Abstract

This article aims to analyze healthcare implementation in recovery and rehabilitation in the country, considering the assistance offered to victims of violence and accidents. Rehabilitation corresponds to the specific guideline of the National Policy on Morbimortality due to Accidents and Violence. A descriptive quantitative study was conducted nationwide by analyzing data collected through the electronic platform to access a questionnaire sent to the municipal health secretaries of the 5,570 Brazilian municipalities (113 answered). The results revealed advances in some areas, such as formulating regulations, decentralizing care, and increasing the availability of services and variability of professionals in most participating cities. However, we identified historical gaps, such as the sector’s underfunding, weak infrastructure and human resources, problems regarding the provision of orthoses and prostheses, and unequal distribution of services in the country’s regions. Although the recovery/rehabilitation backdrop of accident and violence victims has improved in Brazil in recent years, it is still far from offering a universal, comprehensive, and equitable service.

Key words:
Rehabilitation; Recovery; Accidents; Violence; Health Policy

Introduction

Accidents and violence are widespread public health problems that affect people at the time of the adverse event and require subsequent care in the recovery and rehabilitation process. However, these people often do not have access to or face weaknesses in rehabilitation care, to the point that the World Health Organization (WHO) has established commitments to critical actions to strengthen these services in the Institution’s member states by 2030. Notwithstanding this, people who suffer accidents and violence and are left with some kind of disability or impairment, have little access to rehabilitation and recovery services for diagnosis, treatment, referral, and recovery¹1 Morgan R, Asiimwe L, Ager AL, Haq Z, Thumba L, Shcherbinina D. Rehabilitation services must include support for sexual and gender-based violence survivors in Ukraine and other war- and conflict-affected countries. J Public Health Policy Plan Health Policy 2023; 38(3):417-419.

2 Pastor-Moreno G, García-Cuéllar MM, Ruiz-Pérez I, Montiel J. The prevalence of intimate partner violence against women with disabilities: a systematic review of the literature. Disabil Rehabil 2022; 45(1):1-8.^-33 Assis SG, Deslandes SF, Minayo MCS. Atendimento a pessoas em situação de violência pelo Sistema Único de Saúde. In: Minayo MCS, Assis SG, editoras. Novas e velhas faces da violência no século XXI: visão da literatura brasileira no campo da saúde. Rio de Janeiro: Editora Fiocruz; 2017. p. 271-296.. Prioritizing rehabilitation and recovery means investing in the specialization of human, financial, and technological resources to socially reintegrate individuals into work or social life⁴4 Khan F, Amatya B, Hoffman K. Systematic review of multidisciplinary rehabilitation in patients with multiple trauma. BJS Open 2012; 99(Supl. 1):88-96.. The lack of investment in rehabilitation services is a global issue⁵5 Krug E, Cieza A. Strengthening health systems to provide rehabilitation services. Can J Occup Ther 2017;84(2):72-75..

Rehabilitation aims to help people achieve and maintain their maximum functioning, encourage the maintenance of their functions, avoid deteriorating their limitations, and promote greater autonomy and physical, mental, and social capacity to help them readjust to productive life or find new possibilities for their social inclusion⁶6 Marriel NSM, Deslandes, SF, Minayo MCS. Análise da Implementação do Atendimento em Recuperação/Reabilitação. In: Minayo MCS, Deslandes SF, organizadoras. Análise diagnóstica da política nacional de saúde para redução de acidentes e violências. Rio de Janeiro: Editora Fiocruz; 2007. p. 171-192..

