ABSTRACT

Objective

Compare the demand and use of health services between 2013 and 2019, and analyze the associated sociodemographic and health variables in 2019.

Methods:

Cross-sectional study with data from the National Health Survey (PNS) 2013 and 2019. The prevalence and 95% confidence intervals (95% CI) for the demand and use of health services were estimated. In 2019, the differences in the indicators were analyzed according to sociodemographic variables and the crude and adjusted by sex and age prevalence ratios (RP) were estimated.

Results:

There was an increase of 22% in the demand for health care in the last two weeks, going from 15.3% (95%CI 15.0–15.7) in 2013 to 18.6% (95%CI 18.3–19.0) in 2019. There was a reduction in use in the last two weeks, from 97% (95%CI 96.6–97.4) in 2013 to 86.1% (95%CI 85.4–86.8) in 2019, which was observed for most Federation Units. In 2019, the demand for care was greater among women, the elderly, those with high schooling, individuals with health insurance and poor self-rated health. They obtained greater access to health services in the fifteen days prior to the survey: men, children or adolescents up to 17 years of age, people with health insurance and poor health self-assessment.

Conclusion:

The demand for health services has grown and reduced access in the last 15 days between 2013 and 2019. These differences may have been exacerbated by the austerity measures implemented in the country.

Keywords:
Access to health services; Health indicators; Health services accessibility; Cross-sectional studies; Public health; Brazil

INTRODUCTION

Access to health services is a constitutional right of the Brazilian population, guaranteed with the creation of the Unified Health System (SUS)¹1. Paim J, Travassos C, Almeida C, Bahia L, Macinko J. The Brazilian health system: history, advances, and challenges. Lancet 2011; 377(9779): 1778-97. https://doi.org/10.1016/S0140-6736(11)60054-8
https://doi.org/10.1016/S0140-6736(11)60... ,²2. Barreto ML, Rasella D, Machado DB, Aquino R, Lima D, Garcia LP, et al. Monitoring and evaluating progress towards universal health coverage in Brazil. PLoS Med 2014; 11(9): e1001692. https://doi.org/10.1371/journal.pmed.1001692
https://doi.org/10.1371/journal.pmed.100... ,³3. Paim JS. Thirty years of the Unified Health System (SUS). Cien Saude Colet 2018; 23(6): 1723-28. https://doi.org/10.1590/1413-81232018236.09172018
https://doi.org/10.1590/1413-81232018236... . Between 1998 and 2013, there was an increase in access to health services, indicating advances in the performance of the public health system⁴4. Viacava F, Oliveira RAD, Carvalho CC, Laguardia J, Bellido JG. SUS: supply, access to and use of health services over the last 30 years. Cien Saude Colet 2018; 23(6): 1751-62. https://doi.org/10.1590/1413-81232018236.06022018
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https://doi.org/10.5123/s1679-4974201600... , as a result of the expansion and consolidation of the SUS.

The use of health services is an important object of investigation in population surveys, aiming to capture the demand of users regarding health needs⁶6. Travassos C, Martins M. Uma revisão sobre os conceitos de acesso e utilização de serviços de saúde. Cad Saúde Pública 2004; 20(Suppl 2): S190-S198. https://doi.org/10.1590/S0102-311X2004000800014
https://doi.org/10.1590/S0102-311X200400... ,⁷7. Stopa SR, Malta DC, Monteiro CN, Szwarcwald CL, Goldbaum M, Cesar CLG. Use of and access to health services in Brazil, 2013 National Health Survey. Rev Saúde Pública 2017; 51(Suppl 1): 3s. https://doi.org/10.1590/s1518-8787.2017051000074
https://doi.org/10.1590/s1518-8787.20170... . The concept of using health services includes direct contact with users in activities such as medical and dental appointments and hospitalizations, or indirectly, through preventive exams and diagnostic tests (laboratory, radiological, among others)⁷7. Stopa SR, Malta DC, Monteiro CN, Szwarcwald CL, Goldbaum M, Cesar CLG. Use of and access to health services in Brazil, 2013 National Health Survey. Rev Saúde Pública 2017; 51(Suppl 1): 3s. https://doi.org/10.1590/s1518-8787.2017051000074
https://doi.org/10.1590/s1518-8787.20170... . Also, according to Travassos⁷7. Stopa SR, Malta DC, Monteiro CN, Szwarcwald CL, Goldbaum M, Cesar CLG. Use of and access to health services in Brazil, 2013 National Health Survey. Rev Saúde Pública 2017; 51(Suppl 1): 3s. https://doi.org/10.1590/s1518-8787.2017051000074
https://doi.org/10.1590/s1518-8787.20170... , “the use of services can be a measure of access to services, but it is not explained only by it”. However, access is understood as an important determinant of use; the effective use of health services results from a multiplicity of conditions, which include health needs, self-care or the existence of the disease, as well as the severity and urgency of this health problem⁷7. Stopa SR, Malta DC, Monteiro CN, Szwarcwald CL, Goldbaum M, Cesar CLG. Use of and access to health services in Brazil, 2013 National Health Survey. Rev Saúde Pública 2017; 51(Suppl 1): 3s. https://doi.org/10.1590/s1518-8787.2017051000074
https://doi.org/10.1590/s1518-8787.20170... –⁹9. Malta DC, Bernal RTI, Lima MG, Araújo SSC, Silva MMA, Freitas MIF, et al. Noncommunicable diseases and the use of health services: analysis of the National Health Survey in Brazil. Rev Saúde Pública 2017; 51(Suppl 1): 4s. https://doi.org/10.1590/s1518-8787.2017051000090
https://doi.org/10.1590/s1518-8787.20170... .

