Tuberculosis control program in the municipal context: performance evaluation

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1 Rev Súde Púlic 2017;51:23 Originl Article Tuerculosis control progrm in the municipl context: performnce evlution Tiemi Arkw I, Griel Tvres Mgnosco I, Rui Line de Pul Andrde II, Mri Eugeni Firmino Brunello II, Aline Aprecid Monroe II, Antonio Ruffino-Netto III, Luci Mrin Scten IV, Terez Cristin Scten Vill II I Progrm de Pós-Grdução Enfermgem em Súde Púlic. Escol de Enfermgem de Rieirão Preto. Universidde de São Pulo. Rieirão Preto, SP, Brsil II Deprtmento Mterno-Infntil e Súde Púlic. Escol de Enfermgem de Rieirão Preto. Universidde de São Pulo. Rieirão Preto, SP, Brsil III Deprtmento de Medicin Socil. Fculdde de Medicin de Rieirão Preto. Universidde de São Pulo. Rieirão Preto, SP, Brsil IV Deprtmento de Medicin Socil. Fculdde de Medicin. Universidde Federl do Triângulo Mineiro. Uer, MG, Brsil ABSTRACT Correspondence: Tiemi Arkw Ru Itnhém, 198 Vil Mrin Rieirão Preto, SP, Brsil E-mil: tiemi.@gmil.com Received: 15 Jul 2015 Approved: 14 Jn 2016 How to cite: Arkw T, Mgnosco GT, Andrde RLP, Brunello MEF, Monroe AA, Ruffino-Netto A, et l. Tuerculosis control progrm in the municipl context: performnce evlution. Rev Sude Pulic. 2017;51:23. Copyright: This is n open-ccess rticle distriuted under the terms of the Cretive Commons Attriution License, which permits unrestricted use, distriution, nd reproduction in ny medium, provided tht the originl uthor nd source re credited. OBJECTIVE: The ojective of this study is to evlute the performnce of the Tuerculosis Control Progrm in municiplities of the Stte of São Pulo. METHODS: This is progrm evlution reserch, with ecologicl design, which uses three non-hierrchicl groups of the municiplities of the Stte of São Pulo ccording to their performnce in reltion to opertionl indictors. We hve selected 195 municiplities with t lest five new cses of tuerculosis notified in the Notifiction System of the Stte of São Pulo nd with 20,000 inhitnts or more in The multiple correspondence nlysis ws used to identify the ssocition etween the groups of different performnces, the epidemiologicl nd demogrphic chrcteristics, nd the chrcteristics of the helth systems of the municiplities. RESULTS: The group with the worst performnce showed the highest rtes of ndonment (verge [vg] = 10.4, stndrd devition [sd] = 9.4) nd the lowest rtes of supervision of Directly Oserved Tretment (vg = 6.1, sd = 12.9), nd it ws ssocited with low incidence of tuerculosis, high tuerculosis nd HIV, smll popultion, high coverge of the Fmily Helth Strtegy/Progrm of Community Helth Agents, nd eing locted on the countryside. The group with the est performnce presented the highest cure rte (vg = 83.7, sd = 10.5) nd the highest rte of cses in Directly Oserved Tretment (vg = 83.0, sd = 12.7); the group of regulr performnce showed regulr results for outcome (vg cure = 79.8, sd = 13.2; ndonment vg = 9.5, sd = 8.3) nd supervision of the Directly Oserved Tretment (vg = 42.8, sd = 18.8). Lrge popultion, low coverge of the Fmily Helth Strtegy/Progrm of Community Helth Agents, high incidence of tuerculosis nd AIDS, nd eing locted on the cost nd in metropolitn res were ssocited with these groups. CONCLUSIONS: The findings highlight the importnce of the Directly Oserved Tretment in reltion to the outcome for tretment nd rise reflections on the structurl nd mngeril cpcity of municiplities in the implementtion of the Tuerculosis Control Progrm. DESCRIPTORS: Tuerculosis, prevention & control. Progrm Evlution. Qulity Indictors, Helth Cre. Evlution of Helth Services. 1