The history of recovery and rehabilitation in the healthcare sector for people who have suffered accidents and violence in Brazil shows that even in the 1960s, this level of intervention was understood exclusively as a tertiary care service. The professional rehabilitation centers of the National Social Security Institute were the only public institutions to offer this type of care. With the advent of the Brazilian Unified Health System (SUS), rehabilitation was integrated as one of the care levels. In Brazil, the SUS is theoretically organized to meet rehabilitation-related demands through the Care Network for People with Disabilities. The SUS has 228 Specialized Rehabilitation Centers (CER) geographically distributed throughout all Brazilian states. They provide outpatient referral care that includes diagnosis, treatment, adaptation, and maintenance of assistive technology⁷7 Brasil. Ministério da Saúde (MS). SUS de todos: rede para a pessoa com deficiência atende todo o país [Internet]. 2022 [acessado 2024 jun 13]. Disponível em: https://www.gov.br/saude/pt-br/assuntos/noticias/2019/setembro/sus-de-todos-rede-para-a-pessoa-com-deficiencia-atende-todo-o-pais.
https://www.gov.br/saude/pt-br/assuntos/... . Besides the CERs, the system has a Care Network for People with Disabilities consisting of 37 orthopedic workshops, 259 Rehabilitation Services in a single modality, and 293 adapted vehicles⁷7 Brasil. Ministério da Saúde (MS). SUS de todos: rede para a pessoa com deficiência atende todo o país [Internet]. 2022 [acessado 2024 jun 13]. Disponível em: https://www.gov.br/saude/pt-br/assuntos/noticias/2019/setembro/sus-de-todos-rede-para-a-pessoa-com-deficiencia-atende-todo-o-pais.
https://www.gov.br/saude/pt-br/assuntos/... ^,88 Brasil. Ministério da Saúde (MS). Centro Especializado em Reabilitação e Oficina Ortopédica são pontos de atenção à pessoa com deficiência no SUS. 2022 [acessado 2024 jun 13]. Disponível em: https://www.gov.br/saude/pt-br/assuntos/noticias/2022/agosto/centro-especializado-em-reabilitacao-e-oficina-ortopedica-sao-pontos-de-atencao-a-pessoa-com-deficiencia-no-sus.
https://www.gov.br/saude/pt-br/assuntos/... . Obviously, this set of services and equipment does not cover the national reality. The National Health Survey indicated that 3.9 million Brazilian adults had suffered a traffic accident resulting in injury, and 14.9% of these (579 thousand people) were left with some permanent physical aftereffect in 2019⁹9 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde 2019: ciclos de vida. Brasil. Rio de Janeiro: IBGE; 2021.. A critical and additional fact is that the population is aging, and the “Elderly Care Guide” provides guidance on rehabilitation care for functionality in performing activities of daily living, particularly within PHC¹⁰10 Brasil. Ministério da Saúde (MS). Secretaria de Atenção Especializada à Saúde. Departamento de Atenção Especializada e Temática. Guia de atenção à reabilitação da pessoa idosa [Internet]. 2021 [acessado 2024 jun 13]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/guia_atencao_reabilitacao_pessoa_idosa.pdf.
https://bvsms.saude.gov.br/bvs/publicaco... .

The structuring and consolidation of care aimed at the recovery and rehabilitation of accident and violence victims is one of the guidelines of the National Policy for Reducing Morbimortality from Accidents and Violence (PNRMAV)¹¹11 Brasil. Ministério da Saúde (MS). Política Nacional de Redução de Morbimortalidade por Acidentes e Violências. Brasília: MS; 2001.. Professionally, rehabilitation comprises a set of services such as physiotherapy, occupational therapy, speech therapy, and psychotherapy⁶6 Marriel NSM, Deslandes, SF, Minayo MCS. Análise da Implementação do Atendimento em Recuperação/Reabilitação. In: Minayo MCS, Deslandes SF, organizadoras. Análise diagnóstica da política nacional de saúde para redução de acidentes e violências. Rio de Janeiro: Editora Fiocruz; 2007. p. 171-192.. Its guidelines align with the primary actions recommended by the WHO agreement with member countries, which include improving governance and investment in rehabilitation, expanding the high-quality rehabilitation workforce, and improving injury data collection¹²12 World Health Organization (WHO). Rehabilitation 2030: a call for action: the need to scale up rehabilitation. Geneva: WHO; 2017.^,1313 World Health Organization (WHO). Rehabilitation 2030: A call for action: Concept note. Geneva: WHO; 2017., enabling millions of injured people to live longer and live well⁵5 Krug E, Cieza A. Strengthening health systems to provide rehabilitation services. Can J Occup Ther 2017;84(2):72-75.. The World Health Organization’s International Classification of Functioning, Disability, and Health (ICF), which identifies and describes health states and their effects on the population throughout the life cycle, assesses that the consequences can cause loss of functionality or temporary or permanent disability, which requires recovery or rehabilitation measures that need to be addressed in health services¹⁴14 Organização Mundial da Saúde (OMS). Como usar a CIF: Um manual prático para o uso da Classificação Internacional de Funcionalidade, Incapacidade e Saúde (CIF). Versão preliminar para discussão. Genebra: OMS; 2013..

The diagnostic analysis of the PNRMAV in five Brazilian capitals showed that rehabilitation services suffered the most from supply shortages in organization and structure compared to primary, pre-hospital, and hospital care. It is one of the weakest points in the PNRMAV implementation process¹⁵15 Minayo MCS, Deslandes SF, organizadoras. Análise diagnóstica da política nacional de saúde para redução de acidentes e violências. Rio de Janeiro: Editora FIOCRUZ; 2007.. In the same direction, a bibliographic review on care for victims of violence in the SUS reinforces the precariousness of national studies: only 2% of 304 Brazilian publications from 2001 to 2013 address the rehabilitation level³3 Assis SG, Deslandes SF, Minayo MCS. Atendimento a pessoas em situação de violência pelo Sistema Único de Saúde. In: Minayo MCS, Assis SG, editoras. Novas e velhas faces da violência no século XXI: visão da literatura brasileira no campo da saúde. Rio de Janeiro: Editora Fiocruz; 2017. p. 271-296..

A little over two decades since the enactment of the PNRMAV, this article seeks to analyze the implementation of healthcare in recovery and rehabilitation based on the small number of responding municipalities, considering the assistance offered to victims of violence and accidents, describing the geographic distribution of services to victims and analyzing the implementation of guidelines specifically aimed at this public in Brazil.