Among the factors related to seeking for services, the following stand out: sociodemographic characteristics of users (age, gender, region of residence of users), socioeconomic status (education, income, health insurance), in addition to factors related to service providers, such as available resources (availability of doctors, hospitals, clinics) and types of health systems (public or private, legislation and professional regulations, systems, and others). Other authors emphasize geographic accessibility, sociocultural factors⁸8. Cesar CLG, Carandina L, Alves MCP, Barros MBA, Goldbaum M. Saúde e condição de vida em São Paulo. Inquérito multicêntrico de saúde no estado de São Paulo – ISA/SP. São Paulo: Universidade de São Paulo, Faculdade de Saúde Pública; 2005.,⁹9. Malta DC, Bernal RTI, Lima MG, Araújo SSC, Silva MMA, Freitas MIF, et al. Noncommunicable diseases and the use of health services: analysis of the National Health Survey in Brazil. Rev Saúde Pública 2017; 51(Suppl 1): 4s. https://doi.org/10.1590/s1518-8787.2017051000090
https://doi.org/10.1590/s1518-8787.20170... , in addition to aspects related to health and financing policies¹⁰10. Giovanella L, Stegmüller K. The financial crisis and health care systems in Europe: universal care under threat? Trends in health sector reforms in Germany, the United Kingdom, and Spain. Cad Saúde Pública 2014; 30(11): 2263-81. https://doi.org/10.1590/0102-311x00021314
https://doi.org/10.1590/0102-311x0002131... ,¹¹11. Maresso A, Mladovsky P, Thomson S, Sagan A, Karanikolos M, Richardson E, et al. Economic crisis, health systems and health in europe: country experience. Copenhagen: World Health Organization; 2015. Available at:https://www.euro.who.int/__data/assets/pdf_file/0010/279820/Web-economic-crisis-health-systems-and-health-web.pdf
https://www.euro.who.int/__data/assets/p... ,¹²12. McCartney G, Hearty W, Arnot J, Popham F, Cumbers A, McMaster R. Impact of political economy on population health: a systematic review of reviews. Am J Public Health 2019; 109(6): e1-e12. https://doi.org/10.2105/AJPH.2019.305001
https://doi.org/10.2105/AJPH.2019.305001... ,¹³13. Stuckler D, Reeves A, Loopstra R, Karanikolos M, McKee M. Austerity and health: the impact in the UK and Europe. Eur J Public Health 2017; 27(Suppl 4): 18-21. https://doi.org/10.1093/eurpub/ckx167
https://doi.org/10.1093/eurpub/ckx167... ,¹⁴14. Giovanella L, Franco CM, Almeida PF. National primary health care policy: where are we headed to? Cien Saude Colet 2020; 25(4): 1475-82. https://doi.org/10.1590/1413-81232020254.01842020
https://doi.org/10.1590/1413-81232020254... ,¹⁵15. Massuda A. Primary health care financing changes in the Brazilian Health System: advance ou setback? Cien Saude Colet 2020; 25(4): 1181-88. https://doi.org/10.1590/1413-81232020254.01022020
https://doi.org/10.1590/1413-81232020254... .

The use of health services is stimulated by user demand, depending on their perception of the disease or previous medical diagnosis⁷7. Stopa SR, Malta DC, Monteiro CN, Szwarcwald CL, Goldbaum M, Cesar CLG. Use of and access to health services in Brazil, 2013 National Health Survey. Rev Saúde Pública 2017; 51(Suppl 1): 3s. https://doi.org/10.1590/s1518-8787.2017051000074
https://doi.org/10.1590/s1518-8787.20170... ,⁸8. Cesar CLG, Carandina L, Alves MCP, Barros MBA, Goldbaum M. Saúde e condição de vida em São Paulo. Inquérito multicêntrico de saúde no estado de São Paulo – ISA/SP. São Paulo: Universidade de São Paulo, Faculdade de Saúde Pública; 2005.. A study, with data from the National Health Survey (Pesquisa Nacional de Saúde – PNS), showed that patients with comorbidities tend to increase their demand for health services, for example, patients with chronic non-communicable diseases (NCDs)⁹9. Malta DC, Bernal RTI, Lima MG, Araújo SSC, Silva MMA, Freitas MIF, et al. Noncommunicable diseases and the use of health services: analysis of the National Health Survey in Brazil. Rev Saúde Pública 2017; 51(Suppl 1): 4s. https://doi.org/10.1590/s1518-8787.2017051000090
https://doi.org/10.1590/s1518-8787.20170... .

In this sense, it is important to distinguish health needs, which incorporate socio-environmental determinants, from health service needs, which can be defined according to the knowledge of specialists, or according to the needs defined by users. The latter can also be influenced by service producers, industry, among others¹⁶16. Wright J, Williams R, Wilkinson JR. Development and importance of health needs assessment. BMJ 1998; 316(7140): 1310-3. https://doi.org/10.1136/bmj.316.7140.1310
https://doi.org/10.1136/bmj.316.7140.131... . Stevens et al.¹⁷17. Stevens A, Raferty J. Health care needs assessment – the epidemiologically based needs assessment reviews. Oxford: Radcliffe Medical Press; 1994. argue that the interaction between needs, demands, and service offer will define the profile of use of health services.

Political and economic crises can interfere with access to health care. Starting in 2008, the global economic crisis resulted in big cuts in health spending and resulted in the implementation of austerity policies in several European countries; consequently, there was a worsening in the access to health services¹⁸18. Reeves A, McKee M, Basu S, Stuckler D. The political economy of austerity and healthcare: cross-national analysis of expenditure changes in 27 European nations 1995-2011. Health Policy 2014; 115(1): 1-8. https://doi.org/10.1016/j.healthpol.2013.11.008
https://doi.org/10.1016/j.healthpol.2013... . In the United States, the economic crisis has resulted in cuts in the health sector and in donations to philanthropic services, with a consequent reduction in access to health care for unemployed families¹⁹19. Schramm JMA, Paes-Sousa R, Mendes LVP. Políticas de austeridade e seus impactos na saúde: um debate em tempos de crise. Rio de Janeiro: Fiocruz; 2018. https://www.arca.fiocruz.br/bitstream/icict/28240/2/Joyce_Mendes_et_al_politicas_de_austeridade.pdf
https://www.arca.fiocruz.br/bitstream/ic... ,²⁰20. Paes-Sousa R, Rasella D, Carepa-Sousa J. Economic policy and public health: fiscal balance and population wellbeing. Saúde Debate 2018; 42(spe 3): 172-82. https://doi.org/10.1590/0103-11042018S313
https://doi.org/10.1590/0103-11042018S31... .

