Abstract

Resolute and comprehensive health care in remote rural municipalities (RRMs) requires Primary Health Care (PHC) with a strong community dimension anchored in the territory. This paper aims to analyze the performance profile of doctors in PHC, considering their work both in the territory and in PHC units. The perspective of doctors, critical agents in PHC, contributes to understanding whether there is an equitable and comprehensive availability of PHC. A qualitative study was carried out in 27 RRMs, with interviews with 46 Family Health doctors. Content analysis, structuring results in dimensions of arrangements in the performance of doctors in the territories and the organization of activities at the PHC units. Doctors concentrated their activities in the PHC units, primarily in municipal headquarters, with heterogeneous work agreements. Knowledge about the characteristics of the territory and the population was weak, especially those assigned at a considerable distance from municipal headquarters. In the rare work conducted within the territory, an itinerant and/or campaigning model was observed, with the mark of discontinuity. Walk-in patients were prioritized over care actions of follow-up and planning. The findings indicate the need to reinforce interaction with the territory in the provision of PHC services in RRMs.

Key words:
Rural Health; Primary Health Care; Territorialization in Primary Health Care

Introduction

Populations in rural and remote areas worldwide suffer important inequities, highlighting the difficulties in access to health care, which is intertwined with the difficulty of securing a workforce¹1 World Health Organization (WHO). WHO guideline on health workforce development, attraction, recruitment and retention in rural and remote areas. Genebra: WHO; 2021.. These failures in the access and supply of healthcare services are associated with poor health conditions in rural populations, resulting from their marginalization in socioeconomic development²2 Whitehead J, Pearson AL, Lawrenson R, Atatoa-Carr P. Spatial equity and realised access to healthcare - a geospatial analysis of general practitioner enrolments in Waikato, New Zealand. Rural Remote Health 2019; 19(4):5349.^,33 Carneiro FF, Pessoa VM, Teixeira ACA, organizadores. Campo, floresta e águas: práticas e saberes em saúde. Brasília: Editora UnB; 2017..

A clear, customized policy is needed to reverse this situation and ensure the public provision of healthcare services, especially those of Primary Health Care (PHC), which must be constant and integrated into the healthcare networks. In fact, PHC is the main - and sometimes only - form of access to health care in these territories¹1 World Health Organization (WHO). WHO guideline on health workforce development, attraction, recruitment and retention in rural and remote areas. Genebra: WHO; 2021.^,44 Bousquat A, Fausto MCR, Almeida PF, Lima JG, Sousa ABL, Seidl H. Remoto ou remotos: a saúde e o uso do território nos municípios rurais brasileiros. Rev Saude Publica 2022; 56:73.. The National Health Policy for Rural, Forest, and Water Populations (Política Nacional de Saúde das Populações do Campo, Floresta e Águas, in Portuguese) sought to give visibility and a better response to the inequities of these peoples in Brazil³3 Carneiro FF, Pessoa VM, Teixeira ACA, organizadores. Campo, floresta e águas: práticas e saberes em saúde. Brasília: Editora UnB; 2017.. However, its implementation encountered numerous barriers, including little specificity about the various rural scenarios in the country and insufficient integration with other social and health policies³3 Carneiro FF, Pessoa VM, Teixeira ACA, organizadores. Campo, floresta e águas: práticas e saberes em saúde. Brasília: Editora UnB; 2017..

In the Brazilian Unified Health System (SUS, in Portuguese), the Family Health Strategy (FHS) is the preferred PHC model and is present in practically all Brazilian municipalities⁴4 Bousquat A, Fausto MCR, Almeida PF, Lima JG, Sousa ABL, Seidl H. Remoto ou remotos: a saúde e o uso do território nos municípios rurais brasileiros. Rev Saude Publica 2022; 56:73.. The FHS is guided by the relationship of a multidisciplinary team with the users enrolled in a defined territory, in which health care extends from individuals to the perspective of the territory itself⁵5 Brasil. Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União; 2017.. Unlike the traditional PHC model, with fragmented actions and only in the PHC units, the community action of FHS professionals enables activities in and for the territory, inside and outside of the PHC units⁶6 Campos GWS, Figueiredo MD, Pereira Junior N, Castro CP. A aplicação da metodologia Paideia no apoio institucional, no apoio matricial e na clínica ampliada. Interface (Botucatu) 2014; 18(Supl.1):983-995.. However, the Brazilian socio-spatial diversity demands alternative organizational arrangements for the different territories in such a way that the FHS principles can be achieved. Remote Rural Municipalities (RRMs), characterized by the distance from urban centers and a predominance of rural attributes, such as the rarefaction of households⁷7 Instituto Brasileiro de Geografia e Estatística (IBGE). Classificação e caracterização dos espaços rurais e urbanos do Brasil: uma primeira aproximação. Rio de Janeiro: IBGE; 2017., can be considered as areas with important singularities that require a closer look at the organization of FHS activities.