2 Municipl tuerculosis control Arkw T et l. INTRODUCTION The demnd for evidence cple of evluting the performnce of helth progrms is growing in Brzil 15. Since the proposed chnges in the Helth Pct in 2006, the pnorm of mngement policies hs strengthened the evlution of indictors nd the negotition of gols to improve the ssistnce provided within the context of the Brzilin Unified Helth System (SUS) 21. However, the evlution of progrms is still complex tsk, inserted in similr complex context of epidemiologicl relity nd the orgniztion of helth services present in contemporry society. Certin contgious diseses re closer to the comting logic of chronic diseses thn other communicle diseses of rpid course wht chrcterize them s chronic conditions 14. Interventions relted to the cre of chronic conditions include numerous ctivities involving multiple orgniztions nd professionls over time. In these cses, the difficulty in identifying the responsiility of ech one of these elements is greter in reltion to the results chieved 23. Tuerculosis (TB) is one of the most poignnt exmples of this sitution: n insidious disese, with tretment tht lsts t lest six months, nd which requires, for its ctivities of control, permnent nd coordinted cre etween different services t vrious levels of the helth system 1. Despite the Progrm Ncionl de Controle d TB (PNCT Ntionl TB Control Progrm) formulting nd recommending unique guidelines, the implementtion of TB Control Progrms (PCT) in municiplities is developed in different formts nd results ecuse of numerous dministrtive, politicl, nd geogrphicl specificities of the loctions 6. This peculirity comes together with the process of decentrliztion of TB ctions to the services of Primry Helth Cre (PHC), strted round the 2000s, which dvnced the expnsion of the coverge of TB ctions in the municiplities. However, t the sme time, it generted new chllenges for the municipl PCT s it imposes greter permeility in reltion to the commitments in the control of the disese nd exposes weknesses in the structure nd orgniztion of the entire helth system 3. There re severl possile wys to evlute the performnce on TB control: focus on the performnce of specific ctions, or on services tht operte the progrm, or on the PCT itself s n gency tht gthers certin ttriutes nd ctivities. Nevertheless, ntionl pulictions re scrce round performnce evlution of the PCT regrding the progrm s whole 9. The Stte of São Pulo is relevnt setting for TB control: it is responsile for pproximtely 20.0% of the totl urden of disese in Brzil nd it occupies the sixth plce in incidence in the country. In ddition, there re severl prticulrities in reltion to the orgniztionl context of its helth services, including its own system for the notifiction nd monitoring of TB cses, clled TBWEB 5. Thus, this study hs imed to evlute the performnce of the PCT in the municiplities of the Stte of São Pulo. METHODS Ministério d Súde (BR), Secretri de Vigilânci em Súde, Deprtmento de Vigilânci Epidemiológic. Boletim Epidemiológico. Perspectivs rsileirs pr o fim d tuerculose como prolem de súde púlic. V.47, n.13, This is study of helth evlution with ecologicl design nd descriptive-explortory pproch. We hve used the proposed normtive evlution of progrms developed y Gonçlves 6. This proposl suggests the use of cluster nlysis (CA) for the identifiction of groups of municiplities with different opertionl performnces, followed y further ssocition etween these groups with other dt chrcterizing the context, using multiple correspondence nlysis (MCA). We hve considered the municiplities of São Pulo with 20,000 or more inhitnts nd which hd minimum of five new TB cses, outside the prison system, notified in the TBWEB in Of the 466 municiplities with new TB cses reported in 2010, 197 municiplities meet 2

