ABSTRACT

The aim was to identify the healthcare pathways of the elderly in one health region in the Federal District and their perceptions about these pathways. A qualitative study analyzed 14 healthcare pathways of elderly people, using tracer methodology. Interviews were conducted with the elderly and caregivers, processed by content analysis; and medical records were reviewed. Maps of the paths described were prepared by geoprocessing. It was found that the actual healthcare pathways taken by the elderly differ from what law would predict, and that the weaknesses detected were related to poor accessibility conditions, lack of professionals, lack of medicines, and the long waiting time for specialized health care. The expectations reported by the elderly involved humanization of care, emerging elements such as being well received by the personnel, the building of bonds, qualified listening, and a feeling of well-being after the medical consultation. Although the care model is still fragmented and far from ideal, users feel satisfied with the care provision and identify positive aspects in the health care process. However, the organization of work processes and the articulation between levels of health care need to be reviewed and adapted to the specificities of this life phase.

KEYWORDS
Patient acceptance of health care; Health services for the aged; Health services accessibility; Delivery of health care; Health of the elderly

Introduction

The aging of the population reflects a demographic transition resulting from the decline in fertility and mortality rates¹1 Vello LS, Popim RC, Carazzai EM, et al. Saúde do Idoso: percepções relacionadas ao atendimento. Esc. Anna Nery. Rio de Janeiro. 2014; 18(2):330-335. and represents a challenge in view of the need for the development of adequate health policies and care services for the elderly²2 Closs VE, Schwanke CHA. A evolução do índice de envelhecimento no Brasil, nas suas regiões e unidades federativas no período de 1970 a 2010. Rev. Bras. Geriatr. Gerontol. 2012; 15(3);443-58.. In Brazil, the estimated number of elderly (≥60 years old) for 2020 is 32 million, which means an increase of more than 200% as compared to year 2002, when they were 14 million²2 Closs VE, Schwanke CHA. A evolução do índice de envelhecimento no Brasil, nas suas regiões e unidades federativas no período de 1970 a 2010. Rev. Bras. Geriatr. Gerontol. 2012; 15(3);443-58.. In the Federal District (FD), following the national trend, the elderly population has increased by 7.7% in 2010 with a further increase by 10.5%, in 2018³3 Companhia de Desenvolvimento e Planejamento de Brasília. Pesquisa Distrital por Amostra de Domicílios. Ceilândia e Brazlândia. 2018. Brasília, DF: Secretaria de Estado de Planejamento e Orçamento do Distrito Federal; 2018..

Even though the decline in mortality from infectious and communicable diseases contributed to increase life expectancy⁴4 Meireles VC, Matsuda LM, Coimbra JAH, et al. Características dos idosos em área de abrangência do Programa Saúde da Família na região noroeste do Paraná: contribuições para a gestão do cuidado em enfermagem. Saúde Soc. São Paulo. 2007; 16(1):69-80., there has been a rise in the prevalence of chronic and degenerative diseases affecting mostly the elderly. Such scenario points out the need for new strategies to promote healthy ageing⁶6 Gonçalves LHT, Alvarez AM, Sena ELS, et al. Perfil da família cuidadora de idosos doente/fragilizado do contexto sociocultural de Florianópolis, SC. Texto Contexto Enferm. 2006; 15(4):570-77., defined by the World Health Organization (WHO) as the process of developing and maintaining the functional ability that enables well-being in older age⁷7 Organização Mundial de Saúde. Relatório Mundial do Envelhecimento e Saúde. Genebra: Organização Mundial de Saúde; 2015..

Therefore, the Universal Health System (UHS) has adapted itself to ensure qualified and efficient actions and services by means of a new organization structured in networks. The discussion about Integrated Health Services Delivery Networks (IHSDN) emerged with Resolution CD49.R22, adopted on October 02, 2009 by the Pan American Health Organization (Paho) to address the problem of health services fragmentation and hierarchy⁸8 Organización Panamericana de la Salud. Redes Integradas de Servicios de Salud: Conceptos, Opciones de Política y Hoja de Ruta para su Implementación en las Américas. Serie: La Renovación de la Atención Primaria de Salud en las Américas. Washington, D.C. nº 4. 2010..

