Municipal Management , Infrastructure and Perception of Users : a Description of National Program for Improving Access and Quality of Primary Care in the Brazilian Semiarid

Marília Gomes de Sousa Bezerra1, Roseanne de Sousa Nobre 2, Artemízia Francisca de Sousa3, Maísa de Lima Claro4 1 Nutritionist, Professor Master, University Center Uninovafapi. Teresina, Piauí, Brazil. 2 Nurse, Master degree Student, Federal University of Piauí. Teresina, Piauí, Brazil. 3 Nutritionist, Professor Master, Federal University of Piauí. Picos, Piauí, Brazil. 4 Nutritionist, Specialist in Clinical Nutrition and Sports Practices, Federal University of Piauí. Picos, Piauí, Brazil.


Introduction
The Health System has faced many challenges since its creation and regulation, especially in regard to your first level of care, such as inadequate physical infrastructure; lack of necessary equipment in health care; turnover of staff; unwelcoming environment; and lack of information to users, among other factors, which leads to a fragmented and weakened service.
It was thinking about these barriers in Primary Care (AB) that the Ministry of Health (MH) created the National Program for Improving Access and Quality of Primary Care (PMAQ-AB) as strategy to meet changing conditions and operating modes of the Basic Health Units (UBS), and stands today as one of the most important initiatives of MH, which aims to stimulate increased access and improved quality of the Primary care, ensuring a national standard of regional and locally comparable quality, and thus enabling greater transparency and effectiveness of government actions aimed at AB [1,2].
The PMAQ-AB was established by Decree n° 1,654 GM/MS, of 19/07/2011, being the result of negotiations between the three spheres of management of the Unified Health System (SUS), aimed at addressing issues that affect the quality of AB through solutions that prioritize and qualify the health care.
This action is part of the recent MS guidelines for Primary Health Care (APS), highlighting the incentive for local SUS managers to improve the standard of care quality in APS [4].
The PMAQ-AB consists of four phases: (1) Adhesion and contracting; (2) Development; (3) External evaluation; and (4) Recontracting.The third phase of the program, external evaluation includes a set of actions aimed to investigate the conditions of access and quality of AB participating teams. 1 This step promotes the institutionalization of a evaluation culture guided in strengthening initiatives that recognize the quality of health services offered, aimed stimulating the expansion of access in different Brazilian contexts, the social participation of users of the health service and professionals, as well as stimulate participative management [5].
In this sense, the evaluation of the AB management arises as one proposal for comparing a desired pattern with the actually found; therefore, the process of self-assessment should not be seen as bureaucratic and meaningless, but as a mechanism that encourages reflection of the actors involved, recognizing the problems and priorities raised by the team, with practices to be integrated and improved in order to enhance the care of AB, which influence the quality of the attention and the care to users [6].
In this perspective, this article aims to present a description of the role of municipal management, infrastructure assessment and perception of users of AB, in order to provide concrete information of public interest and identify areas for improvement in the work of health management.

Method
This is a descriptive study, cross-sectional, of quantitative approach, which selected information were generated from the municipal database of external evaluation of PMAQ-AB held in 2014 in a city in the Brazilian semiarid region, participant of the 2nd PMAQ-AB cycle (2013-2014 cycle), located in the state of Piauí.
In the health sector, the city has 100% coverage of AB, with performance of 30 family health teams with oral health, three health centers of the health family and a polo of the health academy.In this universe, thirty teams joined the PMAQ-AB (2013-2014 cycle).The data were collected in March and April 2015, during the 2nd assessment cycle of the PMAQ-AB.
The instrument used to perform the third stage of PMAQ-AB, external evaluation, is organized in three modules: Module I -observation of the infrastructure of the Basic Health Units (UBS); Module II -Interview with professionals on primary care team work process (EqAB) and verification of documents; 3 and Module III -interview with users on their user experience, access conditions, use of health services and satisfaction [4].
Based on the information generated by the three modules of the external evaluation, have been defined the dimensions of analysis with their respective components for the description of the assistance offered in the municipality UBS as shown below: management role in the care process, infrastructure and equipment of AB, satisfaction and user participation.
In the evaluation of infrastructure to determine the structure and ambience, it was considered the presence reception room, at least one office, at least one bathroom, procedure room, dressing room, Fogging Room, Vaccine room.Adult pressure apparatus, Nebulizer, 150kg Scales, Infant Scale, anthropometric ruler, adult stethoscope, exclusive refrigerator for vaccine glucometer, Gynecologic Table, Table Sonar clinical examination, thermometer, disposable needles, Bandage, Tape measure, disposable speculum, Crewcutendocervical, Trowel Ayres, Plasters, blade holder, Gauze glass sheet with matte side, strips blood glucose measurement reagents, disposable syringes, recipient for disposal of sharps, male condom.
The data were organized in Microsoft Excel 2010 program, which were presented to give the descriptive tables.
Were respected all ethical aspects necessary for the correct routing and completion of research, safeguarding the privacy and confidentiality provisions of the data used and the principles contained in the National Council of Health (CNS/MS) n° 466/2012.Still, for the conduct of the study was requested Consent Letter from the Health Department of the city analyzed, authorizing the use of the data base of the municipal database of external evaluation of PMAQ-AB.

