Abstract

Access to health services is a banner defended by social movements and informs the flow for seeking care in the urgent and emergency (UE) network. This article analyzes this access in the municipality of Boa Vista do Ramos, Amazonas, and reflects on the flow of UE riverside users. A descriptive study was conducted based on qualitative and geographical data. Research steps consisted of gathering geographic information on the locations of interest; interviewing local actors; organizing and analyzing secondary and primary data; and generating thematic maps. Removal of UE patients in Boa Vista does not follow any fixed pattern, or even a similar one. Establishment of full riverside teams and their uninterrupted stay in the area has consolidated these locations as health care points. The drought and flood of the rivers determine paths, approaching or distancing spatially. Given the complexity of the life scenario, decisions regarding care itineraries are linked to previous experiences with the local health system. User flow has much to inform about the unpredictability of everyday choices and options.

Keywords:
Access to Health Services; Amazon Region; Rural Population; Geographic Mapping

Introduction

Universal access to health services, as well as being a constitutional guarantee, is a key cause championed by social movements and has become one of the fundamental rights of citizenship (Jesus; Assis, 2010JESUS, W. L. A; ASSIS, M. M. A. Revisão sistemática sobre o conceito de acesso nos serviços de saúde: contribuições do planejamento. Ciência e Saúde Coletiva , Rio de Janeiro, v. 15, n. 1, p. 161-170, 2010. https://doi.org/10.1590/S1413-81232010000100022
https://doi.org/10.1590/S1413-8123201000... ). In this study, flow is inseparable from access and represents the search for care in the formal health sector, as well as the path taken by the user and the person responsible for the patient in search of care and resolution in the Urgent and Emergency Care Network (UECN). Here, we agree with Oliveira, Mattos and Auta (2009OLIVEIRA, L. H; MATTOS, R. A; AUTA, I. S. Cidadãos peregrinos: os “usuários” do SUS e os significados de sua demanda a prontos-socorros e hospitais no contexto de um processo de reorientação do modelo assistencial. Ciência e Saúde Coletiva , Rio de Janeiro, v. 14, n. 5, p. 1929-1938, 2009. https://doi.org/10.1590/S1413-81232009000500035
https://doi.org/10.1590/S1413-8123200900... ); the user is an active subject in defending their interests and that, despite being aware of the rules of the health system based on territorial logic, hierarchization, and the concept of the gateway through primary care, they may look for other alternatives with better offer of access in their search for assistance.

In this search, they grasp their historical experience with the offered health services, with all their norms and rules, and depending on their need for access, they reinterpret the norms and look for ways that may provide care experiences in line with their demands.

Recognizing the territory is a basic step towards characterizing the population and their health problems, as well as assessing the impact of services on their health levels (Monken; Barcellos, 2005MONKEN, M.; BARCELLOS, C. Vigilância em saúde e território utilizado: possibilidades teóricas e metodológicas. Cadernos de Saúde Pública, Rio de Janeiro, v. 21, n. 3, p. 898-906, 2005. https://doi.org/10.1590/S0102-311X2005000300024
https://doi.org/10.1590/S0102-311X200500... ). In the context of the Amazon region, the territory of interest in this study is an aqueous one, highlighted by the riverside way of life, where the health-disease- care process is expressed. This territory goes beyond the waterways and has more accentuated variations in spatial and human geography, with very broad combinations of population concentration/ dispersion and very adverse conditions of distance and access (Schweickardt; Lima; Ferla, 2021SCHWEICKARDT, J. C; LIMA, R. T. S; FERLA, A. A. O programa Mais Médicos no território amazônico: acesso e qualidade na atenção básica, travessias de fronteiras e o direito à saúde das gentes. In: SCHWEICKARDT, J. C; LIMA, R. T. S; FERLA, A. A (Org.). Mais Médicos na Amazônia: efeitos no território líquido e suas gentes. ed. Porto Alegre: Rede Unida, 2021. p. 40-52.), causing management, research, teaching-learning and, above all, equity challenges for these populations.

