Primary Health Care in Brazil and the <i>Mais Médicos</i> (More Doctors) Program: an analysis of production indicators

Lima, Rodrigo Tobias de Sousa; Fernandes, Tiotrefis Gomes; Balieiro, Antônio Alcirley da Silva; Costa, Felipe dos Santos; Schramm, Joyce Mendes de Andrade; Schweickardt, Julio Cesar; Ferla, Alcindo Antonio

doi:10.1590/1413-81232015219.15412016

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Article • Ciênc. saúde colet. 21 (09) • Sept 2016 • https://doi.org/10.1590/1413-81232015219.15412016 copy

Primary Health Care in Brazil and the Mais Médicos (More Doctors) Program: an analysis of production indicators

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

This study analyzes the number of medical appointments and referrals performed in primary health care in Brazil focusing on the Mais Médicos Program (More Doctors Program). It is a cross-sectional study on the work of physicians included, or not, to the Mais Médicos Program in 2014. Based on validation protocols, a unified database was created from two health information system databases – SIAB and ESUS. Absolute indicators were defined: the total of medical appointments per month; medical referrals and community health education activities. In addition, other indicators were considered, such as weekly rates and productivity of appointments, in line with the profile of Brazilian municipalities. The mean of all appointments was 285 per month corresponding to an average of 14.4 appointments/day. In the poorest municipalities, the figures for the Mais Médicos Program physicians were higher than national rates. The educational activities provided by primary care teams that included a Mais Médicos Program professional were higher in Brazilian capital cities. The Mais Médicos Program achieved one of its main goals, which was to increase health access for vulnerable populations and to contribute towards the consolidation of primary health care in Brazil.

Key words
Primary health care; Mais Médicos Program; Unified Health System; Health Evaluation; Indicators

