This thesis assesses the effectiveness of the National Prevention of Mother to Child Transmission of HIV (PMTCT) programme in 3 sites in South Africa, and the quality of infant feeding counselling across four countries, Botswana, Kenya, Malawi and Uganda . Implementation and outcome of PMTCT services were very different across the 3 sites. The Paarl site is achieving results comparable to clinical trial studies with a HIV-free survival rate of 85% at 36 weeks, while Umlazi is somewhat lower (74%) and Rietvlei, with HIV-free survival of 64%. Maternal viral load, prematurity and site were independent risk factors for infection and/or death. The regression analysis suggests that some of this difference is explained by the differences in quality of health systems across the sites. Traditional risk factors (e.g. viral load, prematurity) do not seem to explain the substantial differences in HIV-free survival between the Paarl and Rietvlei sites. The overall mortality rate for HIV exposed infants in this cohort was 155 per 1000 live births at 36 weeks, a level higher than most other HIV exposed cohorts. The excess mortality is occurring almost completely amongst HIV infected infants who had a nine fold increased risk of mortality compared with HIV exposed but HIV negative infants. There was no significant difference in 36 week survival rates between those HIV exposed but uninfected infants and those who were not HIV exposed, Hazard ratio 0.7 (95% CI 0.3-1.5). With respect to HIV and infant feeding most health workers across the four countries (234/334, 70%) were unable to correctly estimate the transmission risks of breastfeeding. Exposure to PMTCT training made little difference to this. Infant feeding options were mentioned in 307 out of 640 (48%) observations of PMTCT counselling session and in only 35 (5.5%) were infant feeding issues discussed in any depth; of these 19 (54.3%) were rated as poor. South Africa was similar with only two out of thirty four HIV positive mothers being asked about essential conditions for safe formula feeding before a decision was made. This body of work has demonstrated that the gap between efficacy and effectiveness can be significant.

Background: To address the huge human resources for health (HRH) crisis that Zambia and other low and middle income countries (LMICs) are experiencing, most LMICs have engaged the services of small scale community-based health worker (CBHW) programmes. However, several challenges affect the CBHWs’ ability to deliver services. Integration of national CBHW programmes into health systems is an emerging innovative strategy for addressing the challenges. Integration is important because it facilitates recognition of CBHWs in the national primary health care system. However, the integration process has not been optimal, and a more comprehensive understanding of the factors that shape the integration process is lacking. This study aimed at addressing this gap by analysing the integration process of national CBHW programmes in health systems in LMICs, with a special emphasis on Zambia. Methodology: This was a qualitative study that used case study and systematic review study designs. The case study focused on Zambia and analysed the integration processes of Community Health Assistants (CHAs) into the health system at district level (Papers I-III). Data collected using key informant interviews, participant observation, in-depth interviews and focus group discussions were analysed using thematic analysis. The systematic review analysed, using thematic and pathways analysis, the integration process of national CBHWs into health systems in LMICs (Brazil, Ethiopia, India and Pakistan)-(Paper IV). The framework on the integration of health innovations into health systems guided the overall analysis. Results: Factors that facilitated the integration of CHAs into the health system in Zambia included the HRH crisis which triggered the willingness by the Ministry of Health to develop and support implementation of the integration strategy-the CHA strategy. In addition, the attributes of the CHA strategy, such as the perceived competence of CHAs compared to other CBHWs, enhanced the community’s confidence in the CHA services. Involvement of the community in selecting CHAs also increased the community’s sense of programme ownership. However, health system characteristics such as limited support by some support staff, supply shortages as well as limited integration of CHAs into the district governance system affected CHAs’ ability to deliver services. In other LMICs, as in Zambia, the HRH problems necessitated the development of integration strategies. In addition, the perceived relative advantage of national CBHWs with regard to delivering health services compared to the other CBHWs also facilitated the integration process. Furthermore, the involvement of community members and some politicians in programme processes enhanced the perceived legitimacy, credibility and relevance of programmes in other LMICs. Finally, the integration process within the existing health systems enhanced programme compatibility with health system elements such as financing. However, a rapid scale-up process, resistance from other health workers, ineffective incentive structures, and discrimination of CBHWs based on social, gender and economic status inhibited the integration process of national CBHWs into the health systems. Conclusion: Strengthening the integration process requires fully integrating the programme into the district health governance system; being aware of the factors that can influence the integration process such as incentives, supplies and communication systems; clear definition of tasks and work relationships; and adopting a stepwise approach to integration process.

