Tuberculosis: design of the provision of services in Primary Health Care Tuberculose: desenho da prestação de serviços na Atenção Primária à Saúde Tuberculosis: diseño de la prestación de servicios en la Atención Primaria a la Salud

Objective: To analyze the provision of services in tuberculosis in a Brazilian municipality of border with Paraguay and Argentina, comparing Basic Health Units to Family Health Units, under the health team’s perception. Method: A cross-sectional study, survey, conducted with 105 health professionals, between the second half of 2013 and the first half of 2014 in Foz do Iguaçu (PR). The study used descriptive analysis (mean and standard deviation) and TStudent test, with a significance level of 5%. The questionnaire was elaborated according to MacCooll Institute for Health Care Innovation, adapted and validated in Brazil for evaluating tuberculosis control. Results: The study showed better ability of Basic Health Units in the variable “reference health professional in the unit” in relation to the Family Health Units. Conclusion: The system of provision of services in tuberculosis presents many similarities when comparing the types of Primary Care units.


DISCUSSION
The early diagnosis, rapid adherence to drug treatment and the ability of health professionals to address and identify different conditions of vulnerability and risk are strategies effectively advocated for controlling TB [10][11] .
Regarding teamwork, the practice of work Currently, the CHA has assumed, along with the health team, a very important role in health care, as in the TB surveillance, especially in the early record and follow-up of cases, due to his/her greater contact with the community, creating bond and being able to identify socioeconomic aspects, symptoms and complaints during home visits 14 .
The CHA are key elements in the work process when involved in the therapeutic planning of cases, resulting in advances in care and control of the disease 15 .In both realities witnessed -FHU and BHU, the involvement of CHA was significant in team actions for controlling TB as shown in Table 1, in which 45.8% of health professionals were CHA, who followed-up a patient for at least six months as an inclusion criterion in the study.entrance door to all users for the healthcare system, offering integral care along with the Health Care Network when referrals to specialists are necessary [10][11] .
The work process at health units reflects the "scheduling system in the control of TB".
The turnover of on-duty physicians at traditional BHU is common.nurse is responsible for planning actions and performing the scheduling of medical consultations of the patient directly with the reference physician from the matrix team, since, in some cases, the doctors of the teams refuse to attend to the TB patient, claiming they are not their patients and consequently do not form any bond with them nor with the community.
In the state of Rio de Janeiro, a study developed with residents showed that TB is still as a major problem in the country, once it is the main cause of death in 25% of patients with the disease after two years of diagnosis, mainly due to barriers to access to diagnosis to treatment and interruption of the treatment 16 .
The present study identified that some FHU teams perform the clinical management in the unit itself, and only refer to a matrix team in exceptional situations, being fully responsible for the patient.
Both types of services, although not fully computerized, presented an active scheduling system enabling the "continuity of care to patients with TB".The records are made in paper and electronic charts, book of follow-up of cases in the health units (Green Book) and the accompanying card of the patient.
To refer patients to specialized care ( centralization in nursing also occurred in a municipality in the northeast of Brazil, where the actions on TB are fragmented, and the nurse is responsible for various activities such as notification, prediction of materials, control of absentees and contacts, DOT, among others.This teamwork fragmentation and work process centralization compromises the interaction between health professionals and patients, not favoring the integrality of care and preventing the realization of actions for evaluating both the process of attention as results.This model of organization of services answers social demands in a restricted manner by means of reactive actions directed to acute episodes and to exacerbations of chronic conditions 12 .The work centralization in the nurse was also present in a study conducted in Lisbon -Portugal, due to the insufficient number of workers in the team.However, there was no teamwork resistance, occurring cooperation, exchange of information, construction of the work plan and in-group planning, and of meetings to in-group decision-making, resulting in the appropriate monitoring of people living with chronic diseases 13 .Araújo CR, et al Tuberculosis: design of the provision of services Rev Pre Infec e Saúde.2018;4:7383 6 in order to strengthen the bond with users.The FHS should serve as , depending on the unit and/or situation, communication occurs by phone, online scheduling or the patient or his/her family, with the requisition, can make the schedule.In case of assistance related to the matrix team, this moves up to the reference unit for the patient's care, as field observations.Despite some failures in the work process at health units, professionals are responsible for carrying out the "scheduling system" and the "continuity of care to a TB patient", assessed as reasonable in this research, since, in cases that required the intervention of other professionals (specialists), communication between them occurs by telephone or at meetings at the health unit and between health units, verbally, with formal record (guides and clinical records) and written without using the reference and counter reference register, although not desirable.The support of the matrix team also occurs for other lines of care, representing an established practice, supported by personalized relationships among professionals.In the PHC, it corresponds to a joint action between the health and support team for discussion of TB cases and definition of procedures, even when the treatment is shared with specialists.Thus, the joint action leads to knowledge production, coresponsibility for treatment among the partners of the services and coordination of care17 .the interconnection of two or more teams is of fundamental importance to a positive outcome of the patient's case.The "monitoring of TB in the community" only occurs from the identification of cases by health services.The scenario identified by observations and notes in a field diary differs from the BHU professionals' responses, who evaluated the TB monitoring in the community as reasonable, and FHU workers, as basic.However, there is no planning/organization of actions geared to the needs of the population, from the strategic information from information systems, thus, TB assistance occurs from the identification of new cases by spontaneous demand and not in a programmed manner, with health information derived from information systems present at Health Units.The computerization of health systems is an important tool in the planning of actions for TB control.In a study carried out in Curitiba, this feature positively affected the reduction of the proportion of noncompliance to treatment, since any professional in the public health network of the municipality had access to the information notification and follow-up of cases."The attention planned for TB control" occurs in a timely manner, with cases already diagnosed, and there is no preventive interventions or support groups to the patient.In this respect, both types of services studied evaluated it as reasonable; however, the progress in controlling the disease requires an approach that goes beyond curative actions, focused on preventative measures, as well as continuous follow-up of the patient and his/her family to detect and treat cases among contacts, interrupting the chain of transmission of the disease 18 .Even taking into account the importance of "continuity of care", considered as one of the tools that result in the cure of the disease, THE research shows that this activity was classified as reasonable, in both the BHU as the FHU, with no significant difference between them.In this sense, the study by Silva in 2014, held in Vitoria -ES, states that the non-cure of TB patients relates to factors associated with the organization of the PC service 12 .This study did not involve all actors involved in the TB control in the municipality, such as users and managers, who may have an opinion different from PHC workers, which was Araújo CR, et al Tuberculosis: design of the provision of services Rev Pre Infec e Saúde.2018;4:7383 8 considered a methodological limitation of the research.CONCLUSION The difference in the design of provision of services in TB among the types of phc services in the municipality was small, contrary to expectations, due to the care approach recommended for FHU, showing difference between the modalities of PHC Units only for the variable "existence of a reference professional for TB care".Actions are necessary to improve teamwork and follow-up of TB, which are fundamental, because the involvement of a multidisciplinary team is essential to avoid complications that favor the abandonment, relapse, loss and multidrug resistance.The need for theoretical, conceptual and practical investment regarding the FHU role stands out, which has extended care framework in relation to BHU.Generalizations of the results of this study should be made carefully, considering how this study sample is similar to the context of comparison.

