Abstract

This paper describes and analyzes the legal and normative framework guiding the use of mobile units in Portugal, United States and Brazil, which seek to improve access and continuity of care for people in homelessness. We used a comparative analysis through literature and documentary review relating three categories: context (demographic, socio-economic and epidemiological), services system (access, coverage, organization, management and financing) and, specifically, mobile units (design, care and financing model). The analysis was based on the theory of convergence/divergence between health systems from the perspective of equity in health. Improving access, addressing psychoactive substances abuse, outreach and multidisciplinary work proved to be common to all three countries, with the potential to reduce inequities. Relationships with primary healthcare, use of vehicles and the type of financing are considered differently in the three countries, influencing the greater or lesser extent of equity in the analyzed proposals.

People in homelessness; Health; Portugal; United States of America; Brazil

Introduction

Ensuring access also to vulnerable groups has become an objective of some contemporary health systems, as evidenced by the development of new care models¹1. Massignam FM, Bastos JLD, Nedel FB. Discriminação e saúde: um problema de acesso. Epidemiol e Serviços Saúde 2015; 24(3):544-541.. This paper describes and analyzes proposals aimed at people in homelessness in Portugal, the United States (USA) and Brazil, respectively called Street Teams, Mobile Outreach Clinics and Clinics on the Street.

Under the category “people in homelessness” (PIH) are individuals who share the condition of extreme poverty, the use of streets and public spaces (or possibly hostels) as a primary place of survival, overnight stay and personal relationships, on a temporary or permanent basis. On the other hand, they evidence heterogeneous reasons for going to the streets and life strategies²2. Mattos RM. Situação de rua e modernidade: a saída das ruas como processo de criação de novas formas de vida na atualidade. São Paulo: Universidade São Marcos; 2006.,³3. Brasil. Ministério da Saúde (MS). Manual sobre o cuidado à saúde junto a população em situação de rua. Brasília: MS; 2012.. PIH make up excess population groups that do not keep pace with socio-economic transformations and/or are victims of circumstances – environmental disasters, expropriation, forced migration, etc. The mismatch in relation to the current social model leads to negative discrimination and repressive actions⁴4. Bauman Z. Vidas desperdiçadas. Rio de Janeiro: Jorge Zahar; 2005., since they are considered by society as “an inconvenient and threatening presence”⁵5. Varanda W, Adorno RCF. Descartáveis urbanos: discutindo a complexidade da população de rua e o desafio para políticas de saúde. Saude Soc 2004; 13(1):56-69.. The prevalence of mental disorders and alcohol abuse and other drugs use adds to PIH breaking with their social networks and protective groups, increasing their vulnerability⁶6. Silva MLL. Mudanças Recentes no Mundo do Trabalho e o Fenômeno População em Situação de Rua no Brasil - 1995 a 2005. Brasília: Universidade de Brasília; 2006..

PIH are by the thousands in Brazil, the United States and Portugal⁷7. Estados Unidos da América. The 2013 Annual Homeless Assessment Report (AHAR) to Congress [Internet]. Washington D.C.; 2013. [cited 2016 Jan 10]. Available from: https://www.hudexchange.info/resources/documents/ahar-2013-part1.pdf
https://www.hudexchange.info/resources/d...

8. Pereira AC, Oliveira M. Mais de cinco mil pessoas sem abrigo em Portugal. Público [Internet]. 2014 Mar 31. [cited 2016 Jan 10]. Available from: https://www.publico.pt/sociedade/noticia/mais-de-cinco-mil-pessoas-sem-abrigo-em-portugal-1630338
https://www.publico.pt/sociedade/noticia... -⁹9. META. Relatório final. Pesquisa Censitária e Amostral. População em situação de rua. Porto Alegre; 2008., where problems of access and continuity of health care are identified due to the inadequacy of services to the particularities of this group³3. Brasil. Ministério da Saúde (MS). Manual sobre o cuidado à saúde junto a população em situação de rua. Brasília: MS; 2012.,¹⁰10. Post P. Mobile Health Care for Homeless People : Using Vehicles to Extend Care. Nashville: National Health Care for the Homeless Council; 2007.,¹¹11. Portugal. Estratégia Nacional para integração de pessoas sem-abrigo. Lisboa; 2009. and the stigma they suffer, including from workers¹²12. Borysow IDC, Furtado JP. Access, equity and social cohesion: evaluation of intersectoral strategies for people experiencing homelessness. Rev da Esc Enferm da USP 2014; 48(6):1069-1076.. Faced with these challenges, some countries have adopted outreach and roaming strategies to overcome limitations of spontaneous demand for this group¹³13. Lemke RA, Silva RAN. A busca ativa como princípio político das práticas de. Estud e Pesqui em Psicol 2010; 10(1):281-295.. Such strategies are characterized by teams moving into the territory in order to reach people who are refractory or unsuitable for health networks¹⁴14. Lemke RA, Silva RAN. Um estudo sobre a itinerância como estratégia de cuidado no contexto das políticas públicas de saúde no Brasil. Physis 2011; 21(3):979-1004., overcoming hurdles to access to conventional services²2. Mattos RM. Situação de rua e modernidade: a saída das ruas como processo de criação de novas formas de vida na atualidade. São Paulo: Universidade São Marcos; 2006.,⁵5. Varanda W, Adorno RCF. Descartáveis urbanos: discutindo a complexidade da população de rua e o desafio para políticas de saúde. Saude Soc 2004; 13(1):56-69.,¹⁵15. Borysow IDC, Furtado JP. Acesso e intersetorialidade: O acompanhamento de pessoas em situação de rua com transtorno mental grave. Physis 2013; 23(1):33-50..

Countless political, technical and institutional issues emerge from the itinerant care proposals. In Brazil, the Clinic on the Street initiative totals 129 facilities¹⁶16. Brasil. Consultório na Rua [Internet]. Observatório Crack é possível vencer. 2011 [cited 2016 Jan 10]. Available from: http://www.brasil.gov.br/observatoriocrack/cuidado/consultorio-na-rua.html
http://www.brasil.gov.br/observatoriocra... and, despite its numerical expansion and complex actions, the number of studies on the subject is still limited¹⁷17. Londero MFP, Ceccim RB, Bilibio LFS. Consultório de/na rua: desafio para um cuidado em verso na saúde. Interface (Botucatu) 2014; 18(49):251-260.

18. Pacheco MEAG. Políticas Públicas e capital social: o projeto Consultório de Rua. Fractal, Rev Psicol 2014; 26(1):43-58.

19. Hallais JAS, Barros NF. Consultório na Rua: visibilidades, invisibilidades e hipervisibilidade. Cad Saude Publica 2015; 31(7):1497-504.-²⁰20. Ferreira CPS, Rozendo CA, Melo GB. Consultório na Rua em uma capital do Nordeste brasileiro: o olhar de pessoas em situação de vulnerabilidade social. Cad Saude Publica 2016; 32(8):1-10.. This research seeks to contrast what is common and diverse between the standards geared to PIH itinerant health care, relating national socioeconomic and institutional contexts. It also aims to highlight the contributions and limitations of health equity initiatives for its target population, that is, to analyze the investment and organization of systems and services in the differential and fair treatment of a population that experiences inequalities²¹21. Vieira-da-silva LM. Eqüidade em saúde: uma análise crítica de conceitos. Cad Saúde Publica 2009; 25(Supl. 2):217-226., such as PIH. Given the lack of comparative studies on this subject, we will place the Brazilian proposal under a comparative international perspective, so that the experience of other countries represents an analytical mirror²²22. Fleury S. Democracia, descentralização e desenvolvimento: Brasil e Espanha. Rio de Janeiro: FGV; 2006. and provides useful elements for the transfer of knowledge in this field²³23. James O, Lodge M. The Limitations of ’Policy Transfer and ’Lesson Drawing for Public Policy Research. Polit Stud Rev 2003; 1(2):179-193. and subsidies for future studies.

