Health services performance for TB treatment in Brazil: a cross-sectional study

Villa et al. BMC Health Services Research 2011, 11:241 http://www.biomedcentral.com/1472-6963/11/241 RESEARCH ARTICLE Open Access Health services performance for TB treatment in Brazil: a cross-sectional study Tereza CS Villa1*, Antônio Ruffino-Netto2, Lucia M Scatena3, Rubia LP Andrade4, Maria EF Brunello4, Jordana A Nogueira5, Pedro F Palha4, Lenilde D Sá6, Marluce MA Assis7, Silvia HF Vendramini8, Aline A Monroe4, Ricardo A Arcêncio4 and Tiemi Arakawa4 Abstract Background: Researches to evaluate Primary Health Care performance in TB control in Brazil show that different cities aggregate local specificities in the dynamics of coping with the disease. This study aims to evaluate health services’ performance in TB treatment in cities across different Brazilian regions. Methods: This cross-sectional study was conducted in five cities that are considered priorities for TB control in Brazil: Itaboraí (ITA), Ribeirão Preto (RP) and São José do Rio Preto (SJRP) in the Southeast; Campina Grande (CG) and Feira de Santana (FS) in the Northeast. Data were collected through interviews with 514 TB patients under treatment in 2007, using the Primary Care Assessment Tool adapted for TB care in Brazil. Indicators were constructed based on the mean response scores (Likert scale) and compared among the study sites. Results: “Access to treatment” was evaluated as satisfactory in the Southeast and regular in the Northeast, which displayed poor results on ‘home visits’ and ‘distance between treatment site and patient’s house’. “Bond” was assessed as satisfactory in all cities, with a slightly better performance in RP and SJRP. “Range of services” was rated as regular, with better performance of southeastern cities. ‘Health education’, ‘DOT’ and ‘food vouchers’ were less offered in the Northeast. “Coordination” was evaluated as satisfactory in all cities. “Family focus” was evaluated as satisfactory in RP and SJRP, and regular in the others. ‘Professional asking patient’s family about other health problems’ was evaluated as unsatisfactory, except in RP. Conclusions: Two types of obstacles are faced for health service performance in TB treatment in the cities under analysis, mainly in the Northeast. The first is structural and derives from difficulties to access health services and actions. The second is organizational and derives from the way health technologies and services are distributed and integrated. Incentives to improve care organization and management practices, aimed at the integration of primary, secondary and tertiary services, can contribute towards a better performance of health services in TB treatment. Keywords: Primary Healthcare, Tuberculosis, prevention & control, Health Care, Health Services Accessibility, Health Services Evaluation Background Even in this millennium, tuberculosis (TB) remains the leading killer infectious disease in the world, with 1.7 million deaths in 2009. One third of the world population is infected by Mycobacterium tuberculosis and a * Correspondence: 1 Ribeirao Preto College of Nursing, University of São Paulo, Avenida Bandeirantes, 3900 - Campus Universitário - Ribeirão Preto, SP, CEP: 14040902, Brazil Full list of author information is available at the end of the article great proportion of the population may develop and transmit the disease to the community [1]. Brazil ranks 19th among the 22 countries with the highest incidence levels of tuberculosis (TB) smear-positive cases [1]. The TB incidence rate was 46 cases/100, 000 inhabitants in 2009, considered one of the highest on the American continent. Although the prevalence and mortality the disease provokes have dropped and cure percentages have increased, from 69% in 2002 to 71% in 2009, this rate still remains far below the recommended 85% [1]. © 2011 Villa et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Villa et al. BMC Health Services Research 2011, 11:241 http://www.biomedcentral.com/1472-6963/11/241 Brazil has considerably invested in health system reform, including the development of new primary health care (PHC) organization and delivery models [2]. The country has recommended TB control as a responsibility of this care level [3,4]. To achieve service quality, PHC attributes (access, range of services, coordination, bond and family focus) need to be accomplished, so that a good organization of this level contributes to improve care, with a view to positive impacts on population health and health system efficiency [5]. Despite this recommendation, in some contexts, TB treatment remains centralized in TB reference centers (TRC), so that it has not yet resulted in a uniform performance of health care services in TB control, varying between and within regions. Disease control cannot be achieved through medical advances alone, such as new diagnostic tests and new drugs. It is important to consider the scenarios and complexity of health care services’ context, where technologies are actually incorporated and offered to the community. Currently, research is also lacking a detailed analysis of the interaction between available technologies for TB control and the diversity of local health system contexts, considering the resources, political project and the willingness of local health managers and health care workers [6,7]. Research on the evaluation of PHC performance in TB control in Brazil show that the different care models present in the cities aggregate local (political/organizational/human) specificities, entailing heterogeneity in the dynamics of coping with the disease [8-10]. Considering the diversity of health local systems, regional disparities and inequalities in access to health services that characterize the Brazilian reality, it is appropriate to investigate how health care services carry out TB treatment actions. Thus, this study proposed to evaluate the performance of health services in TB treatment in cities from different Brazilian regions. Page 2 of 8 56.1 cases/100, 000 inhabitants (ITA). The Northeastern study sites were Campina Grande (CG), in Paraíba State, and Feira de Santana (FS), in Bahia State, which reached a TB incidence rate of 28.6 cases/100, 000 inhabitants and 28.1 cases/100, 000 inhabitants, respectively [11]. In the same year, TB incidence was 40.6/100, 000 inhabitants in the Southeast and 38.8/100, 000 inhabitants in the Northeast. Regarding PHC organization, in 2007, FHS coverage corresponded to 23% in RP, 12% in SJRP and 68.7% in ITA. In the Northeast, CG obtained 71% of FHS coverage and FS 60%. The implementation of the FHS has been taking shape in a heterogeneous way in Brazil, with a team composed by a general practitioner, a nurse, a nursing auxiliaries and 5 to 10 Community (...truncated)