In Brazil, the austerity policies implemented in recent years, especially in 2016, with the approval of Constitutional Amendment No. 95 (EC95)²¹21. Brasil. Presidência da República. Casa Civil. Subchefia para Assuntos Jurídicos. Emenda Constitucional no 95, de 15 de dezembro de 2016. Altera o Ato das Disposições Constitucionais Transitórias, para instituir o Novo Regime Fiscal, e dá outras providências. Diário Oficial da União 2016; 15 dez. Available at:http://www.planalto.gov.br/ccivil_03/constituicao/emendas/emc/emc95.htm
http://www.planalto.gov.br/ccivil_03/con... , led to a sharp decrease in investments in health, education, and science and technology²²22. Paes-Sousa R, Schramm JMA, Mendes LVP. Fiscal austerity and the health sector: the cost of adjustments. Cien Saude Colet 2019; 24(12): 4375-84. https://doi.org/10.1590/1413-812320182412.23232019
https://doi.org/10.1590/1413-81232018241... ,²³23. Doniec K, Dall’Alba R, King L. Brazil’s health catastrophe in the making. Lancet 2018; 392(10149): 731-2. https://doi.org/10.1016/S0140-6736(18)30853-5
https://doi.org/10.1016/S0140-6736(18)30... ,²⁴24. Malta DC, Duncan BB, Barros MBA, Katikireddi SV, Souza FM, Silva AG, et al. Fiscal austerity measures hamper noncommunicable disease control goals in Brazil. Cien Saude Colet 2018; 23(10): 3115-22. https://doi.org/10.1590/1413-812320182310.25222018
https://doi.org/10.1590/1413-81232018231... ,²⁵25. Rasella D, Basu S, Hone T, Paes-Sousa R, Ocké-Reis CO, Millett C. Child morbidity and mortality associated with alternative policy responses to the economic crisis in Brazil: a nationwide microsimulation study. PLoS Med 2018; 15(5): e1002570. https://doi.org/10.1371/journal.pmed.1002570
https://doi.org/10.1371/journal.pmed.100... . The effects of the reduction in health financing can already be observed in the reduction in the supply of goods and services, in the impact on mortality rates, whose effects tend to be exacerbated and penalize mainly the most vulnerable populations²²22. Paes-Sousa R, Schramm JMA, Mendes LVP. Fiscal austerity and the health sector: the cost of adjustments. Cien Saude Colet 2019; 24(12): 4375-84. https://doi.org/10.1590/1413-812320182412.23232019
https://doi.org/10.1590/1413-81232018241... ,²⁶26. Rasella D, Hone T, de Souza LE, Tasca R, Basu S, Millett C. Mortality associated with alternative primary healthcare policies: a nationwide microsimulation modelling study in Brazil. BMC Med 2019; 17(1): 82. https://doi.org/10.1186/s12916-019-1316-7
https://doi.org/10.1186/s12916-019-1316-... ,²⁷27. Vieira FS. Health financing in Brazil and the goals of the 2030 agenda: high risk of failure. Rev Saúde Pública. 2020; 54: 127. https://doi.org/10.11606/s1518-8787.2020054002414
https://doi.org/10.11606/s1518-8787.2020... ,²⁸28. Castro MC, Massuda A, Almeida G, Menezes-Filho NA, Andrade MV, Noronha KVMS, et al. Brazil’s unified health system: the first 30 years and prospects for the future. Lancet 2019; 394(10195): 345-56. https://doi.org/10.1016/S0140-6736(19)31243-7
https://doi.org/10.1016/S0140-6736(19)31... ,²⁹29. de Souza LEPF, de Barros RD, Barreto ML, Katikireddi SV, Hone TV, Sousa RP, et al. The potential impact of austerity on attainment of the Sustainable Development Goals in Brazil. BMJ Glob Health 2019; 4(5): e001661. https://doi.org/10.1136/bmjgh-2019-001661
https://doi.org/10.1136/bmjgh-2019-00166... ,³⁰30. Doniec K, Dall’Alba R, King L. Austerity threatens universal health coverage in Brazil. Lancet 2016; 388(10047): 867-8. https://doi.org/10.1016/S0140-6736(16)31428-3
https://doi.org/10.1016/S0140-6736(16)31... .

In view of the austerity policies implemented in the country, it is important to monitor the demand for and access to health services through population surveys. National health surveys have historically included questions relating to access to and use of health services, which enable monitoring of these indicators and, consequently, can support evidence-informed management and planning. Thus, the objective was to compare the demand for and use of health services between 2013 and 2019, and to analyze the associated sociodemographic and health variables in 2019.

METHODS

Study Design and Data Collection

This is a cross-sectional study with data from the PNS, carried out in 2013 and 2019, by the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística – IBGE) in partnership with the Ministry of Health.

The PNS sampling plan was by clusters in three stages of selection. In 2013, the sample was selected by cluster sampling in three stages, with stratification of the primary sampling units (census sectors). In the second stage, in each census sector, a fixed number of households was randomly selected. In the third stage, in each household, a resident aged 18 years old or older was selected with equiprobability³¹31. Souza-Júnior PRB, Freitas MPS, Antonaci GA, Szwarcwald CL. Sampling design for the National Health Survey, Brazil 2013. Epidemiol Serv Saude 2015;24(2):207-16. https://doi.org/10.5123/S1679-49742015000200003
https://doi.org/10.5123/S1679-4974201500... . In 2019, the three stages of selection were also carried out, with the difference that, in the third stage, the resident was randomly selected among those aged 15 years old or older, based on the list of residents obtained at the time of the interview³²32. Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, et al. National Health Survey 2019: history, methods and perspectives. Epidemiol Serv Saúde 2020; 29(5): e2020315. http://doi.org/10.1590/s1679-49742020000500004
http://doi.org/10.1590/s1679-49742020000... .

In 2013, the sample size was calculated at approximately 80 thousand households, with information being collected from 64,348 households³¹31. Souza-Júnior PRB, Freitas MPS, Antonaci GA, Szwarcwald CL. Sampling design for the National Health Survey, Brazil 2013. Epidemiol Serv Saude 2015;24(2):207-16. https://doi.org/10.5123/S1679-49742015000200003
https://doi.org/10.5123/S1679-4974201500... . In 2019, the sample consisted of 108,525 households and data were collected from 94,114 households³²32. Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, et al. National Health Survey 2019: history, methods and perspectives. Epidemiol Serv Saúde 2020; 29(5): e2020315. http://doi.org/10.1590/s1679-49742020000500004
http://doi.org/10.1590/s1679-49742020000... .

Expansion factors were calculated by the inverse product of the selection probabilities at each stage. After weighting the bases by natural expansion factors, a calibration process was carried out based on population projections for Brazil and the Federation Units (FU), including a correction factor for losses. To allow comparisons between the two editions of the PNS, the IBGE recalibrated the PNS 2013 expansion factors³¹31. Souza-Júnior PRB, Freitas MPS, Antonaci GA, Szwarcwald CL. Sampling design for the National Health Survey, Brazil 2013. Epidemiol Serv Saude 2015;24(2):207-16. https://doi.org/10.5123/S1679-49742015000200003
https://doi.org/10.5123/S1679-4974201500... ,³²32. Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, et al. National Health Survey 2019: history, methods and perspectives. Epidemiol Serv Saúde 2020; 29(5): e2020315. http://doi.org/10.1590/s1679-49742020000500004
http://doi.org/10.1590/s1679-49742020000... .

For this study, information on access to and use of health services was obtained through the household informant (proxy informant), who answered the questions for all residents. PNS collected valid information for 205,546 individuals in 2013 and for 279,382 individuals in 2019.

