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Epidemiologia e Serviços de Saúde

versión impresa ISSN 1679-4974versión On-line ISSN 2237-9622

Epidemiol. Serv. Saúde vol.28 no.3 Brasília set. 2019  Epub 20-Ene-2020 


Structure for the work and composition of Family Health Support Unit teams: national survey - Program for Improving Primary Health Care Access and Quality (PMAQ), 2013*

Thamires Lorenzet Seus (orcid: 0000-0001-6714-1586)1  , Denise Silva da Silveira (orcid: 0000-0002-6003-315X)2  , Elaine Tomasi (orcid: 0000-0001-7328-6044)2  , Elaine Thumé (orcid: 0000-0002-1169-8884)3  , Luiz Augusto Facchini (orcid: 0000-0002-5746-5170)2  , Fernando Vinholes Siqueira (orcid: 0000-0002-2899-3062)1 

1Universidade Federal de Pelotas, Programa de Pós-Graduação em Educação Física, Pelotas, RS, Brazil

2Universidade Federal de Pelotas, Faculdade de Medicina, Departamento de Medicinal Social, Pelotas, RS, Brazil

3Universidade Federal de Pelotas, Faculdade de Enfermagem, Programa de Pós-Graduação em Enfermagem, Pelotas, RS, Brazil



to describe the structure of Family Health Support Unit (FHSU) teams with regard to physical space, training received, continuing education and professionals that support Primary Health Care (PHC) teams in Brazil, in 2013.


this is a descriptive study using data from the external evaluation stage of the Program for Improving Primary Health Care Access and Quality (PMAQ).


the 1,773 FHSU teams mainly used shared clinics at primary health care centers (85.7%); 63.4% of professionals were offered specific training when they started work at their FHSU, while 67.4% were offered continuing education; the teams received support mainly from physiotherapists (87.4%) and Physical Education professionals (87,0%).


the structure available for FHSU teams is in accordance with the guidelines; some FHSU professionals have not received any specific training for the job.

Keywords: Structure of Services; Primary Health Care; Health Evaluation; Patient Care Team


Primary Health Care (PHC), in addition to being the main entry point for accessing the Brazilian health system, is capable of providing solutions for some 85% of the population’s health demands.1 The Family Health Support Units (FHSU) were created in 2008, with the aim of qualifying and broadening the scope of PHC actions through multiprofessional teams. In view of their relevance, evaluation of the Family Health Support Units is an important issue.2

Health service evaluation is a quality control mechanism.3 Continually monitoring health service provision enables early detection and correction of deviation from established standards so that services can be better developed and enhanced.4

In Brazil, the objective of the Program for Improving Primary Health Care Access and Quality (PMAQ) is to induce increased access to PHC and improvement of its quality, guaranteeing a nationally comparable standard of quality, so as to enable greater transparency and effectiveness of government actions directed towards Primary Health Care. PMAQ takes place by means of evaluations based on questions ranging from PHC service infrastructure to team work processes and service user satisfaction. These evaluations are carried out by means of observation of service facilities, interviews with PHC service teams (Family Health Strategy, FHSU teams and parameterized teams) as well as with service users.5

Service structure can influence health outcomes, i.e., good structure favors good processes and, consequently, increases the occurrence of positive outcomes.6 The structure of a health service is related to its physical area, human, material and financial resources available to it, including health professional training and service organization.7

Despite the relevance of FHSU for PHC, literature is still scarce on the structure available for the work done by FHSU.8 The objective of this study was to describe FHSU structure with regard to physical space used, training and continuing education received by the professionals who provide support to the PHC teams.


This is a descriptive study using data from the external evaluation stage of PMAQ Cycle II. Teams were included when municipal health service management adhered to the program. Following the external evaluation process the teams were progressively certified and received funding based on their performance. PMAQ was developed by the Federal Government and carried out by 41 Federal Teaching and Research Institutions led by: the Oswaldo Cruz Institute Foundation (Fiocruz), the Federal University of Bahia (UFBa), the Federal University of Minas Gerais (UFMG), the Federal University of Pelotas (UFPel), the Federal University of Rio Grande do Sul (UFRGS), the Federal University of Rio Grande do Norte (UFRN) and the Federal University of Piauí (UFPi).9

PMAQ is divided into four stages of a cyclical process, namely:

  • a) Stage 1

  • Adherence - formal agreement on commitments and indicators, taken on by municipal PHC teams and health service managers with the Ministry of Health.

  • b) Stage 2

  • Development - carrying out of a set of actions, with the aim of promoting changes in management and care provided by the teams.

  • c) Stage 3

  • External evaluation - evaluation of access conditions and team quality.

