Abstract

Introduction

Rural localities may exhibit considerable differences in service provision as a function of financial resources allocation, workforce composition, natural phenomena, and distance from regional reference centers ¹1. Allan J, Ball P, Alston M. Developing sustainable models of rural health care: a community development approach. Rural Remote Health 2007; 7:818.. In the United States, in rural areas, there is a lower proportion of users provided with health insurance, a major hurdle in countries without universal healthcare systems, and a higher incidence of smoking, obesity, physical inactivity, suicide, and severe mental illness ²2. Cyr ME, Etchin AG, Guthrie BJ, Benneyan JC. Access to specialty healthcare in urban versus rural US populations: a systematic literature review. BMC Health Serv Res 2019; 19:974.. These, among other factors, seem to make explicit the need of healthcare organization and delivery models to incorporate strategies to address the needs of people in rural settings ³3. Wakerman J, Humphreys JS, Wells R, Kuipers P, Entwistle P, Jones J. Primary health care delivery models in rural and remote Australia - a systematic review. BMC Health Serv Res 2008; 8:276., who share with urban vulnerable populations a set of access barriers and worse health outcomes ²2. Cyr ME, Etchin AG, Guthrie BJ, Benneyan JC. Access to specialty healthcare in urban versus rural US populations: a systematic literature review. BMC Health Serv Res 2019; 19:974..

The challenges to the organization and availability of health services in locations outside the urban centers, with low population density and small population size have become global. Countries like Australia, since the early 1990s, have implemented policies for these areas that seek to respond to diversified necessities, with securing access being one of the main issues faced ³3. Wakerman J, Humphreys JS, Wells R, Kuipers P, Entwistle P, Jones J. Primary health care delivery models in rural and remote Australia - a systematic review. BMC Health Serv Res 2008; 8:276.^,44. Strasser R. Rural health around the world: challenges and solutions. Fam Pract 2003; 20:457-63.. The concentration of specialists in urban centers results in greater dependence of rural populations on primary health care (PHC) providers, who sometimes undertake an increased scope of practice without proper training and infrastructure ²2. Cyr ME, Etchin AG, Guthrie BJ, Benneyan JC. Access to specialty healthcare in urban versus rural US populations: a systematic literature review. BMC Health Serv Res 2019; 19:974..

In Brazil, the large territorial extension and inequalities in living conditions condition different exposures to health risks and diseases, which are more unfavorable to rural populations, whose cultural, social, and environmental particularities remain largely unknown ⁵5. Coimbra Jr. CEA. Saúde rural no Brasil: tema antigo mais que atual. Rev Saúde Pública 2018; 52 Suppl 1:2s.. The definition of urban and rural spaces, in Brazil, is guided by a conception of residual rurality and being a byproduct of the urban environment, a perspective that disregards the diversity of these backgrounds ⁶6. Miranda C, Silva H, organizadores. Concepções da ruralidade contemporânea: as singularidades brasileiras. v. 21. Brasília: Instituto Interamericano de Cooperação para a Agricultura; 2013. (Série Desenvolvimento Rural Sustentável).. In 2014, the National Policy for the Integral Healthcare of the Rural, Forest, and Water Populations, aligned with a comprehensive and inclusive concept, sought to give visibility and highlight that, in this broad category that is conventionally referred to as “rural”, there are populations with cultural and healthcare practices that require having their needs addressed by the Brazilian Unified National Health System (SUS) ⁷7. Pessoa VM, Almeida MM, Carneiro FF. Como garantir o direito à saúde para as populações do campo, da floresta e das águas no Brasil? Saúde Debate 2018; 42(spe 1):302-14.. In 2017, Brazilian Institute of Geography and Statistics (IBGE) developed a rural-urban typology for the municipal territorial outline, adopting population density as the basic criterion ⁸8. Instituto Brasileiro de Geografia e Estatística. Classificação e caracterização dos espaços rurais e urbanos do Brasil - uma primeira aproximação. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2017.. However, the challenge of identifying particularities of intra-municipal rural spaces remains.

A number of studies highlight additional difficulties in the use of healthcare services by rural populations even when living in urban municipalities and those living in countryside municipalities ⁹9. Garnelo L, Lima JG, Rocha ESC, Herkrath FJ. Acesso e cobertura da atenção primária à saúde para populações rurais e urbanas na região norte do Brasil. Saúde Debate 2018; 42(spe 1):81-99.^,1010. Galvão JR, Almeida PF, Santos AM, Bousquat A. Percursos e obstáculos na Rede de Atenção à Saúde: trajetórias assistenciais de mulheres em região de saúde do Nordeste brasileiro. Cad Saúde Pública 2019; 35:e00004119.. The expansion of the Family Health Strategy (FHS) addresses part of the problem. According to the 2019 Brazilian National Health Survey, the proportion of residents with households registered in family health units is 62.6%, with 78.9% in rural and 59.8% in urban areas ¹¹11. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde 2019: resultados preliminares. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2020.. The extent of coverage, however, may conceal barriers to access, such as the concentration of teams at the headquarters of rural municipalities, in addition to geographical ⁹9. Garnelo L, Lima JG, Rocha ESC, Herkrath FJ. Acesso e cobertura da atenção primária à saúde para populações rurais e urbanas na região norte do Brasil. Saúde Debate 2018; 42(spe 1):81-99. barriers.