The expectations of patients have dramatically changed since the introduction of the first public health services more than a decade ago, as have the surrounding conditions a health system has to tackle. The grown health systems of the industrialised countries counter the challenges of an ageing society, technological advancement and chronic disease by a state of constant reform, which has been present for the last few years, without the abolition of the basic principles of affordability, accessibility and solidarity. One solution to answer all these expectations and requirements is so-called "integrated care", a patient-centred model, which propagates better processes, coordination and cooperation between the different service providers and sectors in health care. Based on a comprehensive discussion of the existing theories on health systems analysis, decision making and performance measurement in health as well as the trade-offs emerging therefrom, the first part of this thesis examines the changing conditions and expectations as well as problem areas of organisation and restructuring in health care systems. This analysis serves as a foundation for the introduction of the integrated care concept, an international expert questionnaire on the decision making in integrated care and conclusions on priority setting of decision makers in health. The analysis of the results demonstrates the high value that is placed on a clear political framework and incentives for the promotion of integrated care, as well as the substantive demand for improved communication, coordination and information structures. (author's abstract)

This thesis aims to fill the gaps in the literature of the theory of constraints (TOC) in publicly funded health systems. While TOC seems to be a natural fit for this resource-constrained environment, there are still no reported application of TOC’s drum-buffer-rope tool and inadequate customizations with regards to defining system-wide goal and performance measures. The “Drum-Buffer-Rope for an Outpatient Cancer Facility” chapter is a real world case study exploring the usefulness of TOC’s drum-buffer-rope scheduling technique in a publicly funded outpatient cancer facility. With the use of a discrete event simulation model populated with historical data, the drum-buffer-rope scheduling policy is compared against “high constraint utilization” and “low wait time” scenarios. Drum-buffer-rope proved to be an effective mechanism in balancing the inherent tradeoff between the two performance measures of instances of delayed treatment and average patient wait time. To find the appropriate level of compromise in one performance measure in favor of the other, the linkage of these measures to system-wide performance measures are proposed. In the “Theory of Constraints’ Performance Measures for Publicly Funded Health Systems” chapter, a system dynamics representation of the classical TOC’s system-wide goal and performance measures for publicly traded for-profit companies is developed, which forms the basis for developing a similar model for publicly funded health systems. The model is then expanded to include some of the factors that affect system performance, providing a framework to apply TOC’s process of ongoing improvement in publicly funded health systems. The “Connecting Low-Level Performance Measures to the Goal” chapter attempts to provide a framework to link the low-level performance measures with system-wide performance measures. It is claimed that until such a linkage is adequately established, TOC has not been fully transferred to publicly funded health systems.

Este estudo analisa o papel do Estado no contexto do Sistema de Saúde Brasileiro, sob a ótica das relações público/privadas, usando como contraponto experiências internacionais, particularmente as reformas ocorridas nos países cêntricos. Parte da análise da teoria Keynesiana para identificar não só um papel a ser desempenhado pelo Estado para além da função anticíclica, como também para situar historicamente o nascimento dos sistemas de proteção social de cunho universalista na Europa. A inflexão sofrida no sistema capitalista nos anos 70s levou à reversão nas orientações político-ideológicas que culminaram em propostas de introdução de mecanismos de mercado nos sistemas de proteção social e de retração do Estado. Para entender o desenho de Estado que daí emerge, são apresentados e analisados os fundamentos conceituais da regulação e sua aplicação frente às especificidades do mercado de serviços de saúde. A apresentação da experiência internacional, particularmente o delineamento das motivações das reformas empreendidas e os resultados alcançados, é feita com o objetivo de contrapor posteriormente, o que é específico no Brasil na convivência público/privado. A reflexão sobre o desenvolvimento do Sistema de Saúde no Brasil passa pela sua evolução no período entre a criação das Caixas de Aposentadoria e Pensão e a Constituição Federal de 1988, para recolher particularidades na relação entre o Estado e o Mercado e, ao mesmo tempo, mostrar o momento de rompimento com o modelo de proteção, baseado no seguro social que acompanha o país neste período. As dificuldades na concretização do conceito de universalidade conforme definido na Constituição são analisadas a partir da extemporaneidade da mudança de modelo e do viés privatista, que acompanha o sistema de saúde no Brasil. As contradições geradas pelas interfaces público/privadas na saúde são exploradas sob o enfoque da inexistência de uma delimitação de espaços de atuação dos mesmos, mas, principalmente, pelo foco do financiamento. As principais conclusões se referem à constatação de que a permissividade do Estado no avanço e apropriação privada de recursos e espaços públicos, ou ainda na ampliação da mercadorização da saúde, dificulta a concretização