Rural and remote areas around the world have inordinate difficulties in attracting and retaining a healthcare workforce, especially doctors¹1 World Health Organization (WHO). WHO guideline on health workforce development, attraction, recruitment and retention in rural and remote areas. Genebra: WHO; 2021.. The shortage of PHC doctors in Brazil is widely recognized, especially in the countryside, culminating in the creation of the Brazilian “More Doctors Program” (Programa Mais Médicos - PMM, in Portuguese) in 2013⁸8 Separavich MA, Couto MT. Programa Mais Médicos: revisão crítica da implementação sob a perspectiva do acesso e da universalização da atenção à saúde. Cien Saude Colet 2021; 26(Supl.2):3435-3446.. The PMM has contributed to discussions on inequalities in access to healthcare services, which strongly affect the RRMs, shedding light on the work of PHC doctors⁸8 Separavich MA, Couto MT. Programa Mais Médicos: revisão crítica da implementação sob a perspectiva do acesso e da universalização da atenção à saúde. Cien Saude Colet 2021; 26(Supl.2):3435-3446.^,99 Anderson MIP. Médicos pelo Brasil e as políticas de saúde para a Estratégia Saúde da Família de 1994 a 2019: caminhos e descaminhos da Atenção Primária no Brasil. Rev Bras Med Fam Comunidade 2019; 14(41):2180..

This article aims to understand the PHC doctors’ work profile in the territory as well as in the PHC units in RRMs. Observing this from the doctors’ perspective, as agents that are essential to the functioning of PHC, it is important to understand the obstacles they face in the equitable, comprehensive provision of health care in RRMs.

Method

A qualitative study was conducted based on interviews with PHC doctors in the research “Primary Health Care in Remote Rural Territories in Brazil”. Of the 323 RRMs defined by the Geography and Statistics Brazilian Institute⁷7 Instituto Brasileiro de Geografia e Estatística (IBGE). Classificação e caracterização dos espaços rurais e urbanos do Brasil: uma primeira aproximação. Rio de Janeiro: IBGE; 2017., six areas with distinct socio-spatial logics were considered for research purposes: the North region, subdivided into “North-waterways” and “North-roads”, “Matopiba” (an agricultural frontier expansion region connecting Maranhão, Tocantins, Piauí and Bahia), Midwest Vector, Semiarid region, and the North of Minas Gerais⁴4 Bousquat A, Fausto MCR, Almeida PF, Lima JG, Sousa ABL, Seidl H. Remoto ou remotos: a saúde e o uso do território nos municípios rurais brasileiros. Rev Saude Publica 2022; 56:73..

Municipalities from each area, with both typical and atypical characteristics, were selected in nineteen socioeconomic and health indicators, as described by Bousquat et al.⁴4 Bousquat A, Fausto MCR, Almeida PF, Lima JG, Sousa ABL, Seidl H. Remoto ou remotos: a saúde e o uso do território nos municípios rurais brasileiros. Rev Saude Publica 2022; 56:73.. The intentional sample of municipalities for the research field, structured from these six areas, was used in this study. Two or more municipalities from each area were chosen that correspond to the municipalities with the most frequent socioeconomic, demographic, and healthcare characteristics in the set of RRMs in the respective area. One or more outliers were added to the municipalities with more unusual characteristics in the area, thus ensuring the inclusion of different RRM realities. A sample was obtained through this procedure, consisting of 27 RRMs distributed in the six defined areas. Figure 1 shows the research areas with some of the information selected for characterization.

Semi-structured interviews were conducted between May and November 2019 with PHC doctors in the 27 RRMs. The interview script included: profile of the interviewee, characteristics of the territory and population, access, structure of the availability of PHC, work process, medical transportation services and emergency network, healthcare workforce, and priority healthcare lines.

The municipal headquarters PHC units and those of areas far from them, called countryside offices, were visited. The interviews were recorded and transcribed. Forty-six PHC doctors were interviewed, 23 of whom worked at the municipal headquarters and 23 in the so-called “countryside offices”. The interview codes consisted of: 1) a number (1 to 6) related to the research area; 2) status; 3) municipality number, according to the order in which the field research was conducted; and 4) MED1, for the municipal headquarters PHC unit, or MED2, for the PHC unit in the municipality’s inner regions. The research was approved by the Research Ethics Committee, logged under opinion number 2,832,559/CAAE 92280918.3.0000.5240.

Content analysis of the interviews was performed as indicated by Minayo¹⁰10 Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 14ª ed. São Paulo, Rio de Janeiro: Hucitec, Abrasco; 2014., with three stages: pre-analysis, exploration of the material, and interpretation of results. The dimensions of the analysis were defined based on the assumptions of a literature review on rural health¹¹11 Franco CM, Lima JG, Giovanella L. Atenção primária à saúde em áreas rurais: acesso, organização e força de trabalho em saúde em revisão integrativa de literatura. Cad Saude Publica 2021; 37(7):e00310520.: 1) professional profile, 2) arrangements for working in the territory, and 3) organization of activities. Excerpts from the interviews in these dimensions were coded with Nvivo®, and the corresponding previous categories were prepared: 1) general characterization, team composition, scarcity of the healthcare workforce, and the PMM; 2) reference link and travels; and 3) workload and organization of the agenda.

