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

BMC Health Services Research Health services performance for TB treatment in Brazil: a cross-sectional study Tereza CS Villa 0 3 Antnio Ruffino-Netto 2 Lucia M Scatena 1 Rubia LP Andrade 7 Maria EF Brunello 7 Jordana A Nogueira 6 Pedro F Palha 7 Lenilde D S 5 Marluce MA Assis 4 Silvia HF Vendramini 8 Aline A Monroe 7 Ricardo A Arcncio 7 Tiemi Arakawa 7 0 Ribeirao Preto College of Nursing, University of Sao Paulo, Avenida Bandeirantes , 3900 - Campus Universitario - Ribeirao Preto, SP, CEP: 14040- 902 , Brazil 1 Departamento de Medicina Social, Triangulo Mineiro Federal University , Uberaba, MG , Brazil 2 Departamento de Medicina Social, Ribeirao Preto School of Medicine, University of Sao Paulo , Ribeirao Preto, SP , Brazil 3 Ribeirao Preto College of Nursing, University of Sao Paulo, Avenida Bandeirantes , 3900 - Campus Universitario - Ribeirao Preto, SP, CEP: 14040- 902 , Brazil 4 State University of Feira de Santana , Feira de Santana, BA , Brazil 5 Departamento de Enfermagem em Saude Publica e Psiquiatrica, Paraiba Federal University , Joao Pessoa, PB , Brazil 6 Departamento de Enfermagem Clinica, Paraiba Federal University , Joao Pessoa, PB , Brazil 7 Ribeirao Preto College of Nursing, University of Sao Paulo , Ribeirao Preto, SP , Brazil 8 Departamento de saude Coletiva e Orientacao Profissional, Sao Jose do Rio Preto School of Medicine , Sao Jose do Rio Preto, SP , Brazil 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: Itabora (ITA), Ribeiro Preto (RP) and So Jos 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. 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 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]. 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. Methods Research Design and Setting A cross-sectional study was conducted in five cities from two Brazilian regions (3 in the Southeast and 2 in the Northeast). These cities were intentionally selected due to their epidemiological and operational TB status, as the National TB Control Program considers them priority cities for disease control in their regions, including implementation of the Directly Observed Therapy Short-Course (DOTS) strategy for at least five years. Ribeiro Preto (RP) and So Jos do Rio Preto (SJRP), in So Pau (...truncated)