Methodology

Comparison is the analytical resource²⁴24. Yin R. Estudo de caso: planejamento e métodos. 3a ed. Porto Alegre: Bookman; 2005. of this multiple case study²⁵25. Conill EM. Sistemas Comparados de Saúde. In: Tratado de Saúde Coletiva. Rio de Janeiro: Hucitec, Fiocruz; 2006. p. 563-614.. We outline the focus on the PIH itinerant initiatives in Portugal, the United States of America and Brazil. We chose the U.S. based on the pioneering provision of this type of service and the volume of indexed publications on the subject; Portugal was chosen for its cultural proximity and similarities between the principles and organizational design of the Portuguese National Health System (SNS) and the Brazilian Unified Health System (SUS).

We define as units of analysis proposals by the federal governments regarding mobile services, considering the national socio-political situation and national health systems²⁶26. Conill EM. A análise comparada na avaliação de serviços e sistemas de saúde. In: Desafios da avaliação de programas e serviços em saúde. Campinas: Unicamp; 2011.. We define three descriptive categories: context, characteristics of the service system and facilities. The first uses a set of indicators that act as approaches (proxy variable) to locate the main factors that influence the health situation – demographic, socioeconomic and epidemiological indicators. We include in this item indicators of health problems with a higher prevalence among PIH, such as alcohol abuse and other drugs use³3. Brasil. Ministério da Saúde (MS). Manual sobre o cuidado à saúde junto a população em situação de rua. Brasília: MS; 2012.,⁹9. META. Relatório final. Pesquisa Censitária e Amostral. População em situação de rua. Porto Alegre; 2008.,²⁷27. Goering P, Tomiczenko G, Sheldon T, Boydell K, Wasylenki D. Characteristics of persons who are homeless for the first time. Psychiatr Serv 2002; 53(11):1472-1474., mental disorders²⁸28. Heckert U, Silva J. Psicoses esquizofrênicas entre a população de rua. Rev Psiq Clín 2002; 29(1):14-19.

29. North C, Pollio D, Smith E, Spitznagel E. Correlates of early onset and cronicity of homelessness in a large urban homeless population. J Nerv Ment Dis 1998; 186(7):393-400.-³⁰30. Cauce A, Paradise M, Ginzler J, Embry L. The characteristics and mental health of homeless adolescents: age and gender differences. J Emot Behav Disord 2000; 8(4):230-239., HIV/AIDS³3. Brasil. Ministério da Saúde (MS). Manual sobre o cuidado à saúde junto a população em situação de rua. Brasília: MS; 2012.,³¹31. National Coalition for the Homeless. HIV/AIDS and homelessness [Internet]. 2009 [cited 2016 Sep 5]. Available from: http://www.nationalhomeless.org/factsheets/hiv.html
http://www.nationalhomeless.org/factshee... and tuberculosis³²32. Brasil. Ministério da Saúde (MS). Manual de Recomendações para o Controle da Tuberculose no Brasil: Populações Especiais. Brasília: MS; 2011.

33. Duarte R, Diniz A. Relatório para o Dia Mundial da Tuberculose. Lisboa: Programa Nacional de Luta Contra Tuberculose; 2013. Vol. I.

34. Paulino J, Martins A, Machado M, Gomes M, Gaio AR, Duarte R. Tuberculosis in native- and foreign-born populations in Portugal. Int J Tuberc Lung Dis 2016; 20(3):357-362.

35. U.S. Department of Health & Human Services. Centers of Disease Control and Prevention. TB in the Homeless Population [Internet]. 2013 [cited 2016 Sep 1]. Available from: http://www.cdc.gov/tb/topic/populations/homelessness/default.htm
http://www.cdc.gov/tb/topic/populations/... -³⁶36. Bamrah S, Yelk Woodruff RS, Powell K, Ghosh S, Kammerer JS, Haddad MB. Tuberculosis among the homeless, United States, 1994-2010. Int J Tuberc Lung Dis 2013; 17(11):1414-1419. – considering the low amount of specific PIH health data in Portugal and Brazil. We also consider PIH estimates, however, it is necessary to consider the limits of its validity due to the difficult operationalization and use of different methodologies⁷7. Estados Unidos da América. The 2013 Annual Homeless Assessment Report (AHAR) to Congress [Internet]. Washington D.C.; 2013. [cited 2016 Jan 10]. Available from: https://www.hudexchange.info/resources/documents/ahar-2013-part1.pdf
https://www.hudexchange.info/resources/d...

8. Pereira AC, Oliveira M. Mais de cinco mil pessoas sem abrigo em Portugal. Público [Internet]. 2014 Mar 31. [cited 2016 Jan 10]. Available from: https://www.publico.pt/sociedade/noticia/mais-de-cinco-mil-pessoas-sem-abrigo-em-portugal-1630338
https://www.publico.pt/sociedade/noticia... -⁹9. META. Relatório final. Pesquisa Censitária e Amostral. População em situação de rua. Porto Alegre; 2008..

The context description summarizes the history of health systems, placing the political-institutional option against the social protection in health prevalent in each country. The operationalization of the systems’ characteristics prioritized access, coverage, organization and management of services and the financing method, as expressed in the normative and legal framework²⁵25. Conill EM. Sistemas Comparados de Saúde. In: Tratado de Saúde Coletiva. Rio de Janeiro: Hucitec, Fiocruz; 2006. p. 563-614.,³⁷37. Pereira AMM, Castro ALB, Malagón Oviedo RA, Barbosa LG, Gerassi CD, Giovanella L. Atenção primária à saúde na América do Sul em perspectiva comparada: mudanças e tendências. Saúde em Debate 2012; 36(94):482-499.. Mobile units were described according to their design, care model and financing.

This paper is based on bibliographical and documentary review, considering laws, governmental ordinances and health sector booklets, among others. Scientific papers were identified through SciELO, PubMed and Google Scholar databases, with the following combinations of terms: in English, “mobile outreach services” and “homeless”, “mobile health” and “homeless”, “mobile unit health service” and “homeless”, and in Portuguese “saúde” (health) and “morador de rua” (homeless). The analysis systematizes similarities and differences between the proposals of mobile units, based on the theory of convergence / divergence between contemporary systems²⁵25. Conill EM. Sistemas Comparados de Saúde. In: Tratado de Saúde Coletiva. Rio de Janeiro: Hucitec, Fiocruz; 2006. p. 563-614.,³⁸38. Saltman R. Convergence versus social embeddedness. Debating the future direction of health care systems. Eur J Public Health 1997; 7(4):449-453..