Results
The results presented below describe the role of municipal management, evaluation of infrastructure as well as the perception of primary care users as to their satisfaction and their interest in the health system.
The teams said they receive good support from management for the planning and organization of the work process (90%).The health department has provided information for the analysis of the health situation through information and reports in 96.67% of cases.
Through the survey of data from the second PMAQ AB-cycle of the municipality was also observed that the municipal administration performed, effectively, the monitoring and analysis of indicators and health information in 96.67% of cases.When asked about receiving institutional support of municipal management for the organization of the work process as the PMAQ-AB standards, 96.67% of the teams demonstrated receive this support (Table 1).
The Table 2 shows the percentage of the structural features, ambience and materials and basic inputs of the municipality UBS.As to the first aspect, it was showing that 46.34% of the national UBS have adequate structure and ambience to meet the demand of the SUS users, while in the state are only 38.45% of them, while the municipal data demonstrate a percentage even smaller, only 25.93%.
When taken into consideration the equipment and inputs of the same UBS, the results are even smaller.Only 14.81% of the municipality have the same for its proper operation.Relationship that does not differ, in proportional terms, when compared to national data because only 30.42% of UBS belonging to the SUS have enough equipment and supplies for their optimal functioning (Table 2).
Data from the second PMAQ AB-evaluation cycle also provide information on satisfaction and user participation in the construction process and use of health services.
In the municipality in question what may be notedis that among users of primary care, 92.62% would recommend it to a friend or family member, and 90.98% of users would NOT switch of UBS if they had opportunity.
Another issue taken into consideration is the participation of citizens in decision-making in the construction process of health services as provided by the SUS premises (Table 3).
According to reports from the municipal database, 83.87% of users have needed and managed to make a complaint or suggestion in UBS, and 66.67% of them have managed to return on criticism or suggestion.As for the instruments of social control: Ombudsman number and Municipal Health Council, only 18.03% and 22.95% of users, respectively, is aware of its existence.

