Abstract

Introduction

Residents of rural areas comprise approximately half of the world population, have less access to care, and present worse health conditions when compared to urban populations ¹1. Working Party on Rural Practice. Política de qualidade e eficácia dos cuidados de saúde rural. Rev Bras Med Fam Comunidade 2013; 8 Suppl 1:15-24.. In most countries, rural areas face difficulties with transportation and communication, funding inequalities in health, and shortage and unequal distribution of healthcare personnel, with worse work conditions ²2. Strasser R. Rural health around the world: challenges and solutions. Fam Pract 2003; 20:457-63.^,33. International Labour Office. Global evidence on inequities in rural health protection. New data on rural deficits in health coverage for 174 countries. Geneva: International Labour Office; 2015. (ESS Document, 47)..

For Strasser ²2. Strasser R. Rural health around the world: challenges and solutions. Fam Pract 2003; 20:457-63., the failure to achieve universal healthcare as proposed in the Declaration of Alma-Ata⁴4. Organización Mundial de la Salud. Informe de la Conferencia Internacional sobre Atención Primaria de Salud. Geneva: Organización Mundial de la Salud; 1978. is particularly severe in rural and remote areas. The premises of Alma-Ata in “health for all by 2000” declared health as a right and the central role of primary healthcare (PHC). In rural and remote areas, PHC is often the only recourse to health ¹1. Working Party on Rural Practice. Política de qualidade e eficácia dos cuidados de saúde rural. Rev Bras Med Fam Comunidade 2013; 8 Suppl 1:15-24.^,22. Strasser R. Rural health around the world: challenges and solutions. Fam Pract 2003; 20:457-63.. Due to its attributes as coordinator of the network of care, access to the necessary services, quality care, early and timely prevention, and follow-up of health problems, resulting in an approach to health problems at the family and community levels and cultural competence of care ⁵5. Starfield B. Atenção primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília: Organização das Nações Unidas para a Educação, a Ciência e a Cultura/Ministério da Saúde; 2002., PHC is the key to confronting iniquities in rural areas ³3. International Labour Office. Global evidence on inequities in rural health protection. New data on rural deficits in health coverage for 174 countries. Geneva: International Labour Office; 2015. (ESS Document, 47).^,66. World Health Organization. Increasing access to health workers in remote and rural areas through improved retention: global policy recommendations. Geneva: World Health Organization; 2010..

Developing countries display situations of greater iniquities in rural health ³3. International Labour Office. Global evidence on inequities in rural health protection. New data on rural deficits in health coverage for 174 countries. Geneva: International Labour Office; 2015. (ESS Document, 47).. Despite the expansion of PHC across Brazil’s territory, the country still suffers from sharp social and spatial inequality in the supply of services, equipment, and healthcare staff ⁷7. Coimbra Jr. CEA. Saúde rural no Brasil: tema antigo mais que atual. Rev Saúde Pública 2018; 52 Suppl 1:2s.^,88. Savassi LCM, Almeida MM, Floss M, Lima MC, organizadores. Saúde no caminho da roça. Rio de Janeiro: Editora Fiocruz; 2018.. The imprecision in the definition of “rural” contributes to the fact that the deficit in universal health in rural areas remains ignored. The lack of clearer approaches to rural contexts results in the lack of definition of perspectives for action in these areas, limited to the agrarian side, without expressing Brazil’s contemporary rural reality ⁹9. Silveira R, Pinheiro R. Sobre o rural, a interiorização na saúde e a formação médica: concepções e ações com destaque para o contexto da Amazônia Legal. In: Pinheiro R , Müller Neto JS, Ticianel FA, Spinelli MAS, organizadores. Construção social da demanda por cuidado: revisitando o direito à saúde, o trabalho em equipe, os espaços públicos e a participação. Rio de Janeiro: CEPESC Editora; 2013. p. 147-72.. A recent revision of the urban/rural classification by the Brazilian Institute of Geography and Statistics (IBGE), considering population density and access to urban hubs, found that 45% of Brazil’s municipalities (counties) had a low degree of urbanization, underlining the importance of rural spaces in the national territory ¹⁰10. 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..

Even in the international debate, there is still little clarity in the definition of criteria on rurality that can distinguish different realities, especially in the case of remote territories ³3. International Labour Office. Global evidence on inequities in rural health protection. New data on rural deficits in health coverage for 174 countries. Geneva: International Labour Office; 2015. (ESS Document, 47).^,66. World Health Organization. Increasing access to health workers in remote and rural areas through improved retention: global policy recommendations. Geneva: World Health Organization; 2010.^,1111. Kulig JC, Andrews ME, Stewart NJ, Pitblado R, MacLeod MLP, Bentham D, et al. How do registered nurses define rurality? Aust J Rural Health 2008; 16:28-32.. Continental-sized and wealthy countries such as the United States, Canada, and Australia have led the research and debates on rural health ³3. International Labour Office. Global evidence on inequities in rural health protection. New data on rural deficits in health coverage for 174 countries. Geneva: International Labour Office; 2015. (ESS Document, 47).^,66. World Health Organization. Increasing access to health workers in remote and rural areas through improved retention: global policy recommendations. Geneva: World Health Organization; 2010.. Australia, particularly, has gained a prominent role in government initiatives for rural health ¹²12. Humphreys J. Rural health status: what do statistics show that we don't already know? Aust J Rural Health 1999; 7:60-3.. Knowing the strategies set out in the international debate on rural health can help understand this theme, which has still received little attention in the Brazilian reality and has been insufficiently incorporated by the Brazilian Unified National Health System (SUS) ⁷7. Coimbra Jr. CEA. Saúde rural no Brasil: tema antigo mais que atual. Rev Saúde Pública 2018; 52 Suppl 1:2s.^,88. Savassi LCM, Almeida MM, Floss M, Lima MC, organizadores. Saúde no caminho da roça. Rio de Janeiro: Editora Fiocruz; 2018..

This article aims to provide elements for a comprehensive understanding of the theme, considering central issues for PHC in rural areas. The article summarizes a review of the international literature that aimed to identify and analyze the challenges for access, organization of healthcare, and health workforce in PHC in rural areas.

Methodology

An integrative review was performed of the literature on PHC in rural areas. Integrative reviews allow a synthesis of diverse studies (quantitative and qualitative, experimental and nonexperimental), aimed at a broad understanding of the state of knowledge on a complex subject. The method is useful for systematically condensing research on a comprehensive theme ¹³13. Mendes KDS, Silveira RCC, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto & Contexto Enferm 2008; 17:758-64.^,1414. Souza MT, Silva MD, Carvalho R. Revisão integrativa: o que é e como fazer. Einstein (São Paulo) 2010; 8:102-6.. Unlike systematic reviews - generally more valued in publications - integrative reviews, although not intended for statistical inference and without the capacity (like the former) to generate more objective and uniform products as to the strength of evidences, nevertheless go farther than experimental studies and are powerful for in-depth analyses of the results and the processes demonstrated in the studies ¹³13. Mendes KDS, Silveira RCC, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto & Contexto Enferm 2008; 17:758-64.^,1414. Souza MT, Silva MD, Carvalho R. Revisão integrativa: o que é e como fazer. Einstein (São Paulo) 2010; 8:102-6..

The review followed the stages recommended by Mendes et al. ¹³13. Mendes KDS, Silveira RCC, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto & Contexto Enferm 2008; 17:758-64. and Souza et al. ¹⁴14. Souza MT, Silva MD, Carvalho R. Revisão integrativa: o que é e como fazer. Einstein (São Paulo) 2010; 8:102-6.. The underlying question and inclusion/exclusion criteria for the studies were determined, proceeding then to the literature search and data collection. The information to be extracted from the selected articles was defined, followed by categorization of the studies, critical analysis of the selected studies, and synthesis of the results ¹³13. Mendes KDS, Silveira RCC, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto & Contexto Enferm 2008; 17:758-64.^,1414. Souza MT, Silva MD, Carvalho R. Revisão integrativa: o que é e como fazer. Einstein (São Paulo) 2010; 8:102-6..

The underlying question in the review of the international literature on PHC and rural health was: what are the effective strategies for guaranteeing comprehensive/integral PHC for rural populations? Considering the underlying question, we aimed to map the production and origin of the literature and identify and analyze three dimensions: access, organization of healthcare, and health workforce for comprehensive/integral PHC for rural populations.

The review defined Brazilian and non-Brazilian publications as international literature, based on the studies’ location, both according to their scope and the origin of the publications and the choice of literature databases that cover studies from various countries. The sample included original scientific articles, empirical or literature reviews, available online, full texts, in English, and published from January 2000 to December 2019, aimed at covering current studies from the 21st century, the period in which classifications of rurality have gained force in international discussions ¹1. Working Party on Rural Practice. Política de qualidade e eficácia dos cuidados de saúde rural. Rev Bras Med Fam Comunidade 2013; 8 Suppl 1:15-24.^,22. Strasser R. Rural health around the world: challenges and solutions. Fam Pract 2003; 20:457-63.^,33. International Labour Office. Global evidence on inequities in rural health protection. New data on rural deficits in health coverage for 174 countries. Geneva: International Labour Office; 2015. (ESS Document, 47).^,66. World Health Organization. Increasing access to health workers in remote and rural areas through improved retention: global policy recommendations. Geneva: World Health Organization; 2010.^,88. Savassi LCM, Almeida MM, Floss M, Lima MC, organizadores. Saúde no caminho da roça. Rio de Janeiro: Editora Fiocruz; 2018. - limited to 2019 since the search was completed in early 2020. Exclusion criteria were: duplicates and unavailability; publications that were not original scientific research articles (editorials, opinion, debates, communications); articles on procedures, substances, tests, medicines, or specific diseases; and articles that did not refer specifically to rural areas, health services provision, and PHC.