Results - context, health systems and structuring of mobile teams in the three countries

Portugal and Street Teams

In 2013, the estimated population for Portugal was over 10 million inhabitants, with a demographic profile marked by low fertility and aging population³⁹39. Organisation for Economic Co-operation and Development (OECD). OECD Labour Force Statistics 2015 [Internet]. OECD Labour Force Statistics. OECD Publishing; 2016 (OECD Labour Force Statistics). [cited 2016 Feb 2]. Available from: http://www.oecd-ilibrary.org/employment/oecd-labour-force-statistics-2015_oecd_lfs-2015-en
http://www.oecd-ilibrary.org/employment/... . In that same year, there were approximately 5,000 PIH, 0.04% of the total population⁸8. Pereira AC, Oliveira M. Mais de cinco mil pessoas sem abrigo em Portugal. Público [Internet]. 2014 Mar 31. [cited 2016 Jan 10]. Available from: https://www.publico.pt/sociedade/noticia/mais-de-cinco-mil-pessoas-sem-abrigo-em-portugal-1630338
https://www.publico.pt/sociedade/noticia... . In Lisbon, the 2015 survey identified a majority of single, divorced or widowed Portuguese men with low schooling and no vocational training⁴⁰40. AMI atendeu 1.511 sem-abrigo em 2014, menos 10% face ao ano anterior. RTP Notícias [Internet]. 2015. [cited 2016 Mar 20]. Available from: http://www.rtp.pt/noticias/pais/ami-atendeu-1511-sem-abrigo-em-2014-menos-10-face-ao-ano-anterior_n826338
http://www.rtp.pt/noticias/pais/ami-aten... .

The per capita Gross Domestic Product (GDP) is US$ 22,080 with a very high Human Development Index (HDI), and a Gini Index of 36,0⁴¹41. Organisation for Economic Co-operation and Development (OECD). Inequality [Internet]. Income Inequality. 2012 [cited 2016 Mar 20]. Available from: https://data.oecd.org/inequality/income-inequality.htm
https://data.oecd.org/inequality/income-... ,⁴²42. Programa das Nações Unidas para o Desenvolvimento. Ranking IDH Global 2014 [Internet]. 2014 [cited 2016 Mar 25]. Available from: http://www.pnud.org.br/atlas/ranking/Ranking-IDH-Global-2014.aspx
http://www.pnud.org.br/atlas/ranking/Ran... . When Portugal joined the European Union in 1986, there was a period of improvement in socioeconomic indicators, but they started to recede by mid-2009 with the worsening of the financial crisis in this geopolitical space, together with austerity social policies⁴³43. Observatório Português dos Sistemas de Saúde. Relatório de Primavera 2015 - Acesso aos Cuidados de Saúde. Um direito em risco? [Internet]. Lisboa; 2015. [cited 2016 Mar 25]. Available from: http://www.opss.pt/sites/opss.pt/files/RelatorioPrimavera2015.pdf
http://www.opss.pt/sites/opss.pt/files/R... .

The SNS was created in 1979, based on ensured universal access, tax-derived financing and partial decentralization of responsibilities in the provision of care to Regional Health Administrations (ARS); but the SNS started with low funding, little development of own services and access problems. Since 1990, the private sector increased its participation in the SNS in an international context of strengthening the neoliberal model⁴⁴44. Santos CBG. Disparidades na Distribuição Geográfica de Recursos de Saúde em Portugal. Braga: Universidade do Minho; 2012..

There was a gradual favoring of the primary healthcare model, but in spite of its good performance⁴⁴44. Santos CBG. Disparidades na Distribuição Geográfica de Recursos de Saúde em Portugal. Braga: Universidade do Minho; 2012.,⁴⁵45. Observatório Português dos Sistemas de Saúde. Relatório Primavera 2014 - Saúde: síndroma de negação [Internet]. Lisboa; 2014 Nov. [cited 2016 Mar 25]. Available from: http://www.opss.pt/sites/opss.pt/files/RelatorioPrimavera2014.pdf
http://www.opss.pt/sites/opss.pt/files/R... , its implementation was reduced with the recent economic crisis. By 2013, spending remained predominantly public (66% of the total), with an increase in private expenditure (out-of-pocket and insurance)⁴⁶46. Organisation for Economic Co-operation and Development (OECD). Health Resources [Internet]. 2013. [cited 2016 Mar 25]. Available from: http://www.oecd-ilibrary.org/social-issues-migration-health/health-resources/indicator-group/english_777a9575-en
http://www.oecd-ilibrary.org/social-issu... . Thus, there are now three health subsystems in Portugal: SNS, insurance of some professional categories and private insurance.

Some Portuguese health indicators are close to the average of the other countries of the Organization for Economic Cooperation and Development (OECD), while others – such as cerebrovascular disease mortality, mental health care and, mainly, HIV/AIDS prevalence – show an unfavorable situation in all European countries⁴⁵45. Observatório Português dos Sistemas de Saúde. Relatório Primavera 2014 - Saúde: síndroma de negação [Internet]. Lisboa; 2014 Nov. [cited 2016 Mar 25]. Available from: http://www.opss.pt/sites/opss.pt/files/RelatorioPrimavera2014.pdf
http://www.opss.pt/sites/opss.pt/files/R... ,⁴⁷47. Organisation for Economic Co-operation and Development (OECD). Health at a Glance 2011: OECD indicators [Internet]. 2011. [cited 2016 Mar 25]. Available from: dx.doi.org/10.1787/health_glance-2011-15-en
dx.doi.org/10.1787/health_glance-2011-15... . In addition, in 2012, 2.7% of the population reported having used some type of drug in the last 12 months, excluding alcohol and tobacco⁴⁸48. Portugal. Ministério da Saúde (MS). Serviço de Intervenção nos Comportamentos Aditivos e nas Dependências. Sinopse Estatística. Lisboa: MS; 2014., and in 2013, a high rate of alcohol consumption per person per year was observed⁴⁹49. Organisation for Economic Co-operation and Development (OECD). Health at a Glance 2013. Paris: OECD Publishing; 2013.. Few cases of tuberculosis were estimated in 2014⁵⁰50. World Health Organization. Incidence of tuberculosis (per 100,000 people) [Internet]. 2014. [cited 2016 Jan 10]. Available from: http://data.worldbank.org/indicator/SH.TBS.INCD
http://data.worldbank.org/indicator/SH.T... , and neuropsychiatric disorders contributed to 25.6% of the global burden of disease.

HIV/AIDS and psychoactive substance use indices have been the argument for the implementation of mobile health teams since 2001, such as Street Teams (ER), aimed at drug users⁴⁵45. Observatório Português dos Sistemas de Saúde. Relatório Primavera 2014 - Saúde: síndroma de negação [Internet]. Lisboa; 2014 Nov. [cited 2016 Mar 25]. Available from: http://www.opss.pt/sites/opss.pt/files/RelatorioPrimavera2014.pdf
http://www.opss.pt/sites/opss.pt/files/R... ,⁵¹51. Barros PP, Machado SR, Simoes JA. Portugal. Health system review. Heal Syst Transit 2011; 13(4):1-156.,⁵²52. Portugal. Decreto Lei no 183/2001, de 21 de Junho. Diário da República 2001.. However, increased PIH in the country led to the establishment, in 2006, of an interinstitutional group that elaborated the “National Strategy for the Integration of Homeless People” (ENIPSA)¹¹11. Portugal. Estratégia Nacional para integração de pessoas sem-abrigo. Lisboa; 2009.. ENIPSA considered the ER as the main means of addressing, monitoring and referring PIH to other points in the network to receive basic care.

