Artigos

Conteúdo (article):

Resilience of Primary Health Care in Northeast Brazil from the Perspective of Community Health Agents

Regina Glaucia Lucena Aguiar Ferreira – Faculdade de Farmácia, Odontologia e Enfermagem (FFOE), Universidade Federal do Ceraá (UFC). reginalucenaa@ufc.br. https://orcid.org/0000-0003-4225-7958.

Hassã Pereira Lemos – Secretaria Municipal de Saúde de Fortaleza. hassalemos11@gmail.com. https://orcid.org/0000-0003-0162-5857.

Grayce Alencar Albuquerque – Universidade Regional do Cariri (URCA). grayce.alencar@urca.br. https://orcid.org/0000-0002-8726-0619.

Andréa Sílvia Walter de Aguiar - Faculdade de Farmácia, Odontologia e Enfermagem (FFOE), Universidade Federal do Ceará (UFC). andrea.aguiar@ufc.br. https://orcid.org/0000-0002-4316-9020.

Isabella Lima Barbosa Campelo – Escola de Saúde Pública do Ceará. isabellaecampelo55@gmail.com. https://orcid.org/0000-0003-1552-7350.

Maristela Inês Osawa Vasconcelos – Universidade Estadual Vale do Acaraú (UVA). Sobral-CE. miosawa@gmail.com. https://orcid.org/0000-0002-1937-8850.

Anya Pimentel Gomes Fernandes Vieira Meyer – Fundação Oswaldo Cruz – Fiocruz Ceará. anyavieira10@gmail.com. https://orcid.org/0000-0003-4237-8995.


Abstract
Primary health care (PHC) is an important tool for reducing health inequities in Brazil, and the PHC resilience capacity is linked to this goal. Objective: To analyse the daily resilience and crise resilience of PHC in 8 municipalities in Northeast Brazil from the perspective of community health agents (CHAs). Method: This was an observational, cross-sectional study with a quantitative approach. A questionnaire was administered to CHAs selected through stratified random sampling. Seven factors were scored, three regarding daily resilience and four regarding crisis resilience, and their overall means were calculated. Results: The overall daily resilience score (3.17) was higher than the overall crise resilience score (2.97), and in general, municipalities in the interior of the region exhibited better resilience indicators than did capital cities. The factors Daily1-Diverse and Crisis3-Diverse had lower values than the other factors did, while the factors Daily3-Aware and Crisis1-Aware factors are notable for their highest scores. However, low CHA coverage, low PHC revenue per capita and urban violence may have influenced the findings. Conclusion: There is heterogeneity in the daily and crisis resilience of the municipalities, with better indicators identified for daily resilience and in interior municipalities compared with the capital cities.
Keywords: health system resilience; primary health care; community health agents