After a horizontal and vertical reading of the coded excerpts, which were broken down by research areas and relationship with the municipal headquarters or countryside offices, the interpretation resulted in the previous categories being restructured into emerging categories, as follows: 1) interviewees’ profile and team composition, 2) weak reference link with the PHC unit territory and limited travel in the territory of operation, and 3) flexibility and agreements on working hours and arrangement of actions with an emphasis on walk-in patients. The dimensions were also standardized in this step. Complementarily, counting and percentage of data compiled from the interviews were performed to define the interviewees’ profile.

Consistent with the objectives of this study, the final structure of the analysis consisted of the context dimension, with the profile of the doctors and their placement in the PHC in RRMs, followed by the two primary dimensions: arrangements for the doctors’ work in the territory and organization of their activities at PHC units. The following results are arranged according to these dimensions and their emerging categories.

Results

Doctors’ profile and placement in the PHC

Interviewee profile

Table 1 shows the profile information of the interviewees. The 46 doctors were evenly distributed across the research areas, except for “North-waterways”, which had the highest representation (30.4%) (Table 1). In general, the doctors were young, with almost half (45.7%) between 24 and 30 years of age, and the majority (65.2%) male (Table 1).

Almost all of them were Brazilians, except for one Cuban and one Peruvian doctor. Half of them had degrees in Bolivia, 17 in Brazil, and six in Cuba, Paraguay, and Peru (Table 1). Twenty-nine (63%) were from the PMM and half were not registered with the Regional Board of Medicine (Conselho Regional de Medicina - CRM, in Portuguese). Thirty-two doctors (69.6%) had been working quite recently, with less than one year on the team. Thirty-three (71.7%) had not accumulated additional links with the FHS (Table 1).

Team configuration

In general, the doctors worked in the PHC units with only one FHS team in its minimum composition. Some doctors mentioned there being more than one nursing technician on the team, mainly for reference and continuous assistance at support points in the territories. The doctors generally did not know how many community health workers (CHW) were on the team, which they attributed to the short amount of time they had worked together and the stronger relationship the CHWs had with the nurses and municipal managers. While the CHWs had a well-defined presence in the territories, the doctors were predominantly associated with the PHC units.

Most teams contained oral health professionals. The Expanded Nucleus of Family Health (Núcleo Ampliado da Saúde da Família - NASF, in Portuguese), with three or four professionals, was mentioned in 35 interviews. Difficulties were reported for the NASF in providing support to the entire territory, especially in the countryside. In addition, guards, doormen, and drivers also played a notable role in responding to emergencies in the communities out of hours. Drivers stood out even more for the time-consuming trips they made in the RRMs.

The departure of the Cuban doctors from the PMM provoked a crisis in the RRMs for four to six months until they could be replaced, which was still incomplete at the time of the interviews. A shortage of doctors on other teams was reported in almost all interviews. The biggest problems were related to medical professionals who are willing to stay, especially in the countryside. Respondents depicted a scenario characterized by an insufficient number of professionals to meet the volume of demands and access to the territory, both for doctors and nurses.

Doctors’ posts were largely covered by the PMM, even though the numbers were still inadequate. The difficulties in finding doctors were not restricted to the municipalities, but extended beyond the municipal limits and became a regional issue. The shortage of doctors overvalued the profession and gave practitioners a certain power in the provision of healthcare services. Doctors commonly registered with the CRM, generally working for the municipality, accumulating other links. The possibility of an additional link helped attract doctors and responded to the demands for emergency care in healthcare centers and small hospitals. At RRM headquarters, it was common to have a 24-hour unit for emergency care for the municipality’s population, such as small hospitals and healthcare centers, which may or may not include FHS.

Working at different points of the health care network in the RRMs and region made it easier to coordinate health care when a user needed hospitalization. However, the longitudinality in the FHS and knowledge of the work process of their own PHC units were compromised. Users sought medical care at the small municipal hospital on weekends or for convenience instead of using the PHC units, thus weakening the link with the PHC.

The presence of doctors in the FHS in the RRMs was strongly associated with the provision through the PMM. Doctors distinguished the PMM mainly because of its professional regulation, which was enacted in several ways: requirement to comply with working hours, supervision, accountability for production, and mandatory distance specialization in Family Health, in addition to the exclusivity to the FHS for those with no CRM registration. This was the main means through which to ensure sustained medical care in the RRMs, especially in the countryside, and with greater dedication in the PHC.

Arrangements for doctors’ work in the territory

Weak reference link with PHC unit territory

Most doctors did not precisely know the extent of the assigned territory. Most of them, even those working in the municipal headquarters, covered parts of the countryside where the territories were extensive and distances could reach the municipal limits, measured in tens or hundreds of kilometers. Territories referring to municipal headquarters or larger communities in the countryside where the PHC units were located were small and, in general, easy to access.

The team’s geographical catchment areas were not always well defined, and most doctors did not know the distribution of micro areas, believing it to be the nurse’s role. Likewise, most doctors were unaware of the number of users and families enrolled or gave inaccurate information, often indicating that this knowledge was also within the nurses’ purview. The lack of user registrations and their outdated status, especially in hard-to-reach locations, also hampered this domain.

