ABSTRACT

This study aimed to analyze the profile and the main demands presented by young people (15 to 29 years old) to the Unified Health System (SUS) General Ombudsman of the Ministry of Health of Brazil. The databases ‘manifestations’ and ‘citizen profile’ of the System were extracted from the OuvidorSUS computerized system, referring to the years 2014 to 2018. The data were analyzed according to the service channels, classification, and typification. The profile was disaggregated by age, race/color, gender, sexual orientation, education, occupation, and income. 114,618 manifestations were registered with the citizen’s profile, with 15.17% being by people from 15 to 29 years old. Blacks (including pardos), women, heterosexuals, with completed or ongoing higher education, income of up to 2 minimum wages, and employed in the private sector prevailed. Most of the manifestations were ‘requests’, followed by ‘complaints’ and ‘denunciations’. Most requests were for consultations and surgeries, in the areas of gynecology and obstetrics, and orthopedics and traumatology. Complaints and denunciations were largely related to management, especially to health professionals and establishments. The suggestions were the least frequent. The demands largely reflect the services used by young people and should be considered by managers to guide health policies appropriate to this population.

KEYWORDS
Adolescent health; Young adult; Social participation; Health services needs and demand; Health management

Introduction

The recognition of the priority for rights of children and adolescents has been consolidated over the years; However, it is more recent the recognition of the different needs of the young population (up to 29 years old), with the objective of directing public policies that ensure an environment that allows them to thrive, reach their full potential and contribute to their own development and that of their community. As outlined in the 2030 Agenda for Sustainable Development¹1 Organização das Nações Unidas. Transformando Nosso Mundo: A Agenda 2030 para o Desenvolvimento Sustentável. Nova York: ONU; 2015. [acesso em 2020 mar 22]. Disponível em: https://nacoesunidas.org/wp-content/uploads/2015/10/agenda2030-pt-br.pdf.
https://nacoesunidas.org/wp-content/uplo... , young people are fundamental agents of change and must be empowered.

Considering the fact that the specific needs of adolescents and young people were not being adequately addressed and taking into account that health outcomes are more effective when health promotion, primary care, social protection and social determinants are considered, in 2008, the countries of the Americas region, going beyond the strategies put at the global level, adopted and committed to the ‘Regional Strategy to Improve the Health of Adolescents and Youth’. The goals of the Strategy referred to the reduction of violence and mortality among adolescents and young people; the decrease in the use of alcohol, tobacco and other drugs; fighting chronic diseases; guaranteeing sexual and reproductive health; and the promotion of mental health, nutrition, physical activity and protective factors²2 Organização Pan-Americana da Saúde. 48º Conselho Diretor. 60ª Sessão do Comitê Regional da Organização Mundial da Saúde para as Américas. Estratégia Regional para Melhorar a Saúde do Adolescente e da Juventude. Washington, DC: OPAS; 2008..

Overall, the region has made progress in implementing the strategy, with 93% of countries and territories in the Americas having developed or updated plans and policies aimed at adolescent and youth health³3 Organização Pan-Americana da Saúde. 57º Conselho Diretor. 71ª Sessão do Comitê Regional da Organização Mundial da Saúde para as Américas. Estratégia e Plano de Ação para a Saúde do Adolescente e do Jovem: Relatório Final. Washington, DC: OPAS; 2019.. However, progress in the region is not homogeneous, and large variations persist between countries and within each country, with greater burdens of morbidity and mortality among groups with lower socioeconomic and educational levels, in addition to rural, indigenous and Afro-descendant populations. Mortality in adolescents, especially from preventable causes, has remained stable or has increased, and the rate of teenage pregnancy remains unacceptably high⁴4 Organização Pan-Americana da Saúde. 56º Conselho Diretor. 70ª Sessão do Comitê Regional da Organização Mundial da Saúde para as Américas. Plano de Ação para a Saúde da Mulher, da Criança e do Adolescente 2018-2030. Washington, DC: OPAS; 2018..

In Brazil, in 2013, the Youth Statute was instituted, providing for the rights of young people and the principles and guidelines of public youth policies. According to the Statute, people aged between 15 and 29 are considered young people. The Statute includes a specific section on the right to health, with broad guidelines, such as universal, integral and humanized access, but also with an emphasis on specific policies and programs, essentially referring to the consumption of alcohol and other drugs and to sexual and reproductive health. The intersectoral character and the promotion of autonomy and the social and political participation of young people receive considerable emphasis, including in the formulation, implementation and evaluation of public policies⁵5 Brasil. Lei nº 12.852, de 5 de agosto de 2013. Institui o Estatuto da Juventude e dispõe sobre os direitos dos jovens, os princípios e diretrizes das políticas públicas de juventude e o Sistema Nacional de Juventude - SINAJUVE. Diário Oficial da União. 5 Ago 2013..

