Abstract

Introduction

Providing comprehensive health care for the Brazilian population has been a significant challenge for the Brazilian National Health System (SUS). The principle of comprehensiveness recognizes the complexity of individual and collective health needs, showing that the right to health in Brazil should not be restricted to a basic supply of services but contemplate the necessary for health care with dignity¹1 Brito-Silva K, Bezerra AFB, Tanaka OY. Direito à saúde e integralidade: uma discussão sobre os desafios e caminhos para sua efetivação. Interface (Botucatu). 2012; 16(40):249-260..

Comprehensiveness is described in the Organic Health Law²2 Brasil. Presidência da República. Lei nº 8.080, de 19 de Setembro de 1990. Dispõe sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes e dá outras providências [Internet]. Brasília: Casa Civil; 1990 [citado 14 Ago 2020]. Disponível em: http://www.planalto.gov.br/ccivil_03/Leis/L8080.htm
http://www.planalto.gov.br/ccivil_03/Lei... as the articulated and continuous set of preventive, curative, individual, and collective actions and services, required for each case at all levels of system complexity, and considered a principle of polysemic conception¹1 Brito-Silva K, Bezerra AFB, Tanaka OY. Direito à saúde e integralidade: uma discussão sobre os desafios e caminhos para sua efetivação. Interface (Botucatu). 2012; 16(40):249-260.^,33 Mattos RA. Os sentidos da integralidade: algumas reflexões acerca de valores que merecem ser defendidos. In: Pinheiro R, Mattos RA, organizadores. Os sentidos da integralidade na atenção e no cuidado à saúde. Rio de Janeiro: UERJ, IMS, Abrasco; 2009. p. 43-68.^,44 Silva RVGO, Ramos FRS. Integralidade em saúde: revisão de literatura. Cienc Cuid Saude. 2010; 9(3):593-601.. Understood either as an integrator axis of services or a holistic view of the subject of care, or even as actions of comprehensive care to demands and needs⁴4 Silva RVGO, Ramos FRS. Integralidade em saúde: revisão de literatura. Cienc Cuid Saude. 2010; 9(3):593-601., the definitions of comprehensiveness express the access to different levels of care and the articulation of different health services, being often based on the reception and relationship between users and teams¹1 Brito-Silva K, Bezerra AFB, Tanaka OY. Direito à saúde e integralidade: uma discussão sobre os desafios e caminhos para sua efetivação. Interface (Botucatu). 2012; 16(40):249-260..

Mattos³3 Mattos RA. Os sentidos da integralidade: algumas reflexões acerca de valores que merecem ser defendidos. In: Pinheiro R, Mattos RA, organizadores. Os sentidos da integralidade na atenção e no cuidado à saúde. Rio de Janeiro: UERJ, IMS, Abrasco; 2009. p. 43-68. identifies at least three sets of meanings of the concept of comprehensiveness: the first, applied to the characteristics of health policies or the scope of government responses, seeking to articulate preventive actions with care actions; the second, related to aspects of the organization of health services, which should ensure both access to care and continuity of care; and a third set, focused on attributes of health practices with an expanded look on the subjects. From other perspectives, Ayres⁵5 Ayres JRCM. Organização das ações de atenção à saúde: modelos e práticas. Saude Soc. 2019; 18 Suppl 2:11-23. understands comprehensiveness from four axes, including: Needs, concerning reception and response to health demands; Purposes, including the relationship between promotion, prevention, care, and rehabilitation measures; Articulations, relevant to the actions of multidisciplinary teams, interdisciplinary knowledge, and intersectoral actions; and Interactions, which address the possibilities and strategies of intersubjective encounters.