The literature bases were the Cochrane Library (https://www.cochranelibrary.com/), MEDLINE (https://www.ncbi.nlm.nih.gov/pubmed/), Rural and Remote Health (https://www.rrh.org.au/), and Australian Journal of Rural Health (https://onlinelibrary.wiley.com/journal/14401584). The latter two are specific journals on rural health in Australia, identified in an initial search, with extensive citations and specificity in articles on rural health.

We chose the descriptors from the Medical Subject Headings (MeSH): “rural health”, “primary health care”, and “access”. The option to include the term “access” was to improve the study’s refinement, according to the centrality of the problem of access in rural areas. In the Australian journals, whose content is specific to rural health, besides the previous descriptors, we also included the term “human resources” to refine the search according to the review’s objectives.

The initial option was for a combined search among the descriptors, but it was necessary to differentiate the search format in each base, considering its search tools and the scope of the target literature. In each base, we prioritized the search format that generated the most articles for the review’s objectives. The search key in each base was:

Initially, 210 articles were selected. After excluding duplicates and unavailable articles, the sample was left with 205, with independent reading of titles and abstracts by two researchers. In this stage, adopting the inclusion and exclusion criteria, 95 articles were selected. The process was repeated with complete reading, producing a final selection of 69 articles (Figure 1).

The articles were organized in Excel (https://products.office.com/). Two researchers proceeded to repeated readings of the material. Each article was assigned to a principal category: access, organization of healthcare, and health workforce. After categorization, in an exhaustive vertical reading, the researchers searched for core meanings based on similarities and particularities between the findings to identify each category’s themes. We calculated frequencies both for categories and themes and for the publication period and the articles’ location. Box 1 describes the references of the selected articles according to the study method, location, and classification of the categories: access, organization of healthcare, and health workforce.

Results

Table 1 provides an overview of the selected articles. The number of publications increased over the 2000s, with the first reference in 2003, but with reduced amount and pace of production in the searched international literature.

The origin of the publications included 23 countries since the spatial cross-section of the studies covered 20 countries. In both forms of location, Australia had the largest share (36.4% and 38%), followed by the United States (17% and 12.7%) and Canada (9.1% and 8.4%) (Table 1). If one does not count 44 articles from the Australian journals, the United States boasts the largest share with 18.4% (n = 7) of the publications, followed by Australia with 15.8% (n = 6).

Table 2 shows the articles’ themes, classified in the categories access (23), organization of healthcare (25), and health workforce (21). Each article was classified in only one category. The themes emerged from the analysis, assigning one or more themes to the same publication. The sum of the themes’ frequencies thus differs from the number of studies in the respective category.

The results’ analytical synthesis is presented next, by category and theme, identifying challenges and the most effective strategies to guarantee comprehensive PHC for rural populations, according to the integrative review’s objectives and underlying question.

Access

Geographic aspects of rural communities

The rural communities’ geographic location affected the rural populations’ timely access to healthcare ¹¹11. Kulig JC, Andrews ME, Stewart NJ, Pitblado R, MacLeod MLP, Bentham D, et al. How do registered nurses define rurality? Aust J Rural Health 2008; 16:28-32.^,1515. Wong ST, Regan S. Patient perspectives on primary health care in rural communities: effects of geography on access, continuity and efficiency. Rural Remote Health 2009; 9:1142.^,1616. Zubieta L, Bequet SAF. Factors of primary care demand: a case study. Rural Remote Health 2010; 10:1520.^,1717. Haggerty JL, Roberge D, Lévesque JF, Gauthier J, Loignon C. An exploration of rural-urban differences in healthcare-seeking trajectories: implications for measures of accessibility. Health Place 2014; 28:92-8.. Distant location means greater evaluation of the option to seek healthcare, weighing costs and risks with transportation ¹⁵15. Wong ST, Regan S. Patient perspectives on primary health care in rural communities: effects of geography on access, continuity and efficiency. Rural Remote Health 2009; 9:1142..

The rural population seeks health services in the community, independently of type ¹⁶16. Zubieta L, Bequet SAF. Factors of primary care demand: a case study. Rural Remote Health 2010; 10:1520.. In general, patients in rural areas exhaust the local options before seeking care outside their community. Still, patients did not always report geographic barriers to accessing health services, since the difficulty in reaching them at long distances is common ¹⁷17. Haggerty JL, Roberge D, Lévesque JF, Gauthier J, Loignon C. An exploration of rural-urban differences in healthcare-seeking trajectories: implications for measures of accessibility. Health Place 2014; 28:92-8..

For Kulig et al. ¹¹11. Kulig JC, Andrews ME, Stewart NJ, Pitblado R, MacLeod MLP, Bentham D, et al. How do registered nurses define rurality? Aust J Rural Health 2008; 16:28-32., access and rurality indices based solely on distance are insufficient. Rather, it is necessary to associate geographic location with the community’s characteristics, availability of human resources, and attributes of professional practice, such as advanced nursing practices. Although populations in more remote areas have worse access, it is possible to find remote areas with good access and metropolitan areas with precarious access, circumstances that involve values, beliefs, and the population’s interaction with services ¹⁸18. McGrail MR, Humphreys JS. Spatial access disparities to primary health care in rural and remote Australia. Geospat Health 2015; 10:358..

Patients’ travel needs

Interestingly, in some cases the rural population simply ignored the local health service and travelled farther than necessary in search of care. Sometimes, even when closer services were available, patients failed to use the local services and preferred to travel to larger cities, a situation the author referred to as “bypassing” local services ¹⁹19. Sanders SR, Erickson LD, Call VR, McKnight ML, Hedges DW. Rural health care bypass behavior: how community and spatial characteristics affect primary health care selection. J Rural Health 2015; 31:146-56.^,2020. Whitehead J, Pearson AL, Lawrenson R, Atatoa-Carr P. Spatial equity and realised access to healthcare - a geospatial analysis of general practitioner enrolments in Waikato, New Zealand. Rural Remote Health 2019; 19:5349.^,2121. Neville S, Napier S, Adams J, Shannon K. Accessing rural health services: results from a qualitative narrative gerontological study. Australas J Ageing 2019; 39:e55-61.^,2222. Smith SC, Carragher L. 'Just lie there and die': barriers to access and use of general practitioner out-of-hours services for older people in rural Ireland. Rural Remote Health 2019; 19:5088.^,2323. Dassah E, Aldersey H, McColl MA, Davison C. Factors affecting access to primary health care services for persons with disabilities in rural areas: a "best-fit" framework synthesis. Glob Health Res Policy 2018; 3:36.^,2424. Doran F, Hornibrook J. Rural New South Wales women's access to abortion services: highlights from an exploratory qualitative study. Aust J Rural Health 2014; 22:121-6..

This phenomenon may involve the practice of so-called “outshopping”: users join together in the same trip to a city for services and shopping for purposes of convenience, satisfaction, or the search for better quality ¹⁹19. Sanders SR, Erickson LD, Call VR, McKnight ML, Hedges DW. Rural health care bypass behavior: how community and spatial characteristics affect primary health care selection. J Rural Health 2015; 31:146-56.^,2020. Whitehead J, Pearson AL, Lawrenson R, Atatoa-Carr P. Spatial equity and realised access to healthcare - a geospatial analysis of general practitioner enrolments in Waikato, New Zealand. Rural Remote Health 2019; 19:5349.. The reliance on services outside the local communities was associated with more distant cities, more intense transportation flows, and individuals with higher income but with worse health status, in addition to elderly persons and women ¹⁹19. Sanders SR, Erickson LD, Call VR, McKnight ML, Hedges DW. Rural health care bypass behavior: how community and spatial characteristics affect primary health care selection. J Rural Health 2015; 31:146-56.^,2020. Whitehead J, Pearson AL, Lawrenson R, Atatoa-Carr P. Spatial equity and realised access to healthcare - a geospatial analysis of general practitioner enrolments in Waikato, New Zealand. Rural Remote Health 2019; 19:5349..

However, heavier barriers were observed for specific rural populations with greater vulnerability. Studies involving the elderly ²¹21. Neville S, Napier S, Adams J, Shannon K. Accessing rural health services: results from a qualitative narrative gerontological study. Australas J Ageing 2019; 39:e55-61.^,2222. Smith SC, Carragher L. 'Just lie there and die': barriers to access and use of general practitioner out-of-hours services for older people in rural Ireland. Rural Remote Health 2019; 19:5088., poor people, and people with disabilities ²³23. Dassah E, Aldersey H, McColl MA, Davison C. Factors affecting access to primary health care services for persons with disabilities in rural areas: a "best-fit" framework synthesis. Glob Health Res Policy 2018; 3:36. identified additional challenges for access to health services, transportation, and costs to patients and accompanying persons. Studies also cited iniquities in access related to female gender and risk behaviors in adolescents ²⁴24. Doran F, Hornibrook J. Rural New South Wales women's access to abortion services: highlights from an exploratory qualitative study. Aust J Rural Health 2014; 22:121-6.^,2525. Alston M, Allan J, Dietsch E, Wilkinson J, Shankar J, Osburn L, et al. Brutal neglect: Australian rural women's access to health services. Rural Remote Health 2006; 6:475.^,2626. Rosenwasser LA, McCall-Hosenfeld JS, Weisman CS, Hillemeier MM, Perry AN, Chuang CH. Barriers to colorectal cancer screening among women in rural central Pennsylvania: primary care physicians' perspective. Rural Remote Health 2013; 13:2504.^,2727. Carlton E, Simmons L. Health decision-making among rural women: physician access and prescription adherence. Rural Remote Health 2011; 11:1599.^,2828. Quine S, Bernard D, Booth M, Kang M, Usherwood T, Alperstein G, et al. Health and access issues among Australian adolescents: a rural-urban comparison. Rural Remote Health 2003; 3:245..