  • d) Stage 4

  • Agreement Resetting - incorporation of new standards and quality indicators, with the aim of establishing a cyclical and systematic process based on the results achieved by participants.

The evaluations took place in 2011 (Cycle I), 2013/14 (Cycle II) and 2017/18 (Cycle III). For this study we used data collected during the external evaluation stage of Cycle II between October 2013 and March 2014, by means of interviews with FHSU professionals and Family Health team professionals. The interviews were conducted in health centers in all of Brazil’s Federative Units, using electronic equipment handled by approximately 1,000 interviewers and supervisors who had been trained beforehand by the leader institutions on using the instruments and interview techniques.

As such, information was collected on the availability of:

  • - spaces for carrying out FHSU activities;

  • - vehicles available;

  • - supplies;

  • - training;

  • - date of joining FHSU;

  • - continuing education; and

  • - FHSU professionals involved in Module IV (for FHSU professionals) and Module II (for interviews with PHC team professionals) of the data collection instrument.9

The data were tabulated and transferred to the Stata 14.0 statistical package. Descriptive analysis was performed on the variables of interest in order to obtain relative and absolute frequencies. Figure 1 shows the variables of interest and their operational status.

Figure 1 - Variables of the structure made available to Family Health Support Unit (FHSU) teas, supplies, FHSU professionals and activity operational status, based on data from the Program for Improving Access and Quality (PMAQ) national survey, Brazil, 2013 

It was possible to describe the structure available for carrying out FHSU activities by asking FHSU professionals the following question,

“What spaces are available for the FHSU to carry out its activities?”

which had the following answer items: (a) Exclusive consulting room; (b) Consulting room shared with team; (c) Meeting room at the health center; (d) Spaces in the health center’s territory; (e) Others. The reply alternative for each of these items was ‘yes’ or ‘no’.

The study project was approved by the Federal University of Pelotas Faculty of Medicine Research Ethics Committee, Report No. 38/12, dated May 10th 2012. All participants signed a Free and Informed Consent form.


In Brazil in 2013, 93.6% of the country’s municipalities (n=5,213) adhered to PMAQ 2, totaling 29,778 PHC teams. Of these, 17,157 (57.6%) received support from 1,773 FHSU teams to assist their actions. Above all, shared consulting rooms at primary health care centers (85.7%) and spaces in health center territories (82.7%) were found to be available for FHSU teams to carry out their activities (Table 1).

Table 1 - Description of aspects of the structure of the Family Health Support Unit (FHSU) teams based on data from the Program for Improving Access and Quality (PMAQ) national survey, Brazil, 2013 

Aspects FHSU team work characteristics
N %
Spaces made available for carrying out FHSU activities (n=1,773)
Exclusive consulting room 689 38.8
Consulting room shared with team 1,520 85.7
Meeting room in health center 1,290 72.7
Spaces in health center territory 1,467 82.7
Other 636 35.8
Availability of vehicle for FHSU (n=1,773)
Yes 1,333 75.2
FHSU needs met according to vehicle availability (n=1,333)
Always 540 40.6
Nearly always 527 39.5
Sometimes 211 15.8
Rarely 52 3.9
Never 3 0.2
Availability of supplies for carrying out FHSU activities (n=1,773)
Yes 1,471 83.0

Among the FHSU teams, 75.2% had a vehicle for carrying out their activities and 80.0% of the teams considered that having a vehicle available to transport them met their need always or nearly always. 83.0% of the teams reported having supplies available for them to carry out their activities (Table 1).

Specific training was offered to 63.4% of professionals when they began working at their FHSU, mainly in the form of an informative meeting (62.1%) and a capacity building workshop (61.8%). Among professionals who received some type of training, 86.9% rated its quality as good or very good (Table 2).

Table 2 - Description of variables related to training of Family Health Support Unit (FHSU) professionals based on data from the Program for Improving Access and Quality (PMAQ) national survey, Brazil, 2013 

Variables N %
Provision of specific training about FHSU when the professional started work there (n=1,773)
Yes for all professionals 808 45.6
Yes for some professionals 315 17.8
No 650 36.6
Type of training provided to FHSU professionals when they started work there (n=1,123)
Introductory course 549 48.9
Capacity building workshop 694 61.8
Informative meeting 697 62.1
Other 189 16.8
Opinion of FHSU professionals on quality of training provided (n=1,123)
Very good 302 26.9
Good 674 60.0
Regular 134 11.9
Poor 13 1.2
Provision of continuing education for FHSU professionals (n=1,773)
Yes for all professionals 915 51.6
Yes for some professionals 280 15.8
No 578 32.6
Opinion of FHSU professionals on quality of continuing education provided (n=1,195)
Very good 303 25.4
Good 734 61.4
Regular 141 11.8
Poor 15 1.2
Very poor 2 0.2
Themes covered by continuing education activities (n=1,195)
Primary Health Care principles and guidelines 860 72.0
Organization of the Primary Health Care work process 841 70.4
Organization of the FHSU work process 949 79.4
Discussion of complex cases and/or building a Unique Therapy Project 800 66.9
Methods for working with groups 731 61.2
Surveillance actions in the territory 636 53.2
Chronic conditions 827 69.2
Mental health 896 75.0
Women’s health 789 66.0
Children’s health 798 66.8
Rehabilitation/Health of People with Disabilities 758 63.4
Social conflict situations (violence, use of alcohol and other drugs etc.) 909 76.0