3 Municipl tuerculosis control Arkw T et l. the criteri nd were included in the study. With the criteri used, the studied municiplities mounted to 95.6% of ll new cses of TB in the Stte of São Pulo in 2010 (n = 14,486). The Stte of São Pulo hs its own system for computing informtion out TB since the 1990s. The Stte hs kept its dtse even fter the ntionl implementtion of the Sistem Ncionl de Agrvos de Notificção Compulsóri (SINAN Ntionl System of Compulsory Notifiction of Diseses) in The dt collected in the Stte of São Pulo using the monthly newsletter nd notifiction form for monitoring include mndtory nd essentil vriles consolidted y other units of the country tht use the SINAN. Additionlly, dt re registered on the discovery of the cse, nme nd ge of the identified contcts, informtion out dmissions, nd numer of doses supervised in the Directly Oserved Tretment (DOT). The TBWEB uses n online formt, in which dt cn e entered nd seen using the Internet throughout the course of TB therpy nd ptients hve unique record (eliminting possile duplictes). The system offers severl fetures for nlysis (cohort, chrts, tles) nd communiction (ility to send messges) using the sme interfce s the record of the dt. Access to TBWEB is restricted to professionls responsile for the epidemiologicl surveillnce in the municiplity. They receive the notifiction records of the cre units tht perform the dignosis nd tretment of the cses nd issue monitoring reports tht will e updted y these tems. The notifiction nd record of the dt of the ptients under tretment is crried out y helth services nd professionls ctive in the cre nd they follow wht is dvocted y the PNCT throughout the country. For the chrcteriztion of the performnce of the PCT, we hve used selection of opertionl indictors proposed in the Mnul of Recommendtions of the Tuerculosis Control Progrm, s well s in prior reserch of Gonçlves 6. They re: Proportion of new cses notified y the municiplity of residence; Proportion of new cses of pulmonry TB with sputum smer microscopy t the eginning of the tretment; Proportion of HIV testing mong new cses; Proportion of HIV testing in progress mong new cses; Proportion of new cses dignosed with cteriologicl confirmtion; Proportion of indiction of DOT nd Proportion of supervision of DOT mong new cses; Proportion of communicnts exmined mong the communicnts identified in new cses; Proportion of ndonment of tretment mong new cses; Proportion of cure mong new cses; nd, Proportion of deth mong new cses. Vriles relted to the ove informtion were collected in the TBWEB in Jnury 2013 nd the clcultion of the indictors ws performed for ech of the municiplities of study y two reserchers independently. The vriles were evluted previously regrding completeness nd they presented more thn 80.0% of filling in the informtion system. Ministério d Súde (BR), Secretri de Vigilânci em Súde, Deprtmento de Vigilânci Epidemiológic. Mnul de recomendções pr o controle d tuerculose no Brsil. Brsíli (DF); Two municiplities were excluded y the impossiility of clculting t lest one opertionl indictor (when the denomintor ws equl to zero), resulting in 195 municiplities under nlysis. After the clcultion of the indictors, we crried out CA pplying the hierrchicl method, using the squred Eucliden distnce s coefficient of similrity. Wrd s method ws used s grouping strtegy, followed y the non-hierrchicl method. The hierrchicl CA identified cutoff point of three groups of municiplities with different performnces, which ws used s strtegy for the implementtion of the non-hierrchicl method. The power of discrimintion of the vriles for the formtion of the groups ws verified y nlysis of vrince, considering the significnce level of 5.0%. We excluded the indictors Proportion of new cses notified y the municiplity of residence, Proportion of new cses of pulmonry TB with sputum smer microscopy t the eginning of the tretment, Proportion of new cses dignosed with cteriologicl confirmtion, nd Proportion of deth mong new cses s they did not show power of discrimintion etween the different groups (p > in the nlysis of vrince). For the MCA, the municiplities of the study were chrcterized in reltion to demogrphic spects (popultion size nd geogrphic loction determined y the region of the Epidemiologicl Surveillnce Group [GVE] of elonging), locl helth systems (Coverge of the Fmily Helth Strtegy [ESF] nd the Progrm of Community Helth Agents [PACS]), s well s the epidemiologicl sitution of TB (prioritiztion of TB control ccording to technicl note from the Ministry of Helth, incidence rte of TB nd 3