Studies on access and population flows in the health sector (with numerous methodologies) have been increasingly common (Pacheco; Silva; Ramos, 2017PACHECO, A. M; SILVA, R. D. M; RAMOS, M. C. Organização do fluxo de atendimento aos usuários abusivos ou dependentes de álcool e outras drogas. Revista Brasileira de Pesquisa em Saúde, Vitória, v. 19, n. 1, p. 21-27, 2017. Disponível em: Disponível em: https://periodicos.ufes.br/rbps/article/view/17712 . Acesso em: 12 jun. 2024.
https://periodicos.ufes.br/rbps/article/... ; Galvani et al., 2021GALVANI, F. B. et al. Fluxo de rede do paciente oncológico no município de Patos de Minas. Brazilian Journal of Health Review, Curitiba, v. 4, n. 3, p. 13389-13395, 2021. https://doi.org/10.34119/bjhrv4n3-287
https://doi.org/10.34119/bjhrv4n3-287... ; Antonacci et al., 2013ANTONACCI, M. H. et al. Estrutura e fluxo da rede de saúde como possibilidade de mudança nos serviços de atenção psicossocial. Revista da Escola de Enfermagem da USP, São Paulo, v. 47, n. 4, p. 891-898, 2013. https://doi.org/10.1590/S0080-623420130000400017
https://doi.org/10.1590/S0080-6234201300... ; Roese, 2005ROESE, A. Fluxos e acesso dos usuários a serviços de saúde de média complexidade no município de Camaquã, RS. Dissertação (Mestrado em Enfermagem) - Universidade Federal do Rio Grande do Sul, Porto Alegre, 2005.; Freire, 2021FREIRE, K. M. R. Mapeamento de fluxo dos casos de dengue nos estabelecimentos de saúde no Distrito Federal. 2021. Dissertação (Mestrado em Geografia) - Universidade de Brasília, Brasília, DF, 2021.), with a strong concentration in metropolitan urban areas. Flows in health networks as a management component are also found in the literature (Brasil, 2013BRASIL. Ministério da Saúde. Manual instrutivo da Rede de Atenção às Urgências e Emergências no Sistema Único de Saúde (SUS). Brasília, DF: Ministério da Saúde , 2013.; ²⁰¹⁴BRASIL. Ministério da Saúde. Implantação das Redes de Atenção à Saúde e outras estratégias da SAS. Brasília, DF: Ministério da Saúde , 2014.; ²⁰¹⁵BRASIL. Ministério da Saúde. Cadernos HumanizaSUS - Volume 5: Saúde Mental. Brasília, DF: Ministério da Saúde, 2015.; ²⁰¹⁷BRASIL. Ministério da Saúde. Portaria de Consolidação nº 3, de 28 de setembro de 2017. Consolidação das normas sobre as redes do Sistema Único de Saúde. Diário Oficial da União, Brasília, DF, 28 set. 2017.) as inducers for states and municipalities. However, there is a scarcity of studies involving the riverside population (Queiroz et al., 2018QUEIROZ, M. K. S. et al. Fluxos assistenciais e a integralidade da assistência à saúde de ribeirinhos. Revista Enfermagem UERJ, Rio de Janeiro, v. 26, e26706, 2018. https://doi.org/10.12957/reuerj
https://doi.org/10.12957/reuerj... ; Reis, 2021REIS, A. E. S. Acesso e fluxos da população ribeirinha aos serviços de saúde no município de Parintins-AM: uma abordagem participativa. 2021. Dissertação (Mestrado em Saúde Coletiva) - Instituto Leônidas e Maria Deane, Manaus, 2021.). In view of the above, this article aims to analyze access to health services in the municipality of Boa Vista do Ramos (BVR), in the state of Amazonas, and to reflect on the flow of riverside users in urgent and emergency situations.

Methodology

This is a descriptive study based on qualitative data. Space was incorporated into the analysis, preceded by an exploratory phase, with visual presentation of the data in the form of graphs, tables, and cartographic maps.

The stages of the study consisted of (1) Gathering information on the geographical location of the communities, admissions and removals of patients at the general hospital, the basic health units, the communities and the municipal health department of the municipality of Boa Vista do Ramos; (2) Interviews with the local actors of interest in this study; (3) Organization and analysis of the secondary (tables and graphs) and primary (speech of local actors) databases; and (4) Generation of thematic maps (representation of the study area and patient removal flows).

Qualitative research came in as a methodological option, especially cartography, which allows for countless forms of narration. Photographic compilation, field diaries, participant observation, and conversations with local actors made up the first approach to the field of study. This stage helped to delimit the study’s territorial base, with the following factors being taken into account: the inseparable recognition of the territory as the interaction of objects and actions; the demarcation of the territory of health work, as it is the work of the teams-reports from managers, health professionals, and users; and the delimitations used that are established and recognized by the local population.