In this study, we understand comprehensiveness as the connections between the multiple dimensions of care⁶6 Cecílio LCO. Apontamentos teórico-conceituais sobre processos avaliativos considerando as múltiplas dimensões da gestão do cuidado em saúde. Interface (Botucatu). 2011; 15(37):589-599. operating to meet the different health needs⁷7 Cecílio LCO, Matsumoto NF. Uma taxonomia operacional de necessidades em saúde. In: Pinheiro R, Ferla AA, Mattos RA, organizadores. Gestão em redes: tecendo os fios da integralidade em saúde. Rio Grande do Sul, Rio de Janeiro: EdUCS/UFRS, IMS/UERJ, CEPESC; 2006. p. 37-50. of the population and individuals. As Mattos³3 Mattos RA. Os sentidos da integralidade: algumas reflexões acerca de valores que merecem ser defendidos. In: Pinheiro R, Mattos RA, organizadores. Os sentidos da integralidade na atenção e no cuidado à saúde. Rio de Janeiro: UERJ, IMS, Abrasco; 2009. p. 43-68. summarizes, what characterizes comprehensive health is the increased understanding of needs and the ability to adapt the offers to the specific context in which the subject meets with the team and where people’s lives are concretely produced.

Considering that health needs are always historical, dynamic, and changing but also have a subjective and individual component, Cecílio and Matsumoto⁷7 Cecílio LCO, Matsumoto NF. Uma taxonomia operacional de necessidades em saúde. In: Pinheiro R, Ferla AA, Mattos RA, organizadores. Gestão em redes: tecendo os fios da integralidade em saúde. Rio Grande do Sul, Rio de Janeiro: EdUCS/UFRS, IMS/UERJ, CEPESC; 2006. p. 37-50. formulated a taxonomy organized into four major axes of needs: 1) having good living conditions; 2) having access and ability to consume all health technology which can improve and prolong life; 3) creating and maintaining (a)effective relationships with health teams and professionals; and 4) having increased autonomy in the way of living. This classification summons an accessible and integrated health system which produces care and subjectivity.

Under the theoretical framework of symbolic interactionism, Utzumi et al.⁸8 Utzumi FC, Lacerda MR, Bernadino E, Gomes IM, Aued GK, Sousa SM. Continuity of care and the symbolic interactionism: a possible understanding. Texto Contexto Enferm. 2018; 27(2):e4250016. Doi: https://doi.org/10.1590/0104-070720180004250016.
https://doi.org/10.1590/0104-07072018000... understand health care as something concrete, a social object from the action of each individual involved in the process. In an inclusive conception, Cecílio⁶6 Cecílio LCO. Apontamentos teórico-conceituais sobre processos avaliativos considerando as múltiplas dimensões da gestão do cuidado em saúde. Interface (Botucatu). 2011; 15(37):589-599. defines health care management as providing health technologies according to the necessities of each person, at different moments of their life, for their well-being, safety, and autonomy to maintain a productive and happy life. The author also proposes producing care in six dimensions – individual, family, professional, organizational, systemic, and societal – which, inherent to each other, present multiple connections, producing a complex network of contact points, shortcuts, collateral paths, and possibilities.

Cecílio⁶6 Cecílio LCO. Apontamentos teórico-conceituais sobre processos avaliativos considerando as múltiplas dimensões da gestão do cuidado em saúde. Interface (Botucatu). 2011; 15(37):589-599. argues that the logic of the first dimension – individual dimension – is the need of self-care, autonomy, the right to choose. The second dimension, family, is composed of family members and also friends, neighbors, affective relationships, and the network of caregivers which surrounds the individual. The logic of this dimension is support, proximity, and all the elements present in the world of life. In the third dimension, the professional one, the actors are health workers and the constitutive elements are technical preparation, acquaintance, and ethics. In the fourth dimension, the organizational one, health teams and managers are the protagonists, coordinating care in the service. The fifth dimension, systemic, is the field of administrators and the locus of production of health policies, organization, financing, and system coordination. The state and society operate in the sixth and final dimension, the societal one, which must guarantee the basic conditions of existence and reproduction of life⁶6 Cecílio LCO. Apontamentos teórico-conceituais sobre processos avaliativos considerando as múltiplas dimensões da gestão do cuidado em saúde. Interface (Botucatu). 2011; 15(37):589-599..