do conceito de universalidade no atendimento à assistência à saúde. Finalmente, o estudo delineia o conflito de interesses dos atores envolvidos no sistema, que dificulta a capacidade de governança do Estado Brasileiro, mas aponta para a necessidade de revisão das bases da relação Estado versus Mercado e a re-definição da sociedade quanto ao tamanho que deseja dar à iniciativa privada no âmbito da saúde. / This study analyses the role of the State in the context of the Brazilian health system, with regard to the public/private relationship, making a comparison with international experiences, in particular the reforms carried out in the centric countries. It is based on an analysis of the Keynesian theory to identify not only the role to be played by the State besides the counter-cyclic function, but also to situate historically the birth of the universalist systems of social protection in Europe. The changes undergone by the capitalist system in the 70s led to a reversal of politico-ideological orientation which brought proposals of the introduction of market mechanisms into social protection systems and a drawing back of the State. To understand the picture of the State that emerges from this, it is presented and analyzed the fundamental concepts of the regulation and its application in the context of the specificity of the health service market. The presentation of international experience, particularly the explanation of the motivation of the reforms carried out and the results achieved, is given here with the aim of comparing later with what is specific in Brazil in the relationship between public and private. The reflection on the development of the health system in Brazil dwells on its evolution during the period between the creation of pension funds (CAP) and the 1988 Federal Constitution in order to gather particularities in the relationship between the State and the Market, and at the same time to show the moment of the break with the model of protection based on social insurance, which the country followed at this time. The difficulties in putting into practice the concept of universality as defined in the Constitution are analysed from the point of view of the untimeliness of the change of model and the bias towards privatism which the health system in Brazil follows. The contradictions generated by the public/private interfaces in health are explored, focusing on the lack of demarcation of room for action by them, but mainly focusing on their financing. The main conclusion drawn is the believe on that the permissivenes of the State in allowing the private sector to encroach on and appropriate public resources and spaces, and even in increasing the commercialisation of health, makes it difficult for the concept of universality in health attendance to become reality. Finally, the study describes the conflict of interests of the actors involved in the system, which makes it difficult for the Brazilian State to exercise its capacity of governance, and points to the necessity to review the basis of the relationship State versus Market and the redefinition by society as to how much involvement it wishes to give to private enterprise in the area of health.

111f. / Submitted by Suelen Reis (suziy.ellen@gmail.com) on 2013-04-24T14:07:19Z No. of bitstreams: 1 dissertacao-Sandra Barrossec-1.pdf: 761446 bytes, checksum: 6b60495961e66d95db7d594d76992b48 (MD5) / Approved for entry into archive by Rodrigo Meirelles(rodrigomei@ufba.br) on 2013-05-08T11:59:33Z (GMT) No. of bitstreams: 1 dissertacao-Sandra Barrossec-1.pdf: 761446 bytes, checksum: 6b60495961e66d95db7d594d76992b48 (MD5) / Made available in DSpace on 2013-05-08T11:59:33Z (GMT). No. of bitstreams: 1 dissertacao-Sandra Barrossec-1.pdf: 761446 bytes, checksum: 6b60495961e66d95db7d594d76992b48 (MD5) Previous issue date: 2005 / Este estudo descritivo analisou a atenção à saúde bucal em 11 municípios da Bahia, a partir do processo de descentralização, da oferta de serviços e da experiência de cárie dentária na população de 15 a 19 anos. A análise foi realizada por agregados, utilizando dados secundários. Para cada um dos municípios foram delineados o perfil sócio demográfico, a caracterização do sistema municipal de saúde, a oferta de serviços odontológicos, a partir do SIA-SUS, e a prevalência e severidade da cárie dentária, obtidas a partir do banco de dados do levantamento das condições de saúde bucal da população brasileira, concluído pelo Ministério da Saúde no ano de 2003. Foi possível verificar que a descentralização das ações e serviços de saúde no âmbito do SUS não tem correspondido ao aumento da cobertura de 1a consulta odontológica, mas, tem contribuído para a expansão da oferta de serviços ambulatoriais e coletivos em saúde bucal. Apesar da redução da participação percentual dos procedimentos cirúrgicos na produção ambulatorial, estes ainda prevalecem como principal tipo de serviço ofertado em municípios de pequeno porte, onde também encontra-se a pior qualidade no registro das informações no SIA-SUS. Para todos os municípios, o registro de Procedimentos Coletivos é o que apresenta maiores problemas. Contudo, há que se considerar as limitações da base de dados utilizada. Além da capacitação dos profissionais para manejo adequado dos sistemas de informação, faz-se necessária a sensibilização acerca da importância dos sistemas de informação em saúde, sua contribuição para uma análise mais integrada da situação de saúde bucal e para tomada de decisões. / Salvador

