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Conteúdo (article):

ANALYSIS OF COVERAGE OF THE FAMILY HEALTH STRATEGY OF THE TWIN CITIES OF BRAZIL 2016-2020

Olga Lucía Mosquera Conde. olgalum09@gmail.com. Universidade Federal da Integração Latino-Americana (UNILA). ORCID: https://orcid.org/0000-0002-4988-1764
Yury Lizeth Cardozo Prada. Universidade Federal da Integração Latino-Americana (UNILA). jujulizeth@gmail.com. https://orcid.org/0000-0001-9059-9798
Giuliano Silveira Derrosso. Universidade Federal da Integração Latino-Americana (UNILA), Giuliano.derrosso@unila.edu.br. https://orcid.org/0000-0002-2360-411X
Carmen Justina Gamarra. Universidade Federal da Integração Latino-Americana (UNILA) Carmen.gamarra@unila.edu.br. https://orcid.org/0000-0003-4029-3859
Ehidee Isabel Gomez la Rotta. Universidade Federal da Integração Latino-Americana (UNILA). Ehidee.rotta@unila.edu.br. https://orcid.org/0000-0003-1194-9898
Gustavo Cezar Wagner Leandro. Universidade Estadual de Maringá (UEM). gustavocezarwl@gmail.com. https://orcid.org/0000-0002-5014-2387
Andrea del Pilar Trujillo Rodríguez. Universidade de São Paulo (USP). ad.trujillo66@gmail.com. https://orcid.org/0000-0002-6950-9716
Larissa Djanilda Parra da Luz. Escola Nacional de Saúde Pública - Fundação Oswaldo Cruz. Lariparra.luz@gmail.com. ORCID: https://orcid.org/0000-0002-1172-9492.

ABSTRACT
Objective: To analyze the temporal trend of Family Health Strategy (FHS) coverage and its associated factors in Brazilian twin cities between 2016 and 2020. Methods: This is a retrospective ecological study of a temporal analysis conducted on the 33 twin cities of Brazil. Secondary data were collected from e-Gestor AB, and variables regarding FHS coverage, population size, border arcs, and temporality were used. Descriptive measures were used in the statistical analysis, which were arcived, tabulated, and analyzed using Microsoft Excel® 2019. Results: It was observed that the Northern arc had the highest coverage, followed by the Southern and Midwestern arcs, respectively, with small twin cities standing out in terms of population size. As regards coverage evolution, the Southern arc stood out with a growing trend, while the Northern and Midwestern arcs showed a decrease in the last year of the study. Conclusion: FHS coverage in twin cities varied among the three arcs, likely due to the sociodemographic characteristics of each arc and the particularities in the management of basic care services in municipalities.
Key words: Border Areas; National Health Strategies; Health Service Coverage; Ecological Studies.