However, comprehensive health care for adolescents and young people is an incomplete agenda in the country. Despite important attempts made in the early 2000s, with strong involvement of civil society and other interested actors, the National Policy for Comprehensive Health Care for Adolescents and Young People never left its preliminary version, presented in 2006, as a result of changes in politics, technical aspects and direction of the agenda⁶6 Lopez SB, Moreira MCN. Quando uma proposição não se converte em política?: O caso da Política Nacional de Atenção Integral à Saúde de Adolescentes e Jovens - PNAISAJ. Ciênc. Saúde Colet. 2013; 18(4):1179-1186.. In 2010, the National Guidelines for Comprehensive Health Care for Adolescents and Young People in the Promotion, Protection and Recovery of Health⁷7 Brasil. Ministério da Saúde, Secretaria de Atenção em Saúde, Departamento de Ações Programáticas Estratégicas. Diretrizes nacionais para a atenção integral à saúde de adolescentes e jovens na promoção, proteção e recuperação da saúde. Brasília, DF: Ministério da Saúde; 2010. were published, with structuring themes such as youth participation, gender equity, sexual and reproductive rights, culture of peace, racial equality and ethnic. The guidelines provide important guidelines for managers and health professionals, however, without the force of an established Policy.

Despite some normative advances, there are still numerous challenges to guarantee the rights of the young population, who experience the consequences of inequality in access to rights due to race/color, gender, sexual orientation, social class, among others. Young black people are the main victims of violence (including that perpetrated by the State)8, as well as LGBTTI+ (Lesbians, Gays, Bisexuals, Transvestites, Transsexuals, Intersexuals and others) experience situations of violence and exclusion on a daily basis, which directly affects their living and health conditions⁹9 Brasil. Ministério da Saúde, Secretaria de Gestão Estratégica e Participativa, Departamento de Apoio à Gestão Participativa. Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais. Brasília, DF: Ministério da Saúde; 2013..

In addition, adolescents and youth continue to face significant legal, political, organizational, and social obstacles to receiving quality, age-appropriate, comprehensive health care, finding services fragmented and not aligned with their needs. To improve the quality of responses adapted to the unique characteristics of this stage of the life cycle, it is necessary to create formal and sustainable mechanisms to facilitate and ensure the full engagement of young people³3 Organização Pan-Americana da Saúde. 57º Conselho Diretor. 71ª Sessão do Comitê Regional da Organização Mundial da Saúde para as Américas. Estratégia e Plano de Ação para a Saúde do Adolescente e do Jovem: Relatório Final. Washington, DC: OPAS; 2019..

In the Unified Health System (SUS), the participation of users in the management of the system is favored both by instances provided for in Law No. 8,142 of 1990¹⁰10 Brasil. Lei nº 8.142, de 28 de dezembro de 1990. Dispõe sobre a participação da comunidade na gestão do Sistema Único de Saúde (SUS) e sobre as transferências intergovernamentais de recursos financeiros na área da saúde e dá outras providências. Diário Oficial da União. 28 Dez 1990., which includes health councils and conferences, as well as by other instances and participatory mechanisms, such as the ombudsman. The SUS Ombudsmen seek to carry out qualified listening for the assessment and care of individual situations, as well as to support decisions that represent collective improvements, qualifying public services. For this, they carry out the process of registering manifestations, forwarding them, responding to citizens and writing reports for management and society¹¹11 Brasil. Ministério da Saúde, Secretaria de Gestão Estratégica e Participativa, Departamento de Ouvidoria-Geral do SUS. Manual das Ouvidorias do SUS. Brasília, DF: Ministério da Saúde; 2014.. However, these reports often present very general information, without a breakdown to identify the specific needs of each group. There is also little information on the access and use of these channels by young people.

It is in this perspective that the present article intends to analyze the demands presented by adolescents and young people from 15 to 29 years old to the SUS General Ombudsman (OuvSUS) of the Ministry of Health and the profile of these citizens, in order to broaden the understanding of the health needs of this population and subsidize the direction of specific actions and policies.

Methodology

This study, carried out using secondary data, was developed from the database of the ‘OuvidorSUS’ computerized system, used in all stages (registration, referral, response and construction of reports) of the process of dealing with citizens’ manifestations to the SUS’ General Ombudsman’s Office of the Ministry of Health.