Methods

This descriptive quantitative study was conducted in 2021 in Brazilian municipalities on providing and operating recovery and rehabilitation care services for victims of accidents and violence. The data were collected through the REDCap electronic research platform. It was supported by the Ministry of Health, the National Council of Health Secretaries, and the National Council of Municipal Health Secretaries, which provided their consent and email addresses of the municipal health secretaries of the 5,570 Brazilian municipalities. These secretaries were contacted, asking them to raise awareness among recovery/rehabilitation care managers to complete the survey questionnaires through a link to access the RedCap platform. The COVID-19 pandemic took center-stage back then, and attention was focused on care during this event. Only 113 municipalities responded to the questionnaire on rehabilitation (2.0% of the total). The analysis was made considering who participated in the study.

The variables analyzed include: a) location of rehabilitation and recovery services by Brazilian region (North, Northeast, Midwest, Southeast, and South) and population size (up to 99,999 inhabitants and over 100,000 inhabitants); b) type of services: municipal, state, federal, private in partnership with the SUS, private, and intermunicipal consortium; c) service infrastructure and meeting rehabilitation needs; d) actions offered: group care, prevention of sequelae and secondary disabilities, neuropsychomotor stimulation, family guidance, clinical and functional or specialized medical assessment, physiotherapy assessment and care, occupational therapy, speech therapy, psychology, social work, nursing, nutrition, drug care with dispensing of medicines, assessment of electromyography and evoked potentials diagnosis, urodynamic assessment, clinical care in several medical specialties, and surgical care; e) use of technological resources: clinical laboratory analysis, conventional radiology, ultrasound, nuclear medicine, urodynamics; f) protocols, routine, and care line that guide the service; g) availability of human resources: physiatrist, neurologist, speech therapist, nurse, social worker, psychologist, nutritionist, physiotherapist, occupational therapist, pharmacist, nursing technician or assistant, music therapist, physical educator, dentist, and oral health technician or assistant; h) care: whether or not the services meet the needs of the municipality and whether the infrastructure is sufficient for local needs. This topic also asked about specialized care by type of accident or violence victim and group (child, adolescent, adult, elderly, woman, and other); i) on referrals: whether municipalities attend to and refer cases, only attend to, only refer, neither attend nor refer. This analysis is broken down by type of service (primary health care unit/health center/health unit, specialized center, hospital, and home care), and type of referral (e.g., health, education, and justice); j) supply and dispensing of orthoses, prostheses, and mobility aids, variety and quality of the supply of these aids, quantity available, continuity in the supply of orthoses, prostheses and mobility aids; variety and continuity of the supply of medicines; variety, continuity and maintenance of essential inputs and equipment to support recovery and rehabilitation.

The data analysis presented includes absolute and relative frequency distributions. All analyses were stratified by region and municipality population size and implemented in the statistical package SPSS 24¹⁶16 Worthen BR, Fitzpatrick J, Sanders JR. Avaliação de programas: Concepções e Prática. São Paulo: Editora Gente; 2004.. Before completing the questionnaire, the participant had access to the Informed Consent Form. The Research Ethics Committee approved the study project (CAAE 27932820.7.0000.5420).

Results

The participation of the 113 municipalities varied by Brazilian region (from 1.6% in the Northeast to 3.3% in the North) and population size (from 1.9% in municipalities with up to 99,999 inhabitants in the South and North to 22.6% in the largest municipalities in the North).

Approximately 98.2% of the 113 municipalities analyzed have at least one Recovery and Rehabilitation service type, and municipal services were the most common (86.7%), followed by state services (25.7%). Around 21.2% of the private entities with agreements with the SUS were reported by the services in the responding municipalities (data not shown). Joint administration of services occurs especially between municipalities in the same state or with private units with agreements. In Brazilian capitals, recovery/rehabilitation care was most frequent at municipal (85.7%) and state (57.1%) levels. Next came private services contracted to the SUS (28.6%) and exclusively private services (14.3%).

Most of the responding municipalities (72.1%) and capitals (83.3%) consider that their municipality meets the recovery and rehabilitation needs of existing accident and violence cases (Table 1). Except for the Midwest, characterized by higher percentages, regardless of population size, the other regions show fluctuations, with values similar to or lower than those found for the general units participating in the study. For example, according to the respondents, the small municipalities in the North meet only 50% of the needs, and the larger municipalities in the Northeast and Southeast and the smaller municipalities in the South only meet 66.7% (Table 1).

Although most municipalities consider that existing services meet the needs of those affected by accidents and violence, 27.9% of the cities surveyed do not have adequate services. At the regional level, the scarcity of services stands out in small units in the North (50.0%) and South (33%) and larger units in the Northeast and Southeast, with a high percentage of cities indicating significant service limitations.

Regarding the availability of infrastructure in care services, 43.8% of all responding services and 14.3% of those located in capital cities state that they “mostly” or “almost always” meet the needs of those traumatized by violence and accidents (data not shown). The services located in larger municipalities in the Northeast, Southeast, and South regions, and the smaller ones in the South, stand out more positively. The larger ones in the Midwest and North stand out negatively, which are the ones with the lowest percentages of care satisfaction.