Comprehensive care still causes dispute and tension within SUS since, despite bringing advances and innovations, care practices are still strongly related to the biomedical, curative paradigm. Such paradigm expresses a more mechanized, controlling, and normatizing assistance, focusing on pathology over human beings⁹9 Pereira TTSO, Barros MNS, Augusto MCNA. O cuidado em saúde: o paradigma biopsicossocial e a subjetividade em foco. Mental. 2011; 9(17):523-526.. Santos and Giovanella¹⁰10 Santos AM, Giovanella L. Gestão do cuidado integral: estudo de caso em região de saúde da Bahia, Brasil. Cad Saude Publica. 2016; 32(3):e00172214. analyzed the conformation of comprehensive care management at the political-institutional and organizational levels and in health practices in a health region, identifying challenges for municipal and between-municipality coordination of essential care for users. One of these challenges are the devices for integration and regulation of care because of fragmented care points of the system and a communication disruption in the network.

To overcome this intense fragmentation of health actions and services and qualify care management, since 2010, the Ministry of Health proposes health care networks (RAS) as an organizational model for SUS¹¹11 Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Implantação das redes de atenção à saúde e outras estratégias da SAS. Brasília: Ministério da Saúde; 2014.. The constitution of RAS was strongly marked by the federal induction to implement thematic networks in health regions. These networks include the Stork Network, the Urgent And Emergency Care Network, the Psychosocial Care Network, the Network for Health of People with Disabilities, and the Chronic Diseases Care Network¹¹11 Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Implantação das redes de atenção à saúde e outras estratégias da SAS. Brasília: Ministério da Saúde; 2014..

Regardless of the organizational model, many countries have been investing in emergency services to meet the growing demand of cases and resolve hospital overcrowding¹²12 Obermeyer Z, Abujaber S, Makar M, Stoll S, Kayden SR, Wallis LA, et al. Emergency care in 59 low- and middle-income countries: a systematic review. Bull World Health Organ. 2015; 93(8):577-586.. Considered a priority agenda for the population, health workers, and administrators, urgent and emergency care in Brazil affects society’s assessment of the guarantee of the right to health, the care offered, and the legitimacy of SUS¹³13 Padilha ARS, Amaral MA, Oliveira DC, Campos GWS. Fragilidade na governança regional durante implementação da rede de urgência e emergência em região metropolitana. Saude Debate. 2018; 42(118):579-593.. Since 2011, the Urgent And Emergency Care Network (RUE) is implemented to articulate and integrate all health equipment, aiming to expand and qualify humanized and comprehensive access to users in an emergency situation swiftly and conveniently. RUE guidelines include territorial action organized from the population’s health needs, risks, and vulnerabilities and professional and management practice aimed at improving the quality of care by developing coordinated, continuous actions for comprehensiveness and longitudinality of health care¹⁴14 Brasil. Ministério da Saúde. Portaria nº 1.600, de 7 de Julho de 2011. Reformula a política nacional de atenção às urgências e institui a rede de atenção às urgências no Sistema Único de Saúde (SUS). Brasília: Ministério da Saúde; 2011..

Considering the multiple dimensions of care management and the different health needs, our question is: How is RUE, as a health policy, effectively built by users who seek to fulfill their needs and gain assistance to their illness processes? Although the knowledge of users of the health system should be considered valid for being an “assessing knowledge”, it is often disregarded by professionals, managers, and researchers¹⁵15 Andreazza R. Narrativas dos caminhos dos cidadãos portugueses no Serviço Nacional de Saúde. In: Carapinheiro G, Correa T, organizadores. Novos temas de saúde, novas questões sociais. Lisboa: Mundos Sociais; 2015.. This study thus aims to analyze the multiple dimensions of care and health needs reported by RUE users in a health region.