The IHSDN may be defined as follows:

The aim is developing Primary Health Care (PHC) as a basis of the healthcare system and providing services in a way that is aligned with the user needs and preferences, with accessibility, equity, efficiency and technical quality⁸8 Organización Panamericana de la Salud. Redes Integradas de Servicios de Salud: Conceptos, Opciones de Política y Hoja de Ruta para su Implementación en las Américas. Serie: La Renovación de la Atención Primaria de Salud en las Américas. Washington, D.C. nº 4. 2010.. In Brazil, they are called Health Care Networks (HCN) and coordinated by the Primary Health Care (PHC), the first contact between users and the communication center with the Health Care Network (HCN)¹1 Vello LS, Popim RC, Carazzai EM, et al. Saúde do Idoso: percepções relacionadas ao atendimento. Esc. Anna Nery. Rio de Janeiro. 2014; 18(2):330-335.^,99 Brasil. Secretaria de Estado de Saúde do Distrito Federal. Portaria nº 77, de 14 de fevereiro de 2017. Publicada no Diário Oficial do Distrito Federal nº 33, seções I, II e III de 15 de fevereiro de 2017. Estabelece a Política de Atenção Primária à Saúde do DF. 15 fev 2017. [acesso em 2020 jul 14]. Disponível em: http://saude.df.gov.br/wp-conteudo/uploads/2018/04/Portaria-SES_DF-n%C2%BA-77-2017-Esstabelece-a-Pol%C3%ADtica-de-Aten%C3%A7%C3%A3o-Prim%C3%A1ria-%C3%A0-Sa%C3%BAde-do-Distrito-Federal.pdf.
http://saude.df.gov.br/wp-conteudo/uploa... . So the PHC strives to avoid the concentration of services and investments at the secondary and tertiary health care levels¹⁰10 Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Saúde do Idoso. [acesso em 2019 set 1]. Disponível em: http:www.portal.saude.gov.br.
http:www.portal.saude.gov.br... ^,1111 Lima-Costa MF, Matos DL, Camargos VP, et al. Tendências em dez anos das condições de saúde de idosos brasileiros: evidências da Pesquisa Nacional por Amostra de Domicílios (1998, 2003, 2008). Ciênc. Saúde Colet. 2011; 16(9):3689-3696..

The Family Health Strategy (FHS) is a model of services suggested by the PHC, emphasizes the whole set of actions and places the individual at the focus as integrated family member¹²12 Brasil. Ministério da Saúde. Política Nacional da Atenção Básica. 2017. [acesso em 2020 jul 14]. Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/prt2436_22_09_2017.html.
https://bvsms.saude.gov.br/bvs/saudelegi... , provides welcoming and qualified listening aimed at meeting the demands¹³13 Tesser CD, Neto PP, Campos GW. Acolhimento e desmedicalização social: um desafio para as equipes de saúde da família. Ciênc. Saúde Colet. 2010; 15(3):3515-624. and orients the user through his or her course of care within the HCN¹⁴14 Brasil. Ministério da Saúde. Portaria nº 4279, de 30 de dezembro de 2010. Estabelece diretrizes para a Rede de Atenção à Saúde. Diário Oficial da União. 30 Dez 2010. [acesso em 2020 jul 10]. Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2010/prt4279_30_12_2010.html.
https://bvsms.saude.gov.br/bvs/saudelegi... . The analysis of this health care pathway makes it possible to identify vulnerabilities and potentialities in the HCN¹⁵15 Gerhardt TE, Pinheiro R, Ruiz ENF, et al. Itinerários Terapêuticos e suas múltiplas dimensões desafios para a prática da integralidade e do cuidado como valor. In: Pinheiro R, Mattos RA. Razões Públicas para a integralidade em saúde: o cuidado como valor. 2. ed. Rio de Janeiro: UERJ-ABRASCO; 2009. p. 279-300. and uncovers the perception by the users of the quality of the care services delivered¹⁶16 Cabral ALLV, Martinez-Hemaez A, Andrade EIG, et al. Itinerários terapêuticos: o estado da arte da produção científica no Brasil. Ciênc. Saúde Colet. 2011; 16(11):4422-4442..

Considering the ageing of the population and the specificities required by the new epidemiological profile, as well as the presuppositions of the HCN and the PHC, this study identified healthcare pathways of the elderly in need for health services in a Health Region in the Federal District.

Material and methods

The qualitative study identified healthcare pathways of the elderly using tracer methodology¹⁷17 Kessner DM, Kalk CE, Singer J. Assessing health quality - the case for tracers. N. Engl. J. Med. 1973; 288(4):189-94.. Semi structured interviews were conducted with the elderly and the caregivers, and medical records were reviewed to serve as tracer for the analysis of the health care processes and to obtain information about how they actually operate on a day-to-day basis¹⁸18 Feuerwerker LCM, Merhy EE. Como temos armado e efetivado nossos estudos, que fundamentalmente investigam políticas e práticas sociais de gestão e de saúde? In: Mattos RA, Baptista TWF, organizadores. Caminhos para análise das políticas de saúde. Porto Alegre: Rede UNIDA, 2015, p. 439-460..

