ABSTRACT

This article aims to evaluate social and health indicators of municipalities according to the rural-urban typology. This is an ecological study that used official publicly accessible data from the 853 municipalities in the state of Minas Gerais, Brazil. Descriptive and bivariate analysis were carried out using Poisson Regression and Kruskal-Wallis Test. 547 (64.12%) are rural municipalities. The highest average of the Municipal Human Development Index (MHDI) was observed among urban municipalities. The highest average coverage of the Family Health Strategy (FHS) was found among rural municipalities. In these municipalities, the best results were shown for the indicators of infant mortality, premature mortality and mortality from preventable causes, vaccine homogeneity and prevalence of malnutrition. The findings of this study show that greater FHS coverage is associated with the occurrence of better general living and health conditions in the populations served in rural municipalities. It is recommended that health managers encourage the consolidation of the FHS in communities with unfavorable socioeconomic and cultural contexts, such as remote rural locations and urban agglomerations, and the establishment of intersectoral actions with a positive impact on health.

KEYWORDS
Primary Health Care; Health status indicators; Social indicators; Urban area; Rural areas

Introduction

In Brazil, rural populations commonly have low education¹1 Instituto de Pesquisa Econômica Aplicada. Educação: contraste entre o meio urbano e o rural no Brasil. Bolet. Reg. Urb. Amb. 2019 [acesso em 2021 mar 9]; 21:63-74. Disponível em: http://repositorio.ipea.gov.br/bitstream/11058/9661/1/BRUA21_Ensaio5.pdf.
http://repositorio.ipea.gov.br/bitstream... , low income¹1 Instituto de Pesquisa Econômica Aplicada. Educação: contraste entre o meio urbano e o rural no Brasil. Bolet. Reg. Urb. Amb. 2019 [acesso em 2021 mar 9]; 21:63-74. Disponível em: http://repositorio.ipea.gov.br/bitstream/11058/9661/1/BRUA21_Ensaio5.pdf.
http://repositorio.ipea.gov.br/bitstream... ,²2 Barbosa ALNH, Menezes TA, Andrade BC. Demandas por produtos alimentares nas áreas rurais e urbanas do Brasil. Pesqui. Planej. Econ. 2014; 44(3):507-43., less access to health services and greater vulnerability to health risk factors³3 Martins-Silva T, Vaz JS, Loret de Mola C, et al. Prevalence of obesity in rural and urban areas in Brazil: National Health Survey, 2013. Rev Bras Epidemiol. 2019; 22:E190049.,⁴4 Arruda NM, Maia AG, Alves LC. Desigualdade no acesso à saúde entre as áreas urbanas e rurais do Brasil: uma decomposição de fatores entre 1998 a 2008. Cad. Saúde Pública. 2018; 34(6):e00213816.. Previous studies indicate that the different stages of socioeconomic development between urban and rural areas in Brazil contribute to inequality in access to basic and essential items for quality of life, such as sanitation and treated water, which makes the health of rural populations more precarious compared to urban populations⁴4 Arruda NM, Maia AG, Alves LC. Desigualdade no acesso à saúde entre as áreas urbanas e rurais do Brasil: uma decomposição de fatores entre 1998 a 2008. Cad. Saúde Pública. 2018; 34(6):e00213816.,⁵5 Soares AN, Silva TL, Franco AAAM, et al. Cuidado em saúde às populações rurais: perspectivas e práticas de agentes comunitários de saúde. Physis. 2020; 30(3):e300332..