Method

This qualitative study used the statements of eight SUS users about their experiences with RUE. The users were interviewed openly and in depth, narrating their illness processes and their experiences using RUE. The interviews were dialogical and started from the invitation “tell me...”, with potential to apprehend feelings, understandings, interpretations, and factual and objective information¹⁶16 Bertaux D. Narrativas de Vida: a pesquisa e seus métodos. Natal, São Paulo: EDUFRN, Paulus; 2010..

The field survey was conducted in two medium-sized municipalities in a health region in the state of São Paulo in March 2019, both chosen by convenience. Interviewees were selected based on information collected in the regulatory centers of the municipalities. The inclusion criterion were having used, in the last month, the health network for urgent or emergency situations in one of the three lines of care of the RUE: cardiovascular, cerebrovascular, and traumatological¹⁴14 Brasil. Ministério da Saúde. Portaria nº 1.600, de 7 de Julho de 2011. Reformula a política nacional de atenção às urgências e institui a rede de atenção às urgências no Sistema Único de Saúde (SUS). Brasília: Ministério da Saúde; 2011.. From the listings provided by the municipalities, users were contacted by telephone to be explained about the research objectives and invited to participate. All users who could be reached and who consented to participate were included, totaling eight interviewees.

The interviews had an average duration of 40 minutes and were conducted in households and health services with participants who consented to participate and signed an informed consent form. The participation of family members and caregivers as mediators was allowed to expand the detailing of information and complement the reports¹⁷17 Boehs AE, Boehs CGE, Fernandes GCM, Nascimento ERP. Process of searching families for data collection in qualitative research. Texto Contexto Enferm. 2018; 27(3):e0670017. Doi: https://doi.org/10.1590/0104-07072018000670017.
https://doi.org/10.1590/0104-07072018000... . The content was recorded and transcribed and the identities were encrypted to ensure confidentiality and anonymity. The observations recorded by the interviewers in field notes were also included as empirical material.

The empirical material was analyzed based on the theoretical-operational references of the Taxonomy of Health Needs⁷7 Cecílio LCO, Matsumoto NF. Uma taxonomia operacional de necessidades em saúde. In: Pinheiro R, Ferla AA, Mattos RA, organizadores. Gestão em redes: tecendo os fios da integralidade em saúde. Rio Grande do Sul, Rio de Janeiro: EdUCS/UFRS, IMS/UERJ, CEPESC; 2006. p. 37-50. and the Multiple Dimensions of Care Management⁶6 Cecílio LCO. Apontamentos teórico-conceituais sobre processos avaliativos considerando as múltiplas dimensões da gestão do cuidado em saúde. Interface (Botucatu). 2011; 15(37):589-599.. After exhaustive reading of the full transcribed interviews, excerpts from statements which expressed health needs and dimensions of care management were selected. These excerpts were categorized according to the proposed analytical framework and organized in summary tables.

The results were interpreted based on the meanings and recurrences observed¹⁶16 Bertaux D. Narrativas de Vida: a pesquisa e seus métodos. Natal, São Paulo: EDUFRN, Paulus; 2010. and questions evidenced were expanded by the inductive method – that is, other concepts and added new theoretical references were researched from the empirical material.

The research was approved by the Research Ethics Committee in accordance with Resolution No. 466/2013 of the National Health Council by opinion no. 2.447.067/2017 and funded by the National Council for Scientific and Technologic Development – CNPq.

Results

The eight SUS users interviewed had a history of recent health episodes which required care in the RUE. Participants were four men and four women and their age ranged from 46 to 75 years. Of the eight interviewees, three were diagnosed with stroke, two with acute myocardial infarction (AMI), and three had orthopedic traumas.

All statements expressed health needs (Frame 1) and dimensions of care management (Frame 2).