The community’s perception of healthcare staff and services’ case-resolution capacity also influenced access in rural areas and the need to travel to reach health services ¹⁵15. Wong ST, Regan S. Patient perspectives on primary health care in rural communities: effects of geography on access, continuity and efficiency. Rural Remote Health 2009; 9:1142.^,2323. Dassah E, Aldersey H, McColl MA, Davison C. Factors affecting access to primary health care services for persons with disabilities in rural areas: a "best-fit" framework synthesis. Glob Health Res Policy 2018; 3:36.^,2929. Burton H, Walters L. Access to Medicare-funded annual comprehensive health assessments for rural people with intellectual disability. Rural Remote Health 2013; 13:2278.. Other reasons involved patients’ concerns with privacy and confidentiality in the rural setting ²⁸28. Quine S, Bernard D, Booth M, Kang M, Usherwood T, Alperstein G, et al. Health and access issues among Australian adolescents: a rural-urban comparison. Rural Remote Health 2003; 3:245..

Access to specialized and hospital services

Gruen et al. ³⁰30. Gruen RL, Weeramanthri TS, Knight SS, Bailie RS. Specialist outreach clinics in primary care and rural hospital settings. Cochrane Database Syst Rev 2003; (4):CD003798., in a review of several countries, showed that the disproportionate concentration of services in urban areas is an important barrier for rural populations (both underprivileged and better-off). Both needed to travel to access specialized care or hospital treatment, but better-off rural people managed to obtain minimum access in nearby cities. For the underprivileged, the barriers were so great that access was only possible when the healthcare staff, equipment, and services visited the rural communities and/or with the use of special transportation (four-wheel drive, aircraft, etc.). This difficulty was also observed in underprivileged rural communities in Nigeria ³¹31. Iliyasu G, Tiamiyu AB, Daiyab FM, Tambuwal SH, Habib ZG, Habib AG. Effect of distance and delay in access to care on outcome of snakebite in rural north-eastern Nigeria. Rural Remote Health 2015; 15:3496..

Meanwhile, Choo et al. ³²32. Choo WK, McGeary K, Farman C, Greyling A, Cross SJ, Leslie SJ. Utilisation of a direct access echocardiography service by general practitioners in a remote and rural area - distance and rurality are not barriers to referral. Rural Remote Health 2014; 14:2736., in rural populations in Scotland, did not identify barriers to echocardiography, explained by the relative ease of access and by institutional protocols for direct echocardiograph orders by general practitioners in the United Kingdom.

Organization of healthcare

Structure and inputs in rural health services

Material shortages in health services in rural areas were identified in studies in Africa ³³33. Brieger WR, Sommerfeld JU, Amazigo UV; CDI Network. The potential for community-directed interventions: reaching underserved populations in Africa. Int Q Community Health Educ 2015; 35:295-316.^,3434. Labhardt ND, Balo JR, Ndam M, Grimm JJ, Manga E. Task shifting to non-physician clinicians for integrated management of hypertension and diabetes in rural Cameroon: a programme assessment at two years. BMC Health Serv Res 2010; 10:339.^,3535. Strasser R, Kam SM, Regalado SM. Rural health care access and policy in developing countries. Annu Rev Public Health 2016; 37:395-412.^,3636. Ambruoso L, van der Merwe M, Wariri O, Byass P, Goosen G, Kahn K, et al. Rethinking collaboration: developing a learning platform to address under-five mortality in Mpumalanga province, South Africa. Health Policy Plan 2019; 34:418-29., but also in Pakistan ³⁷37. Naeem SB, Bhatti R. Clinical information needs and access in primary health care: a comparative cross-sectional study of rural and non-rural primary care physicians. Health Info Libr J 2015; 32:287-99., Greece ³⁸38. Sbarouni V, Tsimtsiou Z, Symvoulakis E, Kamekis A, Petelos E, Saridaki A, et al. Perceptions of primary care professionals on quality of services in rural Greece: a qualitative study. Rural Remote Health 2012; 12:2156., and Australia ³⁹39. 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.. The studies reveal difficulties in providing infrastructure and human resources, especially in poor countries and in the public sector, on which rural populations largely depend.

Insufficient structures and inputs appeared in the form of undersupply, lack of maintenance, and shortages of equipment, health units, and healthcare personnel, opening the way for provision of care by nongovernmental organizations (NGOs) ³³33. Brieger WR, Sommerfeld JU, Amazigo UV; CDI Network. The potential for community-directed interventions: reaching underserved populations in Africa. Int Q Community Health Educ 2015; 35:295-316.^,3434. Labhardt ND, Balo JR, Ndam M, Grimm JJ, Manga E. Task shifting to non-physician clinicians for integrated management of hypertension and diabetes in rural Cameroon: a programme assessment at two years. BMC Health Serv Res 2010; 10:339.^,3535. Strasser R, Kam SM, Regalado SM. Rural health care access and policy in developing countries. Annu Rev Public Health 2016; 37:395-412.^,3636. Ambruoso L, van der Merwe M, Wariri O, Byass P, Goosen G, Kahn K, et al. Rethinking collaboration: developing a learning platform to address under-five mortality in Mpumalanga province, South Africa. Health Policy Plan 2019; 34:418-29.^,3838. Sbarouni V, Tsimtsiou Z, Symvoulakis E, Kamekis A, Petelos E, Saridaki A, et al. Perceptions of primary care professionals on quality of services in rural Greece: a qualitative study. Rural Remote Health 2012; 12:2156.. In Sub-Saharan Africa, the focus of investments by governments and international agencies in vertical PHC programs resulted in the shifting of material and human resources to the agencies’ own priority strategies, targeted to specific diseases and with a short-term vision of results ³⁴34. Labhardt ND, Balo JR, Ndam M, Grimm JJ, Manga E. Task shifting to non-physician clinicians for integrated management of hypertension and diabetes in rural Cameroon: a programme assessment at two years. BMC Health Serv Res 2010; 10:339.^,3535. Strasser R, Kam SM, Regalado SM. Rural health care access and policy in developing countries. Annu Rev Public Health 2016; 37:395-412..

Various studies highlight the need to invest in information and communication technologies in rural areas, such as electronic patient files, to expand access, continuity, coordination, and practices of care ³⁶36. Ambruoso L, van der Merwe M, Wariri O, Byass P, Goosen G, Kahn K, et al. Rethinking collaboration: developing a learning platform to address under-five mortality in Mpumalanga province, South Africa. Health Policy Plan 2019; 34:418-29.^,3838. Sbarouni V, Tsimtsiou Z, Symvoulakis E, Kamekis A, Petelos E, Saridaki A, et al. Perceptions of primary care professionals on quality of services in rural Greece: a qualitative study. Rural Remote Health 2012; 12:2156.^,3939. 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.. Rural inequalities (compared to urban areas) in access to information devices such as computers, Internet, and mobile telephony hinder rural healthcare workers’ performance ³⁷37. Naeem SB, Bhatti R. Clinical information needs and access in primary health care: a comparative cross-sectional study of rural and non-rural primary care physicians. Health Info Libr J 2015; 32:287-99..

Functioning of health services

There were two main questions in the approach to functioning of services in rural territories: how to cover and reach the rural population and how to guarantee an expanded supply to meet the needs with sustainable health workforce.

Strasser et al. ³⁵35. Strasser R, Kam SM, Regalado SM. Rural health care access and policy in developing countries. Annu Rev Public Health 2016; 37:395-412. argue that it is necessary for PHC to have universal health as its premise, and that in Africa, distances, transportation, and exclusion of vulnerable groups by local power interests are barriers to the coverage of rural populations. To reach remote sites with no health services or to supplement the existing services, the approach was to adopt mobile/roving services or extension services from a central base ³³33. Brieger WR, Sommerfeld JU, Amazigo UV; CDI Network. The potential for community-directed interventions: reaching underserved populations in Africa. Int Q Community Health Educ 2015; 35:295-316.^,3939. 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.^,4040. Carey TA, Sirett D, Wakerman J, Russell D, Humphreys JS. What principles should guide visiting primary health care services in rural and remote communities? Lessons from a systematic review. Aust J Rural Health 2018; 26:146-56.. Wakerman et al. ³⁹39. 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. referred to such services as “outreach models”.