Introduction
Primary health care (PHC) in Brazil is among the main strategies employed to expand population coverage and organize the Unified Health System (UHS). 1 Over the 30 years that the UHS has been implemented, innovations in the health system financing model and in the design of organizational arrangements for services has enabled rapid and consistent growth in PHC coverage, transforming the health care model to suit a country with large regional, economic and sociocultural differences.2 The decentralization of federal resources to municipalities, which was associated with the implementation of the family health strategy (FHS), was key to the expansion of PHC in the country. The FHS expanded access to basic health services and promoted improvements in health outcomes, thereby reducing social and regional inequalities. 3,4 As a result, the UHS is internationally recognized as an example of a successful public health policy 5.
Despite these advances, however, structural weaknesses of the UHS and the great heterogeneity among the 5,570 Brazilian municipalities have resulted in different patterns of expansion of the FHS 6 and in the quality of services provided 7, resulting in the diverse performance of essential functions of PHC throughout the country. Studies indicate that the expansion of PHC coverage occurred in different patterns in the country, and as a result, barriers associated with structural weaknesses of the UHS, such as budgetary constraints, fragile regional organization and a low capacity to allocate strategic resources, have been encountered. 8
The implementation of the FHS provided consistent progress in increasing the coverage of PHC services in Brazil. From 1998 to 2018, the FHS was adopted by more than 95% of Brazilian municipalities, and the number of FHS teams increased from 2,000 to 43,000, covering approximately 130 million people (62.5% of the Brazilian population). 9
The attributes of PHC are produced and strengthened by the work of community health agents (CHAs). In addition to facilitating entry into the system and connections between the community and PHC, these workers excel in providing care, prevention and health promotion and establish strong and lasting bonds with their community. 10 However, the actions of CHAs are often limited by the violence in the territory in which they operate. 11
In Brazil, 257,545 CHAs are currently distributed across 98% of the municipalities, which cover of 61% of the Brazilian population. According to data from the Ministry of Health, in December 2020, 100,763 thousand CHAs were present in both the rural communities and urban outskirts of Northeast Brazil, as well as in highly urbanized and industrialized municipalities, covering approximately 82.66% of the population. 12 This evidence reveals the importance of this profession both for increasing access to basic health services 13 and for expanding the coverage of the FHS to the majority of the municipalities throughout the regions of the country.
CHAs are professionals who live and work in the territory where the community is located and therefore create bonds with the people and gaining a good understanding of the needs and challenges of the community. 14 Thus, they recognize and understand the aspects, attributes and particularities of the health system in a unique way, particularly the resilience of PHC.
Health system resilience has emerged as a key concept worldwide in the past decade, ushering in a new perspective on how to adjust to system shocks and keep essential services functioning. 15 According to Kruk et al. 16 (2015), this resilience consists of the “capacity of health actors, institutions and the population to prepare for and respond effectively to crises; to maintain its essential functions when a crisis hits; and, informed by the lessons learned during the crisis, to reorganize itself if conditions demand it”.
According to Jatobá and Carvalho 17 (2024), in addition to the resilience of the health system itself, it is essential to find ways to analyse the potential of health systems to attain resilient performance. According to these authors, resilience is an everyday skill; thus, a resilient health system must be prepared for disturbances that may not happen. Accordingly, to design and manage resilient health systems, it is necessary to identify the factors that contribute to resilience (both daily and crisis-related resilience) and establish measures of these factors.
Frameworks and metrics for evaluating the resilience potential of public health systems have been developed by specialists and have received attention from public managers; however, the perspectives of the PHC professionals who are closer to the community has not been considered. In addition, PHC resilience is not routinely evaluated, especially in territories made vulnerable by violence, such as those in Northeast Brazil.
Considering the inclusion of CHAs in PHC, their role in the community (work and live in the territory) and distinctive perspective to community specificities—which make them able to perceive the health system in a unique way—in this study, we sought to analyse the daily and crisis-related resilience of the PHC in eight municipalities in Northeast Brazil from the perspective of CHAs. The leading role of CHAs, who have unique regional perspectives, combined with the originality of the study methodology (involving the validation of scales of daily resilience and crisis resilience), are strengths that make this study suitable for contributing to the understanding of the dynamics of resilience, not only where the study was conducted but also in other contexts, particularly middle-income countries that have implemented public and decentralized health systems.

Method
This observational, cross-sectional study employs a quantitative approach and is part of a broader study entitled “Resilience of Health Systems in the Face of COVID-19 and Urban Violence from the Perspective of Community Health Agents”. The objective of this broader study is to investigate the resilience of health systems in the context of the COVID-19 pandemic and urban violence with respect to primary health care from the perspective of the CHA who, as part of the community and PHC, understands the PHC’s ability to respond to impacts while maintaining the essential functions of the system, as well as the ability to reorganize itself on the basis of the lessons learned.
The subjects of this study are CHAs located in basic health units in eight cities in four states in Northeast Brazil (Piauí, Ceará, Paraíba and Pernambuco). There are four state capitals—Fortaleza-CE, Teresina-PI, João Pessoa-PB and Recife-PE—and four municipalities in the state of Ceará—Sobral, Juazeiro do Norte, Crato and Barbalha. The choice of these eight municipalities was due to their diversity regarding a number of issues, including population size, CHA coverage, violence rates (inferred from the homicide rates), PHC funding (inferred from the PHC per capita municipal revenue), and the human development index (HDI), among other factors, as presented in Table 1.

Table 1- Characteristics of the eight municipalities involved in the study in 2023.