Variables

The study presents, through a flowchart (Figures 1A and 1B), the questions of the data collection instrument that address the demand for and access to health services in the last two weeks of the surveys, for the years 2013 and 2019. In 2013, the following questions were used: “In the last two weeks, did you look for any place, service or health professional for health-related care?” (Yes/No). Those who answered “Yes” were asked: “This first time you sought health care, in the last two weeks, were you attended?” (Yes/No). Those who were not assisted answered the following question: “Did you seek health care again for the same reason?” (Yes/No). If so: “This last time you sought health care, in the last two weeks, were you attended?” (Yes/No).

In 2019, the flow was similar, but there was a change in the answer options to the question: “This first time you sought health care, in the last two weeks, were you attended?” (I was scheduled for another day or location/No/Yes). For respondents who answered that they were not attended, or for those who were scheduled, the flow remained the same (Figure 1B).

Statistical Analysis

The indicators were compared for Brazil, 27 states and capitals, estimating the prevalence and respective 95% confidence intervals (95%CI). Prevalences and respective 95%CI were also estimated by FU to verify differences between 2013 and 2019.

To analyze the sociodemographic and health variables related to indicators of demand and use of services in 2019, the crude and age-adjusted prevalence ratios (PR) were calculated, as well as their respective 95%CI, using regression models of Poisson with robust variance. The following sociodemographic and health variables were analyzed: gender (male and female); age group (0 to 17, 18 to 29, 30 to 39, 40 to 59, and 60 years old and older); education (no education and incomplete elementary/middle school, complete middle school and incomplete high school, complete high school and incomplete higher education, and complete higher education); health insurance (yes and no) and poor health self-assessment (yes and no); race/color (white, black, and brown). It is noteworthy that the option of not including yellow and indigenous people in the analysis is due to the guidance of the IBGE for the small number of responses in these populations and the high coefficient of variation, which has also been adopted in other PNS analyses³³33. Malta DC, Bernal RTI, Iser BPM, Szwarcwald CL, Duncan BB, Schmidt MI. Factors associated with self-reported diabetes according to the 2013 National Health Survey. Rev Saúde Pública 2017; 51(Suppl 1): 12s. https://doi.org/10.1590/S1518-8787.2017051000011
https://doi.org/10.1590/S1518-8787.20170... .

The main reason for seeking care related to their own health in the last two weeks and the reason for not being attended the first time they sought health care in the last two weeks was also evaluated.

In this study, the Software for Statistics and Data Science (StataCorp LP, CollegeStation, Texas, the United States), version 14.0, was used for data analysis through the survey module, which considers the effects of the sampling plan.

Ethical Aspects

The PNS data are available for public access and use, and both surveys were approved by the National Commission for Research Ethics for Human Beings of the Ministry of Health (Opinion No. 328.159 for the 2013 edition, and No. 3.529.376 for the 2019 edition).

RESULTS

Figure 1 shows the flow of PNS questionnaires for 2013 and 2019 regarding indicators of demand and access to services in the last 15 days. In 2013, 15.3% sought health services, 95.3% were attended in the first search, and among those who were not assisted, 65.2% returned to seek healthcare services for the same reason. Among those who sought care in the last two weeks (31,491), 97% managed to be attended, regardless of whether it was the first time (30,024) or the last time they sought care (526) (Figure 1A).

In 2019, 18.6% sought health services, 73.6% were attended in the first time, 2.4% did not go, and 24% were scheduled for another date/place. Of those who were not assisted, 53.5% returned to seek health services for the same reason and 35.6% were assisted the last time they sought it; of those who were scheduled, 52.4% sought services again and, of these, 95.6% were attended. Considering those who were assisted in the first time or in other attempts, 86.1% managed to be assisted in the last two weeks (Figure 1B).

The prevalence of people who sought health care in the last two weeks prior to the interview date increased by 22%, from 15.3% (95%CI 15.0–15.7) in 2013 to 18.6% (CI95 % 18.3–19.0) in 2019 (Figure 2A). There has been an increase in demand for services in recent weeks in most FUs. By comparing the 95%CI, differences were observed in the following UF: Amazonas, Rondônia, Pará, Ceará, Sergipe, Bahia, Alagoas, Espírito Santo, São Paulo, Rio de Janeiro, Rio Grande do Sul, Mato Grosso, and Distrito Federal (Figure 2A).

In the capitals, there was also an increase in demand for care, with statistically significant differences in Aracaju, Belo Horizonte, Brasília, Campo Grande, Cuiabá, Curitiba, Florianópolis, Fortaleza, João Pessoa, Maceió, Porto Velho, Recife, Rio de Janeiro, Salvador, and Teresina (Supplementary Figure 1).

In 2019, the demand for care in the last two weeks was higher among women (PRadj: 1.46; 95%CI 1.42–1.5); it increased from 30 years of age, being higher at 60 years of age and over (PRadj: 1.81; 95%CI 1.73–1.89); it was higher in individuals with a college degree (PRadj: 1.21; 95%CI 1.16–1.27); higher in those who had health insurance (PRadj: 1.44; 95%CI 1.40–1.50); and who self-rated their health as poor (PRadj: 2.06; 95%CI 1.98–2.14). On the other hand, the demand was lower among people of brown race/color (PRadj: 0.89; 95%CI 0.86–0.92) (Table 1).

Considering all attempts, 97% (95%CI 96.6–97.4) of the people managed to receive care in the last two weeks, in 2013, reducing to 86.1% (95%CI 85.4–86.8) in 2019, a drop of 11% between the two surveys (Figure 2B). This reduction occurred in a statistically significant way in all FUs (Figure 2B). There was also a reduction in all capitals, except Aracaju (Supplementary Figure 2).

In Table 2, the search for health care in the last two weeks and being attended was lower in females (PRadj: 0.98; 95%CI 0.97–0.99) and in those who have complete high school and incomplete higher education (PRadj: 0.98; 95%CI 0.96–0.99). On the other hand, it was higher in the age group from 0 to 17 years old, with health insurance (PRadj: 1.02; 95%CI 1.01–1.04) and who self-rated their health as poor (1.05; 95%CI 1.03–1.07). There were no differences by race/color.

The main reason for seeking care in the last two weeks in 2019 was: illness or treatment of illness (48.3%; 95%CI 47.2–49.3); prevention, medical check-up or childcare (16.3%; 95%CI 15.6–17.1); complementary diagnostic exam (10.2%; 95%CI 9.7–10.7); follow-up with a psychologist, nutritionist or other health professional (7.0%; 95%CI 6.5–7.5); dental problem (6.3%; 95%CI 5.9–6.7); accident, injury or fracture (4.6%; 95%CI 4.3–5.0) (Supplementary Figure 3).