The study has been conducted in the Health Region West (HRW) of the Federal District (FD), which includes two Administrative Regions (AR): Ceilândia and Brazlândia. The first one, with 432 927 inhabitants (7,24% are elderly), is the most populated of the FD; the second region has 53.534 inhabitants (7,01% are elderly)¹⁹19 Companhia de Desenvolvimento e Planejamento de Brasília. Pesquisa Distrital por Amostra de Domicílios (PDAD): Microdados Ceilândia e Brazlândia. Brasília, DF: CODEPLAN; 2018.. The HRW was chosen in view of the high percentage of vulnerable elderly, at increased risk of functional decline and death²⁰20 Oliveira MLC, Amâncio TG, organizadoras. Situações de saúde, vida e morte da população idosa residente no Distrito Federal. Curitiba: CRV; 2016.. Five Family Health teams (FHt) from four Health Basic Units (BHU), three from Ceilândia and one from Brazlândia, were selected based on the age structure of their respective coverage areas.

Following this technique, each team was asked to indicate three meaningful cases of the service profile: typical, 1 succeeded, 1 under tension, totaling 15 tracer cases. The inclusion criteria were residence in the HRW and aged ≥18 years (if interview conducted by a caregiver, in case of cognitive impairment of the elderly person). The exclusion criteria were individuals not found after three attempts of getting in touch at different times of the day and through different media.

The interview script was designed after some exploratory visits²¹21 Gondim SMG. Grupos focais como técnica de investigação qualitativa: desafios metodológicos. Paidéia. 2003; 12(24):149-161., including nine questions related to the reason for going to the UBS, the perception about the care experience, the path of an individual through his course of care, the present health conditions of the elderly and their relationship with the PHC. The information was recorded (voice recorder Sony ICD-PX240), transcribed and interpreted. A semantic analysis of the content was performed, from the categories of analysis that emerged from the information/material²²22 Bardin L. Análise de conteúdo. São Paulo: 70. ed.; 2016..

The interviews subsidized the creation of maps, through geoprocessing tools, for three healthcare paths, using the Geocentric Reference System for America (Sirgas)²³23 Fundação Instituto Brasileiro de Geografia e Estatística. Sistema de Referência Geocêntrico para as Américas (SIRGAS). Rio de Janeiro: IBGE; 2000., and an infographic was designed to display them.

This survey was approved by the Ethics Committee under report numbers 2.202.975 (Brasília University) and 2.269.757 (FD Health Department). All participants signed the Free and Informed Consent Form.

Outcomes and discussion

In this study, one of the 15 cases indicated by the BHU was excluded because the attempts to contact were not returned. Thus, the healthcare pathways for 14 elderly people and their perceptions about health care in the FD were identified. The results showed that the course of care as foreseen by law, based on the norms and protocols of the FD Health Department, diverged from the one actually experienced by the elderly. However, despite the weaknesses they pointed out for the functioning of the HCN, all the respondents reported they were satisfied with the care provision and with their current health situation.

Most of the elderly were aged between 70 and 79 years old (42.9%), female (57.1%) and widowed (85.7%). Table 1 shows sociodemographic features of these elderly people.

Although most of them are widowers (85.7%) – which can have implications, as widowhood is related to more unfavorable health prognosis and early mortality²⁴24 Fernandes BL, Borgato MHA. Viuvez e a Saúde dos Idosos: uma Revisão Integrativa. Revista Kairós. Gerontologia. São Paulo. 2016; 19(3):187-204. –, 92.9% of the elderly lived with a relative, which allows us to infer that they are individuals who count on a social support network, an important aspect when it comes to adhering to treatment²⁵25 Aquino GA, Cruz DT, Silvério MS, et al. Fatores associados à adesão ao tratamento farmacológico em idosos que utilizam medicamento anti-hipertensivo. Rev. Bras. Geriatr. Gerontol. Rio de Janeiro. 2017; 20(1):116-127..

Regarding the situation of registration in the FHS, it was found that it was mostly carried out on spontaneous request in situations of seeking treatment for disease, emphasizing that there is a flaw in the registration made by the BHU, caused by failure in the work organization process or deficit of professionals²⁶26 Merhy EE. A perda da dimensão cuidadora na produção de saúde: uma discussão do modelo assistencial e da intervenção no seu modo de trabalhar a assistência. In: Campos CR, organizador. Sistema Único de Saúde em Belo Horizonte: reescrevendo o público. São Paulo: Xamã; 1998. p. 103-20.(figure 1).