The Recovery and Rehabilitation actions to assist accident and violence victims mentioned most frequently are assessment and care in physiotherapy (74.0%) and in nursing (70.2%) (data not shown). The Southeast and Northeast have more recovery and rehabilitation actions to assist victims, regardless of the municipality’s population size. The most optimistic outlook is seen in the smallest municipalities in the North and South and the most populous units in the Midwest.

The actions not conducted in the responding municipalities are urodynamic assessment (44.6%) and diagnostic assessment of electroneuromyography and evoked potentials (43.1%), followed by group care (36.5%) and assessment and care in occupational therapy (35.0%). In the capitals, there is a greater frequency and variety of actions, emphasizing specialized clinical evaluation in occupational therapy, speech therapy, and nutrition (83.3% for each action) and neuropsychomotor stimulation (80.0%). The actions not conducted in the responding municipalities are urodynamic assessment (44.6%) and diagnostic assessment of electroneuromyography and evoked potentials (43.1%), group care (36.5%), and occupational therapy care (35.0%). Group care is not mentioned by 50% of the respondents.

The recovery and rehabilitation services provided by the health network for those injured by accidents and violence in the municipalities are mainly offered by primary health care units, health centers, and family health units. Most responding municipalities report attending to and referring cases (87.6%) as expected. However, 21.4% stated that there are no specialized centers, 18.3% said they do not have a hospital, and 17.8% do not provide home care (Table 2). In the capitals, the reality shows average results: 66.7% report care and referral for accidents and violence by primary health care units, health centers, family health units, and specialized centers, and half of them report providing home care.

The recovery and rehabilitation services provided by the health network to accident and violence victims by region and population size (data not shown) stand out in the Southeast and South. The first care services are provided at basic health unit and family health strategy (around 95.0% in smaller municipalities). About one-third or more of the services in smaller North, Northeast, and South municipalities mentioned the lack of specialized services. A lack of home care was identified in the North and hospital care in the Northeast. In cities with larger populations, hospital services in the North and home care in the South and Central-West stand out due to their scarcity or non-availability.

Sufficient technological resources for the recovery and rehabilitation of accident and violence victims in the municipalities, such as clinical laboratory analysis (66.3%), conventional radiology (57.0%), and ultrasound (52.5%), are mentioned by most responding municipalities. However, significant gaps related to nuclear medicine (64.0%) and urodynamics (51.0%) are mentioned (data not shown). In Brazilian capitals, conventional radiology, urodynamics, and ultrasound are often reported as scarce or sufficient services. Brazilian regions reveal some congruence by population size: lack of several resources in the municipality, mainly nuclear medicine (except in the Southeast in the largest units) and urodynamics, except in the larger cities of the Southeast, Midwest, and South.

The availability of human resources for the recovery and rehabilitation of those traumatized by accidents and violence shows an almost total lack in the municipalities when it comes to music therapists (87.3%), physiatrists (80.2%), neurologists (45.0%), and occupational therapists (42.6%). Nursing technicians or assistants (80.6%), nurses (77.1%), social workers (73.1%), psychologists (72.4%), physiotherapists (74.0%), dentists (66.0%) and oral health technicians or assistants (65.0%) are identified more. In the capitals, respondents report a shortage of physiatrists and music therapists (66.7% both) and physical educators (33.3%) (data not shown).

Table 3 shows that the assessment of indications for orthoses (61.1%), mobility aids (55.8%), and prescription of orthoses (59.3%) are the procedures most mentioned by the responding municipalities. The municipalities, as a whole, show a shortage of services and support for individuals in need. These support actions are mentioned more only in the South. Only the offer and continuous supply of drugs were mentioned more (46.5% and 50.0%, respectively). The supply of essential inputs was considered adequate by only 40% of respondents. The lack of amount and variety of orthoses, prostheses, and mobility aids was mentioned by 48.5% and 51.0%, respectively). In Brazilian capitals, the critical situation was highlighted by managers associated with high demand. In smaller municipalities in the North and Northeast, followed by those in the Southeast, respondents also pointed out a lack of variety, quality, amount, and continuous supply of orthoses, prostheses, and mobility aids (Table 3).

Significant difficulties were mentioned in managing recovery and rehabilitation care, primarily due to the lack of coordination with services at other care levels (66.4% in the case of in-house services and 75.2% of partner services). Respondents also mentioned the lack of monitoring of services by municipal managers, a reality reported by 81.4% of partner services and 31.0% of in-house services.

Table 4 shows the high proportion of use of protocols and routines for assisting accident and violence victims in the different regions, regardless of population size. The capitals had a lower frequency of reports of protocols and routines for cases of abuse against older adults (66.7% each).

Most municipalities reported offering recovery and rehabilitation services to the following groups (Table 5): children, adolescents, adults, older adults, and women. All capitals offer specialized care to accident victims, except for older adults (83.3%). Most regions show that the most substantial provision of services is found in larger cities. In the case of accidents, the Southeast shows high levels of provision of services, both in larger and smaller cities. For violence, the lowest frequencies are in the North and smaller municipalities.