INTRODUCTION
Health systems are understood as the set of services and programs under the direction of a government agency, which includes health services and public health actions, comprised of a set of elements that determine the health status of a population, primarily aimed at aiding society in general and identifying its needs. These systems have emerged as a response to health problems, consistently addressing its determinants in the community while taking into account social constraints, including demographic and cultural aspects, which shape its evolution and its capacity for change. To achieve these objectives, financial, physical, and human resources, as well as service flows appropriate for each reality, are imperative1.
To respond to these needs, countries develop health systems based on different models. In the case of Brazil, this type of system was based on law 8080/90, a universal health system, known as the Unified Health System (SUS), whose core principles include comprehensiveness, universality, and equity, among others, such as community participation, hierarchy, and territorialization, guaranteed through Primary Health Care (PHC) as the coordinator of care and a gateway to the system, to comply with the right to health stipulated in the 1988 Federal Constitution (Constituição Federal – CF)2.
PHC, considered in Brazil to be equivalent to Basic Care (Atenção Básica – AB), witnessed its historical milestone in the Alma-Ata conference, affirming the responsibility of governments towards the people in the area of health and its determinants. This constitutes the underlying pillar to guarantee the population\'s right to health through integrated and resolute individual and collective health actions, involving health promotion, disease prevention, rehabilitation, protection, diagnosis, treatment, harm reduction, palliative care, and health surveillance, including the Family Health Strategy (FHS), which has as one of its main characteristics the closer monitoring of the community and the organization of PHC2,3.
FHS emerges as a priority strategy to strengthen and organize PHC and SUS, with its main characteristics being territorialization and a multidisciplinary approach, which favors the reorientation of the work process with greater potential to increase resoluteness and impact the health situation of individuals, families, and the community. FHS teams are formed considering a population parameter of 2,000 to 3,500 people, depending on the vulnerability and needs of the region3.
The FHS teams available in a given region represent the capacity to monitor the population, with human-professional resources, according to the number of people assigned to the region. The greater the coverage, that is, the more complete the teams, the greater the access and quality of the provision of health services, considering the health needs and demands of the populations in each location, based on their local-regional specificities4.
The estimated population coverage of FHS teams is used to monitor access to PHC health services, seeking to strengthen the management and planning of SUS actions5. PHC has created programs that strengthen and encourage the expansion, improvement, and quality of FHS team care, such as the National Program for Improving Access and Quality in Primary Care (Programa Nacional de Melhoria do Acesso e da Qualidade na Atenção Básica – PMAQAB), the Mais Médico (More Doctors) program, the Basic Health Unit Requalification Program, and Primary Care Enhancement Programs6.
The monitoring of health actions for the management of local health systems is permeated by several situations that can hinder health management. One of these obstacles can be experienced in the health management of border regions, which, according to Hortelan7, have floating populations, hindering actions for risk prevention, disease control, and the use of the SUS health system by the population that does not reside in the border municipality, whether they are Brazilian citizens or not.
Border cities in Brazil are classified into three types: border cities, located within 150 kilometers of the international dividing line to the countryside of the Brazilian territory; twin cities, separated by the international border line, whether dry or riverine, which may or may not be connected by infrastructure works, and which have an individual population of more than 2,000 inhabitants; and conurbated border cities, considered to be those that share the same urban mesh with the foreign bordering city, with no territorial interruption or geographic features between them (mountains, rivers). It is important to note that every conurbated city is a twin, while not every twin city is a conurbated city8.
International borders are considered physical and geographic spaces that allow the distinction and interaction of collective identities located on the borders of two or more countries, making it a region with a constant flow of people, trade, and cultures between cross-border populations. However, it is important to understand that the intensity of these flows depends on the specificities of each border region. According to Pinto et al., each border region has its own identity. However, most of them are characterized by social deficiencies, exclusion, and environmental degradation.
Brazil has 16,885.7 kilometers of international borders, making it the country on the South American continent with the largest number of land borders, sharing borders with ten countries in South America. Geographically, Brazil\'s border extension is divided into three arcs: north, central, and south. The northern arc stands out for having the presence of the Amazon rainforest, while the central arc is linked to the large extension of the agricultural frontier and the south is characterized by the production of corn, wheat, soybeans, and agribusiness10. The international border involves eleven states and 588 municipalities, of which thirty-three are considered twin cities, characterized by intense cross-border relations11. It is important to highlight the complex and intense interactions that occur in the twin cities, which become a space in which there is mutual dependence between two or more countries, especially between cross-border populations. Cultural, socioeconomic, and health aspects of the nations involved facilitate a particular process of construction and reconstruction of identities, in addition to providing an ideal space for the formal and informal integration of neighboring countries. Furthermore, most border arrangements in Brazil are characterized by sparse population and considerable geographic isolation, as a result of the precarious road conditions and communication structures, coupled with the difficult access to the country\'s major cities.
According to Neves et al.6, municipalities with greater FHS coverage show improvements in the health conditions of the population, such as a decrease in infant mortality, an increase in vaccination coverage, a decline in malnutrition, and an rise in prenatal consultations. However, the peripheral location of the twin cities usually influences the presence of the State in meeting the basic social needs of border populations9, which may well affect the provision of public health services.
For this reason, it is important to analyze the FHS coverage in Brazilian twin cities. Moreover, the indicator of estimated population coverage in PHC is relevant, given that PHC is considered to be a care coordinator, with the capacity to resolve issues in the processes of territorialization and regionalization as its main characteristics, in addition to being the guide in the structuring of programs and projects for health care5.
Therefore, the present study seeks to analyze the FHS coverage in the twin cities of Brazil from 2016 to 2020. It also has the following specific objectives: to identify the FHS coverage of the Brazilian twin cities and to compare the FHS coverage, considering the three arcs – north, central, and south – and population size.