From the database referring to the profile of the citizen, the manifestations of adolescents and young people from 15 to 29 years old (age group considered by the Youth Statute) were collected, extracted from the OuvidorSUS system, through access to the database in SQL – Structured Query Language. The period of analysis considered was the five-year period from 2014 to 2018, considering that, in 2013, there was an evolution in the system that caused a change in the database, ensuring a higher quality of the information presented from then on; and, after the period presented, the citizen profile (survey) was discontinued by the SUS’ General Ombudsman.

Data collection from the system was carried out between May and August 2019, with the extraction of Excel^® spreadsheets for analysis, taking into account the manifestations registered by the young population to the SUS General Ombudsman. The citizen’s profile was analyzed from the categories referring to age, sex, sexual orientation, race/color, education, occupation and income range, derived from the OuvidorSUS System itself. The manifestation was analyzed according to period, service channel, classification and typification (subject, subtopics 1, 2 and 3). The classification and typification of demands are carried out by the SUS General Ombudsman’s Office, according to the SUS Ombudsman System Typification Manual¹²12 Brasil. Ministério da Saúde, Secretaria de Gestão Estratégica e Participativa, Departamento de Ouvidoria-Geral do SUS. Manual de Tipificação do Sistema OuvidorSUS. Brasília, DF: Ministério da Saúde; 2017., which is also included in that System.

Results and discussion

Between 2014 and 2018, the SUS Ombudsman’s Office filed 216,832 manifestations in the OuvidorSUS System, with 114,618 people having responded to the Citizen Profile (52.86%). The survey of the citizen’s profile is optional for those who contact Dial Saúde 136, and it is up to the tele-attendant, in agreement with the Ombudsman’s management, to apply a questionnaire on socioeconomic issues that link the population to registering the manifestation or receiving guidance in health, allowing to present the relation of the demands with the characteristics of the population.

Citizen Profle

Among the users who responded to the Citizen Profile in the period, 17,391 (15.17%) were between 15 and 29 years old (with a higher prevalence of the 20-29 age group), whose characteristics are detailed in table 1. It is worth noting that, according to the last demographic census, in 2010, 26.90% of the Brazilian population was in this age group¹³13 Brasil. Instituto Brasileiro de Geografia e Estatística. Censo Demográfico 2010. Brasília, DF: IBGE; 2010. [acesso em 2020 mar 22]. Disponível em: https://www.ibge.gov.br.
https://www.ibge.gov.br.... , a proportion much higher than that presented by the Ombudsman’s claimants.

There is an increase in the number of profile questionnaires answered until 2017, which represented more than double that of 2014; however, in 2018, a decrease is seen. At the end of that year, the questionnaire was no longer applied. In addition, the use of other channels of the Ombudsman also increased, such as the ‘Meu DigiSUS’ app and e-mail, which do not supply the survey to be filled. It is noteworthy that, in 2018, more protocols were registered with the Ombudsman than in previous years (n=58,975, considering all age groups), but fewer profiles were filled out.

The Health Hotline 136, which is free of charge, is the main service channel of OuvSUS, receiving more than half of the total manifestations of the five-year period. However, among the young population, assistance via the web form was the majority, accounting for 9,227 (53.06%), followed by 8,157 manifestations via Dial Saúde 136 (46.90%) and less than 0.5% via letters and emails.

Given the relevance of digital technology in the daily life of youth, the development of digital health strategies should be promoted as part of the response to adolescent and youth health3. In addition to the web form, the ‘Meu DigiSUS’ app, which has been sending requests to the Ombudsman since 2017, may be promising in expanding the use of this channel, since the use of mobile technologies and applications has increased considerably in the world¹⁴14 Lucena S. Culturas digitais e tecnologias móveis na educação. Educ rev. 2016; (59):277-290.. It is important to emphasize that these channels must include socioeconomic survey, for better understanding of the needs of different population groups.

As for the sex of the plaintiff, the access of the female population prevailed. The literature shows a greater demand by women for health services, in which self-care associated with the search for a health service would be naturalized as more typical of the female public, a situation that needs to be faced for an integral attention to the health of young people and, in particular, to men’s health¹⁵15 Lopez SB, Moreira MCN. Políticas Nacionais de Atenção Integral à Saúde de Adolescentes e Jovens e à Saúde do Homem: interlocuções políticas e masculinidade. Ciênc. Saúde Colet. 2013; 18(3):743-752.. Among the adolescent population, there is also a more negative perception of women about their own health, which can influence the search for services¹⁶16 Higuita-Gutiérrez LF, Cardona-Arias JA. Meta-análisis de la percepción de la calidad de vida relacionada con la salud del adolescente según el género. Rev Fac Nac Salud Pública. 2015; 33(2):228-238..