Table 1 :
Health professionals from the Primary Care who had already accompanied the treatment of at least one patient during six months, prior to data collection, and who were in labor activity in the 8onsidering the epidemiological situation of TB, the conduct of the system and the health model must be organized to give appropriate social responses to the real needs of health expressed by the population7.The main actions for controlling TB are: active structured search, confirmation and immediate notification of cases in the Sistema de Informação de Agravos de Notificação (Information System of Notification Grievances)8.treatment of at least one patient in the period of six months, prior to data collection and who were in labor activity in the PHC.The sample of subjects to be interviewed reached 153 professionals, based on the 252 who worked in the PHC health services of the municipality and who met the inclusion criteria.However, 105 health professionals accepted to participate in the research.These professionals were distributed in 14 health units, and 65 (61.9%)belonged to FHU and 40 (38.1%) to BHU.The Group of Epidemiological-Operational Studies in Tuberculosis developed and validated the data collection instrument to evaluate TB care used for the study, basing on a questionnaire of the MacCooll Institute for Health Care Innovation for evaluation of the PHC in care for chronic conditions.This instrument was used in the project "Choke points of attention to tuberculosis in municipalities in the South, Southeast and Northeast Brazilian regions", which involved the city of Foz do Iguaçu-PR.The questions of the instrument have four levels of response, being A the most Araújo CR, et al Tuberculosis: design of the provision of services Rev Pre Infec e Saúde.2018;4:

Table 2 :
Distribution of variables of dimension "Design of the system of provisiono f services" according to the Primary Health Care Unit in Foz do Iguaçu-Paraná, in 2013-2014.