In Africa, however, mobile units were rarely acknowledged as a solution to the level of needs ³³33. Brieger WR, Sommerfeld JU, Amazigo UV; CDI Network. The potential for community-directed interventions: reaching underserved populations in Africa. Int Q Community Health Educ 2015; 35:295-316.. Community-based health workers aimed at reaching rural communities rarely worked beyond the immediate surroundings of the health unit, for lack of resources ³³33. Brieger WR, Sommerfeld JU, Amazigo UV; CDI Network. The potential for community-directed interventions: reaching underserved populations in Africa. Int Q Community Health Educ 2015; 35:295-316.. In Australia, services with extended office hours were another way of expanding the supply of care to the rural population ⁴¹41. Wakerman J, Humphreys JS. Sustainable primary health care services in rural and remote areas: innovation and evidence. Aust J Rural Health 2011; 19:118-24.^,4242. Russell D, Humphreys J. Meeting the primary healthcare needs of small rural communities: lessons for health service planners. Rural Remote Health 2016; 16:3695.. Telehealth and tele-education were cited as powerful tools, highlighting the specificities of implementation, maintenance, and autonomy in relation to the technologies ³⁵35. Strasser R, Kam SM, Regalado SM. Rural health care access and policy in developing countries. Annu Rev Public Health 2016; 37:395-412.^,3939. 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.^,4343. Pancer Z, Moore M, Wenham JT, Burridge M. The challenge of generalist care in remote Australia: beyond aeromedical retrieval. Aust J Rural Health 2018; 26:188-93..

The second question, how to guarantee the expanded and adequate supply of services, aimed to respond to the challenges of the limited network of services in rural and remote territories and their populations’ specific demands. Various studies emphasized the importance of social determination of the health/disease process in populations that are vulnerable to poverty and deficient sanitation ³³33. Brieger WR, Sommerfeld JU, Amazigo UV; CDI Network. The potential for community-directed interventions: reaching underserved populations in Africa. Int Q Community Health Educ 2015; 35:295-316.^,3636. Ambruoso L, van der Merwe M, Wariri O, Byass P, Goosen G, Kahn K, et al. Rethinking collaboration: developing a learning platform to address under-five mortality in Mpumalanga province, South Africa. Health Policy Plan 2019; 34:418-29.^,3939. 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..

One way to address such demands would be to take services to the communities, allowing visits by PHC workers and equipment and specialized care and implementation of telehealth strategies ³³33. Brieger WR, Sommerfeld JU, Amazigo UV; CDI Network. The potential for community-directed interventions: reaching underserved populations in Africa. Int Q Community Health Educ 2015; 35:295-316.^,3535. Strasser R, Kam SM, Regalado SM. Rural health care access and policy in developing countries. Annu Rev Public Health 2016; 37:395-412.^,3939. 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.^,4040. Carey TA, Sirett D, Wakerman J, Russell D, Humphreys JS. What principles should guide visiting primary health care services in rural and remote communities? Lessons from a systematic review. Aust J Rural Health 2018; 26:146-56.. Another key point would be training of healthcare staff to improve and expand their skills and interpersonal aspects of care ³⁵35. Strasser R, Kam SM, Regalado SM. Rural health care access and policy in developing countries. Annu Rev Public Health 2016; 37:395-412.^,3636. Ambruoso L, van der Merwe M, Wariri O, Byass P, Goosen G, Kahn K, et al. Rethinking collaboration: developing a learning platform to address under-five mortality in Mpumalanga province, South Africa. Health Policy Plan 2019; 34:418-29.^,3939. 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., given that some studies cited discriminatory attitudes towards local customs ³⁵35. Strasser R, Kam SM, Regalado SM. Rural health care access and policy in developing countries. Annu Rev Public Health 2016; 37:395-412.^,3636. Ambruoso L, van der Merwe M, Wariri O, Byass P, Goosen G, Kahn K, et al. Rethinking collaboration: developing a learning platform to address under-five mortality in Mpumalanga province, South Africa. Health Policy Plan 2019; 34:418-29.. Consistent with the weight of social determination in the context of rural health, several studies emphasized activities in health promotion and prevention, alongside the empowerment of communities and community-based health workers ³³33. Brieger WR, Sommerfeld JU, Amazigo UV; CDI Network. The potential for community-directed interventions: reaching underserved populations in Africa. Int Q Community Health Educ 2015; 35:295-316.^,3535. Strasser R, Kam SM, Regalado SM. Rural health care access and policy in developing countries. Annu Rev Public Health 2016; 37:395-412.^,3636. Ambruoso L, van der Merwe M, Wariri O, Byass P, Goosen G, Kahn K, et al. Rethinking collaboration: developing a learning platform to address under-five mortality in Mpumalanga province, South Africa. Health Policy Plan 2019; 34:418-29.^,3939. 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..

Wakerman et al. ³⁹39. 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. report that smaller and remote Australian populations that were unable to sustain specialized services tended to seek “integrated service” arrangements (a variety of supply in a single point, with mutual support among healthcare workers without an exclusive focus on general practitioners) or “comprehensive/holistic services”, including patient care, prevention, and community care, with an expanded scope of practices, dealing with social determinants of health and people’s participation.

Wakerman et al. ³⁹39. 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. also described the configurations of rural PHC in Australia that emphasized retention of general practitioners (discrete services) via attractive conditions, although with turnover of healthcare workers, with continuity of services ensured by the infrastructure of universities or local government, a flow that was generally possible in communities with higher density. The other forms of organization - outreach models, comprehensive services, and integral services - also aimed to ensure the health workforce, for example by inspiration in connections between larger and smaller airports - where healthcare staff makes connections in larger towns and rural communities or in employment formats in oil fields (“fly-in-fly-out”), with full-time stints in remote sites alternating with days off from work ³⁹39. 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..

Community-based management

Community-based management was a key element in the organization of rural healthcare. Thus, external organizational logics, generally conceived for urban areas, would not be imposed on the diverse realities of rural and remote territories. Community-based management includes community autonomy to generate specific actions in the territory, with backup from PHC, aimed at making such actions more adequate and with greater case-resolution capacity through the community’s own perception of the context ³³33. Brieger WR, Sommerfeld JU, Amazigo UV; CDI Network. The potential for community-directed interventions: reaching underserved populations in Africa. Int Q Community Health Educ 2015; 35:295-316.^,4444. Carroll V, Reeve CA, Humphreys JS, Wakerman J, Carter M. Re-orienting a remote acute care model towards a primary health care approach: key enablers. Rural Remote Health 2015; 15:2942..

There are several key studies on this topic in African countries ³³33. Brieger WR, Sommerfeld JU, Amazigo UV; CDI Network. The potential for community-directed interventions: reaching underserved populations in Africa. Int Q Community Health Educ 2015; 35:295-316.^,3535. Strasser R, Kam SM, Regalado SM. Rural health care access and policy in developing countries. Annu Rev Public Health 2016; 37:395-412.^,3636. Ambruoso L, van der Merwe M, Wariri O, Byass P, Goosen G, Kahn K, et al. Rethinking collaboration: developing a learning platform to address under-five mortality in Mpumalanga province, South Africa. Health Policy Plan 2019; 34:418-29.^,4545. Okwundu CI, Nagpal S, Musekiwa A, Sinclair D. Home- or community-based programmes for treating malaria. Cochrane Database Syst Rev 2013; (5):CD009527., but also in Ecuador and Australia ⁴²42. Russell D, Humphreys J. Meeting the primary healthcare needs of small rural communities: lessons for health service planners. Rural Remote Health 2016; 16:3695.^,4444. Carroll V, Reeve CA, Humphreys JS, Wakerman J, Carter M. Re-orienting a remote acute care model towards a primary health care approach: key enablers. Rural Remote Health 2015; 15:2942.^,4646. Eckhardt M, Carlfjord S, Faresjö T, Crespo-Burgos A, Forsberg BC, Falk M. Universal health coverage in marginalized populations: a qualitative evaluation of a health reform implementation in rural Ecuador. Inquiry 2019; 56:46958019880699.. Articles that examined multiple African countries tended to highlight targeted or vertical community strategies ³⁵35. Strasser R, Kam SM, Regalado SM. Rural health care access and policy in developing countries. Annu Rev Public Health 2016; 37:395-412.. Community-based management focused on communicable diseases and used simple procedures, with health services as support and distribution points, highlighting low cost and efficiency ³³33. Brieger WR, Sommerfeld JU, Amazigo UV; CDI Network. The potential for community-directed interventions: reaching underserved populations in Africa. Int Q Community Health Educ 2015; 35:295-316.^,3535. Strasser R, Kam SM, Regalado SM. Rural health care access and policy in developing countries. Annu Rev Public Health 2016; 37:395-412.^,4545. Okwundu CI, Nagpal S, Musekiwa A, Sinclair D. Home- or community-based programmes for treating malaria. Cochrane Database Syst Rev 2013; (5):CD009527.. However, studies with a local/regional scope reported a more complex community-based management experience. They described participation in health system’s organization from the local and regional to the national levels ³⁶36. Ambruoso L, van der Merwe M, Wariri O, Byass P, Goosen G, Kahn K, et al. Rethinking collaboration: developing a learning platform to address under-five mortality in Mpumalanga province, South Africa. Health Policy Plan 2019; 34:418-29.^,4242. Russell D, Humphreys J. Meeting the primary healthcare needs of small rural communities: lessons for health service planners. Rural Remote Health 2016; 16:3695.^,4444. Carroll V, Reeve CA, Humphreys JS, Wakerman J, Carter M. Re-orienting a remote acute care model towards a primary health care approach: key enablers. Rural Remote Health 2015; 15:2942.^,4646. Eckhardt M, Carlfjord S, Faresjö T, Crespo-Burgos A, Forsberg BC, Falk M. Universal health coverage in marginalized populations: a qualitative evaluation of a health reform implementation in rural Ecuador. Inquiry 2019; 56:46958019880699..