Blacks (blacks + browns) were the majority of applicants, in a proportion similar to the distribution of the Brazilian population. In the period from 2014 to 2018, 59.69% of the records of live births in Brazil were of blacks and browns¹⁷17 Brasil. Ministério da Saúde, Departamento de Informática do SUS. Informações de saúde (TABNET). [acesso em 2020 mar 25]. Disponível em: http://www2.datasus.gov.br/DATASUS/index.php?area=02.
http://www2.datasus.gov.br/DATASUS/index... . There were few manifestations of indigenous and yellow people. In addition to the quantitative, it is important that the administrations consider the racial perspective in the analysis of users’ demands, in order to identify specific health needs and evaluate the access and quality of services from the perspective of equity.

Regarding sexual orientation, the majority reported being heterosexual, and the minority, transvestite and transsexual, and these two categories refer to gender, not sexual orientation. There is a high proportion without registration, even higher in the group between 15 and 19 years old (36.45%), which may reflect a citizen’s refusal to respond, but also a resistance from the Ombudsman’s own technician to question. The low amounts of data must be analyzed by management, as they can represent a context of a specific population that suffers prejudice and lack of access and can guide permanent education actions and the implementation of services that improve care, according to equity policies, to the LGBTTI+⁹9 Brasil. Ministério da Saúde, Secretaria de Gestão Estratégica e Participativa, Departamento de Apoio à Gestão Participativa. Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais. Brasília, DF: Ministério da Saúde; 2013. population.

As for education, the data reflect a high level of education, even higher than that of the general population that accesses the OuvSUS service. Some possible errors in data recording were identified, since some cases were marked as Doctoral (n=3) and Post-Doctoral (n=11) for the population aged 15 to 19 years, a very unlikely situation. This inconsistency may result from a possible confusion between the registration of information by the contacting citizen and the person to whom the demand refers or from an error in filling in the technician. However, these cases represented only 1% of the total in this age group.

Occupancy has the highest percentage of missing registration. Among those who responded, most work in the private sector. There is a high proportion of unemployed, almost a third of the respondents. In Brazil, almost 11 million young people aged between 15 and 29 are not in the job market or studying¹⁸18 Instituto Brasileiro de Geografia e Estatística. PNAD Contínua - Suplemento Educação 2018. Brasília, DF: IBGE; 2019.. The issue of youth unemployment is a major concern that also affects health and development issues. The Sustainable Development Goals have specific targets for reducing the proportion of young people without employment, education or training and for achieving full employment and decent work for all women and men, including young people and people with disabilities, with equal pay for work of equal value¹1 Organização das Nações Unidas. Transformando Nosso Mundo: A Agenda 2030 para o Desenvolvimento Sustentável. Nova York: ONU; 2015. [acesso em 2020 mar 22]. Disponível em: https://nacoesunidas.org/wp-content/uploads/2015/10/agenda2030-pt-br.pdf.
https://nacoesunidas.org/wp-content/uplo... .

Income was not answered by almost 25% of citizens. Among the respondents, there is a relatively low income, up to two minimum wages (57.19%), despite high schooling. Social inequalities directly affect young people, and socioeconomic conditions impact their health conditions, morbidity and mortality¹⁹19 Schaefer R, Barbiani R, Nora CRD, et al. Políticas de Saúde de adolescentes e jovens no contexto luso-brasileiro: especificidades e aproximações. Ciênc. Saúde Colet. 2018; 23(9):2849-2858..

Manifestations

Regarding the manifestations, the access channels to a SUS Ombudsman allow the receipt of six types of classifications (requests, praise, denunciation, complaints, suggestions and information), from the perspective of obtaining data to determine the health needs of the population, to guarantee the right, to evaluate practices, actions and services and to support managers in decision-making. Requests during the study period represent about 32.94% of the 17,391 manifestations, followed by complaints (31.48%), denunciation (18.04%) and information (14.30%). Compliments (1.69%) and suggestions (1.55%) were much less frequent.