Faced with the “diseconomy of scale” ³3. Wakerman J, Humphreys JS, Wells R, Kuipers P, Entwistle P, Jones J. Primary health care delivery models in rural and remote Australia - a systematic review. BMC Health Serv Res 2008; 8:276., arising not only from the long distances from urban centers and small dispersed populations, but also from social, demographic, and natural characteristics that characterize the diverse Brazilian territory, what would be the “suitable models” for PHC in remote rural municipalities? This paper aims to identify and analyze the structural characteristics of PHC, in its background and organizational aspects, at remote rural municipalities, based on adaptations to the model of Hogg et al. ¹²12. Hogg W, Rowan M, Russell G, Geneau R, Muldoon L. Framework for primary care organizations: the importance of a structural domain. Int J Qual Health Care 2008; 20:308-13. and Paré-Plante et al. ¹³13. Paré-Plante A, Boivin A, Berbiche D, Breton M, Guay M. Primary health care organizational characteristics associated with better accessibility: data from the QUALICO-PC survey in Quebec. BMC Fam Pract 2018; 19:188.. The objective is to identify critical elements, actions, and policies that contribute to the maintenance and sustainability of PHS in a rural environment.

Methodology

Study design and area

This is a qualitative study, consisting of a national survey with multiple case studies in 27 remote rural municipalities ¹⁴14. Fausto MCR, Fonseca HMS, Penzin VM. Atenção primária à saúde em territórios rurais e remotos no Brasil. https://apsmrr.com.br (acessado em 29/Jul/2020).
https://apsmrr.com.br... , categorized into spatially distinct homogeneous areas ⁸8. Instituto Brasileiro de Geografia e Estatística. Classificação e caracterização dos espaços rurais e urbanos do Brasil - uma primeira aproximação. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2017.. In this paper, results are analyzed from three remote rural municipalities that are part of the Northern Minas Gerais region, Brazil, including the Jequetinhonha Valley, one of the most important “opaque zones” that mirror the unequal process of formation of the territory of Minas Gerais ¹⁴14. Fausto MCR, Fonseca HMS, Penzin VM. Atenção primária à saúde em territórios rurais e remotos no Brasil. https://apsmrr.com.br (acessado em 29/Jul/2020).
https://apsmrr.com.br... . In this area, 22 of the 323 Brazilian remote rural municipalities are clustered. To define the intended sample for the study, first the remote rural municipality were characterized according to a set of socioeconomic, demographic, and health indicators, and then the criterion was to select 2 municipalities that presented similar characteristics in the area - Indaiabira and Rubelita - and 1 with unusual characteristics - Bonito de Minas. It is worth pointing out that, even in the case of a “unit”, that is, a remote rural municipality, in the 3 cases there was a classification of the territory in two areas: the headquarters, identified as the center, and the “rural zone” of the municipality, which corresponds to the small and disperse population groupings located in regions far from the headquarters.

Study population and samples

The study population was composed of 21 interviewees: municipal (6), regional (2), and state (1) managers; and professionals of the family health teams (EqSF) (12), key players in the characterization of the PHC organization (Table 1). In the case of the professionals, the first step was the selection of a basic health unit (UBS) located in the municipalities’ headquarters and another in the rural area, as indicated by the municipal manager. In each UBS, the physician and the nurse were interviewed.

Instruments and data collection

The results are derived from semi-structured interviews, complemented by secondary data from national information systems to characterize the PHC background. The interviews were based on multidimensional scripts for understanding the organization and provision of PHC services, composed of general and specific dimensions, according to the type of interviewee ¹⁴14. Fausto MCR, Fonseca HMS, Penzin VM. Atenção primária à saúde em territórios rurais e remotos no Brasil. https://apsmrr.com.br (acessado em 29/Jul/2020).
https://apsmrr.com.br... . In this paper, we analyze the results of the structural characteristics of PHC, in its background and organizational dimensions ¹²12. Hogg W, Rowan M, Russell G, Geneau R, Muldoon L. Framework for primary care organizations: the importance of a structural domain. Int J Qual Health Care 2008; 20:308-13..

The interviews were face-to-face, audio-recorded, transcribed in full, lasting 1:00 to 2:30 hours, conducted at their respective workplaces from July to October 2019.