Advantages of community-based management ranged from greater access and use of services, reach to underserved areas or those distant from health services, professional satisfaction, cultural competence of care, response to local needs, community empowerment, better health outcomes, and differentiation of PHC with its fundamental attributes ³³33. Brieger WR, Sommerfeld JU, Amazigo UV; CDI Network. The potential for community-directed interventions: reaching underserved populations in Africa. Int Q Community Health Educ 2015; 35:295-316.^,3535. Strasser R, Kam SM, Regalado SM. Rural health care access and policy in developing countries. Annu Rev Public Health 2016; 37:395-412.^,3636. Ambruoso L, van der Merwe M, Wariri O, Byass P, Goosen G, Kahn K, et al. Rethinking collaboration: developing a learning platform to address under-five mortality in Mpumalanga province, South Africa. Health Policy Plan 2019; 34:418-29.^,4242. Russell D, Humphreys J. Meeting the primary healthcare needs of small rural communities: lessons for health service planners. Rural Remote Health 2016; 16:3695.^,4444. Carroll V, Reeve CA, Humphreys JS, Wakerman J, Carter M. Re-orienting a remote acute care model towards a primary health care approach: key enablers. Rural Remote Health 2015; 15:2942.^,4545. Okwundu CI, Nagpal S, Musekiwa A, Sinclair D. Home- or community-based programmes for treating malaria. Cochrane Database Syst Rev 2013; (5):CD009527.^,4646. Eckhardt M, Carlfjord S, Faresjö T, Crespo-Burgos A, Forsberg BC, Falk M. Universal health coverage in marginalized populations: a qualitative evaluation of a health reform implementation in rural Ecuador. Inquiry 2019; 56:46958019880699..

Health workforce

Profile and professional role

Articles on health workforce highlighted the shortage of physicians, but described the inclusion of nurses ⁴⁷47. Lindeke L, Jukkala A, Tanner M. Perceived barriers to nurse practitioner practice in rural settings. J Rural Health 2005; 21:178-81.^,4848. Oliveira AR, de Sousa YG, Alves JP, Medeiros SM, Martiniano CS, Alves M. Satisfaction and limitation of primary health care nurses' work in rural areas. Rural Remote Health 2019; 19:4938.^,4949. Menegat RP, Witt RR. Primary health care nurses' competencies in rural disasters caused by floods. Rural Remote Health 2018; 18:4450.^,5050. De Kock JH, Pillay BJ. Mental health nurses in South Africa's public rural primary care settings: a human resource crisis. Rural Remote Health 2016; 16:3865., workers without graduate training ⁵¹51. Sommanustweechai A, Putthasri W, Nwe ML, Aung ST, Theint MM, Tangcharoensathien V, et al. Community health worker in hard-to-reach rural areas of Myanmar: filling primary health care service gaps. Hum Resour Health 2016; 14:64.^,5252. Martin A, O'Meara P, Farmer J. Consumer perspectives of a community paramedicine program in rural Ontario. Aust J Rural Health 2016 ; 24:278-83.^,5353. Chen M, Lu J, Hao C, Hao M, Yao F, Sun M. Developing challenges in the urbanization of village doctors in economically developed regions: a survey of 844 village doctors in Changzhou, China. Aust J Rural Health 2015; [Online ahead of print]., and other professional categories ⁵⁴54. Allan J, Ball P, Alston M. 'You have to face your mistakes in the street': the contextual keys that shape health service access and health workers' experiences in rural areas. Rural Remote Health 2008; 8:835.^,5555. McFarlane KA, Judd J, Wapau H, Nichols N, Watt K, Devine S. How primary health care staff working in rural and remote areas access skill development and expertise to support health promotion practice. Rural Remote Health 2018; 18:4413.^,5656. Gorsche RG, Woloschuk W. Rural physicians' skills enrichment program: a cohort control study of retention in Alberta. Aust J Rural Health 2012; 20:254-8.^,5757. Wardle J, Adams J, Magalhães RJ, Sibbritt D. Distribution of complementary and alternative medicine (CAM) providers in rural New South Wales, Australia: a step towards explaining high CAM use in rural health? Aust J Rural Health 2011; 19:197-204.^,5858. Williams E, D'Amore W, McMeeken J. Physiotherapy in rural and regional Australia. Aust J Rural Health 2007; 15:380-6. in rural health and PHC.

Nurses play a wide role in care, management, and education, but a study in the United States ⁴⁷47. Lindeke L, Jukkala A, Tanner M. Perceived barriers to nurse practitioner practice in rural settings. J Rural Health 2005; 21:178-81. identified limitations due to the low understanding of their role. Nurses in South Africa were responsible for prescribing psychoactive drugs in PHC due to the lack of physicians ⁵⁰50. De Kock JH, Pillay BJ. Mental health nurses in South Africa's public rural primary care settings: a human resource crisis. Rural Remote Health 2016; 16:3865..

This expanded scope of nursing practice in the delegation of tasks by some healthcare professionals to others, known as “task-shifting”, was a recurrent concept in this review ³³33. Brieger WR, Sommerfeld JU, Amazigo UV; CDI Network. The potential for community-directed interventions: reaching underserved populations in Africa. Int Q Community Health Educ 2015; 35:295-316.^,3434. Labhardt ND, Balo JR, Ndam M, Grimm JJ, Manga E. Task shifting to non-physician clinicians for integrated management of hypertension and diabetes in rural Cameroon: a programme assessment at two years. BMC Health Serv Res 2010; 10:339.^,5050. De Kock JH, Pillay BJ. Mental health nurses in South Africa's public rural primary care settings: a human resource crisis. Rural Remote Health 2016; 16:3865.^,5151. Sommanustweechai A, Putthasri W, Nwe ML, Aung ST, Theint MM, Tangcharoensathien V, et al. Community health worker in hard-to-reach rural areas of Myanmar: filling primary health care service gaps. Hum Resour Health 2016; 14:64.. It involves the incorporation of more specialized responsibilities, especially in diagnosis and treatment, previously exclusive to other professional categories.

Healthcare workers without graduate training and that worked in rural areas were cited as paramedics in Canada ⁵²52. Martin A, O'Meara P, Farmer J. Consumer perspectives of a community paramedicine program in rural Ontario. Aust J Rural Health 2016 ; 24:278-83., community health workers in Myanmar ⁵¹51. Sommanustweechai A, Putthasri W, Nwe ML, Aung ST, Theint MM, Tangcharoensathien V, et al. Community health worker in hard-to-reach rural areas of Myanmar: filling primary health care service gaps. Hum Resour Health 2016; 14:64., and “village doctors” in China, the modern term for the former “barefoot doctors” ⁵³53. Chen M, Lu J, Hao C, Hao M, Yao F, Sun M. Developing challenges in the urbanization of village doctors in economically developed regions: a survey of 844 village doctors in Changzhou, China. Aust J Rural Health 2015; [Online ahead of print].. Activities in health promotion and prevention, home access, and community linkage were emphasized as common characteristics ⁵¹51. Sommanustweechai A, Putthasri W, Nwe ML, Aung ST, Theint MM, Tangcharoensathien V, et al. Community health worker in hard-to-reach rural areas of Myanmar: filling primary health care service gaps. Hum Resour Health 2016; 14:64.^,5252. Martin A, O'Meara P, Farmer J. Consumer perspectives of a community paramedicine program in rural Ontario. Aust J Rural Health 2016 ; 24:278-83.^,5353. Chen M, Lu J, Hao C, Hao M, Yao F, Sun M. Developing challenges in the urbanization of village doctors in economically developed regions: a survey of 844 village doctors in Changzhou, China. Aust J Rural Health 2015; [Online ahead of print]..

Other professions discussed in the studies were physical therapists ⁵⁸58. Williams E, D'Amore W, McMeeken J. Physiotherapy in rural and regional Australia. Aust J Rural Health 2007; 15:380-6., integrative/complementary health providers ⁵⁷57. Wardle J, Adams J, Magalhães RJ, Sibbritt D. Distribution of complementary and alternative medicine (CAM) providers in rural New South Wales, Australia: a step towards explaining high CAM use in rural health? Aust J Rural Health 2011; 19:197-204., physicians ⁵⁶56. Gorsche RG, Woloschuk W. Rural physicians' skills enrichment program: a cohort control study of retention in Alberta. Aust J Rural Health 2012; 20:254-8., social workers, and pharmacists ⁵⁴54. Allan J, Ball P, Alston M. 'You have to face your mistakes in the street': the contextual keys that shape health service access and health workers' experiences in rural areas. Rural Remote Health 2008; 8:835.. A common point was the discussion of generalist practices and specific skills for the rural context. Special skills were considered essential for practice in rural services, both in patient care and in prevention, in keeping with the socio-epidemiological profile, the population’s cultural characteristics, and lack of specialized personnel ⁵⁵55. McFarlane KA, Judd J, Wapau H, Nichols N, Watt K, Devine S. How primary health care staff working in rural and remote areas access skill development and expertise to support health promotion practice. Rural Remote Health 2018; 18:4413.^,5656. Gorsche RG, Woloschuk W. Rural physicians' skills enrichment program: a cohort control study of retention in Alberta. Aust J Rural Health 2012; 20:254-8.^,5757. Wardle J, Adams J, Magalhães RJ, Sibbritt D. Distribution of complementary and alternative medicine (CAM) providers in rural New South Wales, Australia: a step towards explaining high CAM use in rural health? Aust J Rural Health 2011; 19:197-204..