The link with the territory was further weakened by the fluid reference of users to the teams, especially in municipal headquarters, in addition to the recent time in the FHS, high demand for doctor’s appointments, and with little participation in team planning. Nonetheless, some had conducted a situational diagnosis of the territory due to the specialization course offered in the PMM. A smaller number of the interviewees actually demonstrated some knowledge about the organization of the assigned area, describing the scope of the territory, number of micro-areas, the territory’s association with the CHW, and the location of the covered communities.

In general, doctors served the population without differentiating the assigned territory. There was a need to provide universal access, as well as collaboration among colleagues, including coverage for teams without doctors, with insufficient medical care, or when other doctors traveled to communities. It was common for doctors who worked in the municipal headquarters to serve the population with reference to the FHS in the countryside or in other municipalities because of easier access or the users’ intense search for varied services.

Some doctors attracted users from other teams due to the longer time they had worked in the municipality and because they had better qualifications and problem-solving skills. Municipalities in the Midwest Vector and North-roads regions reported frequent care provided to the indigenous population of healthcare districts and foreign users, as they were located on the border with Bolivia and Peru. This form of health care in the FHS in RRMs, with an undefined patient base and outside the territory of operation, made it difficult to know the profile of the population, health surveillance, and longitudinality, according to the interviewees.

Most respondents reported that PHC was the first contact service for most users. This happened more easily in the municipal headquarters or in areas close to the PHC units in the countryside. However, inadequate medication, infrastructure, recent replacement of professionals, inaccessible location, and the centralization of certain services hampered the registered users’ link with the reference PHC unit. Better healthcare provisions in a neighboring town also led to dispersion from the team.

Many doctors perceived that the healthcare center or small municipal hospital for emergency care was widely preferred by many users, especially in rural areas without a PHC unit in the community. This preference was also seen in users who took into consideration the better access to medication in the emergency care center or who were unable to easily access a PHC unit due to restricted appointments or who were unaware of a newly hired doctor after the Cubans had left the PMM. The population looked for a more accessible service, based on the travel route and available vehicle, regardless of the reference for their catchment area. Therefore, it was common for users to travel from the countryside using a free school bus. Transportation costs were high and public transportation was limited.

Only eleven interviewees worked exclusively and routinely at the PHC unit in the countryside, even though the research selected doctors working in municipal headquarters PHC units and those in the countryside. As a rule, they worked in larger communities, where smaller, more widely dispersed communities were also served. Populations in the countryside territories were largely covered by municipal headquarters units, sometimes with dedicated teams. The unequal distribution of the PHC units, which were concentrated in the center of the municipalities or nearby areas, made access unfeasible for people who lived farther away and, as such, did not provide real coverage, leading to a great deal of travel inside and outside the municipality.

Limited travel within the territory of operation

The need to keep the PHC units adequately teamed limited the ability and opportunity to travel to the countryside. In general, nurses and CHWs traveled more often than did the doctors. Travel to the countryside occurred when visits were made to communities and households up to a certain range, with variable frequency, and during occasional actions, such as health-related campaigns. Itinerant health care in these communities was based on points of support, such as outposts or locales owned by the communities. Travel was more commonly made to larger communities that had a healthcare unit, with visits scheduled a few times a week or month, but in those communities that were more difficult to access, return visits were more widely spaced apart.

Complicated access roads required a long period of travel time and special vehicles, and were subject to various problems along the way, arguing that better use could be made of the PHC units rather than long-distance visits. According to the interviewees, planning was necessary, considering the availability and type of vehicle, fuel, equipment, supplies, and meals, and it was not possible to offer more comprehensive medical care than that provided in the PHC units. Medical care in these communities was limited by improvised conditions, lack of materials, and travel time, although they did make it possible to identify cases for better care at the PHC units.

Itinerant medical care provided in the fluvial PHC mobile units required logistics planning for ten days onboard the boat. In the North-waterways region, the interviews revealed that few medical professionals reached communities in the countryside through infrequent trips involving the fluvial PHC mobile units. Some interviewees reported that it was common to cancel community visits or not be able to serve the needs of the entire territory due to a lack of transportation or fuel. A driver went along on the trips, forming another member of the medical team. An automobile was the primary vehicle used, but several others were mentioned ranging from ambulances and trucks to ferries in the North-waterways region.

Most doctors reported a weekly schedule for home visits. Visits to communities and, chiefly, to households, along with a CHW, were the primary way for doctors to become familiar with the territory and better understand the living conditions and travel difficulties the people faced, making it possible to develop more flexible standards of conduct.

Organization of the doctors’ activities at the PHC unit

Flexibility and work schedule agreements

Agreements on working days and autonomy over time, in addition to differences between doctors and nurses, proved to be widespread, even though doctors formally had a 40-hour workload to work in PHC every day of the week. Nurses usually remained in the FHS every day, while it was relatively common for doctors to have only two days a week in the FHS and with an irregular attendance, in addition to the PMM doctors working four days a week, as they had a scheduled day off for studies.

Doctors who spent more time working in the municipality and had varied qualifications were given certain advantages with regard to their workload. In exchange for handling a heavier volume of appointments and helping those who would be referred to specialized care, they were allowed to take courses or offset extended hours with an additional day off to attend to personal and family matters.