Thus, more than 80% of the manifestations registered by young people in the period from 2014 to 2018 referred to some type of difficulty in accessing or problem in the health services. Requests present the need for access to a certain input, consultation, diagnosis or treatment, which possibly were not made available by the normal flow of services or within a period and conditions considered acceptable by the user. Although they may indicate dissatisfaction, they contain requirements and, therefore, are not classified as complaints. Complaints report dissatisfaction with health actions and services. Denunciations, on the other hand, indicate evidence of irregularity in administration and/or service¹²12 Brasil. Ministério da Saúde, Secretaria de Gestão Estratégica e Participativa, Departamento de Ouvidoria-Geral do SUS. Manual de Tipificação do Sistema OuvidorSUS. Brasília, DF: Ministério da Saúde; 2017..

On the other hand, the information is a questioning of citizens about the SUS, the praise shows satisfaction with the service provided and the suggestions propose improvements in SUS practices, actions and services. Citizens can register manifestations in any public service in Brazil, as regulated by Law nº 13,460/2017²⁰20 Brasil. Lei nº 13.460 de 26 de junho de 2017. Dispõe sobre participação, proteção e defesa dos direitos do usuário dos serviços públicos da administração pública. Diário Oficial da União. 26 Jun 2017., which provides for the participation, protection and defense of the rights of the users of public services.

These classified manifestations are categorized in the OuvidorSUS system, which is divided into main subject and sub-subjects 1, 2, 3, according to the typification manual, developed in partnership with technical areas of the Ministry of Health. In this case, when reading the citizen’s report, the main subject is filled in, as well as sub-topic 1 (mandatory data). In some cases, this report can be divided into sub-topics 2 and 3 or even into medication, which are not mandatory and are not present in all subjects, thus having more empty fields.

After the manifestations are registered at OuvSUS and their analysis, they are forwarded to the technical areas of the Ministry of Health or to the states and municipalities (which are also encouraged to have their own SUS ombudsmen), according to the responsibility for the service or action to which they refer. These citizen contacts with the Ombudsman generate important information for management.

The classification and stratification of the main manifestations recorded by the SUS General Ombudsman’s Office are presented below. For the analysis, the two main subjects of each of the six classifications were considered, broken down from the three main sub-subjects 1 and 2. In view of the more restricted number of sub-subjects 3 and their low completion, they were not included in the tables, but, when relevant, they were described in the data analysis.

Requests represented the most frequent classification of manifestations recorded in the 2014-2018 five-year period and are presented in box 1, together with complaints and denunciations. It appears that young people mainly requested health care actions and services (n=3380) of medium and high complexity, such as consultations/attendance/treatments and surgeries, followed by diagnostic services. The most demanded specialties were gynecology and obstetrics, orthopedics and traumatology and ophthalmology, in addition to plastic surgery.

These data enable the construction of specific reports with assessments and assessment of society’s needs, capable of supporting managers in decision-making, effecting social participation in the management of SUS, for its continuous improvement.

It is important to highlight the proportion of pregnancies in this age group, responsible for more than 60% of hospitalizations of the population aged 15 to 29 years in the period¹⁷17 Brasil. Ministério da Saúde, Departamento de Informática do SUS. Informações de saúde (TABNET). [acesso em 2020 mar 25]. Disponível em: http://www2.datasus.gov.br/DATASUS/index.php?area=02.
http://www2.datasus.gov.br/DATASUS/index... . Unwanted pregnancy in adolescence has been the target of health policies for this population. Latin America and the Caribbean is the region with the second highest rate of adolescent fertility in the world and the lowest rate of decline, basically affecting indigenous, rural adolescents with lower education and income, which requires specific health actions and programs⁴4 Organização Pan-Americana da Saúde. 56º Conselho Diretor. 70ª Sessão do Comitê Regional da Organização Mundial da Saúde para as Américas. Plano de Ação para a Saúde da Mulher, da Criança e do Adolescente 2018-2030. Washington, DC: OPAS; 2018..

The issue of orthopedics and traumatology possibly has an important relationship with trauma caused by accidents and violence, the main causes of mortality in the age groups of 15 to 19 years (more than 75%) and 20 to 29 years (of almost 70%)¹⁷17 Brasil. Ministério da Saúde, Departamento de Informática do SUS. Informações de saúde (TABNET). [acesso em 2020 mar 25]. Disponível em: http://www2.datasus.gov.br/DATASUS/index.php?area=02.
http://www2.datasus.gov.br/DATASUS/index... . Ophthalmology represented the third largest request for consultations, indicating possible difficulty in accessing this specialty in some regions of the country. Data from all Ombudsman offices in the SUS network help to identify the need for access in each location.