Proposals for Portuguese ERs were reorganized in 2013 through the establishment of the General-Directorate for Intervention on Addictive Behaviors and Dependencies (SICAD), responsible for health programs related to this theme⁵³53. Portugal. Decreto-Lei no 124/2011. Lisboa: Plano de Redução e Melhoria da Administração Central. Diário da República 2011.,⁵⁴54. Portugal. Portaria no 27 de 2013. Diário da República 2013.. ERs’ financing would be of federal public origin, complemented by funds from social institutions performing the service⁵⁴54. Portugal. Portaria no 27 de 2013. Diário da República 2013..

Disseminating information, tools and programs to reduce harm and risks, interacting with consumers, conducting referrals as needed and providing first aid are ERs’ planned actions⁵²52. Portugal. Decreto Lei no 183/2001, de 21 de Junho. Diário da República 2001.. These teams may or may not use vehicles, consisting of contracted professionals and volunteers⁵²52. Portugal. Decreto Lei no 183/2001, de 21 de Junho. Diário da República 2001.. Presently, ERs receive funding from the federal government through public tenders launched by municipalities for focal activities.

The US and the Mobile Outreach Clinics

A country with a large territorial area and a population estimated at more than 320 million inhabitants⁵⁵55. United States Census Bureau. Population [Internet]. 2015 [cited 2016 Jan 10]. Available from: http://www.census.gov/topics/population.html
http://www.census.gov/topics/population.... , the U.S. accounted for 610,042 PIH in 2013⁷7. Estados Unidos da América. The 2013 Annual Homeless Assessment Report (AHAR) to Congress [Internet]. Washington D.C.; 2013. [cited 2016 Jan 10]. Available from: https://www.hudexchange.info/resources/documents/ahar-2013-part1.pdf
https://www.hudexchange.info/resources/d... , which meant 0.20% of the population. A significant increase in this figure was observed in the 1970s with the de-hospitalization of psychiatric patients, and a new increase occurred following social programs cuts in the 1980s⁵⁶56. Donohoe M. Homelessness in the United States: History, Epidemiology,Health Issues, Women, and Public Policy. Medscape Ob/Gyn Women’s Heal 2004; 9(2).. What happened in 2013 was that a large majority of men over 25 years of age, and 42.17% of people had severe mental disorders and/or disorders related to the use of psychoactive substances⁷7. Estados Unidos da América. The 2013 Annual Homeless Assessment Report (AHAR) to Congress [Internet]. Washington D.C.; 2013. [cited 2016 Jan 10]. Available from: https://www.hudexchange.info/resources/documents/ahar-2013-part1.pdf
https://www.hudexchange.info/resources/d... .

The country has a high GDP per capita, an HDI of 0.915 and a Gini of 41.1. By 2013, per capita health expenditure was twice the average of OECD countries and predominantly private (around 52%). Both child mortality and potential years of life lost are greater than those estimated for Portugal⁴¹41. Organisation for Economic Co-operation and Development (OECD). Inequality [Internet]. Income Inequality. 2012 [cited 2016 Mar 20]. Available from: https://data.oecd.org/inequality/income-inequality.htm
https://data.oecd.org/inequality/income-... ,⁴²42. Programa das Nações Unidas para o Desenvolvimento. Ranking IDH Global 2014 [Internet]. 2014 [cited 2016 Mar 25]. Available from: http://www.pnud.org.br/atlas/ranking/Ranking-IDH-Global-2014.aspx
http://www.pnud.org.br/atlas/ranking/Ran... ,⁴⁶46. Organisation for Economic Co-operation and Development (OECD). Health Resources [Internet]. 2013. [cited 2016 Mar 25]. Available from: http://www.oecd-ilibrary.org/social-issues-migration-health/health-resources/indicator-group/english_777a9575-en
http://www.oecd-ilibrary.org/social-issu... ,⁵⁷57. Organisation for Economic Co-operation and Development (OECD). Health at a Glance 2015 [Internet]. Paris: OECD Publishing; 2015. (Health at a Glance). [cited 2016 Jan 10]. Available from: http://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2015_health_glance-2015-en
http://www.oecd-ilibrary.org/social-issu... .

Throughout the twentieth century, the U.S. health system was structured by a business and philanthropic model with a predominance of financing and private service provision. While U.S. states have autonomy in coordinating the sector⁵⁸58. Costa JP. A reforma Obama e o sistema de saúde dos EUA. Arq Med 2013; 27(4):158-167., the U.S. Department of Health and Human Services (HHS) manages the entire network of care, regulating private plans and services. In 1965, two subsystems, Medicaid, and Medicare were established. The first is care-oriented, aimed at low-income people, with federal subsidies; the second is social insurance financed by fiscal sources and wage contributions to cover people over 65 or who have specific morbidities. HHS also runs programs for other specific groups, such as war veterans and low- and middle-income children⁵⁸58. Costa JP. A reforma Obama e o sistema de saúde dos EUA. Arq Med 2013; 27(4):158-167..

In 2010, 49% of Americans were covered by employer-sponsored insurance, 17% had Medicaid, 12% had Medicare and 16% of individuals had no social protection in health⁵⁹59. Noronha J, Giovanella L, Conill E. Sistemas de saúde da Alemanha, Canadá e dos EUA: uma visão comparada. In: Almeida Filho N, Paim JS. Saúde Coletiva- Teoria e Prática. Rio de Janeiro: Medbook; 2014. p. 170., including PIH. Access difficulties and rising expenditures contributed to the approval of the Patient Protection and Affordable Care Act (ACA), starting the reform known as Obamacare⁶⁰60. United States of America. Patient Protection and Affordable Care Act. Washington D.C.; 2010.. ACA is based on expanded coverage due to mandatory private insurance, increased regulation, Medicare and Medicaid expanded coverage, reforms in the care model, among other actions²⁵25. Conill EM. Sistemas Comparados de Saúde. In: Tratado de Saúde Coletiva. Rio de Janeiro: Hucitec, Fiocruz; 2006. p. 563-614.. Despite criticisms to the business model with private insurance intermediation, this reform has increased access of PIH to services²⁵25. Conill EM. Sistemas Comparados de Saúde. In: Tratado de Saúde Coletiva. Rio de Janeiro: Hucitec, Fiocruz; 2006. p. 563-614.,⁶¹61. United States of America. United States Interagency Council on Homelessness. Opening Doors: Federal strategic plan to prevent and end homelessness. Washington D.C.: United States Interagency Council on Homelessness; 2015..