One interviewee argued that the workload needed to be more flexible to allow for commuting difficulties on arrival at work and home visits, avoid harassment during break times, compensate for work overload, and adapt to an agenda geared to walk-in patients. Another interviewee reported variable arrival and departure times because of a shift worked at the municipality’s small hospital.

PHC units set up in the countryside did not always have a permanent team throughout the week, resembling support points in these cases, working with a full team a few days a week, every two weeks, or according to a monthly schedule. Even when a PHC unit had daily working hours, two interviewees pointed out that the hours could be cut back to just one shift.

Arrangement of medical care with emphasis on walk-in patients

An agenda focused on walk-in patients predominated among the doctors, especially those who worked in the countryside. Few of them prioritized appointments at the PHC units for priority groups. They argued for the need to better organize walk-in care, guided by the possibilities of access with users from remote areas being given priority.

Travel difficulties due to time, wear and tear on the vehicles, and financial costs to the users resulted in a more open agenda. A more flexible organization for seeing patients was required because of an overcrowded waiting room that prevented the customary routine of scheduling appointments due to several factors, such as people traveling by boat or school bus schedules and low availability of doctors with periods when no doctors were on duty.

Doctors preferred to have scheduled appointments but users found it difficult to adapt, and there was a greater demand for medical care for acute illness rather than for chronic disease control. Other reasons cited were the lack of team planning, recommendations for an accessible agenda model in the PMM, and long breaks between healthcare visits in each community.

Although users were advised about the follow-up, the interviews suggested they were not monitored very closely, with the exception of pregnant women. Again, access problems in the countryside prevented follow-up appointments from occurring on a timely basis. There seemed to be a little more control over the follow-up of priority groups in the municipal headquarters, where it was easier to organize the agenda by care pathways.

Nurses played an important role in setting the agenda and often scheduled patients for other care pathways that were not treated by the doctors, such as women’s health or childcare. Although some doctors offered support to nurses in planning healthcare actions, there were statements that the PMM contributed to increasing surveillance actions in the FHS.

There were reports of inequalities in knowledge about the health status of populations from more remote areas, especially those without the presence of a CHW, who played a crucial role in following up on users and home visits, which proved to be key strategies for health surveillance. Community activities, such as home visits, were part of most doctors’ agendas but with little weight. Collective actions were irregular, with the exception of collective health care “great groups” for hypertension and diabetes and waiting room groups. Itinerant care in these communities was best defined with the organization of the agenda itself.

Despite being poorly incorporated into the work process, team meetings were important to the FHS, such as: planning the schedule, home visits, transportation needs, assessment of health surveillance in the territory, discussing territorialization, putting together unique therapeutic projects, and integrating FHS professionals, especially with a CHW.

Chart 1 provides a summary of the main findings and emerging categories on the arrangements for the work of FHS doctors in RRMs, in both dimensions. Illustrative comments of their emerging categories are presented in Charts 2 and 3.

Discussion

The perspective of doctors in the FHS in RRMs shows that work based on the territory was an evident challenge. Regardless of the reference link in the FHS territory, small, dispersed populations were provided with PHC services, mainly in the municipality, with doctors having limited reach to PHC units in RRMs. Due to geographic barriers and travel dynamics in the countryside, medical care was disconnected from the assigned territory, seeking to ensure access to the maximum number of users, even from more remote areas. At the same time, doctors had obscured the notion of the territories under their responsibility, thus hindering surveillance actions. Such a design is not common to other realities that have to face the remoteness and rarefaction of a population, for example in Australia, where diseconomies of scale in rural health are addressed with different modes of organization, in which more remote territories tend to have more integrated and integral PHC configurations¹²12 Wakerman J, Humphreys JS, Wells R, Kuiper P, Entwistle P, Jones J. Primary health care delivery models in rural and remote Australia - a systematic review. BMC Health Serv Res 2008; 29(8):276..

Other studies¹³13 Almeida PF, Santos AM, Cabral LMS, Fausto MCR. Contexto e organização da atenção primária à saúde em municípios rurais remotos no Norte de Minas Gerais, Brasil. Cad Saude Publica 2021; 37(11):e00255020.^,1414 Fausto MCR, Giovanella L, Lima JG, Cabral LMS, Seidl H. A sustentabilidade da Atenção Primária à Saúde em territórios rurais remotos na Amazônia fluvial: organização, estratégias e desafios. Cien Saude Colet 2022; 27(4):1605-1618. have shown that, instead of territories contiguous to the PHC units, extensive territories are managed in the FHS in RRMs with populations that are geographically difficult to access, primarily dispersed in small communities inside the RRMs. Some interviews revealed that part of the users bypassed their medical teams, corroborating the results of international rural health studies on the bypass of local health services²2 Whitehead J, Pearson AL, Lawrenson R, Atatoa-Carr P. Spatial equity and realised access to healthcare - a geospatial analysis of general practitioner enrolments in Waikato, New Zealand. Rural Remote Health 2019; 19(4):5349..