4 Municipl tuerculosis control Arkw T et l. pulmonry TB) nd AIDS (incidence of ids nd TB/HIV coinfection). The dt needed for this chrcteriztion were collected in the TBWEB nd on the wesites of the Brzilin Institute of Geogrphy nd Sttistics ( Deprtment of Informtics of the SUS (DATASUS nd Deprtment of Primry Cre/Ministry of Helth ( in Mrch The vriles of context of the municiplities were included in the MCA fter ctegoriztion in three rnges (low, verge nd high) sed on the vlues of the 30 nd 70th percentiles. Such chrcteristics of the municiplities were included in the model of the MCA s ctive vriles, nd the groups of municiplities with different performnces were considered s dditionl vriles. This reserch hs een pproved y the Reserch Ethics Committee of the Escol de Enfermgem de Rieirão Preto, Universidde de São Pulo (Process CAAE /2012). RESULTS The group with unstisfctory performnce ws composed of 63 municiplities, the group with regulr performnce hd 43 municiplities, nd the group with stisfctory performnce hd 89 municiplities. The chrcteriztion of ech group ws performed y the visuliztion of centroids (Figure 1) nd the verges of the opertionl indictors for ech group (Tle). Differences were identified etween the three groups (p = ) in reltion to the indiction of DOT nd its supervision. The groups with unstisfctory nd stisfctory performnce showed sttisticlly different verges regrding ll indictors studied. In ddition to the issues relted to DOT, the stisfctory group nd the regulr group differed in reltion to the unstisfctory group in the proportion of HIV testing in progress (p = ) (Tle). In reltion to the MCA, we hve oserved two dimensions, which recovered 33.5% of the totl vriility of the dt (inerti). Dimension 1 consisted of vriles tht were mostly relted to the epidemiology of the disese nd to demogrphic chrcteristics; dimension 2 consisted of vriles relted to the chrcteristics of the helth system. The perceptul mp (Figure 2) indictes tht the poor performnce of the PCT (group 1) ws ssocited with the municiplities tht present high levels of TB/HIV coinfection, low nd verge incidence rtes of TB nd cilliferous pulmonry TB, eing locted in the countryside of the Stte (negtive side of dimension 1), s well s with non-priority, smll cities, with high coverge of FHS nd PACS (positive side of dimension 2). The regulr (group 2) nd % HIV testing % HIV in progress % Communicnts % Indiction of DOT % Cure % Supervision of DOT % Andonment Group with unstisfctory performnce Group with regulr performnce Group with stisfctory performnce Figure 1. Centroids relted to the groups formed y the non-hierrchicl method. Stte of São Pulo, Brzil,

5 Municipl tuerculosis control Arkw T et l. Tle. Averge opertionl indictors ccording to the groups of municiplities. Stte of São Pulo, Brzil, Indictor Proportion of HIV testing mong new cses Proportion of HIV testing in progress mong new cses Proportion of communicnts exmined mong the communicnts identified in new cses Proportion of indiction of Directly Oserved Tretment mong new cses Proportion of supervision of Directly Oserved Tretment mong indicted cses Proportion of cure mong new cses with informtion on the outcome Proportion of ndonment of tretment mong new cses with informtion on the outcome Unstisfctory group (n = 63) Regulr group (n = 43) Stisfctory group (n = 89) F-test Averge (SD) Averge (SD) Averge (SD) c 83.0 c * * * * * * * Different letters indicte sttisticlly different verges y Tukey test (p < 0.005). * p < 0.05 y prmetric ANOVA test. 2.0 Dimension 2, vlues: 0,25327 (13,41% of inerti) 1.5 Cost TBP_3 ESF_3 PACS_3 TB_3 1.0 Smll AIDS_1 Group: Reg. 0.5 AIDS_3 TBHIV_1 Priority:N Group: Stisf. 