Health indicators identified a high HIV infection rate, similar to Portugal in 2009⁴⁷47. Organisation for Economic Co-operation and Development (OECD). Health at a Glance 2011: OECD indicators [Internet]. 2011. [cited 2016 Mar 25]. Available from: dx.doi.org/10.1787/health_glance-2011-15-en
dx.doi.org/10.1787/health_glance-2011-15... . Average alcohol consumption was 8.8 liters per capita in 2013⁴⁹49. Organisation for Economic Co-operation and Development (OECD). Health at a Glance 2013. Paris: OECD Publishing; 2013.. Regarding other drugs, 9.2% of the population reported having used some kind of substance in the last month, in 2012⁶²62. Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings [Internet]. NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD; 2013. [cited 2016 Jan 10]. Available from: http://www.google.com/patents/US1870942
http://www.google.com/patents/US1870942... , and a small number of tuberculosis cases was recorded in 2014⁵⁰50. World Health Organization. Incidence of tuberculosis (per 100,000 people) [Internet]. 2014. [cited 2016 Jan 10]. Available from: http://data.worldbank.org/indicator/SH.TBS.INCD
http://data.worldbank.org/indicator/SH.T... . Neuropsychiatric disorders contributed with 30.9%⁶³63. World Health Organization. Mental Health Atlas 2011 [Internet]. Mental Health Atlas. 2011 Dec. [cited 2016 Jan 10]. Available from: http://www.who.int/mental_health/publications/mental_health_atlas_2011/en/
http://www.who.int/mental_health/publica... of the global burden of diseases.

The use of PIH-oriented mobile outreach clinics began in the 1970s.⁶⁴64. Moulavi D, Bushy A, Peterson J, Stullenbarger E, Muolavie D. Thinking about a mobile health unit to deliver services? Things to consider before buying. Aust J Rural Health 2000; 8(1):6-16. Given the serious situation of PIH in the United States, several social movements pressured the federal government to ensure rights to this public, which led to the establishment of a specific section for PIH in the Anti-Drug Abuse Act⁶⁵65. United States of America. Public Law 99th Congress 99-570. Washington D.C.; 1986.. In 1987, under intense pressure from institutions and movements linked to the issue, and from the mobilization of Congressmen Stewart McKinney and Bruce Vento, Congress enacted the McKinney Homeless Assistance Act (later renamed the McKinney-Vento Homeless Assistance Act), which created amendments to the Public Health Service Act for the implementation of PIH services, including outreach strategies⁶⁶66. United States of America. Public Law 100-77. To provide urgently needed assistance to protect and improve the lives and safety of the homeless, with special emphasis on elderly persons, handicapped persons, and families with children. Washington D.C.; 1987 p. 482-538.,⁶⁷67. National Coalition for the Homeless. McKinney-Vento Act [Internet]. Washington D.C.; 2006. [cited 2016 Aug 4]. Available from: http://www.nationalhomeless.org/publications/facts/McKinney.pdf
http://www.nationalhomeless.org/publicat... . The McKinney-Vento Act does not address the organization of mobile teams; it only mentions that they are primary healthcare services that can be complemented by specific teams geared to the treatment of drug addiction and mental disorders.

A study carried out between 2006 and 2007¹⁰10. Post P. Mobile Health Care for Homeless People : Using Vehicles to Extend Care. Nashville: National Health Care for the Homeless Council; 2007. showed that most of the investigated teams used their own vehicle and financing derived from federal, municipal and corporate funds. They consisted of several professional categories, including a doctor in just over half of them¹⁰10. Post P. Mobile Health Care for Homeless People : Using Vehicles to Extend Care. Nashville: National Health Care for the Homeless Council; 2007.. Currently, several elements point out a synergy of policies to overcome PIH’s difficult access to health services. ACA’s implementation expanded the criteria for inclusion in Medicaid and facilitated the funding of innovative experiences. These actions have led to a decreased number of PIH as from 2010, despite national recession⁶¹61. United States of America. United States Interagency Council on Homelessness. Opening Doors: Federal strategic plan to prevent and end homelessness. Washington D.C.: United States Interagency Council on Homelessness; 2015.. National institutional networks coordinated with the federal government, such as the National Coalition for the Homeless and the National Alliance to End Homelessness⁶⁸68. National Alliance to End Homelessness. About Us [Internet]. 2016 [cited 2016 Aug 4]. Available from: http://www.endhomelessness.org/
http://www.endhomelessness.org/... ,⁶⁹69. National Coalition for the Homeless. About NCH [Internet]. 2016 [cited 2016 Aug 4]. Available from: http://nationalhomeless.org/about-us/
http://nationalhomeless.org/about-us/... , which are mobilizers of political actions and train several public and private institutions executing PIH-oriented services nationwide.

Brazil and the Clinic on the Street

With a population estimated at 200 million inhabitants⁷⁰70. DATASUS. População residente - Estimativas para o TCU - Brasil [Internet]. Brasília; 2008. [cited 2016 Aug 4]. Available from: http://tabnet.datasus.gov.br/cgi/tabcgi.exe?ibge/cnv/poptuf.def
http://tabnet.datasus.gov.br/cgi/tabcgi.... , PIH count totaled approximately 50,000 people in 2008, or 0.02% of the Brazilian population of that year⁹9. META. Relatório final. Pesquisa Censitária e Amostral. População em situação de rua. Porto Alegre; 2008.. Most were men of African descent with low schooling, who associated going to the streets to alcohol abuse and/or other drugs use and to unemployment, added to family disagreement⁹9. META. Relatório final. Pesquisa Censitária e Amostral. População em situação de rua. Porto Alegre; 2008..

In 2013, Brazil’s GDP per capita was well below the US and Portugal. Its Gini Index was well above the OECD countries average⁴¹41. Organisation for Economic Co-operation and Development (OECD). Inequality [Internet]. Income Inequality. 2012 [cited 2016 Mar 20]. Available from: https://data.oecd.org/inequality/income-inequality.htm
https://data.oecd.org/inequality/income-... , but its HDI ranked it 75^th in the 2015 Human Development Report⁴²42. Programa das Nações Unidas para o Desenvolvimento. Ranking IDH Global 2014 [Internet]. 2014 [cited 2016 Mar 25]. Available from: http://www.pnud.org.br/atlas/ranking/Ranking-IDH-Global-2014.aspx
http://www.pnud.org.br/atlas/ranking/Ran... . Per capita health expenditure in that year was well below the countries under study, and the potential years of life lost were much higher than those found in Portugal and the United States⁴⁶46. Organisation for Economic Co-operation and Development (OECD). Health Resources [Internet]. 2013. [cited 2016 Mar 25]. Available from: http://www.oecd-ilibrary.org/social-issues-migration-health/health-resources/indicator-group/english_777a9575-en
http://www.oecd-ilibrary.org/social-issu... (Table 1).

With the enactment of the Constitution in 1988, in Brazil, health became a citizenship right ensured by the SUS⁷¹71. Bahia L. Padrões e mudanças no financiamento e regulação do sistema de saúde brasileiro: impactos sobre as relações entre o público e privado. Saúde Soc 2005; 14(2):9-30., whose objective is to provide universal, comprehensive and equitable coverage through organized networks of services under shared management between federal, state and municipal governments⁷²72. Brasil. Constituição da República Federativa do Brasil de 1988. Diário Oficial da União 1988; 5 out.. However, low public funding resulting from the 1990s neoliberal agenda fostered a significant expansion of private health plans. From the standpoint of financing and service delivery, the Brazilian health system can be considered a hybrid system consisting of three subsystems: the SUS financed with state resources and universal access with emphasis on primary health care; a private subsystem, whether for profit or not, maintained with public and private funds; and the supplementary subsystem composed of several types of private plans, which also receives tax subsidies⁷¹71. Bahia L. Padrões e mudanças no financiamento e regulação do sistema de saúde brasileiro: impactos sobre as relações entre o público e privado. Saúde Soc 2005; 14(2):9-30.,⁷³73. Paim J, Travassos C, Almeida C, Bahia L, Macinko J. The Brazilian health system: history, advances, and challenges. Lancet 2011; 377(9779):1778-1797..