One of the main health needs reported was the search for autonomy, especially for work:

Among the dimensions of care management mentioned, the societal dimension was not directly mentioned. Interviewees did not report on the importance of the organization of the Brazilian state and the promotion of public policies such as SUS. Some statements mentioned public social security policies by reporting on social benefits, pensions, and sick leave benefits, which refer to the societal dimension. The statements show strong family care, including the support of neighbors and friends:

Discussion

Understanding what guides users’ actions across the health system could significantly help build comprehensiveness in SUS. For Cecílio et al.¹⁸18 Cecilio LCO, Carapinheiro G, Andreazza R, Souza ALM, Andrade MGG, Santiago SM, et al. O agir leigo e o cuidado em saúde: a produção de mapas de cuidado. Cad Saude Publica. 2014; 30(7):1502-1514., with their action, users produce care maps that indicate a multiplicity of arrangements which escape the standardization of systems. By listening to them we can identify multiple health systems, created from a complex tessitura, in which distinct and interweaving flows of knowledge and actions produce circuits and short circuits that open new flows and paths to produce health care¹⁵15 Andreazza R. Narrativas dos caminhos dos cidadãos portugueses no Serviço Nacional de Saúde. In: Carapinheiro G, Correa T, organizadores. Novos temas de saúde, novas questões sociais. Lisboa: Mundos Sociais; 2015..

This study thus identified dimensions of care present – or absent – in the care of the different health needs expressed. Similarly to Hadad and Jorge’s¹⁹19 Hadad ACAC, Jorge AO. Continuidade do cuidado em rede e os movimentos de redes vivas nas trajetórias do usuário guia. Saude Debate. 2018; 42(4):198-210. study with guide users, this study showed moments of enunciation of living and powerful networks, but also moments of insufficiency or lack of network. It also showed the protagonism of users and their families in their combined use of SUS and private services, the ‘public-private mix’¹⁸18 Cecilio LCO, Carapinheiro G, Andreazza R, Souza ALM, Andrade MGG, Santiago SM, et al. O agir leigo e o cuidado em saúde: a produção de mapas de cuidado. Cad Saude Publica. 2014; 30(7):1502-1514.. Also similarly to the research of Fausto et al.²⁰20 Fausto MCR, Campos EMS, Almeida PF, Medina MG, Giovanella L, Bousquat A, et al. Itinerários terapêuticos de pacientes com acidente vascular encefálico: fragmentação do cuidado em uma rede regionalizada de saúde. Rev Bras Saude Matern Infant. 2017; 17 Suppl 1:73-82. conducted in an interstate region of Northeastern Brazil, our study found several forms of access to services and of service offerings. Despite the guarantee of hospital care, networks were fragmented, with no integration of primary care with other points of the system and with low access to rehabilitation actions.

Statements did not mention directly or understand the societal dimension of health care. The broadest dimension of care management, the societal dimension is how society and the state produce citizenship, the right to life, and access to every form of consumption that contributes to a better life⁶6 Cecílio LCO. Apontamentos teórico-conceituais sobre processos avaliativos considerando as múltiplas dimensões da gestão do cuidado em saúde. Interface (Botucatu). 2011; 15(37):589-599.. Realizing the right to health in Brazil necessarily involves defending SUS and public policies that incorporate this dimension. For this perception, other methodological instruments may be needed to help approach this theme. According to Padilha¹³13 Padilha ARS, Amaral MA, Oliveira DC, Campos GWS. Fragilidade na governança regional durante implementação da rede de urgência e emergência em região metropolitana. Saude Debate. 2018; 42(118):579-593., the RUE does not consolidate itself without public debate, without new interactions between government action and the spaces of society where perceptions about health, values, and consensus are constructed.

The interview statements show people’s need for access to health services, actions, and technologies, the action of professional, organizational, or systemic care dimensions, and the search for autonomy, especially to work. The strong action and importance of family care during and after urgent and emergency health situations also stands out.