Primary Health Care (PHC) has expanded and consolidated in Brazil in recent years, mainly due to the process of decentralization and expansion of care coverage driven by the Family Health Strategy (FHC)⁶6 Paim J, Travassos C, Almeida C, et al. The Brazilian health system: history, advances, and challenges. Lancet. 2011; 377:1778-97.,⁷7 Damasceno RF, Caldeira AP. Fatores associados à não utilização da Teleconsultoria por médicos da Estratégia Saúde da Família. Ciênc. saúde coletiva. 2018; 24(8):3089-98.. However, despite advances, the old challenges to the consolidation of PHC still persist, such as insufficient funding, the distribution of professionals and the need for improvements in access, quality and effectiveness of the services offered⁸8 Almeida PF. Primary health care in Brazil and the 40 years of Alma-Ata: acknowledging the challenges in order to move forward. Cad. Saúde Pública. 2018; 34(8):e00136118.,⁹9 Fausto MCR, Rizzoto MLF, Giovanella L, et al. The future of Primary Health Care in Brazil. Saúde debate. 2018; 24(1):15-17..

In the history of expansion and consolidation of PHC in Brazil, two important elements stand out, which may be related to the quality of care in the extensive national territory: the great expansion of care coverage from the 2000s onwards, with different rhythms between the regions and population size of municipalities¹⁰10 Alves MGM, Casotti E, Oliveira LGD, et al. Fatores condicionantes para o acesso às equipes da Estratégia Saúde da Família no Brasil. Saúde debate. 2014; 38(esp):34-51.,¹¹11 Malta DC, Santos MAS, Stopa SR, et al. Family Health Strategy Coverage in Brazil, according to the National Health Survey, 2013. Ciênc. saúde coletiva. 2016; 21(2):327-38. and the low care performance of the ESF in rural areas¹²12 Pessoa VM, Almeida MM, Carneiro FF. Como garantir o direito à saúde para as populações do campo, da floresta e das águas no Brasil? Saúde debate. 2018; 42(supl1):302-14..

Access to healthcare is considered one of the essential determinants of quality of life and socioeconomic development, with impacts on mortality and life expectancy. Additionally, access to health influences several aspects of the social life of populations, such as demographic dynamics related to the need to travel in search of access to health services, with impacts on mortality and life expectancy of vulnerable individuals⁵5 Soares AN, Silva TL, Franco AAAM, et al. Cuidado em saúde às populações rurais: perspectivas e práticas de agentes comunitários de saúde. Physis. 2020; 30(3):e300332.. Therefore, ensuring access to health services for all Brazilian citizens is still a major challenge for the Unified Health System (SUS), especially for populations living in rural areas⁴4 Arruda NM, Maia AG, Alves LC. Desigualdade no acesso à saúde entre as áreas urbanas e rurais do Brasil: uma decomposição de fatores entre 1998 a 2008. Cad. Saúde Pública. 2018; 34(6):e00213816.,¹³13 Facchini LA, Tomasi E, Dilélio AS. Quality of Primary Health Care in Brazil: advances, challenges and perspectives. Saúde debate. 2018; 42(supl1):208-23..

According to the geographic classification of Brazilian municipalities, carried out by the Brazilian Institute of Geography and Statistics (IBGE) in 2017, more than 64% of Minas Gerais municipalities are rural¹⁴14 Instituto Brasileiro de Geografia e Estatística. Classificação e caracterização dos espaços rurais e urbanos do Brasil: uma primeira aproximação. Rio de Janeiro: IBGE; 2017. [acesso em 2021 jan 4]. Disponível em: https://www.ibge.gov.br/apps/rural_urbano/.
https://www.ibge.gov.br/apps/rural_urban... . This scenario points to interesting opportunities to evaluate certain attributes and dimensions of the population’s health status and the performance of the health system in Minas Gerais municipalities according to the rural-urban typology proposed by IBGE. It is noteworthy that such an assessment could contribute to the definition of public policies aimed at reducing local-regional inequities in the state. Therefore, this study aims to evaluate social and health indicators in municipalities in the state of Minas Gerais according to the rural-urban typology.