In 2009, 0.31% of the population lived with HIV/AIDS⁴⁷47. Organisation for Economic Co-operation and Development (OECD). Health at a Glance 2011: OECD indicators [Internet]. 2011. [cited 2016 Mar 25]. Available from: dx.doi.org/10.1787/health_glance-2011-15-en
dx.doi.org/10.1787/health_glance-2011-15... . In 2013, less liters of alcohol were consumed per person than in the other two countries⁴⁹49. Organisation for Economic Co-operation and Development (OECD). Health at a Glance 2013. Paris: OECD Publishing; 2013., but in 2005, 10.3% of the population reported having consumed some type of drugs, excluding alcohol and tobacco, in the last 12 months⁷⁴74. Duarte PDCAV, Stempliuk VDA, Barroso LP, organizadores. II Levantamento Domiciliar sobre o Uso de Drogas Psicotrópicas no Brasil. Brasília: CEBRID; 2005.. The high incidence of tuberculosis cases in 2014⁵⁰50. World Health Organization. Incidence of tuberculosis (per 100,000 people) [Internet]. 2014. [cited 2016 Jan 10]. Available from: http://data.worldbank.org/indicator/SH.TBS.INCD
http://data.worldbank.org/indicator/SH.T... placed the country on the World Health Organization’s watch list. Neuropsychiatric disorders contributed to 20.3% of the global burden of diseases⁶³63. World Health Organization. Mental Health Atlas 2011 [Internet]. Mental Health Atlas. 2011 Dec. [cited 2016 Jan 10]. Available from: http://www.who.int/mental_health/publications/mental_health_atlas_2011/en/
http://www.who.int/mental_health/publica... .

PIH health strategies emerged from municipal experiences between 1980 and 2000, some related to primary healthcare and others aimed at homeless users of psychoactive substances⁷⁷77. Nery-Filho A, Valério ALR, Monteiro LF. Guia do projeto Consultório de Rua. Brasília, Salvador: SENAD, CETAD; 2012.

78. Canônico R, Tanaka A. Atendimento à população de rua em um Centro de Saúde Escola na cidade de São Paulo. Rev da Esc Enferm da USP 2007; 41(spe):799-803.-⁷⁹79. Carneiro N, Jesus CH, Crevelim MA. A Estratégia Saúde da Família para a Equidade de Acesso Dirigida à População em Situação de Rua em Grandes Centros Urbanos. Saude Soc 2010; 19(3):709-716.. Since 2007, the Ministry of Social Development has teamed up with other ministries (Ministry of Cities, Education, Health, Justice, Labor and Employment, the Special Secretariat for Human Rights and the Federal Government Public Defender), with workers in this area and movements, which resulted in the production of the National Policy for the Social Inclusion of People in Homelessness⁸⁰80. Brasil. Ministério de Desenvolvimento Social e Combate à Fome (MDSCF). Política Nacional para Inclusão Social da População em Situação de Rua. Brasília: MDSCF; 2008..

Based on this document, the Ministry of Health (MS) developed an emergency plan to strengthen and expand the so-called Clinic of Street, mobile itinerant services based on harm reduction strategies and drug addiction treatment⁸¹81. Brasil. Portaria nº 1.190, de 4 de junho de 2009. Institui o Plano Emergencial de Ampliação do Acesso ao Tratamento e Prevenção em Álcool e outras Drogas no Sistema Único de Saúde - SUS (PEAD 2009-2010) e define suas diretrizes gerais, ações e metas. Diário Oficial da União 2009; 5 jun.. Two years later, the MS reorganized the Psychosocial Care Network⁸²82. Brasil. Portaria nº 3.088, de 23 de dezembro de 2011. Institui a Rede de Atenção Psicossocial para pessoas com sofrimento ou transtorno mental e com necessidades decorrentes do uso de crack, álcool e outras drogas, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2011; 30 dez., in coordination with the primary healthcare services, and remodeled the former Clinic of Street to the new Clinic on the Street (CnR), which became part of primary healthcare⁸²82. Brasil. Portaria nº 3.088, de 23 de dezembro de 2011. Institui a Rede de Atenção Psicossocial para pessoas com sofrimento ou transtorno mental e com necessidades decorrentes do uso de crack, álcool e outras drogas, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2011; 30 dez.. In 2012, parameters were established for the implementation of CnRs and criteria for the number of teams based on the population of municipalities⁸³83. Brasil. Portaria nº 122, de 25 de janeiro de 2012. Define as diretrizes de organização e funcionamento das Equipes de Consultório na Rua. Diário Oficial da União; 2012.,⁸⁴84. Brasil. Portaria nº 123, de 25 de janeiro de 2012. Define os critérios de cálculo do número máximo de equipes de Consultório na Rua (eCR) por Município. Diário Oficial da União 2012; 26 jan., and subsequently, the incentive values and the role of professional categories that would be part of the teams were redefined⁸⁵85. Brasil. Portaria no 1.029, de 20 de maio de 2014. Amplia o rol das categorias profissionais que podem compor as Equipes de Consultório na Rua em suas diferentes modalidades e dá outras providências. Diário Oficial da União 2014; 21 maio.,⁸⁶86. Brasil. Portaria nº 1.238, de 6 de junho de 2014. Fixa o valor do incentivo de custeio referente às Equipes de Consultório na Rua nas diferentes modalidades. Diário Oficial da União 2014; 7 jun..

The CnR is a PIH-exclusive PHC multiprofessional service. It includes care for alcohol abuse and use of other drugs through outreach and sharing of actions with other points in the network and other sectors. Its implementation is mandatory according to the number of HIP identified in municipalities. Three types of teams were defined and only modality III provides for the inclusion of doctors⁸⁵85. Brasil. Portaria no 1.029, de 20 de maio de 2014. Amplia o rol das categorias profissionais que podem compor as Equipes de Consultório na Rua em suas diferentes modalidades e dá outras providências. Diário Oficial da União 2014; 21 maio..

Table 1 and the Charts 1 and 2 summarize the main elements found in the comparison between the contexts, the characteristics of the systems and the mobile units in the analyzed countries.