In the FD, isolated experiences of the FHS have been carried out by some teams. However, only in 2017 this model of care was chosen as a structuring element of PHC, using the existing workforce in the BHU²⁷27 Fonseca HLP. A reforma de saúde de Brasília, Brasil. Ciênc. Saúde Colet. 2019; 24(6):1981-1990.. Thus, this panorama probably explains the short time span of the registers of the elderly in the FHS, most of them covering two years.

The healthcare pathways of the elderly

Healthcare pathways are paths chosen by individuals within the health network, and which may or may not lead to resolution and treatment¹⁵15 Gerhardt TE, Pinheiro R, Ruiz ENF, et al. Itinerários Terapêuticos e suas múltiplas dimensões desafios para a prática da integralidade e do cuidado como valor. In: Pinheiro R, Mattos RA. Razões Públicas para a integralidade em saúde: o cuidado como valor. 2. ed. Rio de Janeiro: UERJ-ABRASCO; 2009. p. 279-300.. Here, there is a counterpoint to the definition of a therapeutic path, which involves the search for health care by individuals, who, in quest of solutions to their problems, exceed health services, and their analysis considers socio-cultural aspects, which influence the individual pathways²⁸28 Glote CRM, Gerhardt TE. Itinerários terapêuticos: integralidade no cuidado, avaliação e formação em saúde. As trajetórias assistenciais revelando à rede de atenção à saúde dos portadores de doenças cardiovasculares. In: Pinheiro R, Mattos RA. Razões Públicas para a integralidade em saúde: o cuidado como valor. 2. ed. Rio de Janeiro: UERJ-ABRASCO; 2016.^,2929 Raupp LM, Dhein G, Medeiros CRG, et al. Doenças crônicas e trajetórias assistenciais: avaliação do sistema de saúde de pequenos municípios. Physis. 2015; 25(2).. In this study, we chose to trace the route as care pathways, in view of the need to identify flows between levels of care.

The elderly participants had comorbidities, such as: diabetes mellitus, systemic arterial hypertension, loss of vision limiting the performance in Activities of Daily Living (ADL), dementia, joint pain, pulmonary fibrosis, neoplasms and infectious diseases of compulsory notification, which probably made them go through public and/or private health services. Geoprocessing maps were prepared for only three of the 14 cases analyzed, since the lack of medical records, the memory bias and the absence of documents provided by the elderly and/or their families impaired the identification and confirmation of addresses of the health services accessed. The actual pathways were superimposed on those predicted, as suggested in the regulations governing HCN in the DF, and the result is shown infigure 2.

Figure 2.a represents the path of a 78-year-old woman whose complaint was ringing in the ears. She went to the BHU in her neighborhood, where a medical imaging procedure was prescribed. In view of the delay in care by a specialist in the HCN/UHS, she sought a private otolaryngology clinic. Figures 2.b and 2.c refer to two different paths of the same 89-year-old, who sought BHU due to persistent cough (figure 2.b), having been referred to Specialized Care (SC) to have imaging tests for suspected tuberculosis. In addition, years ago, he had been diagnosed with prostate cancer and had his first access through BHU, as shown in figure 2.c.

In the three presented pathways, it becomes evident that the BHU of the coverage area was the first access for the cases and made the reception and forwarding to the SC. However, from that point on, the flow did not occur as expected, because in two of the three cases (figures 2.b and 2.c), the elderly accessed the private network, for consultation with a specialist and for complementary tests, to avoid waiting lines at UHS This finding corroborates the study by Raupp et al.²⁹29 Raupp LM, Dhein G, Medeiros CRG, et al. Doenças crônicas e trajetórias assistenciais: avaliação do sistema de saúde de pequenos municípios. Physis. 2015; 25(2)., which points out this fragility as present throughout the country. In the DF, it was only in 2018 that the Health Regulatory Complex (CRDF) was implemented, with PHC as the organizer of access, which could explain the difficulty for the elderly to schedule medical consultations and specialized tests³⁰30 Batista SR, Vilarins GCM, Lima MG, et al. O Complexo Regulador em Saúde do Distrito Federal, Brasil, e o desafio da integração entre os níveis assistenciais. Ciênc. Saúde Colet. Distrito Federal. 2019; 24(6):27..