Data analysis

The conceptual model proposed by Hogg et al. ¹²12. Hogg W, Rowan M, Russell G, Geneau R, Muldoon L. Framework for primary care organizations: the importance of a structural domain. Int J Qual Health Care 2008; 20:308-13., which guided the analysis of the results, involves two PHC domains: structural and performance. The structural domain is composed of three dimensions: (a) the general characteristics of the health system (policies, organizations and interest groups, financing, governance); (b) background; and (c) organization of the practice, the last two (b and c) being the focus of this paper. The assumption is that differences in PHC performance (access, continuity, integration, technical quality, among others) are strongly related to dimensions such as vision, practice background, and organizational resources ¹²12. Hogg W, Rowan M, Russell G, Geneau R, Muldoon L. Framework for primary care organizations: the importance of a structural domain. Int J Qual Health Care 2008; 20:308-13.^,1313. Paré-Plante A, Boivin A, Berbiche D, Breton M, Guay M. Primary health care organizational characteristics associated with better accessibility: data from the QUALICO-PC survey in Quebec. BMC Fam Pract 2018; 19:188.. Thus, analyzing critical points and successful measures in the structural and contextual domain of PHC may contribute to understanding and improving its performance.

Based on the model by Hogg et al. ¹²12. Hogg W, Rowan M, Russell G, Geneau R, Muldoon L. Framework for primary care organizations: the importance of a structural domain. Int J Qual Health Care 2008; 20:308-13. and contributions by Paré-Plante et al. ¹³13. Paré-Plante A, Boivin A, Berbiche D, Breton M, Guay M. Primary health care organizational characteristics associated with better accessibility: data from the QUALICO-PC survey in Quebec. BMC Fam Pract 2018; 19:188., the following categories were included in the context of the pratices component: sociodemographic characterization of the population, of the territory, and configuration of the supply of healthcare services. These elements are related to structural characteristics of PHC and may have an important influence on service delivery and professional practices. The organizational aspect encompassed: territorialization and client assignment; types and organization of first contact services; interprofessional action and collaboration; technical, material, and human resources.

For this analysis, the data was sorted based on the general reading of the transcribed material and the triangulation of the interviews and secondary data. The results were systematized in analytical tables, grouped and categorized. We then started to compare the speeches, in a dialectical confrontation of the subjects’ ideas and standings, identifying convergences and divergences for the purpose of critical interpretation. The intention was not the judgment of each municipality, but the understanding of processes in the remote rural municipalities territories through representative scenarios.

The study was approved by the Ethics Reaerch Committee of the Sergio Arouca National School of Public Health, Oswaldo Cruz Foundation (CAAE 92280918.3.0000.5240), and by approval opinion nº 2.832.559, with the consent of the municipalities.

Results

Background aspect of PHC practices

Sociodemographic description of the population and territory

The state of Minas Gerais is home to 853 municipalities, 22 of which are remote rural municipalites ⁸8. Instituto Brasileiro de Geografia e Estatística. Classificação e caracterização dos espaços rurais e urbanos do Brasil - uma primeira aproximação. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2017.. The municipalities analyzed were small-sized, whose population, for the most part, lived in rural areas and were more vulnerable compared to the population that lived in the headquarters. Population density was low, and only Indaiabira had a medium Human Development Index-Municipality (HDI-M). The socioeconomic characterization revealed worse living conditions, taking national parameters as a reference. In general, they were municipalities that depended almost exclusively on government subsidies, especially the Brazilian Income Transfer Program, which in association with other indicators, presented in Table 2, showed a pattern of extreme vulnerability.

Another common feature was the availability of treated and running water and basic sanitation at the headquarters, but not in all rural areas, according to managers and professionals. It was mentioned that federal policies from 2002-2016 provided improvements in living conditions and health in rural areas.

Drought was mentioned as a recurring problem, but without severe water shortages. In the rainy season, road conditions worsened, making traffic in and out of the municipality difficult. There was insufficient/inexistent public transportation routes/times, particularly severe in rural areas, as well as difficulty/absence of telephone/internet network, with implications for the organization of PHC.

Configuration of healthcare services supply

The municipalities only presented PHC services, with potential 100% coverage by the FHS, however, individual enrollment to the EqSF was lower. In general, the UBS were located in the headquarters and in rural areas, except for Bonito de Minas, although the National Register of Health Establishments (CNES) indicated a rural unit (Table 3). The rural area had “support points”, simplified spaces that allowed the care of remote populations. The infrastructure of the UBS was considered suitable by the interviewees, as they had undergone renovations with funds from Requalifica UBS (UBS Requalification Program).

The three municipalities had Family Health Support Centers (NASF) and Health Academy Program with social workers, physical therapists, speech therapists, pharmacists, nutritionists, and psychologists, with a strong role in preventive and health promotion activities, in articulation with the School Health Program, the Health Academy Program, and Brazilian Income Transfer Program.

Minas Gerais is divided into 13 health macro-regions, with the cases belonging to the Northern Macro-region. For highly complex treatments, such as some types of cancer, the reference center was Belo Horizonte (≥ 600km). Most of the specialized services were concentrated in the region's main municipality (up to 50km). In some cases, specialized care was provided at the headquarters of the macro-region, Montes Claros (> 200km) (Table 3). There was a consensus among the interviewees as to the restriction of the offer of specialized services, one of the alternatives being the Intermunicipal Health Consortia, funded by the municipalities.

Table 3 presents the characteristics of the Northern Health Macro-region, resources and equipment in healthcare, based on the state and the Central Macro-region, in which the metropolitan region of Belo Horizonte is located. Most of the hospitals, beds, and high complexity equipment in the Northern Macroregion belonged to the private network.