Indicators		Total
Indicators		Non MM	MM	Total
Medical appointment output (n)		179444	46128	225572
	Total Mean (95% CI)	285 (284–286)	286 (285–288)	285 (285–286)
	Rate Mean (95% CI)	88.8 (88.5–89.0)	88.8 (88.3–89.2)	88.8 (88.5–89.0)
Medical referrals to specialists (n)		7222	1757	8979
	Total Mean (95% CI)	2 (2–2)	2 (2–2)	2 (2–2)
	Rate Mean (95% CI)	0.70 (0.68–0.72)	0.69 (0.63–0.74)	0.70 (0.68–0.72)
Medical referrals to hospital (n)		41443	13238	54681
	Total Mean (95% CI)	2 (2–2)	2 (2–2)	2 (2–2)
	Rate Mean (95% CI)	0.62 (0.61–0.63)	0.63 (0.62–0.65)	0.62 (0.61–0.63)
Medical referrals to emergency (n)		81204	23740	104944
	Total Mean (95% CI)	3 (3–3)	3 (3–3)	3 (3–3)
	Rate Mean (95% CI)	0.90 (0.89–0.91)	0.92 (0.91–0.94)	0.91 (0.90–0.91)
Consultations of the team to health education groups (n)		149464	37153	186617
	Total Mean (95% CI)	4 (4–4)	4 (4–4)	4 (4–4)
	Rate Mean (95% CI)	1.24 (1.23–1.25)	1.14 (1.12–1.16)	1.22 (1.21–1.23)
Indicators		20% poverty
Indicators		NonMM	MM	Total
Medical appointment output (n)		35085	17305	52390
	Total Mean (95% CI)	240 (238–241)^* * Statistically significant differences (CI do not tally).	271 (269–273)^* * Statistically significant differences (CI do not tally).	251 (250–252)
	Rate Mean (95% CI)	81.2 (80.6–81.7)^* * Statistically significant differences (CI do not tally).	90.2 (89.3–91.1)^* * Statistically significant differences (CI do not tally).	84.4 (83.8–84.8)
Medical referrals to specialists (n)		901	399	1300
	Total Mean (95% CI)	3 (2–3)	3 (2–3)	3 (3–3)
	Rate Mean (95% CI)	0.98 (0.87–1.08)	0.97 (0.86–1.32)	0.97 (0.89–1.05)
Medical referrals to hospital (n)		10110	5939	16049
	Total Mean (95% CI)	2 (2–2)	2 (2–2)	2 (2–2)
	Rate Mean (95% CI)	0.73 (0.71–0.75)	0.71 (0.69–0.73)	0.72 (0.71–0.73)
Medical referrals to emergency (n)		14534	8784	23318
	Total Mean (95% CI)	3 (3–3)	3 (3–3)	3 (3–3)
	Rate Mean (95% CI)	1.06 (1.03–1.08)	1.04 (1.00–1.08)	1.05 (1.03–1.07)
Consultations of the team to health education groups (n)		27057	12602	39659
	Total Mean (95% CI)	3 (3–3)	3 (3–3)	3 (3–3)
	Rate Mean (95% CI)	1.00 (0.99–1.02)	0.98 (0.96–0.99)	0.99 (0.98–1.00)
Indicators		G100
Indicators		NonMM	MM	Total
Medical appointment output (n)		13386	4037	17423
	Total Mean (95% CI)	264 (261–266)^* * Statistically significant differences (CI do not tally).	288 (283–293)^* * Statistically significant differences (CI do not tally).	270 (268–272)
	Rate Mean (95% CI)	74.2 (73.3–75.0)^* * Statistically significant differences (CI do not tally).	81.1 (79.8–82.7)^* * Statistically significant differences (CI do not tally).	75.8 (75.2–76.6)
Medical referrals to specialists (n)		380	149	529
	Total Mean (95% CI)	5 (4–5)	1 (1–2)	3 (2–4)
	Rate Mean (95% CI)	1.26 (1.24–1.34)	0.36 (0.30–0.44)	0.94 (0.73–1.22)
Medical referrals to hospital (n)		2399	869	3268
	Total Mean (95% CI)	2 (2–2)	2 (2–2)	2 (2–2)
	Rate Mean (95% CI)	0.45 (0.43–0.47)	0.47 (0.44–0.51)	0.45 (0.44–0.47)
Medical referrals to emergency (n)		6412	2201	8613
	Total Mean (95% CI)	3 (3–3)	3 (3–3)	3 (3–3)
	Rate Mean (95% CI)	0.84 (0.82–0.86)	0.84 (0.80–0.87)	0.84 (0.82–0.86)
Consultations of the team to health education groups (n)		11525	3129	14654
	Total Mean (95% CI)	4 (4–4)	4 (3–4)	4 (4–4)
	Rate Mean (95% CI)	1.12 (1.09–1.15)^* * Statistically significant differences (CI do not tally).	0.97 (0.94–1.02)^* * Statistically significant differences (CI do not tally).	1.09 (1.07–1.12)
Indicators		Metropolitan region
Indicators		NonMM	MM	Total
Medical appointment output (n)		24178	6402	30580
	Total Mean (95% CI)	300 (298–302)^* * Statistically significant differences (CI do not tally).	293 (290–297)^* * Statistically significant differences (CI do not tally).	299 (297–301)