Comparing the actual course of care with the predicted one, it was observed that none of the cases followed the expected treatment path, which is indicative of poor integration between the points of care and flaws in the technologies available in the health system, generating fragmentation of care and a longer and more expensive path for the elderly¹²12 Brasil. Ministério da Saúde. Política Nacional da Atenção Básica. 2017. [acesso em 2020 jul 14]. Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/prt2436_22_09_2017.html.
https://bvsms.saude.gov.br/bvs/saudelegi... ^,3131 Brasil. Ministério da Saúde. Portaria nº 4.279, de 30 de dezembro de 2010. Estabelece diretrizes para a organização da rede de atenção à saúde no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União. 30 Dez 2010. seção I, página 89., in addition to making them more likely to develop other comorbities³²32 Brasil. Ministério da Saúde. Portaria nº 2048/GM, de 05 de novembro de 2002. Diário Oficial União. 2002 Nov 5. [acesso em 2020 jul 10]. Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2002/prt2048_05_11_2002.html.
https://bvsms.saude.gov.br/bvs/saudelegi... ^,3333 Alves MLF, Guedes HM, Martins JCA, et al. Rede de referência e contrarreferência para o atendimento de urgências em um município do interior de Minas Gerais - Brasil. Rev. Med. Minas Gerais. 2015; 25(4):469-475.. The longitudinal monitoring carried out within the health service, especially by the PHC, confirms the efficiency of the BHU and the user’s satisfaction with the care provision. Conversely, these care paths show weaknesses in the functioning of referral and counter-referral flows, thus hindering access to SC³⁴34 Cunha EM, Giovanella L. Longitudinalidade/continuidade do cuidado: identificando dimensões e variáveis para a avaliação da Atenção Primária no contexto do sistema público de saúde brasileiro. Ciênc. Saúde Colet. 2011; 16(1):1029-1042..

The results showed that, although the path of the elderly started in the public network, there were steps taken the private network, regardless of the complexity of the cases, as referrals made to the SC also had flows diverted to services paid for by the users themselves (figure 2.a). It was highlighted that in the situation of greater complexity (treatment of prostate cancer, figure 2.c), in which the actual course of care was outside the health region of the elderly’s residence, the health equipment used was mostly from HCN/UHS, that is, the network itself indicated alternative care paths for timely and free treatment of the neoplasm, although through a longer course of care and outside the HRW.

Spedo et al.³⁵35 Spedo SM, Pinto NRS, Tanaka OY. O difícil acesso a serviços de média complexidade do SUS: o caso da cidade de São Paulo, Brasil. Physis. Rio de Janeiro. 2010; 20(3):953-972., in a similar study conducted in São Paulo (SP), stated that the most complicated bottleneck was in services of medium complexity, especially due to managerial failures related to the lack of political prioritization, despite the existence of mechanisms, such as the regulatory complex and the computerization of the operations. These authors pointed out that there must be a logic of feedback between PHC and medium complexity, because access to SC is necessary for PHC to be more effective in solving health problems, and, in contrast, if PHC has a poor level of effectiveness, referrals to SC will increase. In the FD, the analyzed pathways did not occur as expected, showing a real fragmented flow resulting from weaknesses in the logistical systems involving the FD/HRC, a situation that hinders access to specialized levels and comprehensive care, making the elderly’s journey longer and financially expensive³³33 Alves MLF, Guedes HM, Martins JCA, et al. Rede de referência e contrarreferência para o atendimento de urgências em um município do interior de Minas Gerais - Brasil. Rev. Med. Minas Gerais. 2015; 25(4):469-475..

Perception of the elderly about health care for the elderly in PHC

The perspective of users and their satisfaction with the care in addition to the analysis of the paths taken in search of health care must be considered as strategies for the evaluation of the care provision, so that the gap between the theory and the reality of SUS does not prevent the realization of RAS³⁶36 Uchimura KY, Bosi MLM. Qualidade e subjetividade na avaliação de programas e serviços em saúde. Cad. Saúde Pública. Rio de Janeiro. 2002; 18(6):1561-1569..

The content analysis of the interviews with the elderly allowed us to identify four different analysis categories, all correlated to SUS principles and/or guidelines and PHC (chart 1).

The users’ perceptions were related to both strengths and weaknesses in the path of care, in the Federal District (DF), and the main ones are shown in figure 3.

HUMANIZATION IN CARE SERVICE

In user-centered practices, it is necessary to develop skills for adequate reception and establishment of a bond between staff, professionals and users²⁷27 Fonseca HLP. A reforma de saúde de Brasília, Brasil. Ciênc. Saúde Colet. 2019; 24(6):1981-1990.. Thus, user welcoming should be seen as a powerful device and operational guideline for the health system, being useful for the identification of demands, the construction of a professional-user bond and comprehensive care, in compliance with PHC principles³⁷37 Starfield B. Atenção primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. Brasília, DF: Organização das Nações Unidas para a Educação, a Ciência e a Cultura; Ministério da Saúde; 2002.