Discussion
The municipal management is responsible for promoting and monitoring the organization of work processes of health teams, a fact that has been satisfactorily as well as demonstrate the contents of the municipality evaluated, because what we see is that the data shows that there is a satisfactory support management towards the health service, which does not differ from reality observed in the country as a whole [6].
From this premise of encouragement and support, PMAQ-AB, through the development phase, and encouraging closer ties between management and professional teams, aims to improve the planning of actions undertaken and the evaluation of the municipality's health situation.When this approach happens, the teams feel supported to analyze and  solve the challenges of daily work, thus demonstrating the importance of the approach between management and health services for the successful development of assistance [7].
Another key issue to get a good quality of care to users of SUS is the environment existence, equipment, materials and supplies minimum to adequately meet population [8].
In this perspective, the MS adopts the concept of ambience, broadly, as a social space professional and interpersonal relationships that enable resolutely attention, human and warmly.For this, it has three main guidelines: the comfortability, the production of subjectivities and the work process [4,8].
The first axis values environmental elements such as: ilumination (intensity, quality and impact), color, sound (noise, music, shouts), smell, shape and privacy.Rooms clean, airy, well lit and painted in cheerful colors, as well as restrooms and places accessible to persons with special needs, can provide users and workers comfort and well-being [4,8].
The second axis works with the ambience as a process of reflection of practices and knowledge developed in space to changing environments through the actions that the UBS should be designed to promote meetings among workers and between them with user population.Already last axle uses the space as a facilitate tool of the working process aimed to optimize resources and promote a humanized care, resolutive and warm [4,8].
As basic items to be observed in PMAQ-AB external evaluation, regarding to the ambience and equipment, the MS recommends: Reception Room, At least one office, at least one bathroom, procedure room, dressing room, Fogging room, Vaccination room.And as basics in materials and inputs requirements: adult pressure apparatus, Nebulizer, 150kg Scales, Infant Scale Ruler Anthropometric, adult stethoscope exclusive refrigerator for vaccine Glicometer, gynecologic table, Clinical examination Sonar table, thermometer, disposable needles, bandage, tape measure, disposable speculum, En-docervical Crewcut l, Trowel Ayres, Plasters, Fixer blades, Gauze glass sheet with matte side, strips blood glucose measurement reagents, disposable syringes, Container for disposal of sharps, male condom [4,7].
The rated municipality demonstrates a UBS small percentage that contains the basic items necessary for the proper user service (25.93%), data that meet national surveys demonstrate that in Brazil less than half of UBS has structure and ambience adequate to provide satisfactory service to the users, showing thus, lack of structure to meet the demand of the SUS.These data point to the limitations and difficulties faced by users in the use of services due to the precariousness and inadequacy of structures [9].
Another assessed point was the satisfaction and participation of users in relation to health services.This is an important indicator for the evaluation of the same, as the incorporation of satisfaction in this context has been valued not only for constitute in quality indicator, but also to be potentially related to improved adherence to treatment, to the professional-patient relationship and more appropriate use of the service [10].
The evaluated reports demonstrated that the municipality in question, users show satisfied with the service and still believe that public services be constituted as the most suitable place for citizens seeking assistance as they consider the service better than other services who have access.However, users of SUS, as a whole, still has basic demands such as the delay of attendance and hence, the resolution of their health problems [11].
In order to prevent such situations from becoming commonplace, the users must participate in the SUS decisions.The popular participation is ensured to citizens as well as access to information and participation in the formulation, implementation and evaluation of health policies as a registered action in the right to health and the exercise of citizenship as provided for in Law N° 8.142/90 [12].
The encouraging to the participation of users and civil society in the health work and care network organization, in light of their individual and collective needs, it is essential for the transformation of the population's health and living conditions, as well as the realization of the integrality principles [7].
There are a number of problems in the issue of social participation and representation of users mainly in the advices [12].The data of the present research show that in the city rated there are few who knows the existence of the ombudsman services and the Municipal Council of Health.
It is shown, thus the need to develop interfederations agreements between the three spheres of government, aimed at structuring regional health care networks and promoting innovation in processes and SUS management instruments with a view to organizing it local and regionally and strengthen responsiveness to the needs of users, ensuring equity social [14,15].
The Health Councils are little known and his work is unheralded.The population unaware of its objectives, functions and activities, which produces a distance and not participation in decisions.This situation may lead managers and public authorities to disqualify the roles of directors, taking control of the activities and transforming advice on probate proceedings merely the decisions of the manager, not enhancing it as changing device of power relations between society and Estate.

Conclusion
The study described the role of municipal management, the evaluation of the infrastructure and the perception of an AB users from a city in the Brazilian semiarid region.The results showed, by means of external evaluation of PMAQ-AB, the municipal government provides support to the satisfaction to the municipality UBS.In addition it was shown that there are failures in the supply structure, ambience, equipment, materials and supplies for the proper care of the users.It was also addressed user satisfaction as well as their participation in the health services, where it was observed that even with the flaws in the UBS structure, users still sighted the same as the best place to seek assistance when compared to other existing services in the city, but in return, prevail the number of users who are still unaware of mechanisms for participation and social control.The data show, thus, the need to invest heavily in the structure of UBS and more effective participation of the population in the construction process of the municipal health services.

Table 3 .
Perception of the Primary Care users about their satisfaction and participation.Picos (PI), 2014.