Organizational aspect of PHC practices

Territorialization and customer allocation

The EqSF worked based on enrolled territories, although the flows established by the users were diversified and redefined by the availability of transportation, opening hours, location, and attendance of professionals, especially physicians, in the UBS.

Despite the formal enrollment, teams served users from other areas, including border municipalities. Such flexibility was not seen as a point of conflict, because this organizational dynamic was shared in the region and there was a certain informal agreement that the user should seek and be served by the most accessible service.

The managers recognized the fluidity of the users’ therapeutic itinerary, but needed to balance the enrollment by team, in order not to cause an overload in the assistance, to maintain the parameters required for federal funding, and the teams’ health responsibility for longitudinal follow-up. Defining the location of a new team implied in difficulties facing territories with sparse population and the need of large displacements for professionals and users.

The attraction of investment resources (Federal, State, Parliamentary Amendment) and political party issues influenced the decision to build UBS, without the guarantee of funding and, sometimes, in unsuitable locations from the point of view of care flows, aggravating the problems for maintenance and operation.

Types and organization of first contact services

For managers, the implementation of the FHS has been changing the pattern of service of first contact and regular consultation, especially by offering and providing services closer to the people. Historically, the population sought care in hospitals with emergency care at the headquarters of the health care region and in health centers, PHC units that include low complexity emergency care services operating 24 hours a day, in the municipalities themselves.

In all three cases, managers and professionals considered that most of the population sought the first medical attention in the UBS. Different interviewees pointed out that the fulfillment of 8 hours/day for professionals, especially physicians, was almost non-existent, being more common in the UBS at the headquarters. In the rural area, physicians agreed on different work dynamics with the management: continuous shifts, weekly days off, on call at the headquarters, and/or a work process focused exclusively on individual consultations.

Linked to the rural UBS, there were support points, which served as support for the teams’ actions, where vaccination, diversified programs, preventive tests collection, and oral health care, among others, were carried out, and where the community health workers (ACS) played an important role in organizing access. The logic, in the face of intermittent access, was to provide spontaneous medical care, by complaint and without longitudinal follow-up. Care was also provided in community spaces such as community centers, schools, and churches.

Even with formal 100% coverage by FHS, in all three cases, it was decided to retain the health centers. These structures, kept at the headquarters, were open daily and non-stop for basic healthcare, minor emergencies, and stabilization of patients for removal to another municipality. The modes of operation varied according to the financial capacity of each municipality. There was no 24-hour doctor, but teams of nurses and doctors on call, many from the FHS, who worked in shifts.

Organizational problems of the UBS in rural areas were one of the main reasons for seeking the health centers. These services were used as backup care for workers on weekends and at times when the UBS did not operate, stabilization of critical conditions for transfer, fulfilling an important emergency care function, in some cases even for users from other municipalities. There was, according to managers, a certain popular and political appeal to the maintenance of the health centers, whether by preference for emergency care and individual assistance or difficulties of access to the UBS. The service reinforced the population’s desire, led by politicians, and by some professionals who, according to the interviewees, also valued medicalization over longitudinal follow-up. The funding for the health centers was mostly municipal and represented an expressive expense, which threatened its sustainability due to the non-existence of federal or state support policies.

Besides the availability, different and concomitant strategies organized the provision of PHC: (a) the UBS located at the headquarters and in the rural area, with priority to spontaneous demand healthcare; (b) the UBS located at the headquarters that housed two teams, one of which went to the rural area; (c) due to the dispersion and ease of transportation, part of the rural area population was assigned to a UBS at the headquarters; (d) in more distant rural locations with a larger population, there was a nursing technician who served as a 24-hour reference, as well as a vehicle on duty to respond to emergencies; and (e) due to the dispersion of the population and great distances, heathcare was provided in the communities by an itinerant team and at support points.

Interprofessional performance and collaboration

In all three municipalities, the EqSF were complete, with no formal uncovered area (although the dispersion made it difficult to follow up all the families) and worked with the support of oral health teams and NASF. Such a characteristic implied a concrete possibility of sharing actions, diversity in the menu of services offered, as well as the matrixlization of knowledge and practices.

Thus, nurses and physicians routinely shared the follow-up of people with high blood pressure/diabetics, children, and pregnant women, in the strategy of interleaved consultations and, when necessary, interconsultations. Physicians routinely acted in individual assistance actions, for various reasons. Besides the training and the lack of the necessary qualifications for working in the FHS, it was mentioned that it would not be worth moving him/her from this function for “cost-benefit” reasons.

The interviewees highlighted the role of the ACS in the organization of access and surveillance actions, through the detection of risk situations, active search, and participation, to varying degrees, in collective actions (School Health Program, with NASF). In addition to house calls, it also helped in the transit of clinical information from the population to the EqSF, through the scheduling of appointments and/or communication of the agenda, delivery of medicines, notice of scheduling exams/consultations outside the city and the release of the results, and coordination of healthcare transportation.