The interviews helped to consolidate the previous stage, which was also qualitative, using a semi- structured script that was “applied” in various scenarios of interest to the study. Narrative interviews respond to the desire to “tell a story about an important event in one’s life and social context,” and are considered a form ofunstructured, in-depth interview (Jovchelovitch; Bauer, 2008JOVCHELOVITCH, S; BAUER, M.W. Entrevista narrativa. In: Bauer, M. W.; Gaskell, G. (Ed.). Pesquisa qualitativa com texto, imagem e som: um manual prático. Petropolis: Vozes, 2008. p. 90-113.), from which the analysis sought to highlight the meanings that guided choices, flows, and paths during urgent and emergency situations.

The open questions referring to these situations were applied to the interviews in the different groups of local actors, as in the examples:

Users

How is a referral to the municipal hospital carried out? Does anyone from the Family Health team accompany users during transportation or to the hospital?

Health workers

Report on how people access the Urgency and Emergency Network in the municipality. How do patients get to the municipality’s hospital?

Managers

How is the Urgency and Emergency Network structured in the municipality? How do patients enter the hospital? How are patients from the municipality’s riverside area admitted?

The testimonies of the local actors were recorded and transcribed in full, and the observation notes were duly categorized and ordered according to the themes prioritized in this research. This choice, after approximations, made it possible to analyze and grasp the meanings attributed to the UECN, its access and the surrounding Amazonian context. In order to protect the interviewees’ anonymity, each one was given a code, recorded with their initials and by the category they belonged to. Voice intonation and silences between statements were also taken into account, as well as the emphasis of words or expressions (Gomes et al., 2005GOMES, R. et al. Organização, processamento, análise e interpretação de dados: o desafio da triangulação. In: MINAYO, M. C. S; ASSIS, S. G; SOUZA, E. R. (Org.). Avaliação por triangulação de métodos: Abordagem de Programas Sociais. Rio de Janeiro: Editora Fiocruz, 2005. p. 185-221.). These procedures were used to reveal how the program’s actions worked, the incongruities between what was said and what was practiced in the routines of the health units, the subjects’ understanding of this context and the social relations that took place within it (Minayo, 2004MINAYO, M. C. S. Fase de Trabalho de Campo. In: MINAYO, M. C. S. O Desafio do Conhecimento: Pesquisa Qualitativa em Saúde. 8a. ed. São Paulo: Hucitec, 2004. p. 105-196.).

The secondary data was collected and organized collaboratively by researchers and employees of the Boa Vista do Ramos-Clóvis Negreiro Hospital Unit. The staff involved work directly in the process of transferring patients to other municipalities. To this end, a database of transferred patients treated/hospitalized at the hospital from June 2017 to December 2019 was jointly designed. The data collection period was chosen at the suggestion of hospital employees, considering a change in municipal and hospital management; in addition to improving the organization of data by the sector responsible for transfers. The data was tabulated and analyzed using Microsoft Office Excel 365.

To draw up the thematic maps, geographical coordinates of the communities in the Curuçá and Paraná do Ramos River channels were collected using a Global Positioning System (GPS) receiver; then the geographical database of BVR removals to other municipalities in urgent and emergency situations was organized, with a focus on manual intervention to adjust coordinates and remove records with incompleteness and inconsistencies. Finally, the spatial distribution of the communities and municipalities of interest to the study was carried out. The tool used to produce the maps was the free and open-source program QGIS, version 3.20.3. Maps of patient transfers flows were produced, showing the route taken by users in search of health care through the formal network and based on their origin-destination patterns.

As for the ethical and legal aspects, this study was approved by the Research Ethics Committee (CEP) under CAAE registration 99460918.3.0000.520.

Results and discussion

The transfer of patients in urgent and emergency situations within the Boa Vista territory, represented on the map (Figure 1), markedly does not follow any fixed or even similar pattern over the period analyzed. In 2018, even with the increase in transfers, the flow to the municipal headquarters had a smaller range of displacements in the regional areas. There are factors listed in the interviews and participant observation that allow us to problematize the findings of intra-municipal transfer in BVR.