The referrals most frequently mentioned by 92% of the responding services are to the health and social assistance network and the guardianship council (Table 5). The Public Prosecutor’s Office is also frequently mentioned (82.7%). The least frequently mentioned services are the Police Station for People with Disabilities, the Specialized Reference Center outside the health sector, the Human Rights Reference Center, and the LGBTI+ Rights Council. In general, there is a high frequency of referrals of accident and violence cases in several regions and cities of different population sizes to SUS services (Table 5).

Discussion

Notably, a significant number of managers consider the implementation of the guideline for structuring and consolidating care targeting recovery and rehabilitation to be fair, indicating the need for greater attention to this care level. The main problems highlighted are the lack or scarcity of infrastructure for care and the insufficient technological resources for the recovery of accident and violence victims. Significant gaps stand out regarding nuclear medicine and urodynamics, which do not comply with the general guidelines of the Ministry of Health⁷7 Brasil. Ministério da Saúde (MS). SUS de todos: rede para a pessoa com deficiência atende todo o país [Internet]. 2022 [acessado 2024 jun 13]. Disponível em: https://www.gov.br/saude/pt-br/assuntos/noticias/2019/setembro/sus-de-todos-rede-para-a-pessoa-com-deficiencia-atende-todo-o-pais.
https://www.gov.br/saude/pt-br/assuntos/... ^,88 Brasil. Ministério da Saúde (MS). Centro Especializado em Reabilitação e Oficina Ortopédica são pontos de atenção à pessoa com deficiência no SUS. 2022 [acessado 2024 jun 13]. Disponível em: https://www.gov.br/saude/pt-br/assuntos/noticias/2022/agosto/centro-especializado-em-reabilitacao-e-oficina-ortopedica-sao-pontos-de-atencao-a-pessoa-com-deficiencia-no-sus.
https://www.gov.br/saude/pt-br/assuntos/... ^,1010 Brasil. Ministério da Saúde (MS). Secretaria de Atenção Especializada à Saúde. Departamento de Atenção Especializada e Temática. Guia de atenção à reabilitação da pessoa idosa [Internet]. 2021 [acessado 2024 jun 13]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/guia_atencao_reabilitacao_pessoa_idosa.pdf.
https://bvsms.saude.gov.br/bvs/publicaco... , the PNRMAV¹¹11 Brasil. Ministério da Saúde (MS). Política Nacional de Redução de Morbimortalidade por Acidentes e Violências. Brasília: MS; 2001., and the WHO¹²12 World Health Organization (WHO). Rehabilitation 2030: a call for action: the need to scale up rehabilitation. Geneva: WHO; 2017.^,1313 World Health Organization (WHO). Rehabilitation 2030: A call for action: Concept note. Geneva: WHO; 2017..

Also, most recovery and rehabilitation services in the municipalities in this study are municipally managed, aligning with the principle of healthcare decentralization, which can promote greater access and humanized care. People turn to and receive first aid and referrals, mainly to primary health care units, health centers, and family health units.

However, care is often not resolved at this level, and there is a limited supply of specialized services designed to help people resume their lives in one way or another without becoming dependent. Some services have even been deactivated over the last few decades due to changes in the form and amount of financial transfers from the Ministry of Health¹⁷17 Caetano LA, Sampaio RF, Costa LA. A expansão dos serviços de Recuperação/Reabilitação no SUS. Rev Ter Ocup 2018; 29(3):195-203.^,1818 Mendes JMR, Marques RM, Oliveira PAB, Ferreira MRJ, Devit AH. O SUS em desconstrução: o primeiro ano da gestão Jair Bolsonaro. In: Prates JC, Marques TM, Orth T, organizadoras. Alterações político-econômicas contemporâneas na América Latina: o caso do Brasil, Cuba e Chile. Manaus: Editora da Universidade Federal do Amazonas; 2021. p. 145-159.. Even the growth that may have occurred in specific areas, such as professional training, does not seem to meet the growing needs for recovery and rehabilitation, as mentioned by Gomes et al.¹⁹19 Gomes SM, Miranda GMD, Sousa FOS, Nascimento CMB, Lima MLLT, Silva VL, Vilela MBR. Recuperação/Reabilitação física/funcional no Brasil: análise espaço-temporal da oferta no Sistema Único de Saúde. Cien Saude Colet 2023; 28(2):373-383., primarily due to the high rates of accidents and violence and the poor coordination of the system with the National Health Policy for People with Disabilities²⁰20 Brasil. Ministério da Saúde (MS). Política Nacional de Saúde da Pessoa Portadora de Deficiência. Brasília: MS; 2008., the latter being a privileged target audience for recovery and rehabilitation actions and the target of various types of violence. We also observe an undeniable invisibility of the social issues that affect health in the SUS, possibly due to the naturalized hegemony of the biomedical model.