Work with team integration was found to be undervalued in this research. From the physician’s perspective in the FHS teams in RRMs, a division of the work can be noted, assigning the role of understanding the territory, health surveillance, and community actions to nurses and CHWs, while the focus of medical work was on responding to walk-in patients. Medical teams based on walk-in care, often with a high work flow and without a distinction between territories, added to the difficulties of rural people traveling and of providing services and minimized preventive care by the FHS, prioritizing diagnostic actions, drug therapies, and acute illness, similar to the findings from Garnelo et al.¹⁵15 Garnelo L, Parente RCP, Puchiarelli MLR, Correia PC, Torres MV, Herkrath FJ. Barriers to access and organization of primary health care services for rural riverside populations in the Amazon. Int J Equity Health 2020; 19(1):54..

This work’s limitation, in a scenario with such a prominent social determination of health as the rural environment³3 Carneiro FF, Pessoa VM, Teixeira ACA, organizadores. Campo, floresta e águas: práticas e saberes em saúde. Brasília: Editora UnB; 2017.^,1515 Garnelo L, Parente RCP, Puchiarelli MLR, Correia PC, Torres MV, Herkrath FJ. Barriers to access and organization of primary health care services for rural riverside populations in the Amazon. Int J Equity Health 2020; 19(1):54., refers to a complainant-conduct model, reducing the scope of actions and the need for an expanded clinical perspective⁶6 Campos GWS, Figueiredo MD, Pereira Junior N, Castro CP. A aplicação da metodologia Paideia no apoio institucional, no apoio matricial e na clínica ampliada. Interface (Botucatu) 2014; 18(Supl.1):983-995.. The FHS work process developed with a marked dissociation from the PHC units and the catchment territory as expressed in the weak, distant link between doctors, who had greater control in the PHC units, and the CHWs, who worked in the territories. This split converges with threats to a territorialized model of PHC that is underway in the country, based on an inflection explicitly focused on a neoliberal agenda in place since the Temer government¹⁶16 Faria RM. A territorialização da Atenção Básica à Saúde do Sistema Único de Saúde do Brasil. Cien Saude Colet 2020; 25(11):4521-4530.^,1717 Giovanella L, Franco CM, Almeida PF. Política Nacional de Atenção Básica: para onde vamos? Cien Saude Colet 2020; 25(4):1475-1482..

Territorialization is a guideline provided for in the National Primary Care Policy (PNAB, in Portuguese), which defines the structuring models of its services, considering specific principles, such as longitudinality, resolution, and network ordering, among others⁵5 Brasil. Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União; 2017.. However, the PNAB lacks the affirmation of flexible, integrated models in healthcare networks, in which territorialization fits the movements, as is necessary in the RRMs⁴4 Bousquat A, Fausto MCR, Almeida PF, Lima JG, Sousa ABL, Seidl H. Remoto ou remotos: a saúde e o uso do território nos municípios rurais brasileiros. Rev Saude Publica 2022; 56:73.^,1616 Faria RM. A territorialização da Atenção Básica à Saúde do Sistema Único de Saúde do Brasil. Cien Saude Colet 2020; 25(11):4521-4530.. It is not a matter of preventing the patient flows between the countryside and the municipal headquarters, and accepting walk-in appointments, but of reconciling the work in the office and in the territory so that health care needs can be seen beyond the demands of caring in the context of the community and of the extension of time, and not merely of the individual and the moment.

The doctors’ work was almost always disconnected from the team, and seeing walk-in patients for acute health conditions, “deterritorialized”, was also accompanied by the overlapping of their duties with other points of care, such as responding to the municipalities’ emergency care services. The profile of medical professionals was indicative of the problems in allocating doctors in the RRMs. As in other countries¹1 World Health Organization (WHO). WHO guideline on health workforce development, attraction, recruitment and retention in rural and remote areas. Genebra: WHO; 2021., RRMs in Brazil had weaknesses in maintaining the healthcare workforce. The work process in the FHS was thwarted by the intermittence of medical work. There was a structure of multiple jobs for doctors registered in the CRM, configuring medical power in the provision of health services and reinforcing the imaginary scenario of hospital-based practices.

Although it was pointed out that working in multiple locations favored the coordination of health care, a network of services was not created in which PHC was an organizer, causing its weakening instead of playing a central role. Ney and Rodrigues¹⁸18 Ney MS, Rodrigues PHA. Fatores críticos para a fixação do médico na Estratégia Saúde da Família. Physis 2012; 22(4):1293-1311. revealed that the municipalities’ constraints in expanding the FHS without healthcare workforce counterparts can lead to precarious working hours and various links that impair the quality of work, in addition to resulting from the expansion of PHC without a vision of a specific medical practice and the low regulation of the activity, strengthening the rise of medical corporations.