The study explored the cultural care beliefs, values and attitudes among Shangaans relating to hypertension. The study aimed to describe the cultural values, beliefs and practices such as taboos, rituals and religion within the world view of the Shangaan. The study was undertaken in the Mopani region of the Greater Giyani area, with the purpose of making recommendations on patient care. Data collection was done by conducting focus group and individual interviews. The five themes that emerged were: + Hypertension + The traditional healer: the instrumental role + Traditional medicine versus Western medicine + Magico-religious healings + Experiences of hypertensive patients with regard to traditional healers and hypertension / Health Studies / M. A. (Health Studies)

Este estudo analisa o papel do Estado no contexto do Sistema de Saúde Brasileiro, sob a ótica das relações público/privadas, usando como contraponto experiências internacionais, particularmente as reformas ocorridas nos países cêntricos. Parte da análise da teoria Keynesiana para identificar não só um papel a ser desempenhado pelo Estado para além da função anticíclica, como também para situar historicamente o nascimento dos sistemas de proteção social de cunho universalista na Europa. A inflexão sofrida no sistema capitalista nos anos 70s levou à reversão nas orientações político-ideológicas que culminaram em propostas de introdução de mecanismos de mercado nos sistemas de proteção social e de retração do Estado. Para entender o desenho de Estado que daí emerge, são apresentados e analisados os fundamentos conceituais da regulação e sua aplicação frente às especificidades do mercado de serviços de saúde. A apresentação da experiência internacional, particularmente o delineamento das motivações das reformas empreendidas e os resultados alcançados, é feita com o objetivo de contrapor posteriormente, o que é específico no Brasil na convivência público/privado. A reflexão sobre o desenvolvimento do Sistema de Saúde no Brasil passa pela sua evolução no período entre a criação das Caixas de Aposentadoria e Pensão e a Constituição Federal de 1988, para recolher particularidades na relação entre o Estado e o Mercado e, ao mesmo tempo, mostrar o momento de rompimento com o modelo de proteção, baseado no seguro social que acompanha o país neste período. As dificuldades na concretização do conceito de universalidade conforme definido na Constituição são analisadas a partir da extemporaneidade da mudança de modelo e do viés privatista, que acompanha o sistema de saúde no Brasil. As contradições geradas pelas interfaces público/privadas na saúde são exploradas sob o enfoque da inexistência de uma delimitação de espaços de atuação dos mesmos, mas, principalmente, pelo foco do financiamento. As principais conclusões se referem à constatação de que a permissividade do Estado no avanço e apropriação privada de recursos e espaços públicos, ou ainda na ampliação da mercadorização da saúde, dificulta a concretização do conceito de universalidade no atendimento à assistência à saúde. Finalmente, o estudo delineia o conflito de interesses dos atores envolvidos no sistema, que dificulta a capacidade de governança do Estado Brasileiro, mas aponta para a necessidade de revisão das bases da relação Estado versus Mercado e a re-definição da sociedade quanto ao tamanho que deseja dar à iniciativa privada no âmbito da saúde. / This study analyses the role of the State in the context of the Brazilian health system, with regard to the public/private relationship, making a comparison with international experiences, in particular the reforms carried out in the centric countries. It is based on an analysis of the Keynesian theory to identify not only the role to be played by the State besides the counter-cyclic function, but also to situate historically the birth of the universalist systems of social protection in Europe. The changes undergone by the capitalist system in the 70s led to a reversal of politico-ideological orientation which brought proposals of the introduction of market mechanisms into social protection systems and a drawing back of the State. To understand the picture of the State that emerges from this, it is presented and analyzed the fundamental concepts of the regulation and its application in the context of the specificity of the health service market. The presentation of international experience, particularly the explanation of the motivation of the reforms carried out and the results achieved, is given here with the aim of comparing later with what is specific in Brazil in the relationship between public and private. The reflection on the development of the health system in Brazil dwells on its evolution during the period between the creation of pension funds (CAP) and the 1988 Federal Constitution in order to gather particularities in the relationship between the State and the Market, and at the same time to show the moment of the break with the model of protection based on social insurance, which the country followed at this time. The difficulties in putting into practice the concept of universality as defined in the Constitution are analysed from the point of view of the untimeliness of the change of model and the bias towards privatism which the health system in Brazil follows. The contradictions generated by the public/private interfaces in health are explored, focusing on the lack of demarcation of room for action by them, but mainly focusing on their financing. The main conclusion drawn is the believe on that the permissivenes of the State in allowing the private sector to encroach on and appropriate public resources and spaces, and even in increasing the commercialisation of health, makes it difficult for the concept of universality in health attendance to become reality. Finally, the study describes the conflict of interests of the actors involved in the system, which makes it difficult for the Brazilian State to exercise its capacity of governance, and points to the necessity to review the basis of the relationship State versus Market and the redefinition by society as to how much involvement it wishes to give to private enterprise in the area of health.