Users can enter the hospital by free will or by referral. Users in urgent and emergency situations from the riverside communities may go there on their own initiative, without any member of the health team, or they may be accompanied by members of the riverside health team, with the respective referral and initial possible care for the situation that triggered the transfer. In the first case, there is a strong tendency for the user or the person responsible for the patient to inform the main city as the address of origin, either because they have family ties in the city or because they are looking for faster care. When asked how they came to the hospital, everyone identified themselves as being from their community of origin. Although we were unable to reliably measure hospital admission data, this practice may be being reproduced in BVR. In 2018 and early 2019, two Riverside Basic Health Units were opened in two regions, Curuçá and Lago Preto. The establishment of complete riverine teams and their uninterrupted stay in the area has been consolidating these locations more and more as points of health care in the search for care by the population. The interviewees’ recognition of the improvement in access to local health services can be seen in some of the interviews:

The consolidation of strategies to retain health professionals in riverine areas has gradually redirected the flow of users towards a clear link with the local health team. The work of the riverine teams is fundamental to improving the quality of the health services provided (Santos et al., 2021SANTOS, I. O. et al. Avanços e desafios na saúde das populações ribeirinhas na região amazônica: uma revisão integrativa. Revista APS, Juiz de Fora, v. 24, Supl, 1, p. 185-199, 2021.), including urgent and emergency care.

Figure 1 also shows a continuous flow of users living in communities belonging to the municipality of Barreirinha. In addition to the map, when asked about the flow from other municipalities to the BVR health network, the management explained:

Another reflection coming from the users,a“counterflow” to the previous reflection, refers to the movement of riverine users from BVRto other municipalities insearch of care, especially residents of communities located at the headwaters of the rivers. Flows that are not counted as official removal data occur at certain times of the year (mainly during river floods), with or without the participation of the Community Health Agent.

Living in a community, of a certain social and cultural life, is part of the complex game of care. The context is not just a framework of social determinants but forms a complex scenario that is difficult to represent theoretically because it is, first and foremost, experienced (Heufemann; Lima; Schweickardt, 2016HEUFEMANN, N.E.C; LIMA, R.T.S; SCHWEICKARDT, J.C. A produção do cuidado em saúde num território amazônico: o ‘longe muito longe’ transformado pelas Redes Vivas. In: MERHY, E.E. et al. (Org.). Avaliação compartilhada do cuidado em saúde: surpreendendo o instituído nas redes. Rio de Janeiro: Hexis, 2016. p. 332-335.). The context of life in these statements marks the choices for care and, consequently, the flow of urgency and emergency. The drought and the flood determine paths, open or close ways, bring health care points closer or farther apart. In addition to these choices, which are also financial, it became clear in the research field that there are family ties between community members in the most different municipalities, which also influences the choice of destination transfer. There is no allowance to guarantee accommodation and/or food for the person responsible for the patient, except within the hospital unit itself and during hospitalization.

Given all the complexity of the life scenario, decisions on care itineraries are linked to previous experiences with the local health system and the “community work” itself, when faced with urgent and emergency situations. In the words of Oliveira, Mattos, and Auta (2009OLIVEIRA, L. H; MATTOS, R. A; AUTA, I. S. Cidadãos peregrinos: os “usuários” do SUS e os significados de sua demanda a prontos-socorros e hospitais no contexto de um processo de reorientação do modelo assistencial. Ciência e Saúde Coletiva , Rio de Janeiro, v. 14, n. 5, p. 1929-1938, 2009. https://doi.org/10.1590/S1413-81232009000500035
https://doi.org/10.1590/S1413-8123200900... ):

This informal assessment of everyday life is the first “hole in the wall” of urgent and emergency care, which does not take into account the borders drawn on maps, the limits of municipal jurisdictions or the divisions of a fragmented health system. The search for care re-signifies the border beyond a line of separation, transforming it into a space/place that is, above all, welcoming and effective. Clearly, the holes in the wall are appearing because there is a distancing from the flows of the traditional UECN and those idealized by local health management, as well as from health care models centered on medical practice and hard technologies.

Models of care need to consider the territory, community initiatives, the work of the health workers and, above all, the user of the health network. In order to fulfill the promise of a single system organized for comprehensiveness and humanization, it is essential that it works as an uninterrupted health “care mesh,” and not as a bureaucratic and depersonalized system (Silva Junior; Alves, 2007SILVA JUNIOR, A. G.; ALVES, C. A. Modelos Assistenciais em Saúde: desafios e perspectivas. In: MOROSINI, M. V. G. C. (Org.). Modelos de atenção e a saúde da família. Rio de Janeiro: EPSJV/Fiocruz, 2007.). Furthermore, in relation to the living territory, it makes no sense to maintain a dichotomy between the geographical territory and its people, since it is made up of established relationships. As the expected results show, the distribution of the origins of the removals is strongly centered on users coming from the urban area (85%) in relation to the rural area (15%), which can be seen in Table 1. Of the rural removals, 3.5% come from communities located in another municipality (Barreirinha).