0.0 Countryside Averge GSP nd C TB_1-0.5 TBP_1 Group: Unst. AIDS_2 Lrge TBHIV_2 Priority:S -1.0 PACS_2 TBHIV_3 ESF_2-1.5 TB_2 ESF_1 TBP_2 PACS_ Dimension 1, Vlues: 0,34103 (18,05% of inerti) Smll: smll popultion; Averge: verge popultion, Lrge: lrge popultion; Countryside: Countryside region; Cost: Costl region; GSP nd C: Region of Greter São Pulo nd Cpitl; Priority: S: priority for TB control; Priority: N: Non-priority for TB control; TB_X: Incidence rte of TB nd its respective rnges (1 low, 2 verge, 3 high); TBP_X: Incidence rte of cilliferous pulmonry TB nd its respective rnges (1 low, 2 verge, 3 high); AIDS_X: Incidence rte of AIDS nd its respective rnges (1 low, 2 verge, 3 high); TBHIV_X: proportion of cses of TB/HIV coinfection nd its respective rnges (1 low, 2 verge, 3 high); ESF_X: coverge of the Fmily Helth Strtegy nd its respective rnges (1 low, 2 verge, 3 high); PACS_X: coverge of the Progrm of Community Helth Agents nd its respective rnges (1 low, 2 verge, 3 high) Figure 2. Perceptul mp of ssocition etween groups, demogrphic nd epidemiologicl chrcteristics, nd chrcteristics of the orgniztion of the helth system on TB nd AIDS,

6 Municipl tuerculosis control Arkw T et l. stisfctory performnce (group 3) of the PCT ws ssocited with municiplities tht hd high nd verge incidence rtes of AIDS nd moderte TB/HIV coinfection, high incidence of TB nd cilliferous pulmonry TB, eing locted in the metropolitn region nd on the cost (positive side of dimension 1), s well s priority municiplities, with low to verge coverge of FHS nd PACS (negtive side of dimension 2). DISCUSSION The differences identified in the different performnce groups y the CA llow us to reflect on the reltionship etween the PCT, s plyer of the meso-mngement, nd the locus of helth services, s micro-mngement spces. Among these differences, we highlight the est result of the coverge of the DOT ccompnied y higher rtes of cure nd smller index of ndonment, which possily reffirms the influence of the strtegy of the DOT in chieving fvorle outcome for the tretment. The lower supervision in reltion to the totl of ptients indicted for DOT ws expressive in the unstisfctory nd regulr groups, indicting wekness in the development of the strtegy. Severl issues relted to the implementtion of the DOT come from the mngement of municipl coordintors nd depend on the rticultion etween plyers nd sectors. Among them we cn mention the offering of incentives, such s food stmps, rekfst, nd trnsporttion vouchers, s well s humn resources in sufficient numer nd vehicles for home visits 7. The vilility of these instruments influences the cceptility of helth professionls in reltion to the prctice nd the sustinility to crry them out in the dily service nd must e considered to understnd the results of this study. Despite the different experiences recorded under the nme of the DOT, the strtegy goes eyond the simple oservtion of drug intke. It must e considered s cre mngement technology with n integrted nd humnized pproch 16. Thus, in ddition to the orgniztion nd vilility of the resources mentioned, the good performnce in the supervision of the DOT requires reordering of the cre prctices nd the process of work of helth professionls 13. In this study, fvorle results relted to nti-hiv testing mong new TB cses reched proportion ove 75.0% even mong the group with the worst performnce. Such results cn e explined y the time of implementtion of the nti-hiv rpid test in the network of services in São Pulo strted in mid The trining of the tems responsile for monitoring the TB cses, to crry out the testing in priority municiplities 19 which coincide with the res ssocited with good performnce (cost nd Greter São Pulo), cn signl the enefits of previous experiences of prtnerships etween the progrm of AIDS nd TB control. The control of communicnts lso presented considerle proportions even in the group of unstisfctory performnce. We question the process to produce the dt used to clculte the indictor. The under detection of intr-household communicnts, the gps in the clinicl evlution of contcts, nd the low numer of tests re mentioned in study crried out in the South of Brzil, which rises the need for more reserch