Difficulties in providing care to people with disabilities or injuries are common in many countries, especially those in the developing stage. In general, services focus on improving the individual’s functionality but do not always provide specific care for their general well-being, and they rarely identify recurring abuse that deserves attention and protection network⁴4 Khan F, Amatya B, Hoffman K. Systematic review of multidisciplinary rehabilitation in patients with multiple trauma. BJS Open 2012; 99(Supl. 1):88-96.^,66 Marriel NSM, Deslandes, SF, Minayo MCS. Análise da Implementação do Atendimento em Recuperação/Reabilitação. In: Minayo MCS, Deslandes SF, organizadoras. Análise diagnóstica da política nacional de saúde para redução de acidentes e violências. Rio de Janeiro: Editora Fiocruz; 2007. p. 171-192.^,2121 Kumar SG, Roy G, Kar SS. Disability and Rehabilitation Services in India: Issues and Challenges. J Family Med Prim Care 2012; 70(1):69-73..

In Brazil, we should underscore the flagrant unequal regional distribution of recovery and rehabilitation services. This situation is more delicate in the North and more organized in the Southeast, repeating the socioeconomic inequality in providing services¹⁵15 Minayo MCS, Deslandes SF, organizadoras. Análise diagnóstica da política nacional de saúde para redução de acidentes e violências. Rio de Janeiro: Editora FIOCRUZ; 2007.^,2222 Tomasiello DB, Bazzo J, Parga J, Servo LM, Pereira RHM. Desigualdades raciais e de renda no acesso à saúde nas cidades brasileiras. Brasília, Rio de Janeiro: Ipea; 2023.. A total of 27.9% of the municipalities investigated do not have adequate care for cases of injuries due to accidents and violence, and 43.8% complain about the lack of infrastructure and insufficient technological, material, and human resources, also confirmed by the literature⁴4 Khan F, Amatya B, Hoffman K. Systematic review of multidisciplinary rehabilitation in patients with multiple trauma. BJS Open 2012; 99(Supl. 1):88-96.^,55 Krug E, Cieza A. Strengthening health systems to provide rehabilitation services. Can J Occup Ther 2017;84(2):72-75..

The relevance of the work of primary health care units, health centers, and family health units is essential. Almost all respondents mentioned them as a gateway and for referrals. However, specialized centers, hospitals, and home care services are considered absent by a significant portion of the municipalities. Respondents also refer to gaps in professionals, especially music therapists, physiatrists, neurologists, and occupational therapists¹⁹19 Gomes SM, Miranda GMD, Sousa FOS, Nascimento CMB, Lima MLLT, Silva VL, Vilela MBR. Recuperação/Reabilitação física/funcional no Brasil: análise espaço-temporal da oferta no Sistema Único de Saúde. Cien Saude Colet 2023; 28(2):373-383..

There are still severe and persistent limitations in the provision of orthoses, prostheses, medicines, inputs, equipment, and the discontinuous supply of medicines, essential inputs, and mobility aids⁶6 Marriel NSM, Deslandes, SF, Minayo MCS. Análise da Implementação do Atendimento em Recuperação/Reabilitação. In: Minayo MCS, Deslandes SF, organizadoras. Análise diagnóstica da política nacional de saúde para redução de acidentes e violências. Rio de Janeiro: Editora Fiocruz; 2007. p. 171-192.^,2323 Lima MLC, Deslandes SF, Souza ER, Lima MLLT, Barreira SK. Análise diagnóstica dos serviços de Recuperação/Reabilitação que assistem vítimas de acidentes e violências em Recife. Cien Saude Colet 2009; 14(5):1817-1824.. Due to the high demand, the situation is strongly felt and mentioned in Brazilian capitals.

Specialized care focuses on specific groups of children, adolescents, adults, older adults, and women. Other groups were mentioned in detail: the LGBTQIA+ population, men, newborns, and Indigenous people. The latter are also less served at other care levels¹⁵15 Minayo MCS, Deslandes SF, organizadoras. Análise diagnóstica da política nacional de saúde para redução de acidentes e violências. Rio de Janeiro: Editora FIOCRUZ; 2007..

Access to rehabilitation services is more significant for accident victims than for those traumatized by violence, for whom there is a lack of established protocols and routines. This is the case of abuse or neglect against older adults who are significantly impacted, which is reflected in the high number of hospitalizations²⁴24 Ribeiro AP, Barter EACP. Atendimento de reabilitação à pessoa idosa vítima de acidentes e violência em distintas regiões do Brasil. Cien Saude Colet 2010; 15(6):2729-2740.. In this regard, Ribeiro and Bater²⁴24 Ribeiro AP, Barter EACP. Atendimento de reabilitação à pessoa idosa vítima de acidentes e violência em distintas regiões do Brasil. Cien Saude Colet 2010; 15(6):2729-2740. highlight the unequal contexts and the quality of services. The only issue of violence with a well-established protocol and immediate care is sexual assault, whose services (although precarious) are available in all the municipalities studied. However, the coordination between recovery and rehabilitation services and the accident and violence care network is still substandard. Since the impairments are physical and mental, this fact makes the demand more complex.