To ensure the accuracy of the information, representative samples of the total number of community workers in each city were computed, considering a 95% confidence level and 5% sampling error, and the stratified random sampling technique was used to ensure the participation of health units in all areas of the municipality.
Data collection was performed between July and November 2023 by properly trained collectors who, during the application of the instrument, remained with the respondents, providing them with support and clarifying possible doubts. This study was approved by the Research Ethics Committee of the Institute for the Development of Education LTDA - IPADE, under Opinion No. 5,917,599 (CAAE: 67070323.4.0000.5049).
The dense data collection instrument of the original study (mentioned above) contains sections related to sociodemographic and psychographic data, exposure to urban/community violence, experience with COVID-19, day-to-day resilience of the health system, resilience of the system in the face of health crises, anxiety caused by the coronavirus, perceived social support, general self-efficacy and quality of life.
In this study, the section of the form that refers to sociodemographic data and PHC resilience was considered. Notably, for the questions related to resilience, a five-point Likert scale ranging from 1 (strongly disagree} to 5 (strongly agree) was used. The questionnaire content validation process was based on these sets of items and included the assistance of experts who judged the clarity, relevance and applicability of the items. In addition, exploratory and confirmatory factor analyses were performed to validate the internal structure and create two PHC resilience scales from the perspectives of the CHAs, namely, the 11-item Everyday Resilience Scale (ERS) and the 18-item Crisis Resilience Scale (CRS).
The analysis resulted in the identification of seven factors, three for daily resilience and four for crisis resilience, and the averages of the scores of these factors were calculated. On the basis of the characteristics of the resilience framework proposed by Kruk et al. 18 (2017), the questions of the research instrument were related to each factor, which were named as follows:

Factors of Daily Resilience: Daily1-Diverse; Daily2-Integrated; Daily3-Aware.
Factors of Crisis Resilience: Crisis1-Aware; Crisis2-Self-regulated; Crisis3-Diverse; and Crisis4-Adaptive.
According to Kruk et al. 18 (2017), an “aware system” is capable of tracking the health threats of the population, mapping its strengths and weaknesses and knowing the available resources; an “integrated system” is capable of coordinating public and private government actors, articulating different sectors and involving communities; an “adaptive system” is capable of transforming operations to improve its functionality, acting on the basis of evidence and evaluations and encouraging a flexible response appropriate for the situation; a “self-regulated system” is capable of isolating threats to health, minimizing interruptions to essential services and accessing reserve capacity; and a “diverse system” is capable of addressing a range of health problems and providing quality services that meet the needs of the population.
The values of these factors and the means for the two resilience scales were calculated for each of the included municipalities.
Results
The 1,923 CHAs included in this study were primarily women (81.20%). Of these CHAs, 46.39% had completed high school, the mean age was 47.83 years (SD = 8.98, min. = 21; max. = 72), and the average time they had worked in the health system was 17.69 years (SD = 7.15, min. = 6 months max. = 35 years). These 1,923 CHAs are involved in PHC in the municipalities of Northeast Brazil, whose characteristics are presented in Table 1, as described in the Methods section. Table 2 presents the descriptive and comparative results of all the factors and the general means of the scales of the eight studied municipalities.
Data from this study indicate that the overall score of daily resilience (3.17) of the municipalities were greater than the overall values of crisis resilience (2.97). Generally, the municipalities in the interior had better resilience indicators than do the capital cities. In addition, the overall resilience and crisis scores of the cities noticeably varied (p<0.001), as shown in Table 2.
Table 2 – Predictive Factors of Daily Resilience and Crisis Resilience in the Municipalities of Northeast Brazil, 2023.
Among the factors that compose the resilience scales, the Daily1-Diverse factor had the lowest scores, especially in the capitals João Pessoa (2.92) and Fortaleza (2.99) and in the municipality of Crato (2. 96). Similarly, the Crisis3-Diverse factor had a lower value than the other crisis scores, especially in the capital cities of Recife (2.56), Fortaleza (2.55) and João Pessoa (2.47). Conversely, the Daily3-Aware and Crisis1-Aware factors had the highest scores in their respective dimensions, and the best results of all the resilience measures obtained in the present study were reported by the municipality of Sobral (3.81 and 3.69, respectively).
Discussion
This study analysed the daily resilience and crisis resilience of PHC among eight municipalities in Northeast Brazil from the perspective of CHAs. Factors of daily resilience and crisis resilience were identified, and scores were obtained using specially designed scales, allowing comparisons among the municipalities studied. The results of the comparisons revealed that the scores for daily resilience were generally higher than those for crisis resilience, indicating that, from the perspective of the CHAs, the system is better prepared to cope with daily/chronic stressors, such as violence, than with crisis situations (acute stresses), such as the COVID-19 pandemic.
Heterogeneity was also identified in the resilience values among the municipalities; specifically, those located in the countryside (noncapitals) exhibited better overall scores for both daily resilience and crisis resilience. These findings suggest that, from the perspective of the CHAs, smaller and less populous municipalities are more qualified and prepared to maintain their essential functions under daily stresses and in crisis situations and are also capable of reorganizing themselves based on the lessons learned therein.
It is also important to note the moderate values indicated for the resilience scales (daily and crisis) in all municipalities. This can be observed with the mean values of the scale, which had a variance of 1 to 5 but tended to range between 2.5 and 3.5. This information is important as it highlights the need to invest in strengthening the resilience of PHC in these municipalities.
PHC is the first level of care and assistance and thus represents the gateway to the system; it is therefore responsible for providing comprehensive health care to the users, both collectively and individually. 19 Undoubtedly, PHC is largely responsible for the increase in coverage and access of the Brazilian population to health services, given its large capillarity and proximity to the user.
Through a community-centred approach, PHC teams address the sets of health needs of the people in the community throughout their lives. In addition, the proximity to individuals and the community in the context of their territory makes it possible for these teams to better implement public health actions that are essential for coping with health emergencies. 20 Knowing that improved PHC service delivery is crucial for increasing the resilience of the health care system, good coverage by CHAs can contribute to creating a more resilient health care system.
However, owing to regional, economic and sociocultural differences in our country, coverage and access to health services vary widely depending on the location. 21 The significant reduction in the number of community workers in the family health strategy (FHS) that has occurred in Brazilian municipalities has resulted in reduced CHA coverage. For example, the National Primary Care Policy (PNAB), published in October 2017 through Ordinance No. 2,436/2017 of the Ministry of Health, reduced the minimum number of community workers in the FHS from four agents to one. This reduction in CHA coverage has contributed to the emergence of barriers to accessing services, compromising several processes already established through the relationship of the CHA who has been working with the population, especially in terms of the social determinants of the health-disease process. 22