In the three municipalities, the ACS was fundamental for communicating with users in the more remote rural areas because, in some places, there was no telephone reception and the worker took on the role of spokesperson for the community’s health demands. It was seen that the ACS would be overloaded with administrative duties to the detriment of the more essential functions in the community care process.

In a supplementary manner, the ACS performed blood pressure measurements in all three municipalities. The managers considered it to be an important practice since the ACS were the professionals who were closest to the population and established the most frequent contacts in the households, acting as sentinels for the EqSF. No significant differences were identified in the performance of the ACS in the headquarters and rural areas, only difficulties inherent to the scattered territories, greater communication difficulties due to insufficient internet/telephones network, and challenges faced due to the socioeconomic vicissitudes of the population.

The performance of NASF was very well evaluated by managers and professionals, since they increased the portfolio of services and performed complementary and/or shared clinical actions, unfolding among scattered teams and territories. The collective activities were highlighted, especially the work in the Health Academy Program and in the School Health Program. Moreover, the NASF professionals provided clinical and educational support to the EqSF and played a leading role in health education activities.

The Health Academy Program was considered a success, with great adherence from the population: elderly people, women of all age groups, and men who, in general, were not connected to the healthcare services. An expanded set of preventive and health-promoting practices developed by professionals and NASF at the academies were identified, some in the evening to facilitate participation.

Technical, material and human resources

The transportation of professionals and users presented itself as a critical issue in all evaluations. Roughly speaking, being remote rural municipality implied some need to commute over long distances and/or over precarious roads, often in synergy.

For users, there was health transportation in cases of emergency and for travel to elective appointments in regional references, with some vehicles purchased with resources from parliamentary amendments or other external sources, whose cost, exclusive to the municipality, represented a burden on the budget. The displacement of users to the macro-regional headquarters involved complex transportation logistics, with insurance against accidents, and the Intermunicipal Health Consortium was called to manage it, in order to ensure the legal and safety conditions.

The arrangements for the provision of transportation and the types of vehicles varied, but in general, there was an insufficient guarantee of full travel. To mitigate the difficulties of the rural population, some of the strategies were to keep vehicles on duty in strategic locations - regular vehicles, adapted ambulances, and/or Mobile Emergency Medical Service (SAMU) ambulances - and to schedule out-of-home appointments on days/times when transportation is available.

However, it was common for each user to take responsibility for his or her own travel, especially for routine care in the UBS and health centers. The school bus was used in all three cases as a common means of transportation to the UBS, although there were legal restrictions. Users also sometimes picked up rides with the EqSF or, with their own resources, paid for private cars. Some professionals reported the abusive prices charged to the population of more distant and poorer locations for road transportation.

With the exception of the ACS, the other professionals, with rare exceptions, did not live in rural areas, with some residing in the health region headquarters, relatively close to the remote rural municipalities headquarters. The city halls provided a vehicle, which was also used for home visits and other actions in remote locations. In general, the ACS were not guaranteed support to cover transportation costs, and they used their own cars or a lift, revealing a certain unbalance among PHC professionals.

The service network was not connected by electronic medical records, and the user was the holder of clinical information, which often implied the absence of care coordination by the teams, although some UBS had implemented the e-SUS (https://sisaps.saude.gov.br/esus/) and part of the ACS used a tablet to record their activities. Since these are small municipalities, managers and professionals sought information about clinical management through informal contacts. The ACS was the main reporting agent, allowing some continuity of care, especially in rural areas, although this was not an institutionalized assignment.

The implementation of telehealth was incipient, with initiatives only in cardiology for electrocardiograms, and teleconsulting was hardly used. The telehealth hub was located at the Teaching Hospital in Montes Claros. There were connectivity problems in rural UBSs, insufficient computers, and delays in teleconsulting responses.

In all three remote rural municipalities, attraction, retention and professional profile were mentioned as the main critical issue for the organization of PHC. The labor ties were diverse, ranging from statutory professionals (in general, nursing technicians, nurses, and ACS) to informal contracts that prevailed among physicians (corporate entities), whose strategy of attraction through public examinations was not effective.

The problem of physician turnover was faced in the remote rural municipalities by conciliating strategies such as the on-duty regime of the EqSF physician in the health centers, with a high cost for the municipalities, competing with the assistance itself in the UBS. The problems concerning attraction and retention differed depending on the location of the UBS, with a disadvantage for rural areas. Since the remote rural municipalities headquarters were close to the regions’ headquarters, attraction was facilitated, but also without retention.

The evaluations of the More Doctors Program as a policy to face the difficulty in attracting and retaining physicians varied with regard to the relationship with other professionals, but it was considered successful and fundamental for all the municipalities in the health regions, even for those that didn't join, by changing the dynamics of the physician job market. The departure of Cuban doctors from the More Doctors Program and the dismantling of the policy has increased the difficulty of hiring physicians in the region, especially for rural areas, many of which have remained without a physician for a long time. The municipalities started to lose Brazilian contracted physicians, who preferred to migrate to the More Doctors Program in another municipality due to the stability in the payment of grants.

Box 1 presents a synthesis of the results of the organizational dimension of PHC practices and “expressive phrases” that lend weight to the experiences.