The studies found that all the healthcare workers were supposed to conduct an expanded scope of practices, with new responsibilities (task-shifting) and the need for continuing education, a recurrent theme in the articles ⁵¹51. Sommanustweechai A, Putthasri W, Nwe ML, Aung ST, Theint MM, Tangcharoensathien V, et al. Community health worker in hard-to-reach rural areas of Myanmar: filling primary health care service gaps. Hum Resour Health 2016; 14:64.^,5353. Chen M, Lu J, Hao C, Hao M, Yao F, Sun M. Developing challenges in the urbanization of village doctors in economically developed regions: a survey of 844 village doctors in Changzhou, China. Aust J Rural Health 2015; [Online ahead of print].^,5555. McFarlane KA, Judd J, Wapau H, Nichols N, Watt K, Devine S. How primary health care staff working in rural and remote areas access skill development and expertise to support health promotion practice. Rural Remote Health 2018; 18:4413.^,5656. Gorsche RG, Woloschuk W. Rural physicians' skills enrichment program: a cohort control study of retention in Alberta. Aust J Rural Health 2012; 20:254-8.. Integrative and complementary health practices were considered appropriate for rural areas based on greater affinity, integration with the culture, and ease of access in rural communities, based on studies in Australia ⁵⁷57. Wardle J, Adams J, Magalhães RJ, Sibbritt D. Distribution of complementary and alternative medicine (CAM) providers in rural New South Wales, Australia: a step towards explaining high CAM use in rural health? Aust J Rural Health 2011; 19:197-204. and China ⁵⁹59. Pei H, Sun Y, Bai Z, Yu Z, Chang P, Qiu C, et al. Selective admission policy of medical undergraduates in western China: applicants' real attitudes to the choice of a rural medical career. Rural Remote Health 2018; 18:4519..

Another striking characteristic was community work in rural areas, using home visits, health services outreach, inter-sector or surveillance linkage, and strategic planning in the territory ⁴⁹49. Menegat RP, Witt RR. Primary health care nurses' competencies in rural disasters caused by floods. Rural Remote Health 2018; 18:4450.^,5151. Sommanustweechai A, Putthasri W, Nwe ML, Aung ST, Theint MM, Tangcharoensathien V, et al. Community health worker in hard-to-reach rural areas of Myanmar: filling primary health care service gaps. Hum Resour Health 2016; 14:64.^,5252. Martin A, O'Meara P, Farmer J. Consumer perspectives of a community paramedicine program in rural Ontario. Aust J Rural Health 2016 ; 24:278-83.^,5353. Chen M, Lu J, Hao C, Hao M, Yao F, Sun M. Developing challenges in the urbanization of village doctors in economically developed regions: a survey of 844 village doctors in Changzhou, China. Aust J Rural Health 2015; [Online ahead of print].^,5454. Allan J, Ball P, Alston M. 'You have to face your mistakes in the street': the contextual keys that shape health service access and health workers' experiences in rural areas. Rural Remote Health 2008; 8:835..

Complex relations between healthcare workers and the rural communities where they work shape their practices due to such issues as privacy, confidentiality, perceptions of the worker’s visibility and reputation, and qualities attributed to the respective territories ⁵¹51. Sommanustweechai A, Putthasri W, Nwe ML, Aung ST, Theint MM, Tangcharoensathien V, et al. Community health worker in hard-to-reach rural areas of Myanmar: filling primary health care service gaps. Hum Resour Health 2016; 14:64.^,5353. Chen M, Lu J, Hao C, Hao M, Yao F, Sun M. Developing challenges in the urbanization of village doctors in economically developed regions: a survey of 844 village doctors in Changzhou, China. Aust J Rural Health 2015; [Online ahead of print].^,5454. Allan J, Ball P, Alston M. 'You have to face your mistakes in the street': the contextual keys that shape health service access and health workers' experiences in rural areas. Rural Remote Health 2008; 8:835..

Factors for health workforce attraction and retention

The studies reported intense complexity in the attraction and retention of health workforce, with multiple and intertwining factors, some specific to each context. In general, geographic issues, education, work market regulation, and personal support were reiterated for the health workforce in rural settings ⁶⁰60. Grobler L, Marais BJ, Mabunda S. Interventions for increasing the proportion of health professionals practising in rural and other underserved areas. Cochrane Database Syst Rev 2015; (6):CD005314.^,6161. Wakerman J, Humphreys J, Russell D, Guthridge S, Bourke L, Dunbar T, et al. Remote health workforce turnover and retention: what are the policy and practice priorities? Hum Resour Health 2019; 17:99.^,6262. Russell DJ, McGrail MR, Humphreys JS. Determinants of rural Australian primary health care worker retention: a synthesis of key evidence and implications for policymaking. Aust J Rural Health 2017; 25:5-14..

Geographic issues were cited as the main factor, frequently associating unfavorable health workforce distribution with distance from urban areas ⁶¹61. Wakerman J, Humphreys J, Russell D, Guthridge S, Bourke L, Dunbar T, et al. Remote health workforce turnover and retention: what are the policy and practice priorities? Hum Resour Health 2019; 17:99.^,6262. Russell DJ, McGrail MR, Humphreys JS. Determinants of rural Australian primary health care worker retention: a synthesis of key evidence and implications for policymaking. Aust J Rural Health 2017; 25:5-14.^,6363. Theodorakis PN, Mantzavinis GD. Inequalities in the distribution of rural primary care physicians in two remote neighboring prefectures of Greece and Albania. Rural Remote Health 2005; 5:457.^,6464. McGrail MR, Wingrove PM, Petterson SM, Humphreys JS, Russell DJ, Bazemore AW. Measuring the attractiveness of rural communities in accounting for differences of rural primary care workforce supply. Rural Remote Health 2017; 17:3925.. These issues were occasionally overcome by the greater appeal of seacoast areas and other attractive characteristics in Australia and the United States ⁶⁴64. McGrail MR, Wingrove PM, Petterson SM, Humphreys JS, Russell DJ, Bazemore AW. Measuring the attractiveness of rural communities in accounting for differences of rural primary care workforce supply. Rural Remote Health 2017; 17:3925.. The value assigned to giving to the community and the feelings and relations that healthcare workers developed with the places, influencing their wish to stay or leave - namely bonding with local communities - were emphasized by studies in Myanmar ⁵¹51. Sommanustweechai A, Putthasri W, Nwe ML, Aung ST, Theint MM, Tangcharoensathien V, et al. Community health worker in hard-to-reach rural areas of Myanmar: filling primary health care service gaps. Hum Resour Health 2016; 14:64., China ⁵³53. Chen M, Lu J, Hao C, Hao M, Yao F, Sun M. Developing challenges in the urbanization of village doctors in economically developed regions: a survey of 844 village doctors in Changzhou, China. Aust J Rural Health 2015; [Online ahead of print]., and Australia ⁵⁴54. Allan J, Ball P, Alston M. 'You have to face your mistakes in the street': the contextual keys that shape health service access and health workers' experiences in rural areas. Rural Remote Health 2008; 8:835..

Rural or indigenous origins of students or recruited workers tended towards greater health workforce retention. However, due to the greater socioeconomic vulnerability of the population in rural and remote territories, financial and pedagogical support is necessary for effective training of local health workforce ⁵⁹59. Pei H, Sun Y, Bai Z, Yu Z, Chang P, Qiu C, et al. Selective admission policy of medical undergraduates in western China: applicants' real attitudes to the choice of a rural medical career. Rural Remote Health 2018; 18:4519.^,6060. Grobler L, Marais BJ, Mabunda S. Interventions for increasing the proportion of health professionals practising in rural and other underserved areas. Cochrane Database Syst Rev 2015; (6):CD005314.^,6161. Wakerman J, Humphreys J, Russell D, Guthridge S, Bourke L, Dunbar T, et al. Remote health workforce turnover and retention: what are the policy and practice priorities? Hum Resour Health 2019; 17:99.^,6565. Wanchek TN, Rephann TJ. Effects of a proposed rural dental school on regional dental workforce and access to care. Rural Remote Health 2013; 13:2366..

Exposure of students to rural settings, the discussion of rural issues throughout their undergraduate training, and the installation of teaching institutions in these scenarios were related to greater health workforce retention ⁶⁰60. Grobler L, Marais BJ, Mabunda S. Interventions for increasing the proportion of health professionals practising in rural and other underserved areas. Cochrane Database Syst Rev 2015; (6):CD005314.^,6161. Wakerman J, Humphreys J, Russell D, Guthridge S, Bourke L, Dunbar T, et al. Remote health workforce turnover and retention: what are the policy and practice priorities? Hum Resour Health 2019; 17:99.^,6666. Bowman RC. Measuring primary care: the standard primary care year. Rural Remote Health 2008; 8:1009.. International reviews reported positive findings from curricula with skills applied to rural health ⁶⁰60. Grobler L, Marais BJ, Mabunda S. Interventions for increasing the proportion of health professionals practising in rural and other underserved areas. Cochrane Database Syst Rev 2015; (6):CD005314.^,6161. Wakerman J, Humphreys J, Russell D, Guthridge S, Bourke L, Dunbar T, et al. Remote health workforce turnover and retention: what are the policy and practice priorities? Hum Resour Health 2019; 17:99.. They emphasized the importance, during training, of discussing the identity of healthcare workers in rural contexts, including their duties, limits, and needs ⁵⁴54. Allan J, Ball P, Alston M. 'You have to face your mistakes in the street': the contextual keys that shape health service access and health workers' experiences in rural areas. Rural Remote Health 2008; 8:835.^,5959. Pei H, Sun Y, Bai Z, Yu Z, Chang P, Qiu C, et al. Selective admission policy of medical undergraduates in western China: applicants' real attitudes to the choice of a rural medical career. Rural Remote Health 2018; 18:4519..