38 Fagundes S. Apresentação. In: Ortiz JN, Bordignon MO, Gralha RS, et al. Acolhimento em Porto Alegre: um SUS de todos para todos. Porto Alegre: Prefeitura Municipal de Porto Alegre; 2004. p. 11-2.^-3939 Souza ECF, Vilar RLA, Rocha NSPD, et al. Acesso e acolhimento na atenção básica: uma análise da percepção dos usuários e profissionais de saúde. Cad. Saúde Pública, Rio de Janeiro. 2008; 24(l):100-110..

In this study, welcoming and qualified listening were identified as potential, and the reports were associated with quality and the feeling of well-being after the visits, as shown below:

It was noted that the satisfaction of the elderly was causally related to welcoming and bonding, thus demonstrating their importance for the continuity of care and highlighting them as potentialities of PHC. A similar result was identified by Uchoa et al.⁴⁰40 Uchoa AC, Souza EL, Spinelli AFS, et al. Avaliação da satisfação do usuário do Programa de Saúde da Família na zona rural de dois pequenos municípios do Rio Grande do Norte. Physis, Rio de Janeiro. 2011; 21(3):1061-1076. and by Vello et al.¹1 Vello LS, Popim RC, Carazzai EM, et al. Saúde do Idoso: percepções relacionadas ao atendimento. Esc. Anna Nery. Rio de Janeiro. 2014; 18(2):330-335., who highlighted welcoming and bonding as the most satisfactory dimensions of care for users.

Bond building presupposes the relationships of affection and trust³⁶36 Uchimura KY, Bosi MLM. Qualidade e subjetividade na avaliação de programas e serviços em saúde. Cad. Saúde Pública. Rio de Janeiro. 2002; 18(6):1561-1569., and the ties between those involved are strengthened when socializing becomes frequent, contributing to the effectiveness of the treatment, and avoiding unnecessary consultations and hospitalizations, as users adhere better to the proposed treatments⁴¹41 França AJ, Andrade FA, Araújo TM, et al. Relação intraequipe e produção de vínculos em uma Unidade de Saúde da Família. EFDeportes. 2014; 18(190).. These relational technologies are especially important for the elderly who, for the most part, have chronic non-communicable diseases, depend on drug treatment, and need continued health care.

ORGANIZATION OF WORK PROCESSES

The elderly reported their difficulty in accessing the BHU, which demonstrated the poor organization of work processes. One of the major attributes of PHC is accessibility, defined with the provision of services by HCN, because access is mandatory for health care to be delivered³⁸38 Fagundes S. Apresentação. In: Ortiz JN, Bordignon MO, Gralha RS, et al. Acolhimento em Porto Alegre: um SUS de todos para todos. Porto Alegre: Prefeitura Municipal de Porto Alegre; 2004. p. 11-2.. Access and accessibility have close meanings, since they are related to the capacity, not only to produce and offer services, but also to make them responsive to the health needs of the population. Here we used the concept of accessibility, which includes both the geographic dimension (distance, time and cost of transportation) and the socio-organizational dimension (ability to meet demands adequately and timely)⁴²42 Donabedian A. An introduction to quality assurance in health care. New York: Oxford University, 2003..

Regarding accessibility, the elderly reported important weaknesses in PHC:

According to Franco et al.⁴³43 Franco TB, Bueno WS, Merhy EE. O acolhimento e os processos de trabalho em saúde: o caso de Betim, Minas Gerais, Brasil. Cad. Saúde Pública. 1999; 15(2):345-53., the PHC restructuring took place with the implementation of the ESF to ensure the organization of the work process and service to all users who seek the unit, with no need for number slips and lines at dawn. However, the speech of the user ‘UBS C, I1’ demonstrates that, even 25 years after the implementation of the FHS in Brazil, and considering that two years have passed since the adoption of the FHS in the FD, some BHU still work in the traditional way, forcing users to wait in long lines to be served.

The distance from the service location reported by the user ‘UBS D, I2’ demonstrates the adverse reality of the recommendation made by Silva et al.⁴⁴44 Silva KL, Sena RR, Seixas CT, et al. Desafios da política, da gestão e da assistência para a promoção da saúde no cotidiano dos serviços. REME - Rev. Min. Enferm. 2012; 16(2):178-187., who affirm that the proximity of the service location is one of the fundamental aspects in PHC, which must offer services in a planned way and considering the geographical location of the BHU, which in turn must be strategically close to the population’s homes to improve accessibility, especially for elderly people.

