Primary health care (PHC) is the organ of medical care that commonly is the first and closest contact between a health care professional and the patient. In different countries have been used “The Primary Care Assessment Tool” (PCATool). It has showed to be cross-culturally reliable for assessing primary health care. This study aims to measure and compare PCATool scores in two different neighborhoods in Sorocaba, Brazil. The data were from household interviews. There were 146 interviewees in each neighborhood during the year of 2018. The PCATool average score for Vila Sabia was 7.2, considered good; the average score for Vitoria Regia was 4.3, considered unsatisfactory. Both neighborhoods have problems in First contact–accessibility. Vitoria Regia presents a performance focused in immediate care. Vila Sabia presents a better performance, with a tendency for Universalist Primary Care model. Organizational factors related to the municipality’s health system could explain most part of these differences. Health is the foundation for building further social and economic development, equality and wellbeing for all inhabitants, and health questionnaires are essential for pointing out the weakness in the system and develop a well-functioning PHC-system.

Keywords: primary health care, health care assessment, household interviews, health equity

Primary health care (PHC) is the organ of medical care that commonly is the first and closest contact between a health care professional and the patient. Its function is to prevent illness, promote well-being and offer curative treatment when needed.¹ Alma-Ata´s definition of PHC is formulated as following: “Primary health care is the central function of national health systems and forms an integral part of permanent process of sanitary assistance that includes prevention, promotion, cure and rehabilitation, and of the overall social and economic development of the community, involving cooperation with other sectors to promote social development and confront the social determinants of health”.² The World Health Assembly decided in 1977, that the main social goal for governments and World Health Organization (WHO) would be improving living circumstances globally by the year of 2000, so that everyone would have a chance to live socially and economically productive lives.³ Primary health care is an important factor in promoting and achieving this goal. The WHO’s project encourages governments to improve PHC in their countries and improvement in some countries could be seen in the ´Health For All by 2000´-evaluation.⁴ One of the projects aim is to make the socioeconomical gap between developing and developed countries smaller, and partly, there have been improvements in this sector.⁵

With a population of 208.5 million and density of 23.8/km² in 2018,⁶ Brazil is the most highly populated country in South America. The new constitution founded in 1988 declared health care as a right for all Brazilian citizens. This declaration made possible everything that lead to what today is named Brazil´s National Health System (Sistema Único de Saúde-SUS). During the last two decades, the country’s primary health care has undergone extensive renewal and development.⁷ In 1994, the development of the Family Health Program (Programa Saúde da Família-PSF) additionally played an important component in developing equity in health care for the Brazilians. Today the PSF serves 70% of Brazil´s population and offers them basic health care, immunizations and general inpatient care. Although public health care in Brazil is available for everyone, many citizens trust in private insurance, perceived to offer higher quality and more easily accessible service. Although, citizens who can afford this plan roughly have 2.5 times as high an annual per capita expenditure and therefore more likely higher income as well.⁸

The agenda of the Family Health Program consists of: registration of citizens, defining territory of operation including mapping, assessment and planning of implementation of health care, practicing of extended family care, promotion of interdisciplinary teamwork, developing partnership with community agents and coordination of municipality management, having an holistic, ethical and problem solving approach to problems in the community, promoting community participation in social control, planning, implementation and evaluation and finally, performing systematic monitoring and evaluation of implemented actions in order to develop and maintain good quality of care.⁹

In order to improve and maintain good quality of primary health care, regular assessment is of highest importance. Adequate tools are needed, as further decisions affecting PHC are made based on assessment. A variety of tools has been improved for this purpose. The Primary Care Assessment Tool (PCATool), developed in Johns Hopkins Bloomberg School of Public Health, is used in different countries; it has showed to be cross-culturally reliable for assessing primary health care. According to a literature review and metasynthesis,¹⁰ the PCATool and EUROPEP are the most common tools for PHC-assessment in Brazil. The result of this study showed that the PCATool is the most optimal tool for assessing primary health care in countries like Brazil. The PCATool (adult edition) consists of 87 questions in 10 subgroups; affiliation, utilization, accessibility, continuity, coordination of integration, coordination of information, availability of service, services provided, family orientation and community orientation. Therefore, it offers a wholesome view of the primary health care provided, and points out the weakness in the system for further development.¹¹

This study aims to measure and compare PCATool scores for adults in two different neighborhoods, Vila Sabia and Vitoria Regia, which are suburban areas of Sorocaba in the state of São Paulo, Brazil.