Another result was the identification of the main causes of transfer from BVR to other municipalities, as shown in Figure 2. Parintins (PIN) is the reference municipality in the Lower Amazon Health Region (Resaba) for urgent and emergency situations that go beyond the care of the municipalities in the Region. Of the five main causes of transference in the period studied, leaving BVR, all have the municipality of Parintins as their point of care. A more detailed analysis of the maps reveals that the main reasons for the flow towards the municipality of reference are external causes and those related to pregnancy, childbirth, and the puerperium. The presence of doctors specializing in trauma and orthopedics, general surgery and gynecology/obstetrics increases this flow.

From the words of the municipal management, the collaboration of another reference municipality in the Médio Amazonas Health Region is evident: Itacoatiara. The capital’s “power of attraction” for transfer cannot be overlooked, not only because it has the highest density (hard technology) in the state, but also because it is the only municipality to have Intensive Care Unit (ICU) beds available in the public network, offers an important range of complementary laboratory and imaging tests, and concentrates a diverse spectrum of specialist doctors. In addition, land access to the capital from Itacoatiara is a determining factor in increasing the BVR-ITC flow, the choices of removals and the agreements between the municipalities. It should be noted that when removing the user to the Resaba reference municipality, the distance from the capital Manaus is greater and access is by waterway or air. A study analyzing regionalization in Amazonas highlighted the “cornerstone” of the health reality in the state: an insufficient network of health services and difficulties in securing human resources, especially in small municipalities (Garnelo; Sousa; Silva, 2017GARNELO, L.; SOUSA, A. B. L; SILVA, C. O. Regionalização em Saúde no Amazonas: avanços e desafios. Ciência e Saúde Coletiva, Rio de Janeiro, v. 22, n. 4, p. 1225-1234, 2017. https://doi.org/10.1590/1413-81232017224.27082016
https://doi.org/10.1590/1413-81232017224... ).

The municipality of Itacoatiara, contrary to regional agreements, is the main city attracting BVR removals for the five main causes (Figure 3) highlighted in this study. The severity (greater or lesser/urgency or emergency) of the user activates choice devices for the user’s removal: to which municipality will this removal be directed? In addition to severity, it involves prior coordination and decisions, such as medical referrals and contacts between Regional (PIN) or Extra-Regional (ITC) hospitals. In addition, the severity of the user determines which professional should accompany them in the ambulancha (water ambulance): when it is more serious, a nurse; when it is less serious, a nursing technician.

The local and (extra) regional arrangements are aligned with a flow already established by the very user in distress and go beyond the local regional agreements. In addition, they demonstrate the weaknesses of the “formal, meeting, minutes” agreements and highlight the “manager-manager, director-director agreements” centered on the clinical needs of the moment, seeking to remove barriers to access and circumvent the inequities imposed not only by local geography, but also by the limitations of the Resaba health systems.

The maps show that, in addition to Parintins and Itacoatiara, Barreirinha (BAE) and Maués (MBZ) are, to a lesser extent, references for BVR for some transfers. Absent in the managers’ initial statements, these signal a common weakness in many small hospitals in the Amazon, which is the lack of doctors. When hospital management by another health professional, not a doctor, is exhausted, these users, most of whom are at maternal and fetal risk during labor and other complications during pregnancy, are transferred to MBZ or BAE with doctors in their hospital units and closer to the municipality of BVR. The following speech highlights an additional “extra-regional” agreement and represents the second “hole in the wall” of the formal agreements.

Travel time is a crucial factor in situations involving urgency and emergency; in rural riverside realities, it is linked to periods of drought and flooding of the rivers, inclement weather, the power of the boat’s engine, the purchase of fuel and the presence or absence of fixed riverside teams in the communities. It clashes with the striking aspects mentioned by a user from the Guajará Community, who, as a Community Health Agent (ACS), used to accompanying people on the move and providing initial local care, found himself in an urgent and emergency situation.

Painful journeys involving different routes (lake, river, and forest trail) highlight the dramatic nature of riverineurgencyandemergencyintimesofdrywaterways, aggravated by the absence of health teams to support riverine communities. A closer look at the distressing situation highlights other aspects of the local UECN.

