Políticas e estratégias para a qualidade em sistemas de saúde: lições globais e proposta de um instrumento para o Sistema Único de Saúde

Abstract

The Unified Health System has adopted various initiatives to guarantee quality care, but in a fragmented way. The World Health Organization recommends integrating these actions into a national policy and strategy, evaluating their implementation throughout the system. This study aims to identify instruments for evaluating policies and strategies for quality in health systems and propose an instrument for analyzing their completeness adapted to the context of the Unified Health System. The specific objectives include: a) mapping studies on the evaluation of national policies and strategies for quality in health systems around the world; b) identify available instruments for analyzing strategic interventions for quality; c) describe policies and strategies for quality in health systems in light of the recommendations of the World Health Organization and d) cross-culturally adapt an instrument for measuring strategic interventions for quality of care in the Unified Health System. The research combines two designs: 1) Scoping Review and 2) Cross-Cultural Adaptation of a Measurement Instrument. The review follows the JBI guidelines and the Arksey and O'Malley model, updated by Levac et al.. with searches conducted in databases and gray literature in July 2024. The cross-cultural adaptation involved the translation of the “Questionnaire for Quality of Care Interventions in Health Systems” into Portuguese, conducted between August 2024 and March 2025, according to the updated model by Beaton et al.. The equivalence analyses usually used in crosscultural adaptations were replaced by face validity, content and feasibility analyses to better align them with the object of study and the Brazilian context. To assess the level of agreement, the Delphi Consensus Technique was used, applied to a panel of experts with recognized experience in the field. The review identified 14 documents, nine from databases and five from gray literature, on national quality policies and strategies in health systems. Experiences from various countries were highlighted, including North America, Europe, Africa and Asia. In addition to geographical diversity, the support of international agencies such as the World Health Organization and the World Bank was highlighted, especially in the countries of the Global South. For the adaptation study, an integrated theoretical model was developed which represents the perspective adopted in the questionnaire. The results in the first round indicated an average CVI of 0.93 for face validation and 0.90 for content validation. In the second round, the average CVI was 0.96 for both validations. Although most of the criteria were validated in conceptual terms, adjustments were necessary to ensure their applicability in the Unified Health System. The scoping review revealed variations between countries in the implementation of quality policies and strategies. The presence of governance structures in most of the experiences analyzed stands out, but so does the scarcity of evidence on their impact on health systems. The findings reinforce the need for an integrated model to evaluate and improve quality initiatives. The thesis presents the initial results of the adaptation and validation of the questionnaire which, after analysis by experts, was consolidated into 30 items, distributed into six strategic domains for quality. The purpose of this instrument is to monitor and evaluate quality in the Unified Health System. Given that the validation process takes place in multiple stages, future studies are recommended to improve its validity and reliability.