Discussion

Convergences for reducing inequity: objectives, outreach, multiprofessionality and harm reduction

Despite the structural differences in the health policies of the countries surveyed, all three recognize as main problem the barriers in the access of PIH to the services, implanting strategies and similar resources of approach and care⁵²52. Portugal. Decreto Lei no 183/2001, de 21 de Junho. Diário da República 2001.,⁶⁶66. United States of America. Public Law 100-77. To provide urgently needed assistance to protect and improve the lives and safety of the homeless, with special emphasis on elderly persons, handicapped persons, and families with children. Washington D.C.; 1987 p. 482-538.,⁸³83. Brasil. Portaria nº 122, de 25 de janeiro de 2012. Define as diretrizes de organização e funcionamento das Equipes de Consultório na Rua. Diário Oficial da União; 2012.(Table 3). Outreach, followed by referral to the other points of the network proves to be an essential strategy in the linkage and continued care to people in homelessness, with potential to facilitate the access of services by the population¹³13. Lemke RA, Silva RAN. A busca ativa como princípio político das práticas de. Estud e Pesqui em Psicol 2010; 10(1):281-295.,²⁰20. Ferreira CPS, Rozendo CA, Melo GB. Consultório na Rua em uma capital do Nordeste brasileiro: o olhar de pessoas em situação de vulnerabilidade social. Cad Saude Publica 2016; 32(8):1-10.. The approach and provision of care before issues related to alcohol abuse and use of other drugs was also a convergent action⁵²52. Portugal. Decreto Lei no 183/2001, de 21 de Junho. Diário da República 2001.,⁶⁶66. United States of America. Public Law 100-77. To provide urgently needed assistance to protect and improve the lives and safety of the homeless, with special emphasis on elderly persons, handicapped persons, and families with children. Washington D.C.; 1987 p. 482-538.,⁸³83. Brasil. Portaria nº 122, de 25 de janeiro de 2012. Define as diretrizes de organização e funcionamento das Equipes de Consultório na Rua. Diário Oficial da União; 2012., which is consistent with the high prevalence of psychoactive substances among PIH (as highlighted by PIH censuses of the US and Brazil) and among the general population of the three countries studied (Table 1).

We identified as a convergent resource the establishment of the teams through the integration of professionals of different graduations. The actual multidisciplinary character seems to face the complexity of its object, enabling articulation of different perspectives on the issues⁸⁷87. Almeida Filho N. Transdisciplinaridade e Saúde Coletiva. Cien Saude Colet 1997; 11(1972):1-18.,⁸⁸88. Furtado JP. Equipes de referência: arranjo institucional para potencializar a colaboração entre disciplinas e profissões. Interface (Botucatu) 2007; 11(22):239-255..

Therefore, outreach and harm reduction strategies associated with multiprofessional teams’ resources would favor the promotion of equity by adapting mobility and broadening coverage, range of actions and team composition to people’s essential needs, and alleviating barriers imposed by social inequality, often reproduced by the health network itself²¹21. Vieira-da-silva LM. Eqüidade em saúde: uma análise crítica de conceitos. Cad Saúde Publica 2009; 25(Supl. 2):217-226..

Divergent actions among the proposals: care models and intersectorality

In the United States and Brazil, mobile services originated in the care of alcohol and other drug users⁵²52. Portugal. Decreto Lei no 183/2001, de 21 de Junho. Diário da República 2001.,⁶⁵65. United States of America. Public Law 99th Congress 99-570. Washington D.C.; 1986.,⁷⁷77. Nery-Filho A, Valério ALR, Monteiro LF. Guia do projeto Consultório de Rua. Brasília, Salvador: SENAD, CETAD; 2012., but were later directed and integrated with primary healthcare⁶⁶66. United States of America. Public Law 100-77. To provide urgently needed assistance to protect and improve the lives and safety of the homeless, with special emphasis on elderly persons, handicapped persons, and families with children. Washington D.C.; 1987 p. 482-538.,⁸³83. Brasil. Portaria nº 122, de 25 de janeiro de 2012. Define as diretrizes de organização e funcionamento das Equipes de Consultório na Rua. Diário Oficial da União; 2012.. Thus, Portuguese ERs focused on the strategy of care to users of psychoactive substances in response to the high levels of HIV/AIDS and substance abuse in the country⁸⁹89. Hortale VA, Pedroza M, Rosa MLG. Operacionalizando as categorias acesso e descentralização na análise de sistemas de saúde. Cad Saude Publica 2000; 16(1):231-239., a restriction reinforced by the last decree-law⁵⁴54. Portugal. Portaria no 27 de 2013. Diário da República 2013., even with the proposed expanded functions of ERs by ENIPSA¹¹11. Portugal. Estratégia Nacional para integração de pessoas sem-abrigo. Lisboa; 2009.. Working through primary healthcare, Brazilian and U.S. services enhance comprehensive health care for PIH, considering their complexity and the identified barriers to access. They provide assistance to the most common problems of the population, such as tuberculosis, avoiding excessive referrals to specialties⁹⁰90. Donaldson M, Yordy K, Lohr K, Vanselow N. Primary Care: America’s Health in a New Era. Washington: National Academies Press; 1996.. A broader approach enables a better linkage and continuity to treatments, and care for comorbidities¹⁹19. Hallais JAS, Barros NF. Consultório na Rua: visibilidades, invisibilidades e hipervisibilidade. Cad Saude Publica 2015; 31(7):1497-504.,²⁰20. Ferreira CPS, Rozendo CA, Melo GB. Consultório na Rua em uma capital do Nordeste brasileiro: o olhar de pessoas em situação de vulnerabilidade social. Cad Saude Publica 2016; 32(8):1-10.,⁹¹91. Nuttbrock L, Rosenblum A, Magura S, McQuistion H. Broadening perspectives on mobile medical outreach to homeless people. J Health Care Poor Underserved 2003; 14(1):5-16.. In all three countries, but especially Brazil, primary healthcare could contribute to reducing morbidities among men, which are predominant among PIH, who have the highest rates of potential years of life lost (see Table 1) and are less seeking health services in the country⁹²92. Figueiredo W. Assistência à saúde dos homens: um desafio para os serviços de atenção primária. Cien Saude Colet 2005; 10(1):105-109..

Otherwise, services proposed by the last Portuguese legislation do not serve PIH in general, and they need to seek comprehensive care elsewhere in the network⁷⁷77. Nery-Filho A, Valério ALR, Monteiro LF. Guia do projeto Consultório de Rua. Brasília, Salvador: SENAD, CETAD; 2012.,⁹⁴94. Márcia F, Linhares P. Práticas de saúde das equipes dos Consultórios de Rua Health practices by teams from Street Outreach Offices Prácticas de salud de los equipos de atención callejera. 2014; 30(4):805-814.. Restricting the care modality focused here may result in limited and stigmatizing actions vis-à-vis the target population, with the risk of providing assistance only to urgent issues, not promoting processes to improve the overall quality of health⁹⁵95. Bento A, Barreto E. Sem-amor, Sem-abrigo. Lisboa: Clieipsi Editores; 2002. and not favoring the overcoming of inequity²¹21. Vieira-da-silva LM. Eqüidade em saúde: uma análise crítica de conceitos. Cad Saúde Publica 2009; 25(Supl. 2):217-226.. Moreover, the lack of a more organized axis of health actions can lead to segmented and/or overlapping strategies by ERs⁹⁶96. Gomes TS, Guadalupe S. Redes de Suporte Formal ao Sem-Abrigo na Cidade de Coimbra 1. Interações 2011; 21:71-94..