METHODOLOGY
This is a retrospective ecological study using Brazilian twin cities as the unit of analysis. According to Bonita et al.13, ecological studies are used to compare populations in different locations, which may occur at the same time or in a time series. The description of the research followed the guidelines set forth in Strengthening the Reporting of Observational Studies in Epidemiology (STROBE)14.
A total of thirty-three Brazilian cities were considered, characterized as twin cities, as they have an international border with intense cross-border relations11, and were included for the analysis of FHS coverage in the border arcs of the North, Central, and South of the country (Figure 1).
The variables analyzed in this study included year, population, and percentage of FHS coverage. The cities were also characterized by arcs, according to population size. For the study, the data source used was the e-Gestor AB5 platform, which provides PHC information to support the health management. The data was accessed through the public access environment, and was selected in the period of December of each year studied, choosing the last five years available on the platform. The border arcs were considered according to the macro-regionalization defined by the Ministry of National Integration. The population size was stratified into three groups, as proposed by Calvo et al.15: municipalities with less than 25,000 inhabitants (small-sized), municipalities with 25,000 to 100,000 inhabitants (mid-sized), and municipalities with more than 100,000 inhabitants (large-sized).
Figure 1

Excel® software (version 2019) was used for descriptive data analysis. Next, the annual time series analysis of FHS coverage by municipality and border arc between 2016 and 2020 was performed, followed by the application of the Mann-Kendall time trend test, with a significance level of 5%, in a two-tailed manner. Subsequently, the average municipal FHS coverage was compared according to each border arc (North, Central, and South) and population size (Small, Medium, and Large). To analyze the difference between the averages of FHS coverage (dependent variable) in the twin cities, and border arc and population size (independent variables), Poisson-Tweedie regression was used. The variables considered to be different were those that presented statistical significance (p<0.05) in the backward procedure. All statistical analyses were performed using R (version 4.4.0). The chloroplectic maps were created based on the cartography of Brazilian municipalities in the SIRGAS2000 reference system, provided by IBGE, using the QGIS software (version 3.34.4).
Since the analyzed data come from publicly accessible secondary sources, they are exempt from assessment by the Ethics Committee for Research involving human beings.

RESULTS
Table 1 presents information on the 33 twin cities according to the border arc – 48.4% are located in the Southern Arc (n=16), followed by the Northern Arc (n=9) and the Central Arc (n=8), in that order. Regarding the population size of the twin cities, a concentration of small municipalities was observed; 66.6% in the Northern Arc, 62.5% in the Central Arc, and 56.2% in the Southern Arc. Three large municipalities were identified, two in the Southern Arc (Foz do Iguaçu and Uruguaiana) and one in the Central Arc (Corumbá) (Table 1).
Table 1