Data from the present study reveal that, in the interior municipalities, the coverage of the CHA is greater than 70%, a scenario that may be related to the higher resilience scores. In addition, PHC per capita revenues above R$ 80.00 in these municipalities may also have increased these scores, given that Sobral and Barbalha, municipalities with 100% CHA coverage and PHC per capita revenues above R$ 90.00 per year, report the highest scores for resilience to daily life and resilience to crisis from the perspective of the CHA (especially Sobral). Taking into account the concepts and resilience factors discussed, it can be concluded that, in everyday life, these two municipalities exhibit a more diverse, integrated and conscious PHC. In addition, they have a conscious, self-regulated, diverse and adaptive PHC in the face of health crises, such as that generated by the COVID-19 pandemic.
It is worth remembering that coping with the COVID-19 pandemic has imposed numerous challenges for the world’s health systems as the disease demanded the intense mobilization of resources that overloaded the system, leading to collapse in some regions of the country, with shortages of beds, supplies and health professionals. 22 During the period of growth in the number of cases and deaths due to COVID-19 (April to July 2020), contradictorily, there was a low budgetary and financial execution of the resources allocated for this purpose. 22 These unprecedented challenges tested the ability of health systems to address and respond to shocks, revealing that the world was not prepared to respond to such emergencies. It is evident, therefore, that resilient health systems are essential for realizing the right to health and for maintaining social and economic activities.
The prominence of Sobral in the daily resilience and crisis resilience scores is notable. In the regional organization of the UHS, this municipality is a reference for the northern macroregion of the state of Ceará, which, composed of 55 municipalities, is where most of the medium- and high-complexity services of this macroregion are concentrated. In Sobral, PHC is a priority and is marked by important efforts to expand the coverage of the FHS and improve the infrastructure of the units and the organization of work processes. In addition, the strengthening of articulation with the points of the care network contributes to the reorientation of the health care model, with PHC as the protagonist in the ordering and coordination of care networks in this municipality. 23
Sobral also stands out nationally in terms of education. Over the past 20 years, Sobral’s educational reform has established itself as the main Brazilian reference for quality public education. With basic issues such as truancy, illiteracy and age-grade distortion resolved, the network reached a degree of institutional maturity and stability that allows it to envision more ambitious goals of educational development and may have indirect effects on various aspects of public services in the city. 24
In addition to CHA coverage and the PHC per capita revenue, one cannot fail to mention the violence present in the municipalities studied, which is determined from their homicide rates, given that Northeast Brazil tends to be considered a violent region. The third highest homicide rate in the state is found in Sobral (48.3), which is located in northwest Ceará. In the south, Crato (34.3) and Juazeiro do Norte (29.7) stand out as the most violent. 25
As a social phenomenon, urban violence is expressed as the interpersonal relationship between two or more people who may or may not know each other outside the domestic space that affects the feeling of continuity in daily routines and personal security. 26 In their work process, CHAs face the challenge of confronting situations of violence, in addition to other socioenvironmental determinants, such as poverty and a lack of basic sanitation. 26,27 Violence has also been described as a risk factor for health professionals, especially for those who exercise their activities in the territory by interacting directly with the population. 11, 26.27
Notably, among the cities analysed, Sobral, the municipality with the highest homicide rates, had the highest scores of resilience in terms of daily life and times of crisis (from the perspective of the CHA). Therefore, it is possible to infer that the PHC of this municipality, in response to its stressors, such as violence, has improved and become more resilient. In other words, violence constitutes a chronic stressor for health systems, thus demanding a more resilient PHC that is capable of preparing for and responding effectively to crises while maintaining its essential functions.
Notably, however, that this response to stress has a limit. That is, to a certain extent, the health system is able to react and overcome the challenges established by the stressor; however, if this stressor increases, it is possible that the system will lose its ability to adapt and maintain its resilience. Thus, as an even greater increase in urban violence can lead to a collapse of the system, it is important that actions that mitigate these stressors (e.g., violence) are put into practice to protect the health system.
In contrast to Sobral and Barbalha, whose resilience scores are positive, Recife and Juazeiro do Norte report the lowest score (2.86) for overall crisis resilience, followed by Fortaleza (2.90). While the capital of Pernambuco is one of the most violent cities among those analysed in this study, with a homicide rate of 44.7%, Juazeiro do Norte is among the least violent, with a homicide rate of 29.7%. In addition, Recife has one of the lowest CHA coverages (59.92%) among the capitals, and Juazeiro do Norte has one of the lowest coverage areas among the cities in the interior (74.65%). The latter also has the lowest PHC per capita municipal revenue among the inland cities investigated (R$ 79.80), although it is higher than that of Recife (R$ 56.64), which is one of the lowest among the studied capitals. .