A tuberculose (TB) constitui a principal comorbidade a acometer as pessoas que vivem com HIV/aids (PVHA), sendo considerada a primeira causa de morte nesta população. Assim, a prevenção da coinfecção TB/HIV pelos Serviços de Atenção Especializada ao HIV/aids (SAE) se faz imprescindível. O estudo objetivou analisar a oferta e a integração das ações e serviços de saúde para a prevenção e o controle da TB nas PVHA pertencentes à rede de atenção ao HIV/aids do município de Ribeirão Preto-SP. Utilizou-se o conceito teórico da integralidade da atenção, tomando como eixo de análise a oferta e a integração das ações e serviços dentro das equipes de referência e junto a outros profissionais/especialidades/serviços. Trata-se de um estudo exploratório, do tipo inquérito, com abordagem quantitativa. Participaram 253 PVHA em acompanhamento nos cinco SAE sob gestão municipal, considerando-se os seguintes critérios de inclusão: indivíduos maiores de 18 anos, residentes no próprio município e não pertencentes ao sistema prisional. A coleta de dados foi realizada no período de janeiro/2012 a maio/2013, por meio de entrevistas com apoio de um instrumento específico. Os dados foram analisados por meio de distribuição de frequência, construção de indicadores e análise de correspondência múltipla. Quanto ao perfil dos sujeitos, identificou-se acometimento maior dentre o sexo feminino, faixa etária adulta, indivíduos casados/união estável e solteiros, baixa escolaridade, empregados e predomínio da classe econômica C. Tais características e especificidades sociais e demográficas expõem a complexidade que envolve a assistência às PVHA e, em contiguidade, o controle da TB nesta população. A oferta de ações e serviços para o controle da TB nas PVHA por todos os SAE do município foi considerada regular, reforçando a necessidade de melhor planejamento da assistência de forma integral, articulação dos profissionais nas equipes e entre estas e os demais serviços da rede, além da formação profissional e educação permanente. A integração, de modo geral, foi classificada como satisfatória, entretanto, identificou-se diferentes desempenhos entre os SAE, principalmente no que se refere à abordagem das condições sociais e encaminhamentos realizados, o que permite refletir sobre a complexidade da coordenação da assistência prestada às PVHA. O desafio que se coloca é pensar a integralidade da atenção que articule a oferta de ações e serviços de saúde para o controle da TB, sobretudo, destacando a necessidade de estratégias que favoreçam o desenvolvimento de ações compartilhadas e cooperadas dentro da equipe, entre os programas de TB e HIV/aids e entre os diferentes serviços, com o intuito de fortalecer a rede local de atenção visando a produção de um cuidado integral, singular e resolutivo. Para tanto, urge a necessidade de transformar os conceitos e práticas de saúde que orientam o processo de formação acadêmica no sentido de conceber profissionais capazes de compreensão e ação relativas à integralidade nas práticas de saúde / Tuberculosis (TB) is a major morbidity that affects people living with HIV/ AIDS (PLWHA), and it is considered the leading cause of death among this population. Thus, prevention of TB by HIV/AIDS Care Specialized Services is a prerogative. The study aimed to analyze the supply of health actions and the integration of health services for TB\' prevention and control among PLWHA in treatment at the HIV/AIDS care network in the city of Ribeirão Preto, SP. The theoretical concept of comprehensive care was used, by considering the supply and integration of programs and services within the reference teams and between other professionals/skills/services. This is an exploratory study, survey type, with a quantitative approach. A total of 253 PLWHA participated in the study. They were followed at the five municipal HIV/AIDS Specialized Assistance Services (SAS), and the following inclusion criteria were considered: patients over 18 years old, living in the study site and outside the prison system. Data collection was performed from January 2012 to May 2013, through interviews with the support of a specific instrument. Data were analyzed by frequency distribution, indicators development and multiple correspondence analysis. Regarding the subjects\' profile, we identified a higher prevalence of females, adult age, married/stable union