Figure 1 represents a synthesis of the organization of the PHC in the analyzed remote rural municipalities. The position relative to the center - the PHC - means a certain success (the closer it is) and critical points (the further away) for its provision in remote rural municiplaities.

Discussion

In this paper, the areas for action of the EqSF are defined based on criteria of formal and informal allocation of customers, meeting the needs of the territories. It is observed that the gateway function is shared between the UBS and the health centers, with a predominance of spontaneous demand care. In a positive way, the interprofessional collaboration is leveraged by the action of NASF and by the shared work developed in the Health Academy Program, as well as an expanded action is noticeable in relation to the scope of practice of the ACS. On the other hand, the computerization of the UBS is incomplete and the use of telehealth is quite residual, not having been incorporated into the work flow in the FHS. Roughly speaking, local and federal strategies for the provision and retention of physicians are mixed, with varying degrees of success. In addition, in order to provide access to the APS, especially for the rural areas of the remote rural municipalities, complex transportation arrangements are made possible, sometimes by the municipal management, sometimes by the users themselves.

Regarding the background aspect, the results show that under the remote rural municipalities inequalities are at work that affect the organization and sustainability of the PHC. These are more vulnerable territories than the national average, with significant differences in living conditions between the “headquarters” and the “rural zone”. According to managers and professionals, rural areas have worse socio-sanitary indicators and greater territorial dispersion, factors that influence the provision of health care ¹²12. Hogg W, Rowan M, Russell G, Geneau R, Muldoon L. Framework for primary care organizations: the importance of a structural domain. Int J Qual Health Care 2008; 20:308-13., requiring differentiated patterns of organization of the EqSF so as not to widen or sustain inequalities.

The FHS achieved full coverage, even though it did not guarantee accessibility, a result found in other rural scenarios ⁹9. Garnelo L, Lima JG, Rocha ESC, Herkrath FJ. Acesso e cobertura da atenção primária à saúde para populações rurais e urbanas na região norte do Brasil. Saúde Debate 2018; 42(spe 1):81-99.. The existence of “support points” is a strategy to make the healthcare in these locations viable, even if in improvised and inadequate facilities, and without funding policies ⁷7. Pessoa VM, Almeida MM, Carneiro FF. Como garantir o direito à saúde para as populações do campo, da floresta e das águas no Brasil? Saúde Debate 2018; 42(spe 1):302-14..

In a macro-region of great vulnerability, the supply of high complexity is dependent on the private network contracted to the SUS, an obstacle to the management of integral healthcare ¹⁵15. Santos AM, Giovanella L. Gestão do cuidado integral: estudo de caso em região de saúde da Bahia, Brasil. Cad Saúde Pública 2016; 32:e00172214.. In the three municipalities, the headquarters do not present great distances in relation to the headquarters of the health region, nor severe climate conditions that impede the transit of the population, a different scenario from other remote rural municipalities in the country ⁷7. Pessoa VM, Almeida MM, Carneiro FF. Como garantir o direito à saúde para as populações do campo, da floresta e das águas no Brasil? Saúde Debate 2018; 42(spe 1):302-14.^,99. Garnelo L, Lima JG, Rocha ESC, Herkrath FJ. Acesso e cobertura da atenção primária à saúde para populações rurais e urbanas na região norte do Brasil. Saúde Debate 2018; 42(spe 1):81-99.. Intermunicipal Health Consortia appear as a strategy for provision of medical specialties, but unlike other consortial arrangements ¹⁶16. Almeida PF, Giovanella L, Martins Filho MT, Lima LD. Redes regionalizadas e garantia de atenção especializada em saúde: a experiência do Ceará, Brasil. Ciênc Saúde Colet 2019; 24:4527-40., there was no State or Federal co-funding, which worsened the possibilities of providing comprehensive healthcare by the remote rural municipalities.

In this specific context, regional arrangements for organizing specialized back-up, supported by health transportation, seem to be suitable, which may not be sufficient in other remote realities. Still, for populations in rural areas, the financial barriers to afford transportation are more significant, requiring specific measures, such as available on-call cars or some form of reimbursement/payment for private cars commonly used by the population. The absence of public transportation for rural areas mitigates the access of these populations to a set of public policies ¹⁷17. Wanderley MNB. O mundo rural brasileiro: acesso a bens e serviços e integração campo-cidade. Estudos Sociedade e Agricultura 2009; 17:60-85., in addition to exposing them to unsafe modes of transportation.

In relation to the organizational aspects, formal registration is a secondary instrument, since it does not reflect the different occupation modes and therapeutic itineraries. As the territorial dispersion in rural areas is expressive, the availability of transportation presents itself as the most critical resource to condition the real flow of users, for whom there seemed to be good receptivity and understanding on the part of professionals in the care of spontaneous demand, a result not found in other papers ⁹9. Garnelo L, Lima JG, Rocha ESC, Herkrath FJ. Acesso e cobertura da atenção primária à saúde para populações rurais e urbanas na região norte do Brasil. Saúde Debate 2018; 42(spe 1):81-99..