	Rate Mean (95% CI)	89.4 (88.9–90.1)^* * Statistically significant differences (CI do not tally).	84.6 (83.4–85.8)^* * Statistically significant differences (CI do not tally).	88.4 (87.8–89.0)
Medical referrals to specialists (n)		769	281	1050
	Total Mean (95% CI)	2 (2–2)	2 (2–2)	2 (2–2)
	Rate Mean (95% CI)	0.69 (0.61–0.74)	0.63 (0.56–0.74)	0.67 (0.60–0.73)
Medical referrals to hospital (n)		4346	1387	5733
	Total Mean (95% CI)	2 (2–2)	2 (2–2)	2 (2–2)
	Rate Mean (95% CI)	0.49 (0.48–0.51)	0.47 (0.46–0.52)	0.49 (0.47–0.50)
Medical referrals to emergency (n)		11732	3459	15191
	Total Mean (95% CI)	3 (3–3)	3 (3–3)	3 (3–3)
	Rate Mean (95% CI)	0.87 (0.85–0.89)	0.85 (0.81–0.88)	0.86 (0.85–0.88)
Consultations of the team to health education groups (n)		20294	5550	25844
	Total Mean (95% CI)	4 (4–4)	4 (4–4)	4 (4–4)
	Rate Mean (95% CI)	1.16 (1.13–1.18)	1.15 (1.12–1.19)	1.16 (1.14–1.18)
Indicators		Capitals
Indicators		NonMM	MM	Total
Medical appointment output (n)		33518	5591	39109
	Total Mean (95% CI)	289 (287–291)^* * Statistically significant differences (CI do not tally).	265 (261–269)^* * Statistically significant differences (CI do not tally).	285 (284–287)
	Rate Mean (95% CI)	84.1 (83.6–84.7)^* * Statistically significant differences (CI do not tally).	73.8 (72.8–75.0)^* * Statistically significant differences (CI do not tally).	82.4 (81.9–83.0)
Medical referrals to specialists (n)		1985	230	2215
	Total Mean (95% CI)	2 (2–2)	1 (1–2)	2 (2–2)
	Rate Mean (95% CI)	0.54 (0.49–0.59)	0.44 (0.38–0.52)	0.52 (0.47–0.56)
Medical referrals to hospital (n)		3476	599	4075
	Total Mean (95% CI)	1 (1–1)	1 (1–1)	1 (1–1)
	Rate Mean (95% CI)	0.35 (0.34–0.36)	0.33 (0.32–0.35)	0.35 (0.34–0.35)
Medical referrals to emergency (n)		13289	2052	15341
	Total Mean (95% CI)	2 (2–2)	2 (2–2)	2 (2–2)
	Rate Mean (95% CI)	0.73 (0.71–0.74)^* * Statistically significant differences (CI do not tally).	0.65 (0.61–0.69)^* * Statistically significant differences (CI do not tally).	0.72 (0.70–0.73)
Consultations of the team to health education groups (n)		27639	4663	32302
	Total Mean (95% CI)	5 (5–6)	6 (6–6)	6 (5–6)
	Rate Mean (95% CI)	1.62 (1.59–1.64)^* * Statistically significant differences (CI do not tally).	1.72 (1.65–1.79)^* * Statistically significant differences (CI do not tally).	1.63 (1.61–1.66)
Indicators		Other locations
Indicators		NonMM	MM	Total
Medical appointment output (n)		73277	12793	86070
	Total Mean (95% CI)	304 (303–305)^* * Statistically significant differences (CI do not tally).	312 (310–314)^* * Statistically significant differences (CI do not tally).	305 (304–306)
	Rate Mean (95% CI)	97.3 (96.8–97.7)^* * Statistically significant differences (CI do not tally).	99.8 (99.0–100.7)^* * Statistically significant differences (CI do not tally).	97.7 (97.3–98.0)
Medical referrals to specialists (n)		3187	698	3885
	Total Mean (95% CI)	2 (2–2)	2 (2–2)	2 (2–2)
	Rate Mean (95% CI)	0.70 (0.67–0.72)	0.78 (0.72–0.84)	0.71 (0.69–0.73)
Medical referrals to hospital (n)		21112	4444	25556
	Total Mean (95% CI)	2 (2–2)	2 (2–2)	2 (2–2)
	Rate Mean (95% CI)	0.69 (0.68–0.70)	0.69 (0.67–0.72)	0.69 (0.68–0.70)
Medical referrals to emergency (n)		35237	7244	42481
	Total Mean (95% CI)	3 (3–3)	3 (3–3)	3 (3–3)
	Rate Mean (95% CI)	0.94 (0.92–0.95)	0.97 (0.94–0.99)	0.94 (0.93–0.95)
Consultations of the team to health education groups (n)		62949	11209	74158
	Total Mean (95% CI)	4 (4–4)	4 (4–4)	4 (4–4)
	Rate Mean (95% CI)	1.24 (1.23–1.26)^* * Statistically significant differences (CI do not tally).	1.17 (1.14–1.21)^* * Statistically significant differences (CI do not tally).	1.23 (1.22–1.25)