The large number of doctors who were trained abroad and assigned to RRMs, especially in Bolivia, touches on complex migratory phenomena related to doctors in Brazil and their job market. Restrictions on medical careers, which have led students to seek training in countries with lower educational costs¹⁹19 Villen P. O recrutamento de médicos-imigrantes pelo Programa Mais Médicos e a particularidade do caso cubano. In: Baeninger R, Bógus LM, Moreira JB, Vedovato LR, Fernandes DM, Souza MR, Baltar CS, Peres RG, Waldman TC, Magalhães LFA, organizadores. Migrações Sul-Sul. Campinas: Nepo/Unicamp; 2018. p. 218-230., along with the dismantling of the PMM, weakened the countercurrent direction of supply policies to that of market forces in the healthcare workforce movements⁸8 Separavich MA, Couto MT. Programa Mais Médicos: revisão crítica da implementação sob a perspectiva do acesso e da universalização da atenção à saúde. Cien Saude Colet 2021; 26(Supl.2):3435-3446.^,1919 Villen P. O recrutamento de médicos-imigrantes pelo Programa Mais Médicos e a particularidade do caso cubano. In: Baeninger R, Bógus LM, Moreira JB, Vedovato LR, Fernandes DM, Souza MR, Baltar CS, Peres RG, Waldman TC, Magalhães LFA, organizadores. Migrações Sul-Sul. Campinas: Nepo/Unicamp; 2018. p. 218-230., which further exacerbated inequities between territories at both the global and local levels¹1 World Health Organization (WHO). WHO guideline on health workforce development, attraction, recruitment and retention in rural and remote areas. Genebra: WHO; 2021.. In Brazil, where medical corporations have strict control over the labor market, favoring private-liberal practice¹⁸18 Ney MS, Rodrigues PHA. Fatores críticos para a fixação do médico na Estratégia Saúde da Família. Physis 2012; 22(4):1293-1311.^,1919 Villen P. O recrutamento de médicos-imigrantes pelo Programa Mais Médicos e a particularidade do caso cubano. In: Baeninger R, Bógus LM, Moreira JB, Vedovato LR, Fernandes DM, Souza MR, Baltar CS, Peres RG, Waldman TC, Magalhães LFA, organizadores. Migrações Sul-Sul. Campinas: Nepo/Unicamp; 2018. p. 218-230., RRMs are placed on the fringes of the medical ethos and become a place for medical practitioners who have been trained abroad, through the PMM.

In turn, the PMM in the RRMs that were studied showed consequences in line with research that indicate an expansion of access and a strengthening of PHC attributes⁸8 Separavich MA, Couto MT. Programa Mais Médicos: revisão crítica da implementação sob a perspectiva do acesso e da universalização da atenção à saúde. Cien Saude Colet 2021; 26(Supl.2):3435-3446.. However, even if the PMM had been successful in providing doctors to the RRMs, there is a need to more fully understand the need to work in the territory and with a better balance between meeting the demand and longitudinal comprehensive care by the doctors’ own profile, in general beginning practical work in both rural health and PHC. Cubans doctors, who were prominently included in the PMM, had specialized training in PHC, had more experience, and were widely recognized in community work⁸8 Separavich MA, Couto MT. Programa Mais Médicos: revisão crítica da implementação sob a perspectiva do acesso e da universalização da atenção à saúde. Cien Saude Colet 2021; 26(Supl.2):3435-3446..

The loss of connection with the territory contrasts with one of the most essential characteristics of the FHS⁵5 Brasil. Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União; 2017.^,1616 Faria RM. A territorialização da Atenção Básica à Saúde do Sistema Único de Saúde do Brasil. Cien Saude Colet 2020; 25(11):4521-4530.^,1717 Giovanella L, Franco CM, Almeida PF. Política Nacional de Atenção Básica: para onde vamos? Cien Saude Colet 2020; 25(4):1475-1482.. What can be seen is that the lack of a territorialized arrangement of work practices in the FHS proper to rural scenarios, and the obstacles to healthcare workforce serve as a justification for outlining a work process in PHC according to a hospital-centered model. There is no understanding of a health concept requiring continuous, supply-based services, but rather prompt, demand-based services determined by the disease.

Strategies for overcoming the dilemmas in the FHS work process in RRMs can be extracted from the results. Instead of concentrating services in the municipal headquarters, assigning large territories, the interviews showed that users have easy access to PHC units and teams located in their communities or close to them. It is not enough to set up PHC units inside the RRMs, but territorialization must also be established that considers accessibility with effective participation. Other studies affirm distinctions of spaces in the RRMs and the need for a more equitable distribution of health services in favor of the countryside¹³13 Almeida PF, Santos AM, Cabral LMS, Fausto MCR. Contexto e organização da atenção primária à saúde em municípios rurais remotos no Norte de Minas Gerais, Brasil. Cad Saude Publica 2021; 37(11):e00255020.^,1414 Fausto MCR, Giovanella L, Lima JG, Cabral LMS, Seidl H. A sustentabilidade da Atenção Primária à Saúde em territórios rurais remotos na Amazônia fluvial: organização, estratégias e desafios. Cien Saude Colet 2022; 27(4):1605-1618..