Among those who responded that they were not attended the first time they sought health care in 2019, the main reason was not getting a vacancy or getting a password (38.3%; 95%CI 33.2–43.6), followed by not having an attending physician or dentist (32.4%; 95%CI 27.9–37.1) (Supplementary Figure 4).

DISCUSSION

The study showed that, comparing 2013 with 2019, there was a relative growth of 22% in the demand for health services in the 15 days prior to the survey and a reduction of 11% in access to health services. This scenario of increased demand and reduced access was repeated in almost all states and capitals. The demand for care was greater among women, aged people, with high education, with health insurance, and who self-rated health as poor, and lower among browns. Among the reasons for seeking health care, mentioned in the PNS 2019, half were due to care for illnesses and a quarter for preventive procedures. The main reasons for not being assisted were not getting a vacancy or getting a password and not having a doctor or dentist attending. It was found that men, children, and adolescents up to 17 years old, individuals who had a poor self-rated of their health status, and people who have health insurance had greater access.

The increase in demand and reduced access to health services in Brazil can be explained by several factors, including the increase in demand, due to population growth and increased life expectancy. The growth of the aged population is associated with a greater number of comorbidities and greater demand for health services³⁴34. Passos VMA, Champs APS, Teixeira R, Lima-Costa MFF, Kirkwood R, Veras R, et al. The burden of disease among Brazilian older adults and the challenge of health polices: results of the Global Burden of Disease Study 2017. Popul Health Metr 2020; 18(Suppl 1): 14. https://doi.org/10.1186/s12963-020-00206-3
https://doi.org/10.1186/s12963-020-00206... ,³⁵35. Francisco PMSB, Assumpção D, Borim FSA, Senicato C, Malta DC. Prevalence and co-occurrence of modifiable risk factors in adults and older people. Rev Saúde Pública 2019; 53: 86. https://doi.org/10.11606/s1518-8787.2019053001142
https://doi.org/10.11606/s1518-8787.2019... . Epidemiological, demographic, and nutritional transitions directly impact the increase in the prevalence of NCDs and result in a growing and continuous demand for care³⁶36. Malta DC, Duncan BB, Schmidt MI, Teixeira R, Ribeiro ALP, Felisbino-Mendes MS, et al. Trends in mortality due to non-communicable diseases in the Brazilian adult population: national and subnational estimates and projections for 2030. Popul Health Metr 2020; 18(Supl 1): 16. https://doi.org/10.1186/s12963-020-00216-1
https://doi.org/10.1186/s12963-020-00216... . There is evidence of growing inequalities in Brazil, effects of adopted austerity policies, which result in increased poverty and unemployment²²22. Paes-Sousa R, Schramm JMA, Mendes LVP. Fiscal austerity and the health sector: the cost of adjustments. Cien Saude Colet 2019; 24(12): 4375-84. https://doi.org/10.1590/1413-812320182412.23232019
https://doi.org/10.1590/1413-81232018241... ,²⁵25. Rasella D, Basu S, Hone T, Paes-Sousa R, Ocké-Reis CO, Millett C. Child morbidity and mortality associated with alternative policy responses to the economic crisis in Brazil: a nationwide microsimulation study. PLoS Med 2018; 15(5): e1002570. https://doi.org/10.1371/journal.pmed.1002570
https://doi.org/10.1371/journal.pmed.100... and greater social vulnerability³⁷37. Azevedo E Silva G, Giovanella L, de Camargo Jr KR. Brazil’s National Health Care System at risk for losing its universal character. Am J Public Health 2020; 110(6): 811-2. https://doi.org/10.2105/AJPH.2020.305649
https://doi.org/10.2105/AJPH.2020.305649... , expand the demand for health care²⁵25. Rasella D, Basu S, Hone T, Paes-Sousa R, Ocké-Reis CO, Millett C. Child morbidity and mortality associated with alternative policy responses to the economic crisis in Brazil: a nationwide microsimulation study. PLoS Med 2018; 15(5): e1002570. https://doi.org/10.1371/journal.pmed.1002570
https://doi.org/10.1371/journal.pmed.100... , as well as the worsening of comorbidities and mental suffering³⁸38. Silva AGD, Teixeira RA, Prates EJS, Malta DC. Monitoring and projection of targets for risk and protection factors for coping with noncommunicable diseases in Brazilian capitals. Cien Saude Colet 2021; 26(4): 1193-206. https://doi.org/10.1590/1413-81232021264.42322020
https://doi.org/10.1590/1413-81232021264... ,³⁹39. Bonadiman CSC, Malta DC, Passos VMA, Naghavi M, Melo APS. Depressive disorders in Brazil: results from the Global Burden of Disease Study 2017. Popul Health Metr 2020; 18(Suppl 1): 6. https://doi.org/10.1186/s12963-020-00204-5
https://doi.org/10.1186/s12963-020-00204... . In Greece, austerity policies, which took place during the economic depression between 2009 and 2011, increased mental disorders, the demand for health services, and the consumption of medications, particularly anti-anxiety drugs⁴⁰40. Simou E, Koutsogeorgou E. Effects of the economic crisis on health and healthcare in Greece in the literature from 2009 to 2013: a systematic review. Health Policy 2014; 115(2-3): 111-9. https://doi.org/10.1016/j.healthpol.2014.02.002
https://doi.org/10.1016/j.healthpol.2014... .