Another factor impacting health workforce supply was the prospect of a rural health career, that is, workers that glimpsed a sustained practice in this field. In the United States, training in pediatrics, and especially in family medicine, guaranteed longer permanence in rural PHC after training, regardless of policy and market changes ⁶⁶66. Bowman RC. Measuring primary care: the standard primary care year. Rural Remote Health 2008; 8:1009.. In China, an appropriate understanding of the rural medical careers was considered necessary for recent graduates not to come to work only temporarily, by obligation, in rural areas ⁵⁹59. Pei H, Sun Y, Bai Z, Yu Z, Chang P, Qiu C, et al. Selective admission policy of medical undergraduates in western China: applicants' real attitudes to the choice of a rural medical career. Rural Remote Health 2018; 18:4519..

The studies showed that retention of healthcare personnel in rural areas can be affected by financial issues. According to Grobler et al. ⁶⁰60. Grobler L, Marais BJ, Mabunda S. Interventions for increasing the proportion of health professionals practising in rural and other underserved areas. Cochrane Database Syst Rev 2015; (6):CD005314., financial incentives such as scholarships, benefits, and higher salaries were featured in international studies as strategies to supply health workforce in rural areas. Attraction of healthcare professionals was associated with better salaries in urban areas of the United States ⁶⁶66. Bowman RC. Measuring primary care: the standard primary care year. Rural Remote Health 2008; 8:1009. and higher income expectations with advancing urbanization in China ⁵³53. Chen M, Lu J, Hao C, Hao M, Yao F, Sun M. Developing challenges in the urbanization of village doctors in economically developed regions: a survey of 844 village doctors in Changzhou, China. Aust J Rural Health 2015; [Online ahead of print].. The possibility of the rural population paying for consultations, with reimbursement by health programs and insurance in Taiwan and the United States, led to better supply of health workforce ⁶⁰60. Grobler L, Marais BJ, Mabunda S. Interventions for increasing the proportion of health professionals practising in rural and other underserved areas. Cochrane Database Syst Rev 2015; (6):CD005314.^,6565. Wanchek TN, Rephann TJ. Effects of a proposed rural dental school on regional dental workforce and access to care. Rural Remote Health 2013; 13:2366..

The international literature identified the important weight of the public sector in the healthcare work market for guaranteeing access in rural areas, since the populations in rural and remote areas, generally underprivileged for covering the market costs of healthcare, depend on the provision and regulation of services by the State. The organization of supply and provision of services in the public sector largely impacted the attraction and retention of rural health workforce ⁶³63. Theodorakis PN, Mantzavinis GD. Inequalities in the distribution of rural primary care physicians in two remote neighboring prefectures of Greece and Albania. Rural Remote Health 2005; 5:457.^,6565. Wanchek TN, Rephann TJ. Effects of a proposed rural dental school on regional dental workforce and access to care. Rural Remote Health 2013; 13:2366.^,6666. Bowman RC. Measuring primary care: the standard primary care year. Rural Remote Health 2008; 8:1009..

In the United States, healthcare professionals’ choice to work in rural PHC varied according to market forces and government policies ⁶⁶66. Bowman RC. Measuring primary care: the standard primary care year. Rural Remote Health 2008; 8:1009.. Work market regulation is a strategy for better distribution of the health workforce in rural areas. Foreign physicians limited to rural areas, stimulus for (or compulsory) services for recent graduates, and minimum work time in rural health as a prerequisite for specializations were some of the initiatives cited in international studies ⁵⁹59. Pei H, Sun Y, Bai Z, Yu Z, Chang P, Qiu C, et al. Selective admission policy of medical undergraduates in western China: applicants' real attitudes to the choice of a rural medical career. Rural Remote Health 2018; 18:4519.^,6060. Grobler L, Marais BJ, Mabunda S. Interventions for increasing the proportion of health professionals practising in rural and other underserved areas. Cochrane Database Syst Rev 2015; (6):CD005314.^,6262. Russell DJ, McGrail MR, Humphreys JS. Determinants of rural Australian primary health care worker retention: a synthesis of key evidence and implications for policymaking. Aust J Rural Health 2017; 25:5-14..

There is a need for personal and family support to adequately sustain rural health workforce. Living conditions in the rural setting, such as housing, schools, and academic and professional development, as well as affective relations, are conditioning factors ⁵¹51. Sommanustweechai A, Putthasri W, Nwe ML, Aung ST, Theint MM, Tangcharoensathien V, et al. Community health worker in hard-to-reach rural areas of Myanmar: filling primary health care service gaps. Hum Resour Health 2016; 14:64.^,5454. Allan J, Ball P, Alston M. 'You have to face your mistakes in the street': the contextual keys that shape health service access and health workers' experiences in rural areas. Rural Remote Health 2008; 8:835.^,6060. Grobler L, Marais BJ, Mabunda S. Interventions for increasing the proportion of health professionals practising in rural and other underserved areas. Cochrane Database Syst Rev 2015; (6):CD005314.. The forms of support feature a time limit on activities in remote territories, personalized financial incentives, and psychological support ⁶¹61. Wakerman J, Humphreys J, Russell D, Guthridge S, Bourke L, Dunbar T, et al. Remote health workforce turnover and retention: what are the policy and practice priorities? Hum Resour Health 2019; 17:99.^,6262. Russell DJ, McGrail MR, Humphreys JS. Determinants of rural Australian primary health care worker retention: a synthesis of key evidence and implications for policymaking. Aust J Rural Health 2017; 25:5-14..

The undervaluation of the rural doctor’s image, fed by a cultural bias that “real doctors” are those that work in big-city hospitals, was seen in China as a challenge to understanding rural practice and attraction/retention of health professionals ⁵⁹59. Pei H, Sun Y, Bai Z, Yu Z, Chang P, Qiu C, et al. Selective admission policy of medical undergraduates in western China: applicants' real attitudes to the choice of a rural medical career. Rural Remote Health 2018; 18:4519.. In Australia, health workforce retention resulted from a complex combination of the local context, professional role, personal strengths, and relationships ⁵⁴54. Allan J, Ball P, Alston M. 'You have to face your mistakes in the street': the contextual keys that shape health service access and health workers' experiences in rural areas. Rural Remote Health 2008; 8:835..

Returning to the underlying question: what are the effective strategies to guarantee comprehensive/integral PHC for rural populations? Box 2 presents a synthesis of the principal strategies found in the selected literature to overcome obstacles to access, organization, and health workforce supply.

Discussion

The review’s results provide an overview of rural health in the international literature in the last 20 years, on questions of access, organization, and health workforce in PHC. The review featured a range of rural scenarios, views, and socioeconomic and spatial realities.

The analysis of categories and themes involved in rural PHC revealed a broad view of questions and challenges, already well-known, but also strategies, models, and foundations for health policies, planning, and practices in rural areas. Although these points were extracted separately from the studies, the three categories (access, organization, and health workforce) showed many intersections. Thus, articles focused on one category also discussed questions and strategies from the other two.

The cross-cutting questions in the various themes related to space and population. Vast territories with limited resources in transportation, infrastructure, and services condition difficulties with access and the needs for economically viable solutions. Small, dispersed populations, marginalized from socioeconomic development to a greater or lesser degree, are vulnerable to unfavorable social, health, and epidemiological condition that are specific to the rural context ³³33. Brieger WR, Sommerfeld JU, Amazigo UV; CDI Network. The potential for community-directed interventions: reaching underserved populations in Africa. Int Q Community Health Educ 2015; 35:295-316.^,3939. 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.^,6767. Thomas S, Wakerman J, Humphreys J. What does it cost to provide equity of access to high quality, comprehensive primary health care in rural Australia? A pilot study. Rural Remote Health 2017; 17:4019..

Such characteristics raised a recurrent concern on the costs of guaranteeing healthcare for the rural population. High costs were identified for the health workforce ⁶⁷67. Thomas S, Wakerman J, Humphreys J. What does it cost to provide equity of access to high quality, comprehensive primary health care in rural Australia? A pilot study. Rural Remote Health 2017; 17:4019., difficult to attract and retain, reiterated as a critical problem for access and organization of rural healthcare due to the insufficient amounts and skills ¹⁷17. Haggerty JL, Roberge D, Lévesque JF, Gauthier J, Loignon C. An exploration of rural-urban differences in healthcare-seeking trajectories: implications for measures of accessibility. Health Place 2014; 28:92-8.^,3535. Strasser R, Kam SM, Regalado SM. Rural health care access and policy in developing countries. Annu Rev Public Health 2016; 37:395-412.^,3838. Sbarouni V, Tsimtsiou Z, Symvoulakis E, Kamekis A, Petelos E, Saridaki A, et al. Perceptions of primary care professionals on quality of services in rural Greece: a qualitative study. Rural Remote Health 2012; 12:2156.. Shortages of infrastructure and inputs in the services, combined with unfavorable work conditions, further aggravate the complex web of factors related to maintenance of qualified health workforce in rural communities, as well as quality of care and access to health, reflecting the “inverse care law” enunciated by Hart ⁶⁸68. Hart JT. The inverse care law. Lancet 1971; 297:405-12..