Continuing education was provided to 67.4% of FHSU professionals (some or all of them). Among those who took part in continuous education, 86.8% classified its quality as being good or very good. The main themes covered were: FHSU work process organization (79.4%), social conflict situations (76,0%) and mental health (75,0%) (Table 2).

The primary health care center teams received support mainly from FHSU team physiotherapists (87.4%), Physical Education professionals (87.0%) and veterinarians (85.0%) (Table 3). Moreover, 85.1% (n=14.605) of primary health care team professionals considered that the FHSUs needed to have additional professional categories.

Table 3 - Percentage of Primary Health Care (PHC) teams supported by Family Health Support Unit (FHSU) professionals based on data from the Program for Improving Access and Quality (PMAQ) national survey, Brazil, 2013 

FHSU professionals supporting PHC teams (n=17,157) PHC teams supported by FHSU professionals
N %
Physiotherapi st 14,993 87.4
Physical Education professional 14,931 87.0
Veterinarian 14,580 85.0
Social Worker 11,850 69.0
Nutritionist 10,665 62.2
Pharmacist 7,012 40.19
Public Health Physician 4,248 24.7
Pediatrician 3,017 17.6
Gynecologist 2,850 16.6
Art-Educator 1,022 6.0
Occupational Therapist 882 5.1
Psychologist 636 3.7
Geriatrician 519 3.0
Obstetrician 414 2.4
Occupational Health Physician 326 1.9
Acupuncturist 285 1.7
Clinical Medicine Physician 229 1.3
Homeopathic Physician 174 1.0


The main spaces made available for carrying out FSU team activities were shared consulting rooms at primary health care centers and spaces in health center territories. Most teams had a vehicle available for their actions. The majority also reported having sufficient supplies to carry out their work.

The reality found based on these results was in accordance with FHSU guidelines.2 According to Ministry of Health recommendations, FHSU teams do not need to have their own facilities for carrying out their activities and should use spaces at the primary health care units to which they are attached or other spaces available in the health center territory, such as fitness centers, schools, parks etc.2

The availability of spaces for FHSU teams to carry out their activities appears to be reasonable. Moreover, the professionals considered the availability of a vehicle to be sufficient most of the time (39.5%) or always (40.5%). These results corroborate a previous study conducted using PMAQ Cycle II data, which concluded that infrastructure aspects were adequate for the work of the FHSU teams.10

According to Donabedian, good structure conditions represent a favorable situation for a good work process, increase the likelihood of positive outcomes and, therefore, greater service ability to provide solutions to health problems.6 As such, having knowledge of service characteristics is fundamental for health system planning.

With regard to health professional training, we believe that FHSU had not been included as a theme in Health degree curricula because it was a relatively new program created in 2008. In the opinion of students of a postgraduate specialization course in Primary Family Health Care (n=15), there are limitations in the initial training of professionals for working in PHC, which could be overcome by restructuring the curriculum, greater closeness to reality by means of internships, ensuring the theme cross cuts curriculum topics and disciplines integrated with other areas of interest to Health, such as Physical Education.11

The development of further training situations (courses, lectures, workshops etc.) is relevant for professionals working in FHSU teams. However, just over 30% of these professionals reported not having received any kind of specific training when they began working at their FHSU (36.6%), or continuing education during their job (32.6%). This data indicates the need to increase the availability of capacity building actions for FHSU teams. PMAQ results reported by Bocardo et al. also indicated the importance of greater development of initial training and continuing education in the context of the work of FHSU professionals.10

Continuing education is equally important in view of the challenges faced by professionals in their actions, such as multiprofessional work, difficulties in creating and developing joint, intersectoral and integrated actions, so as to incorporate service user participation.12 Results of a qualitative study involving FHSU professionals working in municipalities in Bahia state revealed that educational activities aimed at them were too scarce and insufficient to transform working practices.13