Studies in countries of the Organization for Economic Cooperation and Development (OECD) showed the worsening of health indicators under the austerity policies¹⁸18. Reeves A, McKee M, Basu S, Stuckler D. The political economy of austerity and healthcare: cross-national analysis of expenditure changes in 27 European nations 1995-2011. Health Policy 2014; 115(1): 1-8. https://doi.org/10.1016/j.healthpol.2013.11.008
https://doi.org/10.1016/j.healthpol.2013... . Simou and Koutsogeorgou⁴⁰40. Simou E, Koutsogeorgou E. Effects of the economic crisis on health and healthcare in Greece in the literature from 2009 to 2013: a systematic review. Health Policy 2014; 115(2-3): 111-9. https://doi.org/10.1016/j.healthpol.2014.02.002
https://doi.org/10.1016/j.healthpol.2014... , in Greece, analyzing the period from 2009 to 2013, identified a reduction in public spending on health, a reduction in the supply of health services, inputs, and quality. In Brazil, there was a reduction in the Gross National Product (GNP) and in investments in health, both national and state and municipal⁴¹41. Massuda A, Hone T, Leles FAG, Castro MC, Atun R. The Brazilian health system at crossroads: progress, crisis and resilience. BMJ Glob Health 2018; 3(4): e000829. https://doi.org/10.1136/bmjgh-2018-000829
https://doi.org/10.1136/bmjgh-2018-00082... . In addition, the combination of economic crisis and fiscal austerity policies resulted in the worsening of the health sector’s performance²²22. Paes-Sousa R, Schramm JMA, Mendes LVP. Fiscal austerity and the health sector: the cost of adjustments. Cien Saude Colet 2019; 24(12): 4375-84. https://doi.org/10.1590/1413-812320182412.23232019
https://doi.org/10.1590/1413-81232018241... ,²⁵25. Rasella D, Basu S, Hone T, Paes-Sousa R, Ocké-Reis CO, Millett C. Child morbidity and mortality associated with alternative policy responses to the economic crisis in Brazil: a nationwide microsimulation study. PLoS Med 2018; 15(5): e1002570. https://doi.org/10.1371/journal.pmed.1002570
https://doi.org/10.1371/journal.pmed.100... , highlighting, in recent years, the increase in morbidity and mortality, the resurgence of communicable diseases (measles, yellow fever), fall in vaccination coverage, and an increase in infant and maternal mortality¹⁹19. Schramm JMA, Paes-Sousa R, Mendes LVP. Políticas de austeridade e seus impactos na saúde: um debate em tempos de crise. Rio de Janeiro: Fiocruz; 2018. https://www.arca.fiocruz.br/bitstream/icict/28240/2/Joyce_Mendes_et_al_politicas_de_austeridade.pdf
https://www.arca.fiocruz.br/bitstream/ic... ,²⁰20. Paes-Sousa R, Rasella D, Carepa-Sousa J. Economic policy and public health: fiscal balance and population wellbeing. Saúde Debate 2018; 42(spe 3): 172-82. https://doi.org/10.1590/0103-11042018S313
https://doi.org/10.1590/0103-11042018S31... ,²²22. Paes-Sousa R, Schramm JMA, Mendes LVP. Fiscal austerity and the health sector: the cost of adjustments. Cien Saude Colet 2019; 24(12): 4375-84. https://doi.org/10.1590/1413-812320182412.23232019
https://doi.org/10.1590/1413-81232018241... ,²⁵25. Rasella D, Basu S, Hone T, Paes-Sousa R, Ocké-Reis CO, Millett C. Child morbidity and mortality associated with alternative policy responses to the economic crisis in Brazil: a nationwide microsimulation study. PLoS Med 2018; 15(5): e1002570. https://doi.org/10.1371/journal.pmed.1002570
https://doi.org/10.1371/journal.pmed.100... ,²⁶26. Rasella D, Hone T, de Souza LE, Tasca R, Basu S, Millett C. Mortality associated with alternative primary healthcare policies: a nationwide microsimulation modelling study in Brazil. BMC Med 2019; 17(1): 82. https://doi.org/10.1186/s12916-019-1316-7
https://doi.org/10.1186/s12916-019-1316-... . Additionally, there is a worsening of NCD indicators, increased mortality from cardiovascular diseases (CVD) and greater adoption of unhealthy behaviors²⁴24. Malta DC, Duncan BB, Barros MBA, Katikireddi SV, Souza FM, Silva AG, et al. Fiscal austerity measures hamper noncommunicable disease control goals in Brazil. Cien Saude Colet 2018; 23(10): 3115-22. https://doi.org/10.1590/1413-812320182310.25222018
https://doi.org/10.1590/1413-81232018231... ,³⁸38. Silva AGD, Teixeira RA, Prates EJS, Malta DC. Monitoring and projection of targets for risk and protection factors for coping with noncommunicable diseases in Brazilian capitals. Cien Saude Colet 2021; 26(4): 1193-206. https://doi.org/10.1590/1413-81232021264.42322020
https://doi.org/10.1590/1413-81232021264... ,⁴²42. Malta DC, Silva AG, Machado ÍE, Sá ACMGN, Santos FM, Prates EJS, et al. Trends in smoking prevalence in all Brazilian capitals between 2006 and 2017. J Bras Pneumol 2019; 45(5): e20180384. https://doi.org/10.1590/1806-3713/e20180384
https://doi.org/10.1590/1806-3713/e20180... . Furthermore, in 2019 alone, SUS lost R$ 20 billion in investments due to EC95⁴³43. Brasil. Ministério da Saúde. Conselho Nacional de Saúde. Saúde perdeu R$ 20 bilhões em 2019 por causa da EC 95/2016 [Internet]. 2020 [cited on October 25, 2020]. Available at:http://www.conselho.saude.gov.br/ultimas-noticias-cns/1044-saude-perdeu-r-20-bilhoes-em-2019-por-causa-da-ec-95-2016#:∼:text=Desde%20que%20a%20Emenda%20Constitucional,tem%20diminu%C3%ADdo%20cada%20vez%20mais.&text=Ou%20seja%2C%20um%20encolhimento%20de,bilh%C3%B5es%20nos%20recursos%20em%20sa%C3%BAde
http://www.conselho.saude.gov.br/ultimas... , which may contribute to the reduction in the supply of health services. It is also noted that the most frequent difficulties in accessing these services were the lack of vacancies and the scarcity of medical and dental professionals, reflecting the reduction in the supply of services, which may have been influenced by budget cuts in health³⁷37. Azevedo E Silva G, Giovanella L, de Camargo Jr KR. Brazil’s National Health Care System at risk for losing its universal character. Am J Public Health 2020; 110(6): 811-2. https://doi.org/10.2105/AJPH.2020.305649
https://doi.org/10.2105/AJPH.2020.305649... ,⁴³43. Brasil. Ministério da Saúde. Conselho Nacional de Saúde. Saúde perdeu R$ 20 bilhões em 2019 por causa da EC 95/2016 [Internet]. 2020 [cited on October 25, 2020]. Available at:http://www.conselho.saude.gov.br/ultimas-noticias-cns/1044-saude-perdeu-r-20-bilhoes-em-2019-por-causa-da-ec-95-2016#:∼:text=Desde%20que%20a%20Emenda%20Constitucional,tem%20diminu%C3%ADdo%20cada%20vez%20mais.&text=Ou%20seja%2C%20um%20encolhimento%20de,bilh%C3%B5es%20nos%20recursos%20em%20sa%C3%BAde
http://www.conselho.saude.gov.br/ultimas... .