to understnd the results 10. Regrding the results identified y the MCA, we need to consider the structurl conformtion of the network of services, the dynmics of the cre model, nd the issues tht delves into the reltions etween the meso- nd mcro-mngement (level tht corresponds to the sphere of helth policies nd the decision-mking nd regultory power). The results show tht the high incidence of TB nd AIDS re epidemiologicl spects of the prioritiztion of ctions of control, which serve s forml tool of visiility of the prolems surrounding the disese. The ssocition etween unstisfctory performnce nd high TB/HIV coinfection points to the need for incresed vigilnce nd improvement in the 6

7 Municipl tuerculosis control Arkw T et l. mngement of cses tht re more vulnerle nd t greter clinicl nd ndonment risk even in plces with less urden of TB. Smll municiplities generlly hve lower popultion qulifiction in mngement positions nd functions nd low humn resources, while lrge municiplities hve greter mngeril nd regultory cpcity 22. These differences my explin the ssocition of etter performnce with lrger popultions, s they more frequently hve the instruments to mintin the politicl commitment round the opertionliztion of the TB progrm nd ensure the resources necessry for the PCT. Both in lrge nd in smll municiplities, the dministrtive discontinuity, the lck of utonomy in executive decisions, the politicl ptronge, nd the conflict of interests etween the different politicl-prty options ffect the degree of coopertion chieved etween the mcro nd meso-mngement. They re prolems commonly fced y coordintors of TB progrms in the execution of their ctivities 18. Lrger municiplities nd in urn regions usully hve wider rnge of own/contrcted services. They hve greter trend in the orgniztion nd offer of cre of medium nd high complexity 8. On the other hnd, these municiplities hve greter difficulty to implement strtegies, such s the FHS nd PACS, either ecuse of insufficient popultion coverge y the PHC, or ecuse of ineffective reference systems etween the levels of complexity, or ecuse of the low presence of professionls in these services 4. The very dynmics of the helth-disese process nd the use of helth services in mjor urn centers indicte pttern of helth cre consumption sed on speciliztion, which wekens the implementtion nd sustinility of the PHC 8. The ssocition etween incresed coverge of the FHS nd PACS nd the group of municiplities with the worst performnce my suggest tht strtegies for the strengthening of the PHC do not lwys produce ctions in line with the needs of their territories. In ddition, the lck of professionl expertise in the mngement of cses my led to unfvorle results, discussion lso rised in the rticle of Ymmur et l. 24 The consolidtion of new cre model in the PHC is not only chrcterized y the singulrities of the horizontl dimension of extension s expressed y the coverge of strtegies, such s the FHS nd PACS, ut lso y the verticl dimension of the depth of its institutionliztion 14. We need to consider the discrepncy etween the conception of the PHC in the design of the ntionl policy nd its expression in locl relities 4,11. In ddition, the decentrliztion of TB ctions for the PHC is chrcterized s deconcentrtion of ctivities in scenrio of high turnover of professionls nd ccumultion of functions 3,4. Unstisfctory performnces of TB control re n importnt messge in reltion to the qulity of the helth cre nd the cre models prcticed in the relity of helth services. Tht is ecuse the sujects with TB experience the weknesses of the pulic helth system s whole in greter frequency nd intensity. Although this study hs selected the coverge of the FHS nd PACS s strtegic indictor for the chrcteriztion of the helth system, the decentrliztion of control ctions for PHC cnnot e nlyzed seprtely 13. We need to consider the lortory support, the flows, the communiction etween levels, tht is, the network needs to e orgnized round cre line, which enles the