It is noteworthy that plastic surgery is the second most requested among the consultations, especially mammoplasty (n=37). In general, plastic surgeries in the SUS are performed only for health reasons, and not for aesthetic reasons. Reconstructive plastic surgery aims to correct congenital and/or acquired deformities, or when there is a functional deficit, seeking to improve or recover functions²¹21 Brasil. Ministério da Saúde. Cirurgia Plástica Reparadora. [acesso em 2020 mar 25]. Disponível em: https://www.saude.gov.br/atencao-especializada-e-hospita-lar/especialidades/cirurgia-plastica-reparadora.
https://www.saude.gov.br/atencao-especia... .

It is worth pointing out that the number of surgical procedures and consultations carried out in the requested areas has large proportions, and the demands to the Ombudsman represent possible difficulties in accessing services, so they must be carefully considered by managers. The ombudsmen, in general, are sought as a second instance of relationship with the citizen²²22 Silva RCC, Pedroso MC, Zucchi P. Ouvidorias públicas de saúde: estudo de caso em ouvidoria municipal de saúde. Rev Saúde Pública 2014; 48(1):134-141.. Another caveat is that the procedures are, in general, the responsibility of other spheres (municipal and/or state) and that many records can be made directly to the local SUS ombudsmen (which record almost 90% of the manifestations of SUS users).

In Pharmaceutical Services, requests for non-standardized drugs were identified, featuring drugs that are not available by the SUS, with greater demand for the anticoagulant enoxaparin sodium (32), which was incorporated into the system for the treatment of pregnant women with thrombophilia only in 2018; drugs of the specialized component, with isotretinoin (23), a drug used to treat severe acne, as the most requested; and primary care, especially the benzodiazepine clonazepam (14).

A detailed analysis of the drugs requested by users makes it possible to identify, through the management of possible problems in the purchase and distribution of drugs, as well as better information on their use by the young population. It is worth noting that there is a division of responsibilities for the acquisition of medicines between the spheres. Although the basic component is the responsibility of municipal administrations, requests were made to OuvSUS, which may occur due to lack of knowledge of the population or belief in the possibility of intervention by the Ministry of Health in states and municipalities.

Complaints from young people referred essentially to Management (n=3704), with a good part reflecting dissatisfaction with health professionals and establishments, which can characterize a malfunction of the services, but also a health care not adapted to the specific needs of this people.

Medical professionals were the ones who generated the greatest number of dissatisfactions (n=518), as well as the absence of this professional (236), followed by nurses (148) and receptionists/attendants (139). Also, issues regarding the hiring of health workers or the non-fulfillment of working hours by these professionals were the target of dissatisfaction. Fernandes and Santos²³23 Fernandes ESF, Santos AM. Desencontros entre formação profissional e necessidades de cuidado aos adolescentes na Atenção Básica à Saúde. Interface (Botucatu). 2020; (24):e190049. point out that there is still a need for greater investment in the training of professionals to improve the practice in the services, adapting it to the logic of care and the needs and ways of life of adolescents. The unpreparedness of the professional can represent an obstacle, for example, for linking adolescents to primary care services.

Health facilities were mentioned in relation to the difficulty of access, mainly due to the delay or refusal of care, inadequate routines and protocols and interruption of services. Material and financial resources were also mentioned as insufficient, with a lack of office materials and/or defect in equipment for continuous or permanent use, demands that may have been registered not only by users of the system but also by health professionals who suffer from inadequate working conditions.

The second issue that generated the most complaints, with a lower proportion than the previous one, was Health Surveillance. In this case, mainly problems related to potential breeding sites, lack of vaccination, in addition to the presence of synanthropic animals were pointed out. The notification of possible breeding sites and the presence of animals by society is essential for fighting diseases that affect the population, such as arboviruses, an important public health problem in the country. Between 2014 and 2017, more than 4 million cases of dengue were reported in Brazil¹⁷17 Brasil. Ministério da Saúde, Departamento de Informática do SUS. Informações de saúde (TABNET). [acesso em 2020 mar 25]. Disponível em: http://www2.datasus.gov.br/DATASUS/index.php?area=02.
http://www2.datasus.gov.br/DATASUS/index... , and between 2016 and 2017, the country experienced an outbreak of yellow fever, affecting many of the young population.

The denunciations were similar to the themes of the complaints, mainly related to human resources, health facilities and material resources, but they present, in addition to dissatisfaction, the character of irregularity and non-compliance with laws and regulations. The sub-topic ‘others’ refers to data not found in the classification of the OuvidorSUS system.