It was noted that the average FHS coverage between twin cities located in the Northern Arc was higher than that of the municipalities in the other border arcs (Table 1). In 2016, the three border arcs had an average coverage of over 70%, with the North at 91.8%; the Central at 75.5%, and the South at 73.4%.
When analyzing the temporal trend of FHS coverage between the border arcs in the established period, it is observed that the Northern Arc showed a decrease in the indicator, with values above 90% until 2019, reducing to 88.7% in 2020. The Central Arc showed similar results, with FHS coverage of 75.5% in 2016 and 69.0% in 2020, showing an unstable behavior of declines and increases, being classified as decreasing in the analyzed period. By contrast, the Southern Arc demonstrated growth in FHS coverage during the period, starting at 73.4% and reaching 79.1% in 2020 (Table 1).
In relation to the 9 twin cities of the Northern Arc, five achieved full coverage of the resident population, with a notable drop in the indicator from 2019 to 2020, mainly in Santa Rosa do Purus (small-sized) and Epitaciolândia (mid-sized), with a decreasing temporal trend (Table 1).
In the Central Arc, most municipalities recorded a decline in the indicator, with significant reductions in the temporal trend in Bela Vista, Coronel Sapucaia, and Paranhos, while Ponta Porã was the only location with stability throughout the years analyzed. In addition, the municipality of Mundo Novo (small-sized) maintained coverage above 93% throughout the period, while Cáceres (mid-sized) presented coverage below 50% throughout the study (Table 1).
In the Southern Arc, most of the small twin cities maintained coverage with values between 96% and 100%. Statistical significance was observed in the increasing trend in Quaraí, and a decreasing trend in Aceguá. Chuí started with no coverage (0.0%) and reached 100% in 2018, with oscillations between 50% and 52%. Mid-sized municipalities, such as Guaíra and Jaguarão, showed an increasing trend, starting with FHS coverage above 70%, reaching more than 90% in 2020. The variation in large-sized municipalities stands out: Foz de Iguaçu showed an increasing trend, from 45.8% in 2016 to 71.2% in 2020, while Uruguaiana decreased from 53.2% in 2016 to 35.3% in 2020 (Table 1).
Figure 2

Figure 2 shows the averages of FHS coverage between the twin cities according to the border arc and population size. Small-sized cities located in the Northern Arc have an average FHS coverage (96.1%) that is higher than mid-sized cities (82.3%). While in the Central Arc, large municipalities demonstrate an average coverage (80.3%) that proved to be higher when compared to mid-sized (54.9%) and small-sized (79.1%) cities. In the Southern Arc, small cities represent greater population coverage (89.2%), as compared to mid-sized (64.4%) and large-sized (52.5%) cities (Figure 2).
Table 2 presents the results of the Poisson-Tweedie regression on the difference in the means of FHS coverage (dependent variable) in the twin cities, according to arc, population size, and year (independent variables), from which a statistically significant difference was found between the Central and Northern Arcs (p=0.013) and a possible difference between the South and the North (p=0.051). No difference was found between the Central and Southern Arcs (p=0.353). No differences were found between the years, but when comparing the sizes, a statistically significant difference was observed.
Figure 2