Home visits by health personnel have the effect of providing satisfaction to the elderly, because of the direct contact with users. Conill⁴⁵45 Conill EM. Políticas de atenção primária e reformas sanitárias: discutindo a avaliação a partir da análise do Programa saúde da Família em Florianópolis, Santa Catarina, Brasil, 1994-2000. Cad. Saúde Pública. 2002; 18(1):191-202. identified in his survey that visits were assessed as positive by respondents. In the present study, the elderly showed a greater sense of well-being and satisfaction when home visits were part of their prescribed care and claimed a higher frequency of this type of service.

Efforts were also noted to prioritize care for the elderly, perhaps to comply with the Elderly Statute (EI), which ensures them this right in public and private bodies⁴⁶46 Brasil. Lei nº 10.741, de 01 de outubro de 2003. Dispõe sobre o Estatuto do Idoso e dá outras providências. Diário Oficial da União. 1 Out 2003 [acesso em 2020 jul 10]. Disponível em: http://www.planalto.gov.br/ccivil_03/leis/2003/l10.741.htm.
http://www.planalto.gov.br/ccivil_03/lei... . The records of some users show situations in which access was facilitated:

A study with multidisciplinary teams in São Paulo identified a positive change in the behavior of those involved in caring for the elderly after the publication of the IS and found, above all, greater respect in care⁴⁷47 Martins MS, Massarollo MCKB. Mudanças na assistência ao idoso após promulgação do estatuto do idoso segundo profissionais de um hospital geriátrico. Rev. Esc. Enferm. USP 2008; 42(1):26-33.. In Salgueiro, in the inland area of the state of Pernambuco, elderly people interviewed about their satisfaction with the care provision at the PHC, reported that their expectations were met whenever they sought the service (82.3%). However, regarding the priority, 38.5% stated that there is no differentiation, emphasizing that, in some PHC, the course of care of the elderly followed the same criteria as that of users of other ages⁴⁸48 Parente AS, Mesquita FOS, Oliveira MR. Satisfação dos idosos atendidos pela estratégia de saúde da família em um município do interior de Pernambuco. Rev. Adm. Saúde. 2017; 17(68)..

PHC ORGANIZATIONAL RESOURCES

The lack of medicines and medical materials for users demonstrates the fragility of the free UHS principle, which should not generate financial costs for the elderly, and must guarantee pharmaceutical assistance⁴⁹49 Viacava F, Oliveira RAD, Carvalho CC, et al. SUS: oferta, acesso e utilização de serviços de saúde nos últimos 30 anos. Ciênc. Saúde Colet. Rio de Janeiro. 2018; 23(6):1751-1762.. Elderly people are frequent users of health services and, for the most part, they need medication throughout their lives⁵⁰50 Brasil. Ministério da Saúde. Política Nacional de Medicamentos. Aprovada pela Portaria nº 3.916, de 01 de outubro de 1998. Brasília: 1998. [acesso em 2020 jul 14]. Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/gm/1998/prt3916_30_10_1998.html.
https://bvsms.saude.gov.br/bvs/saudelegi... . Thus, this unavailability affected the lives of elderly users.

Adding to this, the deficient infrastructure was also pointed out by a user as a hindrance to the resolution of problems.

For Paim⁵¹51 Paim JS. Sistema Único de Saúde (SUS) aos 30 anos. Ciênc. Saúde Colet. 2018; 23(6):1723-1728., the negative aspects of the consolidation of the UHS include medication and pharmaceutical assistance policies, and incipient infrastructure. For him, this may be the result of limited investments in the public health sector in Brazil, which are reflected in difficulties in maintaining services and expanding infrastructure.

In addition to the lack of medicines and supplies, the elderly perceived a lack of health professionals. The eSF must include at least one family doctor or general practitioner, one nurse, one nursing assistant and one Community Health Agent (CHA) for every 750 people⁹9 Brasil. Secretaria de Estado de Saúde do Distrito Federal. Portaria nº 77, de 14 de fevereiro de 2017. Publicada no Diário Oficial do Distrito Federal nº 33, seções I, II e III de 15 de fevereiro de 2017. Estabelece a Política de Atenção Primária à Saúde do DF. 15 fev 2017. [acesso em 2020 jul 14]. Disponível em: http://saude.df.gov.br/wp-conteudo/uploads/2018/04/Portaria-SES_DF-n%C2%BA-77-2017-Esstabelece-a-Pol%C3%ADtica-de-Aten%C3%A7%C3%A3o-Prim%C3%A1ria-%C3%A0-Sa%C3%BAde-do-Distrito-Federal.pdf.
http://saude.df.gov.br/wp-conteudo/uploa... . However, this number of professionals is often insufficient due to the large coverage area and the high demand. In addition to the disruption of work processes, this may result in loss of quality of the services provided, in addition to causing professional overload, as shown below:

The speech of the elderly person ‘UBS B, I1’ illustrates health awareness, as the user understands that there is a deficit of professionals and recognizes that they are overloaded. The recognition of the population and their participation in the organization, management and control of health actions and services play a major role in improving public policies, due to the importance of the division of responsibilities between users and UHS⁵²52 Arakawa AM, Simone ALH, Magali LC, et al. Percepção dos usuários do sus: expectativa e satisfação do atendimento na Estratégia de Saúde da Família. Rev. CEFAC. 2012; 14(6):1108-1114.. The pressure exerted on the team shows the disorganization of the care provision and points out the need for strategies and skills to deal with aging.

Considering the reform of the PHC (Converte APS), through which the FHS became mandatory in all BHU in the FD, the low adherence on the part of physicians was highlighted, which could explain the situation reported above. Physicians who chose not to remain in PHC were relocated to other levels of health care. This prompted actions to maintain minimal health care for the population, such as the creation of the position of nurse specialist in family and community health and the carrying out of public exams for hiring nurses and doctors specialized in family and community medicine. However, the deficit of CHA is an even greater bottleneck: three thousand professionals are necessary, and only a minimum is available for the training of the teams, totaling one thousand CHA²⁷27 Fonseca HLP. A reforma de saúde de Brasília, Brasil. Ciênc. Saúde Colet. 2019; 24(6):1981-1990..

HEALTH CARE IN THE SC

The operation of the SC within the UHS goes without the organization in HCN, which responds for the accomplishment of the principle of integral care, to avoid fragmenting the health care delivery at different levels of complexity³⁰30 Batista SR, Vilarins GCM, Lima MG, et al. O Complexo Regulador em Saúde do Distrito Federal, Brasil, e o desafio da integração entre os níveis assistenciais. Ciênc. Saúde Colet. Distrito Federal. 2019; 24(6):27.^,5353 Arruda C, Lopes SGR, Koerich MHAL, et al. Redes de atenção à saúde sob a luz da teoria da complexidade. Esc. Anna Nery. 2015; 19(1):169-173..

When asked whether they had already sought health care from other services and how their experience had been after their consultation in BHU, the elderly reported negative experiences with being referred to specialized levels of medium and high complexity.

Survey indicates lack of communication between the levels of care as responsible for further fragmenting the health care process and compromising the integrity of the actions⁵⁴54 Gouveia GC, Souza WV, Luna CF, et al. Satisfação dos usuários do sistema de saúde brasileiro: fatores associados e diferenças regionais. Rev. Bras. Epidemiol. 2009; 12(3):281-96.. The elderly is referred to other levels of care when the PHC does not provide the care required, as when tests are necessary that require greater technological density⁵⁵55 Santos CTB, Andrade OLM, Silva MJ, et al. Percurso do idoso em redes de atenção à saúde: um elo a ser construído. Physis. 2016; 26(1):45-62.. Thus, the demand for SC exceeds the service provision, generating huge lines and causing the fragmentation of the elderly health care.

User ‘UBS C, I1’ reports difficulty to get a test and to return for a new consultation with the doctor. This uncovers a problem with provision of appropriate access, as well as a failure in communication between different points of care, thus imposing on the elderly a longer treatment path, with higher social costs⁵¹51 Paim JS. Sistema Único de Saúde (SUS) aos 30 anos. Ciênc. Saúde Colet. 2018; 23(6):1723-1728.. Furthermore, the financial costs of the SC are increased as the user needs to take new tests for not having been able to schedule a follow-up consultation in due time.

Final considerations

The pathway of an elderly through his course of care is still quite different from what is stipulated by the law, and accessibility barriers cause difficulties that hinder the provision of appropriate access and the solution of care related problems. It became evident that even though the model of health care is still fragmented and far from an ideal situation where all PHC features are present, the users are satisfied with the care provided and identify humanizing attitudes and solidarity building in the health care practices.

Vulnerable points include the lack of materials and medicines, infrastructure and human resources, difficulties to access the care services and failures in the communication among levels of care/departments.

The BHU has a great potential that is perceived by the users. However, the organization of related processes and their articulation with the other levels of health care need to be revised and revamped to meet the specificities of this life cycle.

References

Publication Dates

History