Family care

In a systematic review on therapeutic itineraries, Demétrio et al.²¹21 Demétrio F, Santana ER, Pereira-Santos M. O itinerário terapêutico no Brasil: revisão sistemática e metassíntese a partir das concepções negativa e positiva de saúde. Saude Debate. 2019; 43(spe 7):204-221. identified the family and health services as the main support networks to realize, assess, and select care. The family dimension of care management is located in the world of life, that is, its privileged actors are family members, friends, neighbors, and other affective relationships. This dimension has been increasingly significant due to the accelerated aging of the Brazilian population⁶6 Cecílio LCO. Apontamentos teórico-conceituais sobre processos avaliativos considerando as múltiplas dimensões da gestão do cuidado em saúde. Interface (Botucatu). 2011; 15(37):589-599..

A study with users submitted to cardiac revascularization surgery after AMI²²22 Wottrich SH, Moré CLOO. Redes pessoais de pacientes cirúrgicos cardíacos. Paidéia. 2017; 27(1):422-429. identified that health care processes often make invisible the family members and significant personal relationships who are co-responsible for caring for patients and favoring their protagonism. Maldonado et al.²³23 Maldonado A, Vizeu B, Giacomozzi A, Berri B. Representações sociais do cuidado ao idoso e mapas de rede social. Liberabit. 2017; 23(1):9-22. observed that in the social network of older adults, in case of limitation and loss of autonomy, care is usually delegated to an informal female family member. For Cecílio⁶6 Cecílio LCO. Apontamentos teórico-conceituais sobre processos avaliativos considerando as múltiplas dimensões da gestão do cuidado em saúde. Interface (Botucatu). 2011; 15(37):589-599., family care is not a world without difficulties: it includes conflicting relationships, especially those caused by the complexity of family ties, the absence of affective relationships, work overload for caregivers, and permanent requirements of the patient in care.

The relationship between health professionals and family members must also be strengthened. In a study conducted with patients hospitalized in intensive care beds²⁴24 Mendes AP. Sensibility of professionals to information needs: experience of the family at the intensive care unit. Texto Contexto Enferm. 2016; 25(1):e4470014. Doi: https://doi.org/10.1590/0104-07072016004470014.
https://doi.org/10.1590/0104-07072016004... , family members reported that the sensitivity of the health professionals was essential to answer their information needs. Moreover, knowledge of the real and potential needs of the family is determinant in the professional practice of nurses. In home care, information was necessary to develop care competencies for eating, turning around, and moving, facilitating the construction and application of educational technology for family caregivers²⁵25 Landeiro MJL, Martins TV, Peres HHC. Nurses’ perception on the difficulties and information needs of family members caring for a dependent person. Texto Contexto Enferm. 2016; 25(1):e0430015. Doi: https://doi.org/10.1590/0104-070720160000430015.
https://doi.org/10.1590/0104-07072016000... . Health care teams should therefore always include family caregivers in the formulation and implementation of therapeutic projects.

This study values and gives visibility to the family dimension, focusing on the importance of including this affective network in the care process, which could significantly affect the production or not of a living network that allows more qualified care. Besides the health workers, the care team should also open themselves to people’s socio-affective network, caring ‘with’ and ‘for’ the caregiver.

The need for autonomy for life and work

Considering that humans are motivated by the desire to meet multiple needs, Maslow²⁶26 Regis LFLV, Porto IS. Necessidades humanas básicas dos profissionais de enfermagem: situações de (in)satisfação no trabalho. Rev Esc Enferm USP. 2011; 45(2):334-341. structured his theory of human motivation considering as basic human needs the physiological, security, social, esteem, and self-realization needs. The author believes that human beings need means for existence and survival, individual protection, social life and affection, self-satisfaction, and personal accomplishment. As a necessity, autonomy can be transversal to all of them. For Cecílio and Matsumoto⁷7 Cecílio LCO, Matsumoto NF. Uma taxonomia operacional de necessidades em saúde. In: Pinheiro R, Ferla AA, Mattos RA, organizadores. Gestão em redes: tecendo os fios da integralidade em saúde. Rio Grande do Sul, Rio de Janeiro: EdUCS/UFRS, IMS/UERJ, CEPESC; 2006. p. 37-50., the need for increasing degrees of autonomy in the ‘way of leading life’ implies that subjects can reconstruct the meanings of their life. This resignification would significantly affect their way of living, including the struggle for the satisfaction of their needs in the broadest possible way.