Clearly, the transfer narrated shows the seriousness of the situation experienced by the user, as well as clarifying and corroborating the findings found in the database in the testimonies of managers and in the thematic maps. The most serious clinical situations are transferred to the city of Itacoatiara, and the Manaus health network is configured as a support and gateway for emergency situations in the state. The binary system (river and air travel) of relations between Manaus and other municipalities establishes a type of organization of care, in which residents in the interior of the state are forced to regularly turn to the metropolis in search of care, with no network of health interactions that resembles what is recommended for a health region (Garnelo; Sousa; Silva, 2017GARNELO, L.; SOUSA, A. B. L; SILVA, C. O. Regionalização em Saúde no Amazonas: avanços e desafios. Ciência e Saúde Coletiva, Rio de Janeiro, v. 22, n. 4, p. 1225-1234, 2017. https://doi.org/10.1590/1413-81232017224.27082016
https://doi.org/10.1590/1413-81232017224... ) and reinforcing/ deepening the weaknesses of the municipal health systems that make up Amazonas. The narrative sequence shows other points of regional attention.

The cities of Maués and Parintins appear as points of support in the report, through the interlocution of the user himself as the protagonist of his care and in the doctor’s decision to transfer to the Resaba reference municipality.

Time and distance in the Amazon are plural. They are not defined by chronological logic or mileage. Time is measured in hours and/or days of travel. There is an intensedynamismthatmoves allthetime, takingon other senses and meanings than just the chronological; health care in this riverside territory incorporates singularities that do not only involve clinical aspects, coinciding with the user’s biomedical grammar (Martins et al., 2022MARTINS, F. M. et al. Produção de existências em ato na Amazônia: “território líquido” que se mostra à pesquisa como travessia de fronteiras. Interface, Botucatu, v. 26, e210361, 2022. https://doi.org/10.1590/interface.210361
https://doi.org/10.1590/interface.210361... ).

Final considerations

Boa Vista do Ramos faithfully represents the reality of a large number of small Amazonian municipalities, which have rivers as their roads, and therefore an important and preponderant riverine component. This opens up an important dimension in the process of understanding spatialization in health and its contribution as a complementary tool to health evaluation and planning processes.

There is no denying the importance of the foreign gaze and, above all, the incorporation of the speech of those involved and directly implicated in the transfer of users in acute distress and the patient’s guardian, enriching the secondary data, the maps and the quality of the writing. The analytical detachment from the context, as a “third party” in the processing of one’s own experience, is fundamental to breaking the naturalization with which the lack of assistance or the omission of public policies operates in the analysis of the production of health in the Amazon territory.

The flow of users from Barreirinha to Boa Vista do Ramos and, above all, the “counterflow” from the latter to Maués, Urucurituba, and Itacoatiara represent the first “hole in the wall” of care, which is intended to be comprehensive and equitable. The protagonism of the community and the users is striking in the speeches and reinforces that health care in the formal network has numerous aspects, but its availability does not recognize maps, municipalities, or institutional flows, and the logic of costs and time, as well as the regime of the rivers and the presence of family members, are essential to delineate the coming and going of the user in a situation of suffering.

The discontinuity of medical care, with the absence of professionals in the hospital network at occasional times, showed a discordance with formal agreements, demonstrating the emergence of the informal support network between managers and how demands mobilize resources, teams, agreements and, above all, creativity in doing health.

The limitations of this study are consistent with the choice of research design, one of them being the impossibility of “tracing” the route from home to the riverside community, given that there are human conglomerations even more dispersed than the “larger community” mentioned that were not part of this analysis, which could help to compose new investigations and deepen the understanding of the dynamics of people’s movement in times of acute distress.

The flow of users in this study says a lot about the unpredictability of choices, options in daily life and, most of all, how care can be diversified in the health network. Inequities in access to health services require users to rethink their care and that of the community. It is important that other studies delve deeper into aspects linked to traditional medicine and community care, outlining more clearly the impact that these practices can have in urgent and emergency situations. Complex territories with complex population flows require complex solutions, signaling the need for re-agreements in collegiate bodies, such as health councils, the Regional Inter-Management Commission and the Bipartite Inter-Management Commission, to further qualify access to the UECN, including valuing the user’s path in seeking help in the health network, investing in permanent and continuing training for professionals who directly deal with situations of acute suffering, and allocating material resources that complement care.

References

Publication Dates

History