or single, low education, employees and a predominance of economic class C. Such social and demographic characteristics expose the complexity involving the assistance to PLWHA, and, as a result, the complexity of controlling TB in this population. The availability of services for TB control in PLHIV in all five SASs was rated as regular, reinforcing the need for better planning focused on comprehensive care, coordination of professionals inside their teams, as well as between different teams and services, thinking beyond vocational training and continuing education. Although integration was generally rated as satisfactory, SASs presented different performances, especially with regard to addressing the social conditions and establishing referrals, allowing a reflection on the complexity of PLWHA care coordination. The challenge that arises is thinking about an integrated care that articulates the availability of health actions and services for TB control, e highlighting the need for strategies that favor the development of cooperative actions within health teams, between TB and HIV/AIDS programs and among different services in order to strengthen the local care network and develop unique, decisive and comprehensive care. Therefore, there is an urgent need to transform the health concepts and practices that guide the process of academic training to build professionals capable of understanding and acting for comprehensive health practices

Made available in DSpace on 2014-08-20T13:49:48Z (GMT). No. of bitstreams: 1 Roberta Antunes Machado.pdf: 899364 bytes, checksum: f046d9426ba318f617fa9e7b2b2d3633 (MD5) Previous issue date: 2011-03-29 / Aiming to verify the prevalence of training of workers of primary health care was carried out a cross-sectional study with 4749 workers in 41 cities with more than 100 thousand inhabitants in the South and Northeast (NE) of Brazil. The training in infectious diseases and no transmissible chronic diseases were the most realized by the workers in the entire sample (54,5% e 38,5%), in both regions and model of attention. The use of the protocol was 43,7% for all sample and its prevalence was higher in Northeast (47,8%) and in family health strategy (46,4%). Access to publications of Health Ministry was 48,3% for the entire sample, its prevalence was higher in the South (51,2%) and among workers who worked in the family health strategy (56,8%). The differences in the prevalence of outcomes by region and model reaffirm the inherent expectations related to the Family Health Strategy as the model of reorientation of primary health care. The results indicate that despite of training studied composed the normative of primary health care, its prevalence were low, since most of the workers worked on average four years in primary health care. So, the construction of strategies to improve the offer and the encouragement of continuing education and training for these workers is responsibility of Health and Education Ministries. / Com o objetivo de verificar a prevalência de capacitação dos trabalhadores de saúde da atenção básica foi realizado um estudo transversal com 4749 trabalhadores de 41 municípios com mais de 100 mil habitantes das regiões Sul e Nordeste (NE) do Brasil. As capacitações em doenças infecciosas e doenças crônicas não transmissíveis foram as mais realizadas pelos trabalhadores em toda amostra (54,5% e 38,5%), em ambas as regiões e modelo de atenção. O uso de protocolo foi de 43,7% para toda amostra e sua prevalência foi maior no Nordeste (47,8%) e na estratégia saúde da família (46,4%). O acesso a publicações do Ministério da Saúde foi de 48,3% para toda amostra, sua prevalência foi maior no Sul (51,2%) e entre os trabalhadores que atuavam na estratégia saúde da família (56,8%). As diferenças das prevalências dos desfechos por região e modelo reafirmam as expectativas inerentes relacionadas à Estratégia Saúde da Família como modelo de reorientação da atenção básica. Os resultados indicam que apesar das capacitações estudadas fazerem parte das normativas da atenção básica, suas prevalências foram baixas, visto que, grande parte dos trabalhadores atuavam em média há quatro anos na atenção básica. Portanto, cabe aos Ministérios da Saúde e da Educação, a construção de estratégias para melhorar a oferta e o incentivo de educação permanente e treinamento para esses trabalhadores.