A new item that appears in denunciations about health facilities refers to the companion for pregnant women in the health service. Law No. 11,108/2005 guarantees pregnant women the right to have a companion of their choice during labor, delivery and the immediate post-partum period²⁴24 Brasil. Lei nº 11.108 de 7 de abril de 2005. Altera a Lei nº 8.080, de 19 de setembro de 1990, para garantir às parturientes o direito à presença de acompanhante durante o trabalho de parto, parto e pós-parto imediato, no âmbito do Sistema Único de Saúde - SUS. Diário Oficial da União. 7 Abr 2005.. However, there is still a lack of compliance with this law by services that both restrict the presence of the companion and often want to define who should accompany the pregnant women. In addition, obstacles also highlight inequalities. A population-based study showed that black and brown women had a higher risk of not having a companion when compared to white women²⁵25 Leal MC, Gama SGN, Pereira APE, et al. A cor da dor: iniquidades raciais na atenção pré-natal e ao parto no Brasil. Cad. Saúde Pública. 2017; 33(supl1):e00078816..

The second most denounced issue was the Brazilian Popular Pharmacy Program (Programa Farmácia Popular do Brasil) – a co-payment system, mainly due to non-compliance with the program’s operating rules and misuse of the Users’ Natural Person Register (CPF) (an individual taxpayer identification). The program was instituted by the federal government in 2004 as a strategy to expand the population’s access to essential medicines, offering medicines at cost price, with up to 90% discount, or free of charge. Several frauds and errors in the program have been denounced over the years, with the adoption of measures aimed at greater control and inspection, including audits²⁶26 Silva RM, Caetano R. Programa “Farmácia Popular do Brasil”: caracterização e evolução entre 2004-2012. Ciênc. Saúde Colet. 2015; 20(10):2943-2956..

As mentioned earlier, the citizen who contacts the Ombudsman can register a manifestation for another person, a situation that possibly occurs in the complaints regarding geriatric diapers presented as sub-topic 3.

Most of the time, the requested information is answered directly by the Health Hotline 136 operator during the call, from a large Technical Health Information Bank (called BITS). In five years, almost 1 million pieces of information were disseminated by the operators of the SUS Ombudsman’s Office, representing more than four times the number of registered manifestations. In cases where BITS does not address the question, protocols are registered to seek the requested information. These protocols do not include requests for information made via the Citizen Information System (SIC), linked to the Access to Information Law, which has its own registration and treatment system.

Box 2 details requests for information filed with the Ministry of Health, as well as compliments and suggestions. Most of the information was from the Management scope, referring to various health actions and programs, human resources and health establishments. Questions about human resources especially addressed the hiring of professionals and public exams, in addition to issues related to technical-professional training and payment. Considering the high level of education observed in the profile, there is, possibly, an important number of health professionals among those requesting this information.

As for health facilities, requests for information on routines, protocols and service addresses may reflect the still insufficient transparency and availability of information by the management, as well as a possible lack of knowledge of the population about where to access this information.

The second most demanded topic was health guidelines, such as coverage of SUS procedures and diseases. Information on communication materials, such as publications, e-mail, website, among others, was also requested. As pointed out by Silva et al.²⁴24 Brasil. Lei nº 11.108 de 7 de abril de 2005. Altera a Lei nº 8.080, de 19 de setembro de 1990, para garantir às parturientes o direito à presença de acompanhante durante o trabalho de parto, parto e pós-parto imediato, no âmbito do Sistema Único de Saúde - SUS. Diário Oficial da União. 7 Abr 2005., the Ombudsman’s Office plays an important role in providing information and publicizing the health network, not only explaining and guiding the population about the appropriate entry points into the system, but also facilitating access to health services.

The compliments recorded were mostly for health professionals, who, on the other hand, were also the target of the highest number of complaints and denouncements. Satisfaction was mainly with the health team (69), physicians (56) and nurses (21).

It is noteworthy that the second biggest subject of praise is the SUS Ombudsman itself, in relation to telemarketers and staff, possibly when responding to the citizen about a registered manifestation. Peixoto et al.²⁷27 Peixoto SF, Marsiglia RMG, Morrone LC. Atribuições de uma ouvidoria: opinião de usuários e funcionários. Saude soc. 2013; 22(3):785-794. point out that users tend to see the ombudsman services as a superior sector or, at least, with decision-making power for a possible solution to their problems. When the problem is solved, particularly briefly, it leads to the satisfaction of the user, while the opposite usually causes dissatisfaction and distrust regarding the effectiveness of the ombudsman.