The characteristics of greater demand for services are in accordance with the literature: aged people, women, and populations with higher education⁶6. Travassos C, Martins M. Uma revisão sobre os conceitos de acesso e utilização de serviços de saúde. Cad Saúde Pública 2004; 20(Suppl 2): S190-S198. https://doi.org/10.1590/S0102-311X2004000800014
https://doi.org/10.1590/S0102-311X200400... . The greater demand for services by aged people is due to the greater presence of comorbidities in this age group, the greater perception of the severity of the disease, the risks and the threat to health. However, although aged people have greater demand, access was lower. The attendance in the last 15 days was higher among children and adolescents under 17 years of age. Historically, health services offer more services for children⁴⁴44. Oliveira MM, Andrade SSCA, Campos MO, Malta DC. Fatores associados à procura de serviços de saúde entre escolares brasileiros: uma análise da Pesquisa Nacional de Saúde do Escolar (PeNSE), 2012. Cad Saúde Pública 2015; 31(8): 1603-14. https://doi.org/10.1590/0102-311X00165214
https://doi.org/10.1590/0102-311X0016521... ,⁴⁵45. Pinheiro RS, Viacava F, Travassos C, Brito AS. Gênero, morbidade, acesso e utilização de serviços de saúde no Brasil. Cien Saude Colet 2002; 7(4): 687-707. https://doi.org/10.1590/S1413-81232002000400007
https://doi.org/10.1590/S1413-8123200200... .

This study identified that women sought more services, which has already been identified in other surveys. However, the use was higher among men⁴⁶46. Dias-da-Costa JS, Olinto MTA, Soares SA, Nunes MF, Bagatini T, Marques MC, et al. Utilização de serviços de saúde pela população adulta de São Leopoldo, Rio Grande do Sul, Brasil: resultados de um estudo transversal. Cad Saúde Pública 2011; 27(5): 868-76. https://doi.org/10.1590/S0102-311X2011000500005
https://doi.org/10.1590/S0102-311X201100... ,⁴⁷47. Rosenstock IM. The health belief model: explaining health behavior through expetancies. In: Glanz K, Lewis FM, Rimer BK, eds. Health behavior and health education: theory, research and practice. San Francisco: Jossey-Bass; 1990. p. 39-62.. Women, in general, have a greater perception of signs and symptoms of diseases and seek services for promotion and prevention practices, in addition to the demands of prenatal care³⁶36. Malta DC, Duncan BB, Schmidt MI, Teixeira R, Ribeiro ALP, Felisbino-Mendes MS, et al. Trends in mortality due to non-communicable diseases in the Brazilian adult population: national and subnational estimates and projections for 2030. Popul Health Metr 2020; 18(Supl 1): 16. https://doi.org/10.1186/s12963-020-00216-1
https://doi.org/10.1186/s12963-020-00216... ,⁴⁵45. Pinheiro RS, Viacava F, Travassos C, Brito AS. Gênero, morbidade, acesso e utilização de serviços de saúde no Brasil. Cien Saude Colet 2002; 7(4): 687-707. https://doi.org/10.1590/S1413-81232002000400007
https://doi.org/10.1590/S1413-8123200200... ,⁴⁶46. Dias-da-Costa JS, Olinto MTA, Soares SA, Nunes MF, Bagatini T, Marques MC, et al. Utilização de serviços de saúde pela população adulta de São Leopoldo, Rio Grande do Sul, Brasil: resultados de um estudo transversal. Cad Saúde Pública 2011; 27(5): 868-76. https://doi.org/10.1590/S0102-311X2011000500005
https://doi.org/10.1590/S0102-311X201100... . A possible explanation for the greater attendance among men may be due to greater access to emergency services, while women had a greater proportion of appointments.

Poor health self-assessment increases the demand for services, due to self-assessment of the severity of the disease and worse health conditions. According to Travassos and Martins⁶6. Travassos C, Martins M. Uma revisão sobre os conceitos de acesso e utilização de serviços de saúde. Cad Saúde Pública 2004; 20(Suppl 2): S190-S198. https://doi.org/10.1590/S0102-311X2004000800014
https://doi.org/10.1590/S0102-311X200400... , the subjective perception of disease risk and severity, in addition to feelings and concerns about the disease, such as death, pain or disability, lead to greater demand for services. The fact that the user feels susceptible, with fear of the disease, is an important motivator for the use of services⁶6. Travassos C, Martins M. Uma revisão sobre os conceitos de acesso e utilização de serviços de saúde. Cad Saúde Pública 2004; 20(Suppl 2): S190-S198. https://doi.org/10.1590/S0102-311X2004000800014
https://doi.org/10.1590/S0102-311X200400... ,⁹9. Malta DC, Bernal RTI, Lima MG, Araújo SSC, Silva MMA, Freitas MIF, et al. Noncommunicable diseases and the use of health services: analysis of the National Health Survey in Brazil. Rev Saúde Pública 2017; 51(Suppl 1): 4s. https://doi.org/10.1590/s1518-8787.2017051000090
https://doi.org/10.1590/s1518-8787.20170... . Feeling sick and believing in the benefits of treatment are fundamental to using the services⁶6. Travassos C, Martins M. Uma revisão sobre os conceitos de acesso e utilização de serviços de saúde. Cad Saúde Pública 2004; 20(Suppl 2): S190-S198. https://doi.org/10.1590/S0102-311X2004000800014
https://doi.org/10.1590/S0102-311X200400... ,⁹9. Malta DC, Bernal RTI, Lima MG, Araújo SSC, Silva MMA, Freitas MIF, et al. Noncommunicable diseases and the use of health services: analysis of the National Health Survey in Brazil. Rev Saúde Pública 2017; 51(Suppl 1): 4s. https://doi.org/10.1590/s1518-8787.2017051000090
https://doi.org/10.1590/s1518-8787.20170... ,⁴⁷47. Rosenstock IM. The health belief model: explaining health behavior through expetancies. In: Glanz K, Lewis FM, Rimer BK, eds. Health behavior and health education: theory, research and practice. San Francisco: Jossey-Bass; 1990. p. 39-62..

