Rev Saúde Pública 2011;45(2) Aparecida de Cássia Rabetti Evaluation of actions Sérgio Fernando Torres de Freitas concerning systemic arterial hypertension in primary healthcare ABSTRACT OBJECTIVE: To evaluate the effi ciency of the Family Health Strategy in actions related to hypertension. METHODS: Evaluative, cross-sectional quantitative research based on secondary data of 66 small municipalities located in the state of Santa Catarina, Southern Brazil, with maximum potential coverage of 100% by the Family Health Strategy in 2007. Input indicators, products and results were evaluated. The municipalities’ effi ciency of services production and results production was compared through data envelopment analysis. RESULTS: The municipalities were more effi cient in services production (37.8%) than in results production (16.6%). Forty-one municipalities (62.2%) were ineffi cient in the services: enrolment in the Hypertension and Diabetes Information System, individual assistance and home visit for hypertensive users, and 55 (83.3%) were ineffi cient in the production of impact against hypertension. CONCLUSIONS: The evaluation model used in this study proved to be capable of measuring effi ciency in primary healthcare by evaluating the productivity of services and results. DESCRIPTORS: Hypertension, prevention & control. Family Health Program. Health Services Evaluation. Primary Health Care. Cross- Sectional Studies. INTRODUCTION Núcleo de Extensão e Pesquisa em Avaliação Public expenditure on health is increasing and is related to factors such as em Saúde. Departamento de Saúde Pública. population aging, new health technologies, improvement in income levels, Universidade Federal de Santa Catarina. a Florianópolis, SC, Brasil consolidation of the wellbeing state and universalization of sanitary coverage. In these circumstances, the use of economic methodological instruments in the Correspondence: fi eld of health is justifi ed by the criterion of scarcity and by the diffi culty in Aparecida de Cássia Rabetti resources allocation.16 Núcleo de Extensão e Pesquisa em Avaliação em Saúde – Nepas Campus Universitário Trindade Data envelopment analysis (DEA), created in the 1980s, measures productive 88040-970 effi ciency in the social area. It was developed to evaluate public programs in Florianópolis, SC, Brasil E-mail: [email protected] such a way that the organizations’ fi nancial aspect is not the only one that is considered. This tool is applied to studies on the productivity and technical Received: 3/24/2010 Approved: 8/28/2010 a Ministério da Saúde. Secretaria-Executiva. Área de Economia da Saúde e Desenvolvimento. Avaliação econômica em saúde: desafi os para gestão no Sistema Único de Saúde. Brasília (DF); Article available from: www.scielo.br/rsp 2008. 2 Effi ciency of actions in hypertension Rabetti AC & Freitas SFT effi ciency of productive units that employ multiple of Instituto Brasileiro de Geografia e Estatística inputs to generate multiple products, and it enables (Brazilian Institute of Geography and Statistics), to identify the best practices by means of empirical Sistema de Informação Orçamentária Pública em frontiers of linear programming.6 Saúde (Health Public Budget Information System), and Sistema de Informação sobre Hipertensão e Since its implementation, Sistema Único de Saúde Diabete (SISHIPERDIA – Hypertension and Diabetes (SUS – National Health System) has dealt with lack of Information System). resources, given the adverse scenario from the economic point of view at the time it was created. Programa Saúde An evaluative model was constructed as recommended da Família (PSF – Family Health Program) emerged by Rabetti (2009).b The data were organized into in light of the initial criticism of being a care program SAH-related inputs and products in primary healthcare. that had restrictive characteristics. However, its rapid Financial resources, material resources and workforce expansion in the last years and its importance have trans- were considered inputs for services production, and formed it in a conversion strategy of the primary health- actions for SAH control and diagnosis, as products. care model. The control and diagnosis of hypertension The generated services were transformed into inputs, have been an attribution of the Family Health Program, and their product was the control of the immediate and have a character of priority action in the adult’s health in mediate health conditions deriving from SAH (Figure 1). its initial phase and have become a strategic action after the Pacto em Defesa da Vida (Pact for Life Defense), The inputs were: fi nancial resource (the total amount of 2005.1 Systemic Arterial Hypertension (SAH) is a employed by the municipality to defray the cost of highly prevalent chronic