The explanation for the low performance of these municipalities on the resilience scale to crisis is not clear; however, it is possible that the low coverage of CHWs and the low PHC revenue per capita in these municipalities are reflected in their failure to be adequately prepared to face the challenges encountered during times of health crises, a conclusion inferred based on their low scores on the crisis resilience scale. Studies indicate that during the COVID-19 pandemic, community health workers were forced to reduce many of their activities, including home visits. 28-30 Knowing the importance of CHAs in improving the health conditions of the population through their performance in different contexts, it is possible that the reduction in home visits may have contributed to the low scores on the resilience to crisis scale in the capitals of Fortaleza and Recife.
It is important to note that, from the perspective of the CHAs in the present study, in all the analysed municipalities, both daily (Day1-Diverse) and crisis diverseness (Crisis3-Diverse), presented the lowest resilience scores. On the other hand, Awareness, expressed by the factors Daily3 and Crisis1, were notable because they presented the highest values. On the basis of these findings, it can be inferred that, within the scope of primary care, the CHAs are aware of the threats to which the health care system is exposed as well as its strengths and weaknesses and the resources available to it. However, according to these same CHAs, PHC does not have the ability to effectively meet the health needs of the population.
In this context, Andrade et al. 31 (2018) emphasize that, despite the progress achieved, Brazilian PHC faces challenges and threats. The expansion of PHC coverage, which occurred in various patterns throughout the country, faced barriers associated with structural weaknesses of the UHS, such as budgetary restrictions, fragile regional organization and a low capacity to allocate strategic resources. 32.33
Past epidemics allowed for the accumulation of knowledge among health managers and professionals working at the municipal, state and federal levels, including that related to finances regarding the improvement of the allocation of resources in exceptional times. 34 However, in the face of a crisis such as the COVID-19 pandemic, UHS funding was unprepared to cope with such a stressor. 35 As Massuda et al. 8 (2020) emphasize, some countries have achieved success in combating the pandemic, which is in line with efficient government and societal involvement combined with the implementation of effective information systems and health professionals who specialize in specific areas and technologies, all of which contribute to strengthening PHC.
Paschoalotto et al. 36 (2022) emphasize that the underfunding of the UHS and its highly unequal funding structure had a great impact on its response capacity, and accordingly, the funding and funding structure must be more thoroughly analysed in resilience studies. In the face of a crisis, it is important to explore how public and private financial resources are allocated and how inequalities in funding influence the resilience of the UHS. Although the present study did not confirm the existence of a relationship between PHC funding and resilience, its findings support this hypothesis.
In the present study, we analysed the daily and crisis resilience of the PHC of eight municipalities in Northeast Brazil from the perspective of CHAs. According to Khalil et al., analyses focusing on the causes and effects of low potential for resilience are beneficial for health system management. 37 Furthermore, as Costa et al. 38 (2021) emphasize, in the complex context that usually involves public policies, funding models must be constantly reassessed on the basis of the lessons learned in the face of crises and the consequent depletion of resources.
Finally, the construction of a resilient health system involves the strengthening of structural aspects, such as increasing the resources allocated to health; expanding social protection through social programs; reducing extreme poverty and poverty contributors, such as governance, expansion policies and the implementation of more adherent programs. 8 Thus, the complexity involved in the resilience of health systems is perceived not only in times of crisis but also in daily life. The COVID-19 pandemic has emphasized the need for health systems with increasing potential for resilient performance and, hence, the need to continually assess the resilience of health systems to highlight their strengths and mitigate their weaknesses. 15
It is believed that the identification of points lacking resilience, from the perspective of CHAs, as well as the relationships of resilience with the characteristics of the municipalities and their health systems, provides evidence that may contribute to the establishment of priority areas and favour the planning of policies regarding the specific measures of the adequacy of primary health care more suited to the multiple realities encountered. The understanding, for example, that locations with greater CHA coverage and greater per capita PHC funding are related to better indicators of resilience may well interfere with the public policies being implemented. From this perspective, financial incentives and increased CHA coverage in more vulnerable locations may be a potent practice of health equity, enhancing the beneficial effects of the UHS where it is most needed and thus contributing to the health and quality f life of the population.
This study has several limitations that should be noted. First, certain information (extracted from official sources) that supported the characterization of the municipalities studied was collected from years prior to the collection of the primary data. This was due to the unavailability of more up-to-date data from the same time base for all of the municipalities studied. Another limitation is that the data presented here are not generalizable.
Conclusion
The findings of this study indicate that, from the perspective of community health workers, there is heterogeneity in the resilience of primary health care in the studied municipalities, both in terms of daily resilience and crisis resilience. In general, the resilience values were moderate. However, the values for daily resilience were better than those for crisis resilience. In addition, cities in the interior were more resilient than were the capitals, with the municipality of Sobral demonstrating the greatest daily and crisis resilience. Low CHA coverage, low PHC per capita revenue and high levels of urban violence may have influenced the resilience values of the municipalities investigated and their heterogeneity.



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