Comparing the results obtained in this research with those of the study conducted in 2006¹⁵15 Minayo MCS, Deslandes SF, organizadoras. Análise diagnóstica da política nacional de saúde para redução de acidentes e violências. Rio de Janeiro: Editora FIOCRUZ; 2007., in that year, there was a need for considerable progress so that the PNRMAV could be effectively implemented in the five capitals investigated regarding the recovery and rehabilitation care of patients who were victims of violence. The authors questioned the inadequate information provided by managers and health professionals about their roles concerning people with aftereffects, disabilities, and their families. The weaknesses physical structure of the healthcare network were exposed, emphasizing poor post-hospital monitoring, deficient transportation of patients with sequelae, discontinuous distribution of medicines, and training for the use of orthoses and prostheses. The small network at this care level was also highlighted and was totally inadequate for the scale of the problem in the population. The authors also mentioned the shortage of qualified professionals and the long, time-consuming, and painful waiting list to receive orthoses, prostheses, and wheelchairs. A lack of adequate financial support for this care level was underscored, as was the need to establish protocols for care and adequate records.

Sixteen years later, data from this research show advances in some areas, such as available regulations, an increase in decentralized services for municipalities, and an increase and the diversity of professionals in a good part of the units participating in the research. However, very problematic issues remain, such as underfunding of the health sector as a whole and of this care level in particular¹⁸18 Mendes JMR, Marques RM, Oliveira PAB, Ferreira MRJ, Devit AH. O SUS em desconstrução: o primeiro ano da gestão Jair Bolsonaro. In: Prates JC, Marques TM, Orth T, organizadoras. Alterações político-econômicas contemporâneas na América Latina: o caso do Brasil, Cuba e Chile. Manaus: Editora da Universidade Federal do Amazonas; 2021. p. 145-159., aggravated in recent years by budget cuts to the health sector and the advent of the COVID-19 pandemic, weaknesses in infrastructure and ways of recruiting human resources, besides problems with the provision of orthoses and prostheses.

Some weaknesses pointed out in this study are supported by the literature. A literature review study conducted by Caetano et al.¹⁷17 Caetano LA, Sampaio RF, Costa LA. A expansão dos serviços de Recuperação/Reabilitação no SUS. Rev Ter Ocup 2018; 29(3):195-203., focusing on the recovery and rehabilitation of people with disabilities, indicates that the provision of these public services depends on institutional aspects such as the availability of a legal framework, the definition of budgetary transfers, and structural conditions. The authors report the relevance of this care level being anchored in federal decrees and ordinances providing equipment availability and financial transfers. They consider that such services have been growing incrementally and slowly since 1989. However, some structural changes became evident only in 2012, such as the legislation creating a recovery and rehabilitation network for people with disabilities. The authors affirm that “this institutional apparatus is an indication of progress and structuring of recovery and rehabilitation equipment in health, and acts as an inducing mechanism so that states and municipalities take responsibility for implementing the recovery and rehabilitation network in the context of decentralized and regionalized health policy”¹⁷17 Caetano LA, Sampaio RF, Costa LA. A expansão dos serviços de Recuperação/Reabilitação no SUS. Rev Ter Ocup 2018; 29(3):195-203. (p.201). However, the authors highlight the change in how resources were transferred to health in 2017 (Ordinance MS/GM No. 3,992/2017) in the context of financial and budgetary restrictions, which weakened the Ministry of Health, making it a simple transfer of resources to states and municipalities instead of being the organizer of structuring policies for the SUS, thus increasing conflict and bargaining spaces at the local level¹⁷17 Caetano LA, Sampaio RF, Costa LA. A expansão dos serviços de Recuperação/Reabilitação no SUS. Rev Ter Ocup 2018; 29(3):195-203..

Gomes et al.¹⁹19 Gomes SM, Miranda GMD, Sousa FOS, Nascimento CMB, Lima MLLT, Silva VL, Vilela MBR. Recuperação/Reabilitação física/funcional no Brasil: análise espaço-temporal da oferta no Sistema Único de Saúde. Cien Saude Colet 2023; 28(2):373-383. were also concerned with the structure of the recovery and rehabilitation sector, evaluating the distribution of physiotherapy, speech therapy, and occupational therapy professionals in the Unified Health System (SUS) between 2007 and 2019. They found an increasing temporal trend in the potential supply of the three professional categories in Brazil and all regions but with a slowdown in this growth from 2010 onwards. They also observed differences between professions and regions of the country. They drew attention to a situation of inequality in the supply of health workers, in which the North - as found in this study - is the weakest and the Southeast is the richest in recovery and rehabilitation professionals. The authors point out the need to expand access to services at this care level in the country, given the aging population, the growing proportion of people with disabilities, and the higher demand resulting from post-COVID-19 syndrome or Long-COVID-19.