The suggestions, which were the object of the fewest manifestations to OuvSUS, largely referred to health actions and programs, implementation of a sector/service/unit, routines/protocols, hiring or technical-professional training of health workers. The subject of communication received suggestions about campaigns and communication channels, such as e-mail or website.

The importance of encouraging the use of participation channels for suggestions is highlighted, especially so that services are adapted and appropriate to the specific demands of the young population. The ombudsman also needs to present and disseminate their results, to encourage use by the population, as well as by management. Antunes²⁸28 Antunes LR. Ouvidorias do SUS no processo de participação social em saúde. Rev Saude Colet. 2008; 5(26):238-41. points out that both the advertising of employees and the users themselves already served by the ombudsman are usually the main forms of dissemination and referral of users to the service.

The final report of the Pan American Health Organization (PAHO) on the Strategy and Plan of Action for Adolescent and Youth Health3 points out as crucial activities to accelerate progress in the area of adolescent and youth health: increased investment; the design, updating and implementation of multisectoral policies based on addressing social determinants and reducing inequities; the implementation of evidence-based and low-cost interventions aimed at improving and promoting the mental, physical, sexual and reproductive health of adolescents, with the empowerment of vulnerable groups; the elimination of barriers to universal access to health services; the establishment of specific mechanisms for adolescents and young people to participate in the processes of elaboration and monitoring of policies; and the increase in the country’s capacity to produce reliable information on this population, among others.

For this, the SUS Ombudsman and the information produced and systematized by them can be of great value, not only to enable the participation of adolescents and young people and the production of information about this public, but also to direct health policies that meet the needs of that population.

Final considerations

As shown, there was a significant increase in the number of manifestations registered by young people aged 15 to 29 to the SUS Ombudsman’s Office from 2014 to 2017, with a reduction only in 2018. However, this population still represents just over 15% of plaintiffs. It should only be noted that OuvSUS is not the only access channel for citizens and that other demands from this public may be registered by the ombudsman of other spheres (municipal and state).

Most young applicants are between 20 and 29 years old, are black, female and heterosexual. There is a high level of education, with the majority attending or having completed higher education, however, with a relatively low income, up to 2 minimum wages, and employed in the private sector.

Requests, complaints and denunciations concentrated almost 80% of the manifestations. The requests were mainly linked to health care of medium and high complexity, such as consultations/assistance/treatments, surgeries and diagnostic services, in addition to medication. Complaints and denunciations dealt, above all, with human resources and health facilities, which may indicate, in addition to a malfunction of the services, an inadequacy to the health needs of the young population.

The topics of human resources and health facilities, as well as health actions and programs, were also frequent in requests for information, praise and suggestions, the latter being the least registered. Thus, it is necessary to further encourage the use of the SUS Ombudsman also to suggest improvements to the system, in order to meet the real needs of the population, also considering the specificities of different groups.

The importance of making available channels accessible to the young population is highlighted, through technologies and strategies of the Active Ombudsman, as well as the need to carry out research on the profile of the citizen, for a better characterization of the demanding population and for the direction of the decision of managers.

The information presented can serve as a baseline on pre-pandemic demands, subsidizing studies that could investigate the effects of the pandemic on the demands of young people to OuvSUS. For this, filling in the citizen’s profile in the Ombudsman’s services is of great importance. It is also necessary to monitor the demands and record the consequences arising from the manifestations made, which was not possible to verify in this database, in order to analyze the effectiveness of this service channel. The effectiveness of the mechanisms of social participation and the knowledge on the part of the population are crucial for their use.

It is important to highlight that, despite the availability of mechanisms, social participation in public policies is not guaranteed at all. Despite constitutional and legal provisions on user participation in public administration, recent losses in the agenda have been experienced, such as the rejection of the National Social Participation Policy by the National Congress in 2014²⁹29 Brasil. Decreto nº 8.243 de 23 de maio de 2014. Institui a Política Nacional de Participação Social - PNPS e o Sistema Nacional de Participação Social - SNPS, e dá outras providências. Diário Oficial da União. 23 Maio 2014. and the mass extinction, in 2019, of councils, committees, commissions, groups and other types of collegiate bodies in the federal public administration³⁰30 Brasil. Decreto nº 9.759 de 11 de abril de 2019. Extingue e estabelece diretrizes, regras e limitações para colegiados da administração pública federal. Diário Oficial da União. 11 Abr 2019.. Thus, social participation and empowerment of young people are constructions that need to be defended on a daily basis.

References

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