Health Policy and Planning Advance Access originally published online on March 30, 2007
Health Policy and Planning 2007 22(3):167-177; doi:10.1093/heapol/czm008
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A rapid assessment methodology for the evaluation of primary care organization and performance in Brazil
1Robert Wood Johnson Foundation Health and Society Scholars Program, University of Pennsylvania, Philadelphia, PA, USA.
2Department of Health Administration and Planning, National School of Public Health/Oswaldo Cruz Foundation, Rio de Janeiro, Brazil.
3Faculty of Medicine of Petrópolis, Municipal Health Secretariat, Petrópolis, Brazil.
*Corresponding author. RWJF Health & Society Scholars Program, University of Pennsylvania, 3641 Locust Walk, 309 Colonial Penn Center, Philadelphia, PA 19104-6218, USA. Tel: +1 215 746-3171; Fax: +1 215 746-0397; E-mail: macinko{at}wharton.upenn.edu
Introduction This study presents a methodology for the rapid assessment of the organization and performance of primary care services at district level. It compares results from an earlier provider survey in Petrópolis, Brazil with those obtained directly from users of two types of primary care services (newly developed Family Health Program services or ‘PSF’—Programa de Saúde da Família—and traditional services) in the same municipality. The aim is to demonstrate the validity of the methodology and its potential use in measuring and improving district-level primary care services in developing countries.
Methods The study adapted a previously developed questionnaire to measure essential dimensions of primary care. Users (n = 468) were randomly selected from each of the 40 primary care clinics in the district and administered a question survey. Responses were used to create nine measures: an overall composite ‘total primary care index’ and eight sub-indices each pertaining to an essential primary care dimension.
Results Primary care services show considerable variation in user experiences. Users of the new (PSF) clinics reported higher overall assessments of the total primary care index and the sub-indices for gatekeeping, comprehensiveness, family focus and community orientation than did users of traditional services (P < 0.05). The total primary care score was internally consistent with a Cronbach's alpha of 0.8, and could be reduced to only one principal component. User assessments of primary care services were predicted by self-rated health (OR 1.72) and the site of care (OR 1.03). User and provider assessments of the total primary care index were not significantly different, disagreeing on only two sub-indices (gatekeeping and family focus, P < 0.05).
Conclusions The study presents a rapid and valid method of obtaining information about clinic-level variation in primary care organization and performance at district level. The total primary care index was not sensitive to demographic or socio-economic characteristics of clients, was internally consistent and appears valid given similar results obtained using two different data sources. With some adaptation the instrument could potentially be applied in other developing countries.
Key Words: Health care reform, primary health care, Brazil, health services evaluation
Accepted for publication 25 January 2007.