With the creation of Family Health Support Centers (NASF) in 2008, more professional categories started integrating primary care teams, such as physiotherapists, speech therapists, and occupational therapists²⁵25 Brasil. Ministério da Saúde (MS). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Cadernos de atenção básica: diretrizes do NASF. Brasília: MS; 2009.. From then on, primary care can count on these professionals to guide and coordinate care, which has improved access to rehabilitation for victims of accidents and violence. A study conducted by Silva et al.²⁶26 Silva MGP, Silva VL, Nascimento CMB, Vilela MBR, Lima MLLT. Acesso à reabilitação fonoaudiológica e a continuidade do cuidado pela Atenção Primária em Saúde para vítimas de acidente de motocicleta. Codas 2020; 32(1):e20170097. on speech therapy rehabilitation and care continuity in Primary Health Care for victims of motorcycle accidents points out the distance to services and the waiting time to start treatment as the main obstacles to access. They also highlight the low frequency of home visits, a distinguishing feature of this care level. Notably, most Brazilian municipalities are small, which means that they often only have primary health care services, indicating the need to strengthen those who work at the recovery and rehabilitation level because disabilities, traumas, and injuries occur in all locations.

Other studies highlight the difficulties of the recovery and rehabilitation level with referral and counter-referral actions²⁶26 Silva MGP, Silva VL, Nascimento CMB, Vilela MBR, Lima MLLT. Acesso à reabilitação fonoaudiológica e a continuidade do cuidado pela Atenção Primária em Saúde para vítimas de acidente de motocicleta. Codas 2020; 32(1):e20170097.^,2727 Pereira JS, Machado WCA. Referência e contrarreferência entre os 1033 serviços de Recuperação/Reabilitação física da pessoa com deficiência: a (des)articulação na microrregião Centro-Sul Fluminense, Rio de Janeiro, Brasil. Physis 2016; 26(3):1033-1051.. They draw attention to the lack of coordination between this sector and others due to the low number of professionals specialized in these issues, which overwhelms the few with a lot of work¹⁹19 Gomes SM, Miranda GMD, Sousa FOS, Nascimento CMB, Lima MLLT, Silva VL, Vilela MBR. Recuperação/Reabilitação física/funcional no Brasil: análise espaço-temporal da oferta no Sistema Único de Saúde. Cien Saude Colet 2023; 28(2):373-383.^,2828 World Health Organization (WHO). Guide for rehabilitation workforce evaluation: project officer handbook. Geneva: WHO; 2023., the reduced number of services, the lack of a multidisciplinary team and technological support, the poor intra and intersectoral coordination, and the little investment in victims and their families²³23 Lima MLC, Deslandes SF, Souza ER, Lima MLLT, Barreira SK. Análise diagnóstica dos serviços de Recuperação/Reabilitação que assistem vítimas de acidentes e violências em Recife. Cien Saude Colet 2009; 14(5):1817-1824.^,2929 Lima MLLT, Lima MLC, Deslandes SF, Souza ER, Barreira AK. Assistência em Recuperação/Reabilitação para vítimas de acidentes e violência: a situação dos municípios em Pernambuco, Brasil. Cien Saude Colet 2012; 17(1):33-42..

The main limitation of this work is the low participation of municipal managers in the survey, which, due to commitments in the public notice, was conducted during the COVID-19 pandemic. This moment drained the energy of professionals and the performance of health services, and, understandably, answering a research questionnaire was something postponed from any essential activity amid their excessive and distressing tasks. We understand, however, that extensive and detailed information offered by the research allows for an overview, albeit incomplete, that points out paths, advances, problems, and solutions that help improve PNRMAV’s universalization, especially in its guidelines on recovery and rehabilitation, a fundamental level for SUS users.

Conclusion

With the creation of the SUS in the 1980s, rehabilitation was transferred to the administration of the Ministry of Health and consequently assumed a decentralized character. Its services were initially offered in urban regions and concentrated in more affluent areas, with low healthcare coverage and organized by type of disability³⁰30 Ribeiro CTM, Ribeiro MG, Araújo AP, Mello LR, Rubim LC, Ferreira JES. O sistema público de saúde e as ações de reabilitação no Brasil. Rev Panam Salud Publica 2010; 28(1):43-48..

In recent years, considering health services as a management responsibility of municipalities, we found in the research that gave rise to this article that municipal health secretariats began to take on, not without difficulties, the construction of actions for comprehensive healthcare, which includes rehabilitation assistance. Expanding coverage by family health teams (ESF), establishing family health support centers (NASF), and constructing Specialized Rehabilitation Centers (CER) have contributed to the decentralization of these services, which is essential to guarantee timely access to rehabilitation services for accident and violence victims.

Despite all the advances listed here, the data presented show that the analysis of the implementation of healthcare in recovery and rehabilitation in the country reveals numerous weaknesses in the different Brazilian regions and municipalities, regardless of their population size. The country is clearly still far from offering services with a proposal for universality, comprehensiveness, and equity and the PNRMAV remains insufficiently implemented, even after two decades of publication. Establishing this care level properly for the population’s good is essential, with protocols and routines, equipment, specialized professionals, and services that consider the Ministry of Health’s and the World Health Organization’s recommendations.

References

Publication Dates

History