The FHS has changed the pattern of seeking first contact services in Brazil ¹⁸18. Macinko J, Mendonça CS. Estratégia Saúde da Família, um forte modelo de atenção primária à saúde que traz resultados. Saúde Debate 2018; 42(spe 1):18-37. and has also been found in the surveyed remote rural municipalities. However, the sharing of this function with the health centers is well-known, units with a long tradition in Minas Gerais State, whose sustainability, especially in medical care, is not assured due to the financial burden on the municipalities. Although in the three cases there are no small-sized hospitals, the health centers seem to have functions and problems similar to those of such units regarding the difficulties to respond in a problem-solving manner to healthcare demands and the lack of integration with the UBS ¹⁹19. Souza FEA, Nunes EFPA, Carvalho BG, Mendonça FF, Lazarini FM. Atuação dos hospitais de pequeno porte de pequenos municípios nas redes de atenção à saúde. Saúde Soc 2019; 28:143-56.. In the cases, the maintenance is justified by the recognition of the barriers to access to PHC, the territorial characteristics and displacement dynamics of rural populations, and political costs of its suppression, as also occurs in relation to small-sized hospitals ¹⁹19. Souza FEA, Nunes EFPA, Carvalho BG, Mendonça FF, Lazarini FM. Atuação dos hospitais de pequeno porte de pequenos municípios nas redes de atenção à saúde. Saúde Soc 2019; 28:143-56.. National policies such as “Health on the Spot” ²⁰20. Ministério da Saúde. Portaria nº 930, de 15 de maio de 2019. Institui o Programa "Saúde na Hora", que dispõe sobre o horário estendido de funcionamento das Unidades de Saúde da Família. Diário Oficial da União 2019; 17 mai. do not serve the remote rural municipalities, which still could be provided with some resources directed to the maintenance of the health centers, even though from the care and quality point of view they do not represent the most adequate option.

The challenge of balancing care for spontaneous and scheduled demand is present in many urban centers and rural areas ¹⁰10. Galvão JR, Almeida PF, Santos AM, Bousquat A. Percursos e obstáculos na Rede de Atenção à Saúde: trajetórias assistenciais de mulheres em região de saúde do Nordeste brasileiro. Cad Saúde Pública 2019; 35:e00004119., but in remote rural municipalities the former prevails. Although the end result is not, in fact, continuing healthcare, it allows for immediate contact with a professional. This seems to be an intrinsic issue in remote areas, since the difficulty of access imposes on the PHC organization to deal with the spontaneous demand of those in transit at the municipal headquarters. Studies show that first-contact access is associated with same-day care and longer family physician hours ¹³13. Paré-Plante A, Boivin A, Berbiche D, Breton M, Guay M. Primary health care organizational characteristics associated with better accessibility: data from the QUALICO-PC survey in Quebec. BMC Fam Pract 2018; 19:188.. Even if the presence of the physician was not guaranteed for 40 hours in the EqSF, especially in rural areas, efforts were made to ensure timely access, also by sharing the monitoring of priority groups with nurses, with intermittent consultations. This is a strategy to minimize the lack of care in case of vacancy of the medical professional, recurrent in rural settings ²¹21. Pereira LL, Pacheco L. O desafio do Programa Mais Médicos para o provimento e a garantia da atenção integral à saúde em áreas rurais na região amazônica, Brasil. Interface (Botucatu) 2017; 21 Suppl 1:1181-92..

The most strongly interprofessional component lies in the performance of the NASF/Health Academy Program. Municipalities have joined national policies to increase the scope, support, and increment of health promotion from such devices. The greater the dispersion, lower population density, and longer travel times, the greater the need for integrated and comprehensive PHC care provision, with incorporation of areas such as, for example, mental health ³3. Wakerman J, Humphreys JS, Wells R, Kuipers P, Entwistle P, Jones J. Primary health care delivery models in rural and remote Australia - a systematic review. BMC Health Serv Res 2008; 8:276.^,2222. Hine JF, Grennan AQ, Menousek KM, Robertson G, Valleley RJ, Evans JH. Physician Satisfaction With Integrated Behavioral Health in Pediatric Primary Care. J Prim Care Community Health 2017; 8:89-93.. For rural municipalities, dependent on the federal government’s subsidies, the lack of funding for NASF poses a concrete threat to interprofessional activities.

The ACS act on several fronts, from mediating access to the UBS to covering communication gaps, which are more frequent in rural areas. Professionals and managers report an overload of duties to the ACS, also found in other papers ²³23. Riquinho DL, Pellini TV, Ramos DT, Silveira MR, Santos VCF. O cotidiano de trabalho do agente comunitário de saúde: entre a dificuldade e a potência. Trab Educ Saúde 2018; 16:163-82.. In all three cases, blood pressure measurement is part of the scope of practice, positively evaluated by managers and professionals. Although controversial due to several arguments ²⁴24. Targa LV. A avaliação da pressão arterial por agentes comunitários pode ser uma estratégia útil para o cuidado da saúde? Rev Bras Med Fam Comunidade 2006; 1:141-51.^,2525. Silva TL, Soares AN, Lacerda GA, Mesquita JFO, Silveira DC. Política Nacional de Atenção Básica 2017: implicações no trabalho do agente comunitário de saúde. Saúde Debate 2020; 44:58-69., in a rural setting and facing the vicissitudes in timely access, such practice should be analyzed in the light of the production of healthcare, even serving to disseminate safe information for disease prevention and health promotion.