Intersectoral action received greater investment from the U.S. federal government, which articulated intersectoral and interinstitutional partnerships to care for PIH, setting an organized network that promoted a reduced number of this population group, considering its multiple needs⁷7. Estados Unidos da América. The 2013 Annual Homeless Assessment Report (AHAR) to Congress [Internet]. Washington D.C.; 2013. [cited 2016 Jan 10]. Available from: https://www.hudexchange.info/resources/documents/ahar-2013-part1.pdf
https://www.hudexchange.info/resources/d... ,⁶¹61. United States of America. United States Interagency Council on Homelessness. Opening Doors: Federal strategic plan to prevent and end homelessness. Washington D.C.: United States Interagency Council on Homelessness; 2015.. Both the Brazilian and Portuguese governments proposed the coordination of several sectors in their national strategies¹¹11. Portugal. Estratégia Nacional para integração de pessoas sem-abrigo. Lisboa; 2009.,⁸⁰80. Brasil. Ministério de Desenvolvimento Social e Combate à Fome (MDSCF). Política Nacional para Inclusão Social da População em Situação de Rua. Brasília: MDSCF; 2008.. However, only Brazilian ordinances in the health sector covered this principle⁸²82. Brasil. Portaria nº 3.088, de 23 de dezembro de 2011. Institui a Rede de Atenção Psicossocial para pessoas com sofrimento ou transtorno mental e com necessidades decorrentes do uso de crack, álcool e outras drogas, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2011; 30 dez.,⁸³83. Brasil. Portaria nº 122, de 25 de janeiro de 2012. Define as diretrizes de organização e funcionamento das Equipes de Consultório na Rua. Diário Oficial da União; 2012., and both countries have not displayed concrete results on this action so far. Intersectorality for PIH care is an essential strategy in face of the complexity of its demands, avoiding inadequate services to its users and promoting equity⁹⁷97. Borysow IC. Acesso e equidade: avaliação de estratégias intersetoriais para a população em situação de rua com transtorno mental grave [tese]. São Paulo: Universidade Federal de São Paulo; 2013..

Diverse resources and limitations to the fight against inequity

The existence or not of a vehicle available to the teams seems to be an indicator of the actual capacity to monitor people in their respective territories, since this resource enables transport of professionals along with their equipment and supplies, besides the transfer of patients to other services¹⁹19. Hallais JAS, Barros NF. Consultório na Rua: visibilidades, invisibilidades e hipervisibilidade. Cad Saude Publica 2015; 31(7):1497-504.,⁶⁴64. Moulavi D, Bushy A, Peterson J, Stullenbarger E, Muolavie D. Thinking about a mobile health unit to deliver services? Things to consider before buying. Aust J Rural Health 2000; 8(1):6-16.. By omitting the requirement of a car in ERs’ proposals, the Portuguese initiative compromises one of the pillars of this strategy, particularly based on the mobility of its team, not contributing to reduced inequity before the difficult access of PIH to services.

With regard to financing, Portugal and the U.S. operate with a public-private resource sharing scheme. However, such legislation differs from one another because of the fact that Portuguese ERs are outsourced, while U.S. law allows both the public and third parties to perform the service, even under a system heavily influenced by private initiative⁵²52. Portugal. Decreto Lei no 183/2001, de 21 de Junho. Diário da República 2001.,⁵⁴54. Portugal. Portaria no 27 de 2013. Diário da República 2013.,⁶⁶66. United States of America. Public Law 100-77. To provide urgently needed assistance to protect and improve the lives and safety of the homeless, with special emphasis on elderly persons, handicapped persons, and families with children. Washington D.C.; 1987 p. 482-538.. In the case of the Brazilian proposal, the federal government and municipalities bear the costs and perform the CnRs⁸³83. Brasil. Portaria nº 122, de 25 de janeiro de 2012. Define as diretrizes de organização e funcionamento das Equipes de Consultório na Rua. Diário Oficial da União; 2012..

Direct contracting by a public body ensures stability and favors the maintenance of bonds between them and users. However, hiring through private institutions allows greater agility in the recruitment of professionals, but carries the risk of precariousness of labor ties and workers’ dissatisfaction, which may affect the quality of care⁹⁸98. Jorge MSB, Guimarães JMX, Nogueira MEF, Moreira TMM, Morais APP. Gestão de recursos humanos nos centros de atenção psicossocial no contexto da Política de Desprecarização do Trabalho no Sistema Único de Saúde. Texto Context - Enferm 2007; 16(3):417-425.. However, even with the advantage of continued care provided by a public service, maintaining a fully functioning and adequate team when inserted in an underfunded health system is quite a challenge, as we have seen in Brazil⁷³73. Paim J, Travassos C, Almeida C, Bahia L, Macinko J. The Brazilian health system: history, advances, and challenges. Lancet 2011; 377(9779):1778-1797..

Conclusion

In addition to a product of technical and institutional decisions, health policies are the result of successive mediations between different agents, until their operational expression in terms of services or programs occurs. Thus, the legal and normative framework we described and compared in this study represents only part of this picture. Each of the countries surveyed organized mobile service according to their respective economic and political context, their health systems and the way in which the issue of PIH has been shaped in each of these societies. However, the comparative perspective allowed us to point out the main elements that underpin interventions of this nature.

The objective of improving access, establishing multiprofessional teams, outreach and care in addressing substance abuse are common to all three initiatives, suggesting an essential axis in PIH care. However, we identified a divergence between care strategies and resources – on the one hand, primary healthcare and compulsory use of a vehicle, and on the other, care limited to harm reduction actions with optional vehicle use. There is greater potential to reduce access time and ensure continuity of care if itinerant teams can provide primary healthcare actions combined with in situ harm reduction actions, as proposed by Brazilian and U.S. strategies, resulting in greater equity. However, offering all the care possible on the street or specifying services only for PIH may lead to lower attendance of this group in the traditional units, generating a segregating care circuit⁹⁹99. Lester H, Wright N, Heath I. Developments in the provision of primary health care for homeless people. Br J Gen Pr 2002; 52(475):912.. Moreover, the excess of team assignments associated with the fragile working conditions resulting from the situations found in the streets can lead to the simplification of tasks by the workers, and reduction of what could be offered to service users, mechanizing care in PHC¹⁰⁰100. De Paula PP. Saúde mental na atenção básica: política, trabalho e subjetividade. São Paulo: Universidade de São Paulo; 2011.,¹⁰¹101. Lipsky M. Street-level bureaucracy: dilemmas of the individual in public services. Nova York: Russell Sage Foundation; 2010..

The U.S. health system surprisingly presented proposals for PIH care with greater integration into primary healthcare, when compared to the Portuguese initiative, which is inserted in a system guided by the primary model. The U.S. also indicated a better introduction of health actions in the intersectoral framework⁶¹61. United States of America. United States Interagency Council on Homelessness. Opening Doors: Federal strategic plan to prevent and end homelessness. Washington D.C.: United States Interagency Council on Homelessness; 2015. in synergy with measures to improve access through the ACA⁶⁰60. United States of America. Patient Protection and Affordable Care Act. Washington D.C.; 2010..

The main aspects of each country studied stem from a bibliographical review and analysis of the legal and normative framework. However, new methodological approaches and further evaluations would be necessary to identify how the aspects identified materialize in the daily practice.

Acknowledgements

To São Paulo Research Foundation (FAPESP), for granting scholarship to the first author.

References

Publication Dates

History