So many challenges illustrate the debate on access and efficiency of investments in rural health and PHC. Rashidian et al. ⁶⁹69. Rashidian A, Joudaki H, Khodayari-Moez E, Omranikhoo H, Geraili B, Arab M. The impact of rural health system reform on hospitalization rates in the Islamic Republic of Iran: an interrupted time series. Bull World Health Organ 2013; 91:942-9., in Iran, show that implementation of PHC in unserved areas generates effects on access that exceed the effects of efficiency, increasing hospitalizations and health costs, contrary to the tendency in wealthy countries, as confirmed by Probst et al. ⁷⁰70. Probst JC, Laditka JN, Laditka SB. Association between community health center and rural health clinic presence and county-level hospitalization rates for ambulatory care sensitive conditions: an analysis across eight US states. BMC Health Serv Res 2009; 9:134., who point to a drop in hospital admissions for PHC-sensitive conditions associated with presence of primary care units in the United States.

Consequences of failures in access, organization, and health workforce were identified as resumption, postponement, or abandonment of the search for healthcare; patient preference for emergency services (regardless of the health problem); aggravation of health conditions; and costs and risk of traveling to services ¹⁷17. Haggerty JL, Roberge D, Lévesque JF, Gauthier J, Loignon C. An exploration of rural-urban differences in healthcare-seeking trajectories: implications for measures of accessibility. Health Place 2014; 28:92-8.^,1919. Sanders SR, Erickson LD, Call VR, McKnight ML, Hedges DW. Rural health care bypass behavior: how community and spatial characteristics affect primary health care selection. J Rural Health 2015; 31:146-56.^,2222. Smith SC, Carragher L. 'Just lie there and die': barriers to access and use of general practitioner out-of-hours services for older people in rural Ireland. Rural Remote Health 2019; 19:5088..

The challenges identified in the international debate were like those in the Brazilian reality. Citizens from economically dynamic areas enjoy better access to health than those from less developed regions, such as rural and remote territories ⁷¹71. Travassos C, Oliveira EXG, Viacava F. Desigualdades geográficas e sociais no acesso aos serviços de saúde no Brasil: 1998 e 2003. Ciênc Saúde Colet 2006; 11:975-86.. In Brazil, as in the international scenario, rural populations’ underprivilege leads to worse epidemiological and health indicators ⁷7. Coimbra Jr. CEA. Saúde rural no Brasil: tema antigo mais que atual. Rev Saúde Pública 2018; 52 Suppl 1:2s.^,88. Savassi LCM, Almeida MM, Floss M, Lima MC, organizadores. Saúde no caminho da roça. Rio de Janeiro: Editora Fiocruz; 2018.^,7272. 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 (n.spe 1):302-14.. Investments in infrastructure and inputs, functioning of services, and health workforce, especially through synergic policies such as the More Doctors Program and the Program for Improvement of Access and Quality of Basic Care ⁷³73. Giovanella L, Mendonça MHM, Fausto MCR, Almeida PF, Bousquat A, Lima JG, et al. A provisão emergencial de médicos pelo Programa Mais Médicos e a qualidade da estrutura das unidades básicas de saúde. Ciênc Saúde Colet 2016; 21:2697-708., in recent years, have been dismantled and redirected to an economic efficiency approach, to the detriment of universal and equitable care ⁷⁴74. Giovanella L, Franco CM, Almeida PF. Política Nacional de Atenção Básica: para onde vamos? Ciênc Saúde Colet 2020; 25:1475-82..

The focus on deficiencies in rural health appears to predominate in the international literature, as reported by Wakerman & Humphreys ⁴¹41. Wakerman J, Humphreys JS. Sustainable primary health care services in rural and remote areas: innovation and evidence. Aust J Rural Health 2011; 19:118-24.. But the current review also shows that challenges in rural areas require innovative conceptions and approaches, different from the urban rationality and that serve to reflect on PHC throughout the system. By outlining the strategies for the observed challenges, the studies shaped some organizational models in the rural territories. The review by Wakerman et al. ³⁹39. 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. on rural Australia distinguished between models for discrete services, outreach, integrated, integral, and comprehensive models, and virtual reach (telehealth), corresponding to the rural population’s degree of rarefaction and distance. Thus, the more remote the location and the smaller the population, the more necessary is an integral and integrated arrangement of health services to maximize scale economy gains in rural territories ³⁹39. 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..

Crosscutting actions in access, organization, and health workforce in rural PHC include community action, outreach models, use of communication and information technologies (ICTs), access to care, and professional training and development. Community action, indissociable from the need to respond to the social determination of health/disease processes, appeared in the provision of means for presence in rural communities and recommendations on promotion/prevention activities to expand access and the more incisive view of the contexts’ specificity and the more complex perspective of geographic aspects vis-à-vis access, referring to notions of critical geography and living territory ⁷⁵75. Santos M. Técnica, espaço, tempo. 5ª Ed. São Paulo: Edusp; 2008.. Community involvement in the organization of healthcare, emphasis on horizontal strategies for comprehensive care, surveillance of care, inter-sector collaboration, integration of local and regional health networks, and valuation of healthcare workers’ bonding with rural communities show the relevance of community action in the initiatives analyzed in the international literature.

Various dynamics that guarantee adequate care in outreach models must respond to the multiplicity of contexts, needs, and resources in distinct rural areas. They require complex planning of the health workforce, logistics, and use of space, with collaboration ranging from the local level of communities to the highest government echelons. ICTs can also back various strategies in access, organization, and health workforce for rural health. These feature telehealth, allowing to reach locations unserved with care and surveillance and the expansion of health practices supply. ICTs are also essential for more effective systems in diagnosis, plans, and follow-up at the individual and community levels.

Access to care obviously permeated the strategies for rural PHC. Although the concern for medical care predominated, the strategies also included nursing staff, community health workers, social workers, and integrative/complementary providers. Multidisciplinary teamwork strategies are important. Access to care is based mainly on continuing care, beyond discrete interventions. Configurations of the supply of such care vary widely according to the circumstances - specific vulnerabilities in rural populations, possibilities of local access and resources, distance to urban centers, cultural characteristics, capacity to attract and retain health workforce, and the public sector’s regulatory force and mechanisms, among others. According to Wakerman et al. ³⁹39. 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., the more remote and the smaller the communities, the greater the tendency for services to seek more comprehensive healthcare models.

Professional training and development formed another set of strategies, not only for health workforce, but also for healthcare access and organization. Training and expansion of professional practices were highlighted, ranging from generalist to specific skills for situations in each rural context, from culturally sensitive attitudes to adequate, continuing, and coordinated care, improving access and organization of PHC in rural areas. Professional development includes continuing education, task-shifting to the available workers in rural areas, and health workforce training, based on members of the rural communities, with exposure to healthcare settings and contents on rural health.

The strategies identified by Wakerman et al. ³⁹39. 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. point beyond the scale economy perspective. The more remote and disperse the population, the sharper the magnifying glass on ways to offer access, organize health services, and ensure health workforce in the essence of the individual/family/community triad. While it is possible to find a condensation of urban models, marked by the production of care captured by the capitalist logic and thus by what Donnangelo ⁷⁶76. Donnangelo MCF. Saúde e sociedade. São Paulo: Duas Cidades; 1976. calls “medicalization”, the articles in this review also identified critiques of a rural model of selective PHC that focuses on vertical and fragmented programs, applying narrow cost-efficiency concepts and a framework of the natural history of diseases for rural populations’ health.

Rural areas are fundamentally what Milton Santos ⁷⁵75. Santos M. Técnica, espaço, tempo. 5ª Ed. São Paulo: Edusp; 2008. (p. 89) defines as horizontalities: “both the place of the finality imposed from outside, from afar, and from above, and the counter-finality, locally generated, the stage for a compatible daily reality, but not a conformist one”. Ways to ensure comprehensive access to health, proper to rural areas, thus represent the possibility of subverting established models. Rural areas can contribute more adequate perspectives for PHC, given their diversity and the challenges they pose to common sense. In short, they can invert the logic, bringing the essence of unicity to the more general system.

Final remarks

The specificities of each country or region’s historical context and health systems require considering the limits on generalization of results. New studies with systematic review designs may be more adequate to statistically extrapolate the information from a total set of studies on the most frequently addressed problems, treated here comprehensively for the purposes of an integrative review. Another limitation of this review was having included only studies in English. Articles with the greatest international reach are usually written in English, but the literature selected here was unable to capture studies published in other languages, which would better express other realities as for example in Latin America. Among the leading countries in the international debate on rural health - Australia, United States, and Canada - Australia stood out in this review, considering the inclusion of specific Australian journals on the review’s theme as literature search bases, which appeared in the initial search. Even so, the review produced a broad overview of challenges and strategies for PHC in terms of access, organization, and health workforce in rural health.

This comprehensive understanding of rural health, expressed in different contexts and from different perspectives in this review, can motivate and guide the formulation of public policy strategies and health actions with a view to equity for rural populations, for the latter to attain the same health status aspired to by the rest of the population ¹1. Working Party on Rural Practice. Política de qualidade e eficácia dos cuidados de saúde rural. Rev Bras Med Fam Comunidade 2013; 8 Suppl 1:15-24.. However, as this review demonstrated, effective strategies require knowledge of the resident population in different rural realities, calling for in-depth studies of the heterogeneity of these areas.

This review contributes to the understanding of additional challenges for PHC in the regionalized healthcare network, in the rural context, and contemplates the clear diversity of territories, health needs, and possible paths outlined by international experiences. Understanding the rural areas’ characteristics, both in terms of PHC access, organization, and health workforce and their historical, social, and environmental process in transformation, favors the creation and strengthening of practices and public policies that are renewed according to the founding principles of the SUS, with universality, equity, and comprehensiveness, from an inclusive perspective in the rural reality.

References

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