Indicators			Total						p^* * Statistical test used: Pearson's chi-square test.
			Non MM		MM		Total
			N	%	N	%	N	%
Medical referrals to:
	Specialists								<0.001
		none	809570	(97.2)	59299	(97.0)	868869	(97.2)
		1 or more	23137	(2.8)	1845	(3.0)	24982	(2.8)
	Hospital								<0.001
		none	664250	(81.0)	46696	(77.0)	710946	(80.7)
		1 or more	156154	(19.0)	13962	(23.0)	170116	(19.3)
	Emergency								<0.001
		none	531826	(64.6)	35469	(58.5)	567295	(64.2)
		1 or more	290854	(35.4)	25144	(41.5)	315998	(35.8)
	Consultations to health education groups								<0.001
		none	76144	(33.8)	19762	(34.7)	95906	(33.9)
		1 or more	149464	(66.2)	37153	(65.3)	186617	(66.1)
Indicators			20% poverty						p ^* * Statistical test used: Pearson's chi-square test.
			Non MM		MM		Total
			N	%	N	%	N	%
Medical referrals to:
	Specialists								0.097
		none	177331	(97.9)	22170	(98.0)	199501	(97.9)
		1 or more	3854	(2.1)	443	(2.0)	4297	(2.1)
	Hospital								<0.001
		none	136982	(77.0)	16108	(71.5)	153090	(76.4)
		1 or more	40879	(23.0)	6405	(28.5)	47284	(23.6)
	Emergency								<0.001
		none	120900	(67.6)	12983	(57.8)	133883	(66.5)
		1 or more	58026	(32.4)	9491	(42.2)	67517	(33.5)
	Consultations to health education groups								<0.001
		none	15756	(36.8)	27057	(38.7)	23702	(37.4)
		1 or more	27057	(63.2)	12602	(61.3)	39659	(62.6)
Indicators			G100						p ^* * Statistical test used: Pearson's chi-square test.
			Non MM		MM		Total
			N	%	N	%	N	%
Medical referrals to:
	Specialists								0.004
		none	67881	(97.6)	5238	(97.0)	73119	(97.6)
		1 or more	1642	(2.4)	161	(3.0)	1803	(2.4)
	Hospital								<0.001
		none	59830	(86.1)	4480	(82.5)	64310	(85.8)
		1 or more	9659	(13.9)	951	(17.5)	10610	(14.2)
	Emergency								<0.001
		none	43706	(63.3)	2897	(54.1)	46603	(62.7)
		1 or more	25329	(36.7)	2454	(45.9)	27783	(37.3)
	Consultations to health education groups								0.457
		none	5772	(33.4)	1608	(33.9)	7380	(33.5)
		1 or more	11525	(66.6)	11525	(66.6)	3129	(66.1)
Indicators			Metropolitan region						p ^* * Statistical test used: Pearson's chi-square test.
			Non MM		MM		Total
			N	%	N	%	N	%
Medical referrals to:
	Specialists								<0.001
		none	112757	(97.2)	8484	(96.5)	121241	(97.2)
		1 or more	3221	(2.8)	304	(3.5)	3525	(2.8)
	Hospital								<0.001
		none	98801	(85.3)	7301	(82.9)	106102	(85.1)
		1 or more	17032	(14.7)	1511	(17.1)	18543	(14.9)
	Emergency								<0.001
		none	70427	(62.0)	4963	(57.0)	75390	(61.6)
		1 or more	43169	(38.0)	3738	(43.0)	46907	(38.4)
	Consultations to health education groups								<0.002
		none	10124	(33.3)	2549	(31.5)	12673	(32.9)
		1 or more	20294	(66.7)	5550	(68.5)	25844	(67.1)
Indicators			Capitais						p ^* * Statistical test used: Pearson's chi-square test.
			Non MM		MM		Total
			N	%	N	%	N	%
Medical referrals to:
	Specialists								<0.001
		none	127472	(97.9)	7193	(96.9)	134665	(97.9)
		1 or more	2716	(2.1)	233	(3.1)	2949	(2.1)
	Hospital								0.011
		none	120371	(92.4)	6800	(91.6)	127171	(92.4)
		1 or more	9886	(7.6)	623	(8.4)	10509	(7.6)
	Emergency								0.626
		none	91538	(70.5)	5246	(70.8)	96784	(70.6)
		1 or more	38229	(29.5)	2163	(29.2)	40392	(29.4)
	Consultations to health education groups								0.61
		none	14430	(34.3)	2401	(34.0)	16831	(34.3)
		1 or more	27639	(65.7)	4663	(66.0)	32302	(65.7)
Indicators			Other locations						p ^* * Statistical test used: Pearson's chi-square test.
			Non MM		MM		Total
			N	%	N	%	N	%
Medical referrals to:
	Specialists								<0.001
		none	324129	(96.5)	16214	(95.8)	340343	(96.5)
		1 or more	11704	(3.5)	704	(4.2)	12408	(3.5)
	Hospital								<0.001
		none	248266	(75.9)	12007	(72.9)	260273	(75.8)
		1 or more	78698	(24.1)	4472	(27.1)	83170	(24.2)
	Emergency								<0.001
		none	205255	(61.9)	9380	(56.2)	214635	(61.7)
		1 or more	126101	(38.1)	7298	(43.8)	133399	(38.3)
	Consultations to health education groups								0.323
		none	30062	(32.3)	5258	(31.9)	35320	(32.3)
		1 or more	62949	(67.7)	11209	(68.1)	74158	(67.7)

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[1] Collaborations

FS Costa, AS Balieiro worked on the text, on the construction of the figures and tables. RTS Lima, TG Fernandes, JC Schweickardt, JMA Schramm, AA Ferla worked on the concept, on the text and final draft of this article.