The enormous difficulties in transportation indicate that it needs to be provided on a regular, accessible basis for travel to the PHC unit, as well as school buses for access to basic education. Transportation guarantees are required for both the population and the FHS team. The interviews underscored the importance of improving conditions for the territorialized practice by healthcare professionals, allocating more resources to the transportation fleet, support points, and access routes. Alternative FHS arrangements, such as riverside and fluvial FHSs, although hardly ever implemented³3 Carneiro FF, Pessoa VM, Teixeira ACA, organizadores. Campo, floresta e águas: práticas e saberes em saúde. Brasília: Editora UnB; 2017., are good examples of work processes that adapt to the reality of their territories, maintaining PHC from the perspective of the FHS model and providing for different conditions³3 Carneiro FF, Pessoa VM, Teixeira ACA, organizadores. Campo, floresta e águas: práticas e saberes em saúde. Brasília: Editora UnB; 2017.^,1515 Garnelo L, Parente RCP, Puchiarelli MLR, Correia PC, Torres MV, Herkrath FJ. Barriers to access and organization of primary health care services for rural riverside populations in the Amazon. Int J Equity Health 2020; 19(1):54..

Walk-ins need to be associated with the agenda for scheduled health surveillance actions and the prevention of specific problems in the territory. Home visits were denoted as a prominent means of following the care pathways, recognizing the territory, and integrating with CHWs. Close contact with CHWs in the work process provides a way to overcome the split between the PCH unit and the territory. National and international studies highlight the relevance of integrated action of CHWs with PHC teams, offering an important expansion of the scope of practices in rural areas¹¹11 Franco CM, Lima JG, Giovanella L. Atenção primária à saúde em áreas rurais: acesso, organização e força de trabalho em saúde em revisão integrativa de literatura. Cad Saude Publica 2021; 37(7):e00310520.^,1414 Fausto MCR, Giovanella L, Lima JG, Cabral LMS, Seidl H. A sustentabilidade da Atenção Primária à Saúde em territórios rurais remotos na Amazônia fluvial: organização, estratégias e desafios. Cien Saude Colet 2022; 27(4):1605-1618..

Itinerant care may be a relevant strategy in PHC in RRMs. Some forms for this itinerary have already been observed in rural and remote parts of Australia, such as hub-and-spoke models - harkening back to aviation standards, with air travel distribution from a hub - and fly-in-fly-out - similar to operations in oil and mining fields, with periods of full-time work compensated afterward by free time¹²12 Wakerman J, Humphreys JS, Wells R, Kuiper P, Entwistle P, Jones J. Primary health care delivery models in rural and remote Australia - a systematic review. BMC Health Serv Res 2008; 29(8):276.. The need to maintain health care at the PHC units leads to the possibility of expanded teams with professionals sometimes in permanent work, sometimes in itinerant work, highlighting close liaison and joint responsibility for comprehensive health care within the territory.

Flexibility in working hours and compensation for travel needs to be formalized in working conditions in order to avoid losing sight of their purpose. The presence of nursing technicians at support points in the countryside was a relevant strategy, in addition to attending to users’ acute health problems. Boat drivers and pilots need to be incorporated as FHS team members. A greater participation of the NASF beyond the RRM headquarters was another verified need.

Research corroborates the importance of federal programs in providing professionals in the FHS. The PMM proved to be a broad, successful strategy that ought to be reinforced and developed, rather than dismantled, as in the Bolsonaro government with the Doctors for Brazil Program, which provides for a privatization mechanism in PHC and a restricted number of doctors (only those registered in the CRM), and indicates setbacks to the universality of SUS/FHS⁹9 Anderson MIP. Médicos pelo Brasil e as políticas de saúde para a Estratégia Saúde da Família de 1994 a 2019: caminhos e descaminhos da Atenção Primária no Brasil. Rev Bras Med Fam Comunidade 2019; 14(41):2180.. Proposing a distinctive arrangement of the FHS for RRMs requires increasing the availability of doctors, ensuring a supply for PHC without competing with small hospitals and emergency care centers, and maintaining regulations for good practices, including nurses and dentists, reducing turnover, and sustaining itinerant work by the medical teams. Considering an appropriate care model necessarily implies observing the healthcare workforce management¹⁸18 Ney MS, Rodrigues PHA. Fatores críticos para a fixação do médico na Estratégia Saúde da Família. Physis 2012; 22(4):1293-1311.. The World Health Organization (WHO)¹1 World Health Organization (WHO). WHO guideline on health workforce development, attraction, recruitment and retention in rural and remote areas. Genebra: WHO; 2021. recommends instituting policies based on education, regulation, incentives, and support as a way to attract and implement healthcare workforce in rural remote areas, emphasizing that interventions must be interconnected, aggregated, and adjusted to the local context.

This study has some limitations in terms of analyzing the role of doctors in the FHS in RRMs. The focus of this article was on the doctors’ work at the national level without differentiating by research areas. The considerable diversity of RRMs and different rural realities were highlighted, requiring specific models among the municipalities and regions. The doctors’ perspective on their own work process was only partial, with little time of work, and different analysis angles could be formed with other research subjects, such as managers, users, nurses, and CHWs.

Contributing with information and discussions on regions that have not been the priority field of investigations in Public Health, the interpretation of the results brought to light challenges of the role of doctors in the FHS in RRMs and a glimpse into the organizational arrangements from which they derive. Work disconnected from the territory and organized based on walk-ins also occurs in urban populations, but for rarefied rural populations, they pose additional challenges without their own policies to guide them in these realities. Possibilities for new models arise, consistent with the FHS’s objective of a community-based, territorialized PHC.

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