Another important finding refers to the incipiency of telehealth due to the difficulties of connectivity and computerization of the UBS, when the justification should be exactly the opposite: it is precisely because they are rural remote municipalities, dispersed and with long distances to be traveled by users, that telehealth strategies are indispensable, urgent and part of the solution to ensure more comprehensive care ²2. Cyr ME, Etchin AG, Guthrie BJ, Benneyan JC. Access to specialty healthcare in urban versus rural US populations: a systematic literature review. BMC Health Serv Res 2019; 19:974..

Despite all the advances in the production of care via PHC in the remote rural municipalities, there are real limitations to sustainability through discontinuous provision of professionals. This is a worldwide problem for rural and peripheral areas ²⁶26. Ono T, Schoenstein M, Buchan J. Geographic imbalances in doctor supply and policy responses. Paris: Organisation for Economic Co-operation and Development; 2014. (OECD Health Working Papers, 69).^,2727. Ag Ahmed MA, Diakité SL, Sissoko K, Gagnon MP, Charron S. Factors explaining the shortage and poor retention of qualified health workers in rural and remote areas of the Kayes, region of Mali: a qualitative study. Rural Remote Health 2020; 20:5772.. Continental countries, such as Australia and Canada present PHC organizational models specific to such contexts ²⁸28. Vanni T, Cyrino AP, Ribeiro ACRC. Provimento médico no sistema de saúde da Austrália: uma conversa com Megan Cahill. Interface (Botucatu) 2017; 21 Suppl 1:1367-76.^,2929. Bosco C, Oandasan I. Review of family medicine within rural and remote Canada: education, practice, and policy. Mississauga: College of Family Physicians of Canada; 2016.. In Brazil, in turn, the only federal policy that addressed, even partially, such problem - the More Doctors Program - was discontinued and mischaracterized. The new federal policy, while not responding to the gaps in the More Doctors Program ³⁰30. Giovanella L, Bousquat A, Almeida PF, Melo EA, Medina MG, Aquino R, et al. Médicos pelo Brasil: caminho para a privatização da atenção primária à saúde no Sistema Único de Saúde? Cad Saúde Pública 2019; 35:e00178619., was not effectively implemented and again left the municipalities adrift, responsible for attracting and retaining physicians, which proves unsustainable for maintaining the APS in its FHS model.

This paper considered the experience of managers and professionals, whose perceptions and evaluations proved to be synergistic regarding the organizational characteristics of the PHC. However, the experiences of other key players, such as users, were not included. The three cases, belonging to the North Minas Gerais territory, present unique and distinct characteristics from other remote rural municipalities in Brazil.

Conclusions

Devices and actions implemented from successive national primary health care policies have had positive effects on the organization of the PHC, making it more accessible and giving direction to the model. At the same time, initiatives and informal arrangements, undertaken by municipal administrations and EqSF, are evidenced in the organizational aspect of the APS, seeking to account for the unique reality of the remote rural municipalities and the gaps not addressed by federal policies, despite the great difficulties for maintenance and sustainability.

This paper reveals that remote rural municipalities are not a single unit. Headquarters and rural areas are unequal in relation to living conditions and need different organization and resources for PHS provision. In any case, the paper ratifies the undeniable need for maintenance and improvement of federal policies for the provision and training of physicians to work in the remote rural municipalities; co-funding for transportation, essential to ensure access to health care in rural areas; training of the EqSF (training and infrastructure) to undertake a greater role in emergency care, linked with the health centers; maintenance of federal funding for NASF teams in a scenario that requires greater problem-solving and with few facilities for health promotion; effectiveness of telehealth in its various functions; and appreciation of the expanded scope of practice of nurses and ACSs, which already occurs.

In an unequal, continental, federative country that faces the vicissitudes arising from political culture, one of the challenges for the formulation of national and state policies is the balance between induction and recognition of local realities and initiatives, which, in the cases researched, are the only ones to recognize the distinct needs of the population in the remote rural municipalities’s headquarters and rural areas, with partial and insufficient answers. Besides this, the recognition of the worst living conditions, of mobility that characterize rurality scenarios, requires the coordinated action of several policy sectors, which are not effectively covered by district/municipal policies, as the experience of many countries shows.

Finally, understanding the forms of use of space and social life that define rural healthcare itineraries, the context of PHC practices and organizational context represents an important step towards the improvement and implementation of actions and policies that guarantee the right to healthcare for its populations.

Acknowledgments

To Brazilian Ministry of Health and Oswaldo Cruz Foudation for funding the study. To Brazilian National Research Council (CNPq) for its support to P. F. Almeida through the productivity in research scholarship.

References

Publication Dates

History