The population of Sorocaba was 671,186 people in 2018,⁶ with 14,587 inhabitants (3,734 households) in Vitoria Regia neighborhood (extreme Northeast) and 7,864 inhabitants (1,356 households) in Vila Sabia (extreme Southeast)–20 Km distanced. Because the Family Health Strategy Program, the Basic Health Units (primary health care facilities) have a complete list of households in their areas. The sample included 146 households in each neighborhood according with following parameters: an expected total PCATool score of 6.6 points (10), an error of 0.25, a level of significance equal 0.05, power of 0.80, and expected missing of 0.10. We selected the households by computer randomization based on registered addresses. This is a cross sectional study design. During 2018, the main responsible in each household selected was interviewed.

The Portuguese version of PCATool adult edition was applied, computing subgroups First contact–utilization; First contact–accessibility; Family centeredness; Coordination–integration; Coordination–information system; Continuity of care; Comprehensiveness–services provided; Comprehensiveness–services available; Community orientation; and calculating scores accordingly. The final scores in each dimension of PCATool and their total score for both neighborhoods, Vila Sabia and Vitoria Regia, are described.¹²

The Analysis of Primary Health Care of Suburban Areas of Sorocaba using the PCATool Adult Edition, in Vila Sabia and Vitoria Regia shows:

In Vila Sabia the average score was 7.2 and the situation is considered good. The main challenge in Vila Sabia is accessibility, which received the score 4.6 (the only score under 6.6 in this neighborhood). Its best score was for Coordination – information system (9.8) (Figure 1).

Figure 1 Comparison of PCA Tool-results in Vitoria regia and Vila sabia.

In Vitoria Regia the average score was 4.3 and the situation is considered unsatisfactory. The best score, 7.3, was given for First contact–utilization (the only score above 6.6 in this neighborhood). The people of Vitoria Regia use service actively, but when it comes to other aspects, the points are low, as for First contact–accessibility(3.1).

Both neighborhoods have problems in First contact – accessibility. The first contact access attribute and its sub item accessibility making up part of the evaluation of Health Services structure. The low performance found may reflect geographical and organizational barriers to PHC services, such as reduced facility working hours, difficulties faced in scheduling appointments, and waiting time at the facility in order to be serviced. This low percentage impairs individual comprehensive health care, since, when faced with access barriers, health care tends to be postponed, hampering the impact of possible prevention actions, incurring future additional expenses.¹³

Surpassed this barrier, both neighborhoods present good performance in First contact–utilization, but an important distinction need be made. Vitoria Regia presents a performance focused in immediate care, showing unsatisfactory evaluation for continuity, comprehensiveness, coordination, and community orientation; these characteristics are typical of Selective Primary Care models. Vila Sabia presents a good performance in almost every subgroups evaluated, although Coordination–integration had a discrete performance (6.7), which could be explained by a fragility of the health net, mainly its secondary level as specialties treatment and diagnose support; these characteristics are typical of services with a tendency for Universalist Primary Care models, but including limitations.¹⁴ Future researches about organizational factors related to Sorocaba municipality health system could explain most part of these differences.

A systematic review¹⁵ found good performance studies rates as follows: First Contact accessibility in 15,8%; First Contact utilization in 71,4%; Family Centeredness in 13,3%; Coordination integration in 37,5%; Coordination information system in 35,7%; Continuity of care in 64%; Comprehensiveness services provided in 50%; Comprehensiveness services available in 25%; Community orientation in 11,1%. It shows that the difficulties to improve comprehensiveness, different levels of health net support and community integration, are common problems. Moreover, considering the results of this systematic review, Vila Sabia and Vitoria Regia are consistent with First contact–accessibility and utilization; Vila Sabia is better for Continuity of care, Coordination integration, and Comprehensiveness–services provided; and Vitoria Regia is worst for Coordination–information, Comprehensiveness–services available, and Community orientation.

Primary health care is essential for countries to be able to offer their citizens better living-conditions. Health is the foundation for building further social and economic development, equality and wellbeing for all inhabitants. It is important for every country to commit to universal goals within health-care. Health questionnaires as the PCATool analyzed in this research are essential for pointing out the weakness in the system and further develop a well-functioning PHC-system.

This research was approved by the Ethical Research Committee, Brazil-CONEP (CAAE number 13482113.3.0000.5373).

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Reinaldo José Gianini declares that there is no conflict of interest.

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