coordintion of the cre provided in ll its phses nd fcilittes the pproprite service for every need/profile of T cse 2,12. In the context of the meso-mngement, the coordintor of the PCT must know the helth cre network nd how the process of work of tems nd services tht will detect, dignose, nd tret TB cses is crried out. In ddition, the mngement tem of the PCT must rticulte the inclusion of the suject of TB in the existing mtrix of strtegies nd guide the disese nd its control in permnent eduction ctivities 17. These tools cn e wy to fce the lck of knowledge on TB y the professionls working on PHC 17. 7

8 Municipl tuerculosis control Arkw T et l. The coordintors in TB must strengthen their mngement ction y incorporting instruments such s helth plns nd reports, vlule documents tht give pulic knowledge on helth ctions, nd y plnning ctions of indirect (such s routines relted to the nlysis of the informtion ville) nd direct monitoring (such s visits/meetings with helth professionls nd other plyers involved in the provision of cre) 20,c. The PNCT itself promotes ctivities of monitoring nd evlution since 2000, mking visits to priority Sttes nd municiplities in order to contriute politiclly nd techniclly to improve the responsiveness to TB. This is positive exmple of the prtnership etween different federted entities whose model cn serve s reference to locl mngers. The method of evlution developed provides possiilities for understnding the performnce of locl PCT. However, we ssume s wekness the unknown vlues of other indictors or vriles le to explore in greter depth the context in which helth interventions re performed. Future studies re needed on this suject. REFERENCES 1. Atun R, Weil DE, Eng MT, Mwkyus D. Helth-system strengthening nd tuerculosis control. Lncet. 2010;375(9732): Brrêto AJR, Sá LD, Nogueir JA, Plh PF, Pinheiro PGOD, Fris NMP, et l. Orgnizção dos serviços de súde e gestão do cuiddo à tuerculose. Cienc Sude Coletiv. 2012;17(7): Cunh NV, Cvlcnti MLT, Cost AJL. Dignóstico situcionl d descentrlizção do controle d tuerculose pr Estrtégi Súde d Fmíli em Jrdim Ctrin, São Gonçlo (RJ), Cd Sude Coletiv. 2012;20(2): Escorel S, Giovnell L, Mendonç MHM, Senn MCM. O Progrm de Súde d Fmíli e construção de um novo modelo pr tenção ásic no Brsil. Rev Pnm Slud Pulic. 2007;21(2-3): Glesi VMN. Ddos de tuerculose do Estdo de São Pulo. Rev Sude Pulic. 2007;41Supl 1: Gonçlves MJF. Avlição de Progrm de Súde: o Progrm Ncionl de Controle de Tuerculose no Brsil. Sude Trnsform. Soc. 2012;3(1): Gonzles RIC, Monroe AA, Assis EG, Plh PF, Vill TCS, Ruffino-Netto A. Desempenho de serviços de súde no trtmento diretmente oservdo no domicílio pr controle d tuerculose. Rev Esc Enferm USP. 2008;42(4): Iñez N, Roch JSY, Cstro PC, Rieiro MCSA, Forster AC, Noves Mri HD, et l. Avlição do desempenho d tenção ásic no Estdo de São Pulo. Cienc Sude Coletiv. 2006;11(3): Kritski AL, Vill TS, Trjmn A, Lp e Silv JR, Medronho RA, Ruffino-Netto A. Dus décds de pesquis em tuerculose no Brsil: estdo d rte ds pulicções científics. Rev Sude Pulic. 2007;41 Supl 1: Lim LM, Schwrtz E, Crdozo-Gonzles RI, Hrter J, Lim JF. O progrm de controle d tuerculose em Pelots/RS, Brsil: investigção de conttos intrdomicilires. Rev Guch Enferm. 2013;34(2): Mchdo CV, Lim LD, Vin LS. Configurção d tenção ásic e do Progrm Súde d Fmíli em grndes municípios do Rio de Jneiro, Brsil. Cd Sude Pulic. 2008;24 Supl 1:s c Ministério d Súde (BR), Secretri de Vigilânci em Súde, Deprtmento de Vigilânci Epidemiológic. Experiêncis de monitormento e vlição no controle d tuerculose no Brsil. Brsíli (DF); Mlt DC, Merhy EE. O percurso d linh do cuiddo so perspectiv ds doençs crônics não trnsmissíveis. Interfce Comun Sude Educ. 2010;14(34): Mrcolino ABL, Nogueir JA, Ruffino-Netto A, Mores RM, Sá LD, Vill TCS, et l. Avlição do cesso às ções de controle d tuerculose no contexto ds equipes de súde d fmíli de Byeux - PB. Rev Brs Epidemiol. 2009;12(2):

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