Severe health situations such as AMI, stroke, and trauma can affect living conditions and self-care by temporarily or permanently limiting autonomy. For Cecílio⁶6 Cecílio LCO. Apontamentos teórico-conceituais sobre processos avaliativos considerando as múltiplas dimensões da gestão do cuidado em saúde. Interface (Botucatu). 2011; 15(37):589-599., the individual dimension of health care management is ‘taking care of oneself’, meaning that each of us can or has the power to produce a singular way of life, a nonlinear process often hindered by multiple relationships and social conditions of life that go beyond individual choices.

The relationship between need for autonomy and work capacity was greatly significant in the statements collected in this study. The fulfillment of basic human needs, including subsistence, affects the world of work. Work is often studied in the field of social sciences as a form of exploitation and productive accumulation in capitalism²⁷27 Pereira MS. Trabalho, classe e capitalismo: sobre a interpretação de Marx por Postone. Rev Direito Prax. 2020; 11(2):997-1028. and in the field of collective health as a risk and cause of illness and death²⁸28 Lacaz FAC. Continuam a adoecer e morrer os trabalhadores: as relações, entraves e desafios para o campo Saúde do Trabalhador. Rev Bras Saude Ocup. 2016; 41:e13.. However, the understanding of work as a social value has gained new meaning. Affective labor, as a dimension of immaterial labor, can produce subjectivity, values, self-realization, sociability, and life²⁹29 Hardt M. O trabalho afetivo. In: Varela FJ. O reencantamento do concreto. São Paulo: Hucitec; 2003. p. 143-157.. Although most respondents in this research do not practice immaterial labor, according to their statements, they understand that being healthy, among other things, is having autonomy and capacity to work and to guarantee different self needs, including self-valorization. Considering the large social inequality and different social conditions, the possibility of access to work is also essential to produce life and guarantee access to basic conditions of survival. This study reinforces that the process of care should focus more on the search for autonomy and the suffering from the lack of it.

Our findings show the complexity of comprehensiveness as a principle of SUS, indicating the observance of health needs and different dimensions of care as a path to construct comprehensive care. This research, however, has limitations, including: 1) the collection of exclusive statements of SUS users who survived severe health risk situations and obtained access to urgent and emergency care services; 2) the possible ‘gratitude bias’³⁰30 Esperidião MA, Viera-da-Silva LM. A satisfação do usuário na avaliação de serviços de saúde: ensaio sobre a imposição de problemática. Saude Debate. 2018; 42(2):331-340. of the users who obtained care in the various services of the RUE, expressed by their lack of criticisms; and 3) the cognitive and communication difficulties of some of the interviewees as after-effects of the illness processes they experienced. Future studies should further research questions on the need for autonomy and family care, exploring other health needs and dimensions of care management.

Final considerations

Formulators, managers, workers, and researchers of public policies may not always perceive and consider the emotions, rationalities, and senses from urgent and emergency situations. This study observed that users of RUE produced different care maps in their search for maintaining and improving their health and their lives. Understanding and including health needs of SUS users in urgent and emergency care situations and recognizing the different dimensions of care management is essential to formulate health policies and organize networks, services, and care processes as a fundamental strategy for comprehensiveness in health care networks.

This study thus shows the centrality of health needs and dimensions that are often disregarded, such as the autonomy to care for oneself and to work and family care. These refer to looking beyond the care arrangements restricted to health services and emphasizing the importance of being guided by the concept of health connected to and inseparable from the concrete production of life.

Acknowledgments

To the members of the Laboratório de Saúde Coletiva – Lascol/Unifesp who supported and contributed to this research.

References

Publication Dates

History