the Editor” modality, since theobjective is to inform readers of what is considered as somethingunprecedented in the use of the PCAT instrument, that is, they believe it isthe first time that a continental country such as Brazil conducted a nationalhousehold sample survey with the application of the this evaluation tool inall regions, federation units and capitals of a country.Harzheim et al. International Journal for Equity in Health          (2019) 18:176 Page 2 of 3Ethics approval and consent to participateThe National Survey of Health (PNS-2019) was approved by the NationalHealth Ethics Committee (CONEP) (process n° 3.529.376).Consent for publicationBy Federal Law, the IBGE, although collecting household data does notdisclose data in order to identify the person interviewed, anonymizing thedata collected.Competing interestsEH published one article with Professor Barbara Starfield in 2006. The othershave published some articles about PCAT Brazil.Author details1Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS),Porto Alegre, Brazil. 2Departamento de Medicina em Atenção Primária àSaúde, Faculdade de Medicina, Universidade Federal do Rio Janeiro (UFRJ),Rio de Janeiro, Rua Laura de Araújo, 36 – 2º andar – parte, Cidade Nova, Riode Janeiro CEP.21250-540, Brasil. 3IHMT/Universidade Nova de Lisboa, Lisboa,Portugal. 4Faculdade de Odontologia, Universidade Federal de Pelotas(UFPel), Pelotas, Brasil. 5TelessaudeRS, UFRGS, Brazil, Rua Ramiro Barcelos,2400, Santa Cecilia, Porto Alegre, RS CEP.90035-003, Brasil.Received: 16 September 2019 Accepted: 31 October 2019References1. Cassady CE, Starfield B, Hurtado MP, Berk RA, Nanda JP, Friedenberg LA.Measuring consumer experiences with primary care. Pediatrics. 2000;105(4Pt 2):998–1003.2. Shi L, Starfield B, Xu J. Validating the adult primary care assessment tool.The Journal of Family Practice. 2001;50(2):161–4.3. Johns Hopkins Bloomberg School of Public Health. The Johns HopkinsPrimary Care Policy Center. Primary Care Assessment Tools [recursoeletrônico]. Baltimore, 2016. http://www.jhsph.edu/research/centers-and-institutes/johns-hopkins-primarycare-policy-center/pca_tools.html. Accessed05 Sept 2019.4. Wang W, Shi L, Yin A, Lai Y, Maitland E, Nicholas S. Development andvalidation of the Tibetan primary care assessment tool. BioMed ResearchInternational, May. 2014;21:308739. https://doi.org/10.1155/2014/308739.5. Wei X, Li H, Yang N, Wong SY, Chong MC, Shi L, et al. Changes in theperceived quality of primary care in Shanghai and Shenzhen, China: adifference-indifference analysis. Bulletin of the World Health Organization.2015;93(6):407–16. https://doi.org/10.2471/BLT.14.139527.6. D’Avila OP, Pinto LF, Hauser L, Gonçalves MR, Harzheim E. The use of thePrimary Care Assessment Tool (PCAT): an integrative review and proposedupdate. Ciênc. saúde coletiva, 22(3): 855–865, 2017. http://www.scielo.br/pdf/csc/v22n3/en_1413-8123-csc-22-03-0855.pdf, https://doi.org/10.1590/1413-81232017223.03312016 Accessed 17 Oct 2019.7. Harzheim E, Starfield B, Rajmil L, Álvarez-Dardet C, Stein AT. Consistênciainterna e confiabilidade da versão em português do Instrumento deAvaliação da Atenção Primária (PCATool-Brasil) Para serviços de saúdeinfantil [internal consistency and reliability of primary care assessment tool(PCATool-Brasil) for child health services]. Cad Saúde Pública. 2006;22(8):1649–59 https://doi.org/10.1590/S0102-311X2006000800013. Accessed 19Oct 2019.8. Brasil. Ministério da Saúde. Secretaria de Atenção em Saúde. Departamentode Atenção Básica. Manual do instrumento de avaliação da atençãoprimária à saúde: primary care assessment tool pcatool - Brasil / Ministérioda Saúde, Secretaria de Atenção em Saúde, Departamento de AtençãoBásica. – Brasília : Ministério da Saúde, 2010, 80 p. http://bvsms.saude.gov.br/bvs/publicacoes/manual_avaliacao_pcatool_brasil.pdf Accessed 05 Sept2019.9. Hauser L. Aprimoramento do Instrumento de Avaliação da Atenção Primáriaà Saúde: PCATool-Brasil. Tese de Doutorado (Doctoral PhD Thesis). PortoAlegre, Rio Grande do Sul: Programa de Pós-Graduação em Epidemiologia,Faculdade de Medicina, Universidade Federal do Rio Grande do Sul(UFRGS), 2016.10. Harzheim E, Pinto LF, Hauser L, Soranz D. Assessment of child and adultusers of the degree of orientation of Primary Healthcare in the city of Riode Janeiro, Brazil. Ciênc. saúde coletiva, 21(5): 1399–1408. http://www.scielo.br/pdf/csc/v21n5/en_14138123-csc-21-05-1399.pdf, https://doi.org/10.1590/1413-81232015215.26672015. Accessed 05 Sept 2019.11. Pinto LF; Harzheim E; Hauser L; D’Avila OP; Gonçalves MR; Travassos P et al.Primary Health Care quality in Rocinha – Rio de Janeiro, Brazil, from theperspective of children caregivers and adult users Ciênc. saúde coletiva,22(3): 771–781, 2017. http://www.scielo.br/pdf/csc/v22n3/en_1413-8123-csc-22-03-0771.pdf, https://doi.org/10.1590/1413-81232017223.33132016.Accessed 17 Oct 2019.12. Berra S, Rocha KB, Rodríguez-Sanz M, Pasarín MI, Rajmil L, Borrell C, StarfieldB. Properties of a short questionnaire for assessing primary care experiencesfor children in a population survey. BMC Public Health. 2011;11:285. https://doi.org/10.1186/14712458-11-285.13. Brazilian National Institute of Geography and Statistics (IBGE). For the firsttime, IBGE carries out survey on patient check-in in public health system.https://agenciadenoticias.ibge.gov.br/en/agencia-news/2184-newsagency/news/25542-for-the-first-time-ibge-carries-out-survey-on-patient-check-in-inpublic-health-system Accessed 02 Oct 2019.14. Starfield B. Atenção primária: equilíbrio entre necessidades de saúde,serviços e tecnologia. Brasil. Ministério da Saúde, 2002.15. Conselho Nacional de Secretários Estaduais de Saúde (CONASS) [NationalCouncil of State Health Secretaries]. Pautas e Resumo CIT, 2019. https://www.conass.org.br/pautas-e-resumos-cit-2016/ Accessed 20 Oct 2019.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Harzheim et al. International Journal for Equity in Health          (2019) 18:176 Page 3 of 3

Following the legacy of professors Barbara Starfield and Leiyu Shi in Brazil as health policy : the National Health Survey (PNS), led by the Brazilian National Institute of Geography and Statistics (IBGE) and the Primary Care Assessment Tool (PCAT)

https://lume.ufrgs.br/bitstream/10183/212788/1/001115894.pdf

Following the legacy of professors Barbara Starfield and Leiyu Shi in Brazil as health policy : the National Health Survey (PNS), led by the Brazilian National Institute of Geography and Statistics (IBGE) and the Primary Care Assessment Tool (PCAT)

Abstract

Similar works

Full text

Available Versions

Lume 5.8