non-communicable disease primary healthcare); material resource (weekly hours whose diagnosis and control are fundamental in the of occupation of offi ces destined to primary healthcare), handling of serious diseases like congestive heart failure, and workforce (average weekly working hours of the cerebrovascular diseases, acute myocardial infarction, Family Health teams per month). hypertensive nephropathy, peripheral vascular disease Enrolment (number of enrolled individuals with SAH); and hypertensive retinopathy. individual assistance (number of SAH assistances Evaluation of the effi ciency of SAH-related services, performed by the ESF), and home visit (number of with the identifi cation of strong points of action of visits of community health agents to users with SAH) reference municipalities, could represent an impor- were the considered services. tant management and planning tool. It would enable The SAH-related services performed by ESF were clas- the improvement in the provided care by identifying sifi ed as inputs in the stage of results production. The municipalities and actions with effi cient impact, thus number of observed services was corrected to number subsidizing information on how to produce services of services projected for effi ciency by the DEA tool, in and results with more effi ciency. The present study order to maintain the relationship with the initial inputs. aimed to evaluate the effi ciency of Estratégia Saúde da Família (ESF – Family Health Strategy) in the actions A result indicator or rate was created that represented related to hypertension. protection to cardiovascular (CV) outcomes. This rate was called rate of SAH-related hospitalizations poten- METHODS tially avoided by primary healthcare, calculated by the formula: rate = [(population between 20 and 65 years In the study, 66 small municipalities located in the – number of hospitalizations due to SAH, Congestive state of Santa Catarina, Southern Brazil, were selected, Heart Failure and Cerebrovascular Diseases in indi- whose model of Atenção Primária à Saúde (APS – viduals between 20 and 65 years): population between Primary Healthcare) was ESF for the entire population. 20 and 65 years] * 10,000. Information on the above-mentioned municipalities DEA was employed to construct empirical frontiers referring to 2007 was collected in the databases of of productive effi ciency, that is, a grouping of the Sistema de Informação da Atenção Básica (SIAB – best observed productivities, forming a set of units Primary Healthcare Information System), Sistema of maximum productivity, and no productive unit is de Informação de Internação Hospitalar (Hospital above this limit. One of its greatest advantages is the Admission Information System), Cadastro Nacional identifi ed effi ciency, which is real and not calculated de Estabelecimentos de Saúde (National Record of as a theoretical combination of the best that could be Healthcare Establishments), the population basis done in ideal conditions.c b Rabetti AC. A efi ciência das ações relacionadas à Hipertensão Arterial Sistêmica: uma avaliação na atenção básica em saúde nos municípios catarinenses [Master’s dissertation]. Florianópolis: Universidade federal de Santa Catarina; 2009. c Calvo MCM. Análise da efi ciência produtiva de hospitais públicos e privados no Sistema Único de Saúde (SUS). In: Piola SF, Jorge EA. Prêmio em economia da saúde: 1º prêmio nacional, 2004: coletânea premiada. Brasília (DF): Instituto de Pesquisa Econômica Aplicada; 2005. Rev Saúde Pública 2011;45(2) 3 The maximum productivities that were observed Efficiency in services Efficiency in results formed an empirical frontier of effi ciency among Santa production production Catarina’s small municipalities. Maximum productivity assumed a score equal to 1 and was classifi ed as effi - cient; scores above 1 were categorized as ineffi cient. By means of DEA, effi cient productivity goals were calculated to the ineffi cient units and ineffi ciency for Financial Control of the each product was evaluated. resources Actions for immediate the control and mediate Material and diagnosis health RESULTS resources of SAH conditions deriving Of the 66 municipalities, 25 (37.8%) were effi cient in Workforce from SAH the production of services related to SAH and 41 were ineffi cient (62.2%). Figure 1. Theoretical model of effi ciency in the production of services and results of actions related to systemic arterial The scores of the ineffi cient municipalities ranged from hypertension (SAH) in primary healthcare. Santa Catarina, 1.06 to 2.09 (productivities 0.6 to 1.9 lower than the Southern Brazil, 2007. maximum productivity that was observed). The effi cient municipalities with similar input arrangements were able to produce more services and became reference