DISCUSSION
The present study revealed that when comparing the average FHS coverage in the twin cities of Brazil, according to population size (small, medium, and large), the small twin cities stand out, with greater coverage. According to the comparison by arcs: North, Midwest, and South, the greatest coverage is found in the Northern arc. Regarding the evolution of coverage, the Southern arc stands out, which maintained an increasing trend, contrary to the Northern and Midwestern arcs, with a decrease in the last year of the study, which were below the average found in the first year of the study. Considering the population size of the twin cities, it is evident that small cities often concentrate the greatest FHS coverage, but most of these cities are characterized by a deficit of economic and structural resources. However, in large cities, the implementation of FHS occurs in a complex context, which makes it difficult to provide AB services16,17. Thus, the present study showed that FHS coverage in large-sized municipalities in the southern region presented lower coverage, which is in line with the study carried out by Cecílio and Reis18, considering that managers of mid-sized and large-sized municipalities in the South and Southeast regions, which have low FHS coverage and that resist changing the traditional model of basic care to the FHS model.
However, the Ministry of Health, with the aim of expanding and improving access to and quality of PHC, has strived to develop incentives over time, contributing to spontaneous adherence, without significant setbacks, especially in more vulnerable cities. Among these incentives, the PMAQ and Mais Médicos programs stand out for contributing significantly to FHS coverage6. This was also shown in the present study, revealing that even though some municipalities still have low coverage, few have had a setback that will impact the average coverage of the arc.
According to Pêgo et al.19, during 2013 to 2018, the Mais Médicos Program sought to meet the demand for basic health services in border municipalities, which are considered to be unattractive to Brazilian professionals. However, at the end of 2018, the interruption of the participation of Cuban doctors in the Mais Médicos Program was reflected in a 10% decrease in FHS coverage, when compared to 2017. Furthermore, studies show that by August 2019 the number of said professionals had not been restored, even if one considers the strategies implemented by the government at the time. In this context, it is clear that the decrease in FHS coverage in the Northern and Midwestern regions is possibly associated with the interruption of the Mais Médicos Program in the country.
The same study identified that there is a regional disparity in the distribution of human resources in health, mainly in the category of doctors, with a greater concentration in the Southeastern and Northeastern regions of the country, which is in line with the result of the study, showing greater coverage in these two regions, with the Midwest preseting the lowest average in FHS coverage20.
A study carried out by Monteiro21, indicates that the twin cities have a higher Infant Mortality Rate (IMR) than their states, due to the living conditions of these regions, with the Northern region having the highest IMR, followed by the Midwest and the South, where investment in FHS is greater, considering the importance that this indicator reveals in terms of the health of the population in a given region.
These initiatives to improve the provision of health services, and consequently adherence to the FHS, through programs and incentives, consider that municipalities, even though the PNAB indicates the FHS as the best way to achieve the objective of PHC, are autonomous in prioritizing investments in health. In the case of the FHS, the main resource is the health professionals, who make up the team, through which the percentage of the population covered can be calculated according to the number of complete teams. It is up to the management to implement actions to maintain the balance between supply and demand in their municipality3,20.
It is important to highlight that there may be a perception that investment in health Human Resources (HR) constitutes an expense and not an investment to improve the health and development of the municipality; the scarce HR in health, and the factors that promote or hinder permanence or adherence to the program, are also key elements22,23.

FINAL CONSIDERATIONS
When analyzing the coverage of the Family Health Strategy in the twin cities of Brazil from 2016 to 2020, it was found that the three arcs behaved differently. Even with the specificities of the twin cities, these do not diverge from the reality when the Brazilian states are compared in these arcs. However, when comparing the cities by population size, there are significant differences in each arc.
A limitation of this study is the reality of the pandemic that began in March 2020, which may have influenced the prioritization of PHC professionals. Therefore, studies that contemplate broader timeframes before and after the pandemic are suggested, as are studies that can offer a more in-depth analysis of the characteristics of the twin cities individually and can reveal other issues that may influence FHS coverage, such as the HDI, the participation of these municipalities in programs that encourage adherence to FHS, and the implementation of strategies for the retention of professionals. Furthermore, it is suggested that research be carried out to assess the performance and quality of the program in border arrangements.
This study, however, is relevant, as it analyzes PHC coverage in all of Brazil\'s twin cities, allowing for a more holistic view of the reality of these cities, and because of the quality of the data, which, although secondary, are official data from the Ministry of Health. Hence, these data do not cause bias in FHS coverage, making the results valuable for the description of the temporal situation of the FHS in the Brazilian twin cities. Finally, this study aims to contribute to the production of scientific evidence on the reality of health in border regions, especially as regards PHC.

AUTHORSHIP
OLMC, YLCP: preparation, collection, analysis, and interpretation of data, critical review of the manuscript. GSD, CJG: critical review and approval of the manuscript. GCWL, EIGL: analysis and interpretation of data, critical review and approval of the manuscript. APTR: critical review and approval of the manuscript.

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