The results also showed greater demand among people with higher education. However, access to services according to education level was similar between low and higher education, being lower among secondary education⁹9. Malta DC, Bernal RTI, Lima MG, Araújo SSC, Silva MMA, Freitas MIF, et al. Noncommunicable diseases and the use of health services: analysis of the National Health Survey in Brazil. Rev Saúde Pública 2017; 51(Suppl 1): 4s. https://doi.org/10.1590/s1518-8787.2017051000090
https://doi.org/10.1590/s1518-8787.20170... ,⁴⁸48. Barros MBA, Cesar CLG, Carandina L, Torre GD. Desigualdades sociais na prevalência de doenças crônicas no Brasil, PNAD-2003. Cien Saude Colet 2006; 11(4): 911-26. https://doi.org/10.1590/S1413-81232006000400014
https://doi.org/10.1590/S1413-8123200600... ,⁴⁹49. Barros MBA, Francisco PMSB, Zanchetta LM, César CLG. Tendências das desigualdades sociais e demográficas na prevalência de doenças crônicas no Brasil, PNAD: 2003-2008. Cienc Saude Colet 2011; 16(9): 3755-68. https://doi.org/10.1590/S1413-81232011001000012
https://doi.org/10.1590/S1413-8123201100... . In the National Household Sample Survey (PNAD 2003 and 2008) and in the PNS 2013, there was less use of health services and a lower proportion of medical appointments in a population with lower education and income⁹9. Malta DC, Bernal RTI, Lima MG, Araújo SSC, Silva MMA, Freitas MIF, et al. Noncommunicable diseases and the use of health services: analysis of the National Health Survey in Brazil. Rev Saúde Pública 2017; 51(Suppl 1): 4s. https://doi.org/10.1590/s1518-8787.2017051000090
https://doi.org/10.1590/s1518-8787.20170... ,⁴⁸48. Barros MBA, Cesar CLG, Carandina L, Torre GD. Desigualdades sociais na prevalência de doenças crônicas no Brasil, PNAD-2003. Cien Saude Colet 2006; 11(4): 911-26. https://doi.org/10.1590/S1413-81232006000400014
https://doi.org/10.1590/S1413-8123200600... ,⁴⁹49. Barros MBA, Francisco PMSB, Zanchetta LM, César CLG. Tendências das desigualdades sociais e demográficas na prevalência de doenças crônicas no Brasil, PNAD: 2003-2008. Cienc Saude Colet 2011; 16(9): 3755-68. https://doi.org/10.1590/S1413-81232011001000012
https://doi.org/10.1590/S1413-8123201100... . This change in access, even after adjusting for age and gender, may indicate that the SUS has been able to provide access to the population, regardless of education.

Individuals with health insurance used the services more. This result corroborates the PNAD data, which showed that people with a private health insurance have higher prevalence of medical appointments and hospitalization in the last 12 months, and use of services in the last two weeks⁴⁸48. Barros MBA, Cesar CLG, Carandina L, Torre GD. Desigualdades sociais na prevalência de doenças crônicas no Brasil, PNAD-2003. Cien Saude Colet 2006; 11(4): 911-26. https://doi.org/10.1590/S1413-81232006000400014
https://doi.org/10.1590/S1413-8123200600... ,⁴⁹49. Barros MBA, Francisco PMSB, Zanchetta LM, César CLG. Tendências das desigualdades sociais e demográficas na prevalência de doenças crônicas no Brasil, PNAD: 2003-2008. Cienc Saude Colet 2011; 16(9): 3755-68. https://doi.org/10.1590/S1413-81232011001000012
https://doi.org/10.1590/S1413-8123201100... , data also similar to what was found in PNS 2013⁹9. Malta DC, Bernal RTI, Lima MG, Araújo SSC, Silva MMA, Freitas MIF, et al. Noncommunicable diseases and the use of health services: analysis of the National Health Survey in Brazil. Rev Saúde Pública 2017; 51(Suppl 1): 4s. https://doi.org/10.1590/s1518-8787.2017051000090
https://doi.org/10.1590/s1518-8787.20170... . It is noteworthy that the logic of health plans encourages curative medicine and greater consumption of services⁴⁸48. Barros MBA, Cesar CLG, Carandina L, Torre GD. Desigualdades sociais na prevalência de doenças crônicas no Brasil, PNAD-2003. Cien Saude Colet 2006; 11(4): 911-26. https://doi.org/10.1590/S1413-81232006000400014
https://doi.org/10.1590/S1413-8123200600... –⁵⁰50. Viacava F, Bellido JG. Health, access to services and sources of payment, according to household surveys. Cien Saude Colet 2016; 21(2): 351-70. https://doi.org/10.1590/1413-81232015212.19422015
https://doi.org/10.1590/1413-81232015212... . Studies comparing exclusive SUS users with those with health insurance found lower frequencies of medical appointments and screening tests in the first group⁵¹51. Lima-Costa MFF, Guerra HL, Firmo JOA, Vidigal PG, Uchoa E, Barreto SM. The Bambuí Health and Aging Study (BHAS): private health plan and medical care utilization by older adults. Cad Saúde Pública 2002; 18(1): 177-86. https://doi.org/10.1590/S0102-311X2002000100018
https://doi.org/10.1590/S0102-311X200200... ,⁵²52. Malta DC, Moura EC, Oliveira M, Santos FP. Usuários de planos de saúde: morbidade referida e uso de exames preventivos, por inquérito telefônico, Brasil, 2008. Cad Saúde Pública 2011; 27(1): 57-66. https://doi.org/10.1590/S0102-311X2011000100006
https://doi.org/10.1590/S0102-311X201100... ,⁵³53. Malta DC, Bernal RTI, Vieira Neto E, Curci KA, Pasinato MTM, Lisbôa RM, et al. Noncommunicable diseases, risk factors, and protective factors in adults with and without health insurance. Cien Saude Colet 2020; 25(8): 2973-83. https://doi.org/10.1590/1413-81232020258.32762018
https://doi.org/10.1590/1413-81232020258... ,⁵⁴54. Dantas MNP, Souza DLB, Souza AMG, Aiquoc KM, Souza TA, Barbosa IR. Factors associated with poor access to health services in Brazil. Rev Bras Epidemiol 2020; 24: e210004. https://doi.org/10.1590/1980-549720210004
https://doi.org/10.1590/1980-54972021000... .

Among the limitations, although the cross-sectional design is not adequate to attribute causality, the study sought to characterize a population according to attributes of interest. The health services utilization module was answered by one of the residents, the proxy, and not by residents themselves, which may underestimate the prevalence. In addition, in 2019, the questionnaire was changed, including another answer option on appointment scheduling, which limits the comparison of some questions and does not allow us to know when the scheduled appointment was carried out. The questionnaire measures the demand perceived by the user, the service received or scheduled. Furthermore, it is highlighted that there is no way to assess the quality of care, as well as whether the health response was the most adequate.

In summary, the findings of this study show that there was an increase in demand for health services and a reduction in access in the last 15 days. The implementation of the SUS has been fundamental for reducing inequities in Brazil. However, austerity policies have contributed substantially to the deterioration of the health situation. Between 2013 and 2019 there was an increase in the demand for health services, which may be due to the aging population, but also to increased vulnerability, increased unemployment, cuts in social programs, and the austerity policies implemented in Brazil.

It emphasizes the importance of the SUS and the doctrinal principles of universality, integrality, and equity, guaranteeing access to services by the population with less education and without health insurance. Therefore, it is essential to invest in the expansion and adequate and sustainable financing of the SUS.

ACKNOWLEDGMENTS

Malta DC and Szwarcwald CL are thankful to Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), which financed the research productivity grant. Prates EJS thanks the National Health Fund of the Ministry of Health for the research grant.

REFERENCES

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