The main themes covered by the continuing education activities provided to FHSU professionals were organization of the FHSU work process, social conflict situations and mental health. It appears to be coherent that these are the most frequent subjects, as it is fundamental for professionals to know the principles of the work process in their field of action. Social conflict situations, such as violence and use of alcohol and drugs, are frequent and PHC professionals need to be able to deal with them in their contact with the population.14 In Brazil, whereas violence was the seventh leading cause of premature death in 1990, it was the main cause in 2005 and came in second place in 2015.14

Furthermore, the FHSU guidelines provide for prioritizing mental health professionals and actions, given the significant level of epidemiological data on mental disorders cared for by the Family Health service,2 with prevalence of up to 50% among primary health care center users.15

The choice of professionals who comprise the FHSU teams is made by municipal health service managers, in accordance with priorities based on analysis of the epidemiological data, the needs of the territory and the needs of the Primary Health teams to be supported by FHSU.2 The actions of the FHSU teams must be aimed at prevention, health promotion, protection and rehabilitation, within the context of the social determinants of a population or an individual.2

The FHSU professionals who most provided support to PHC teams were physiotherapists (87.4%) and Physical Education professionals (87%), who were taken to be most prevalent because of their work with chronic non-communicable diseases (CNCD). CNCDs are known to be the main component of Brazil’s disease burden, hence why working with them has gained priority status in health services.16 There is evidence that physical activity can both prevent CNCDs from appearing17 and also help to treat them1.8 In view of this, health promotion strategies focused on levels of physical activity have been implemented.19

Veterinarians working in PHC are responsible for observing and contributing to aspects related to human/animal integration.20 Among the PHC professionals taking part in PMAQ, 85% reported counting on the support of FHSU veterinarians.

According the Federal Council of Veterinary Medicine, the actions of veterinarians working in FHSUs include (a) evaluation of health risk factors, (b) prevention, control and diagnosis of diseases transmitted by animals, (c) health education focusing on preventing anthropozoonoses, (d) Public Health studies and research with emphasis on territoriality and quality of care, among others.21 The high participation of veterinarians in FHSUs is attributed to factors that collaborate with disease dissemination, such as close contact with pet animals, which increases risk of exposure to zoonoses.20 According to data produced by the Brazilian Institute of Geography and Statistics (IBGE), the National Health Survey conducted in 2013 revealed that 44.3% of Brazilian households had at least one dog, 17.7% had at least one cat and that Brazil had a total of 52.2 million dogs and 22.1 million cats.22

Notwithstanding, according to a literature review conducted in 2017 on publications about FHSUs, no health study on the theme of the human/animal relationship was found.23 It is important for the work of veterinarians to be explored more by scientific literature in order to consolidate and disseminate knowledge about the role of these professionals in FHSUs.

The limitations of this study include the condition of the teams who answered the PMAQ evaluation questionnaire. They were designated by the municipalities and this may have been because their work performance was better than that of those who were not indicated. As such judicious interpretation of the results presented is recommended.

Another important point is the study’s national coverage. Moreover, it is a quantitative study on the work of FHSU teams, whereas the majority of studies on FHSUs are qualitative.23 The data presented can contribute in a relevant manner to public health policy planning and evaluation.

In view of the lack of a criterion that establishes a parameter for evaluating team structure, classifying them as adequate or inadequate, the results found suggest that the FHSU teams are structured in accordance with the recommendations of the FHSU guidelines: inexistence of an exclusive space;2 – of them having a vehicle available when carrying out their activities.

The need stands out to increase to increase the scope of further training actions for FHSU professionals, given the high percentage of these professionals to whom no specific training or continuing education was offered in relation to the work they do.

With regard to Family Health Support Unit professionals who provide support to Primary Health Care teams, a wide diversity of professions was found, with physiotherapists, Physical Education professionals and veterinarians being the most prevalent. We suggest that further studies be conducted with the aim of verifying whether these professionals meet the needs of the territories in which the teams they support work.


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*Article derived from the Ph.D. dissertation entitled ‘Family Health Support Units and Physical Education professionals’, defended by Thamires Lorenzet Seus at the Federal University of Pelotas Physical Education Postgraduate Program in 2018. Research funded by the Ministry of Health / Health Actions Secretariat / Primary Health Care Department: Process No. 25000.187078/2011-11.

Received: February 08, 2019; Accepted: September 10, 2019

Correspondence: Thamires Lorenzet Seus - Rua Luís de Camões, No 625, Pelotas, RS, Brazil. Postcode: 96055-630. E-mail:

Authors’ contributions

Seus TL, Silveira DS, Tomasi E, Thumé E, Facchini LA and Siqueira FV participated in the study conception and design, data analysis and interpretation, writing and revision of the manuscript content. All authors have approved the final version of the manuscript and are responsible for all its aspects, including ensuring its accuracy and completeness.

Associate editor: Doroteia Aparecida Höfelmann -

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