Material and methods

This is an ecological study¹⁵15 Merchán-Hamman E, Tauil PL. Proposal for classifying the different types of descriptive epidemiological studies. Epidemiol. Serv. Saúde. 2021; 30(1):e2018126. that covers the municipalities of Minas Gerais. The state, whose capital is Belo Horizonte, is one of the 27 states in Brazil, being the fourth largest in territorial extension (586,528 km²2 Barbosa ALNH, Menezes TA, Andrade BC. Demandas por produtos alimentares nas áreas rurais e urbanas do Brasil. Pesqui. Planej. Econ. 2014; 44(3):507-43.) and the second most populous, with an estimated population for 2020 of 21,292,666 inhabitants¹⁶16 Instituto Brasileiro de Geografia e Estatística. IBGE Cidades: Minas Gerais. 2020. [acesso em 2021 jan 2]. Disponível em: https://cidades.ibge.gov.br/brasil/mg/panorama.
https://cidades.ibge.gov.br/brasil/mg/pa... . The state has 853 municipalities, divided into 12 mesoregions¹⁶16 Instituto Brasileiro de Geografia e Estatística. IBGE Cidades: Minas Gerais. 2020. [acesso em 2021 jan 2]. Disponível em: https://cidades.ibge.gov.br/brasil/mg/panorama.
https://cidades.ibge.gov.br/brasil/mg/pa... , 14 health macro-regions and 89 health micro-regions¹⁷17 Minas Gerais. Secretaria de Estado de Saúde de Minas Gerais. Ajuste do Plano Diretor de Regionalização da Saúde de Minas Gerais (PDR/MG). Belo Horizonte: SES/MG; 2020. [acesso em 2021 jan 2]. Disponível em: https://www.saude.mg.gov.br/images/1_noticias/06_2023/2-jul-ago-set/regionalizacao/1-PDR%202020.pdf.
https://www.saude.mg.gov.br/images/1_not... .

Minas Gerais is characterized by having a large territorial extension¹⁷17 Minas Gerais. Secretaria de Estado de Saúde de Minas Gerais. Ajuste do Plano Diretor de Regionalização da Saúde de Minas Gerais (PDR/MG). Belo Horizonte: SES/MG; 2020. [acesso em 2021 jan 2]. Disponível em: https://www.saude.mg.gov.br/images/1_noticias/06_2023/2-jul-ago-set/regionalizacao/1-PDR%202020.pdf.
https://www.saude.mg.gov.br/images/1_not... , a predominance of small and medium-sized municipalities¹⁷17 Minas Gerais. Secretaria de Estado de Saúde de Minas Gerais. Ajuste do Plano Diretor de Regionalização da Saúde de Minas Gerais (PDR/MG). Belo Horizonte: SES/MG; 2020. [acesso em 2021 jan 2]. Disponível em: https://www.saude.mg.gov.br/images/1_noticias/06_2023/2-jul-ago-set/regionalizacao/1-PDR%202020.pdf.
https://www.saude.mg.gov.br/images/1_not... and by presenting evident socioeconomic disparities between the mesoregions¹⁸18 Cardoso DF, Ribeiro LCS. Índice relativo de qualidade de vida para os municípios de Minas Gerais. Planej. polít. públicas. 2015; 4:347-75.. Regarding the economic aspect, the state presents a great diversification of economic activities between the mesoregions, with a concentration of important industrial centers in the Central and South mesoregions, while, in the North and Jequitinhonha mesoregions, activities linked to the primary segment of the economy stand out, such as mineral extraction, extensive livestock farming and subsistence agriculture¹⁸18 Cardoso DF, Ribeiro LCS. Índice relativo de qualidade de vida para os municípios de Minas Gerais. Planej. polít. públicas. 2015; 4:347-75.. The state has the municipality with the smallest population among the municipalities in Brazil, Serra da Saudade (815 inhabitants), while the metropolitan region of Belo Horizonte has around 5 million inhabitants¹⁷17 Minas Gerais. Secretaria de Estado de Saúde de Minas Gerais. Ajuste do Plano Diretor de Regionalização da Saúde de Minas Gerais (PDR/MG). Belo Horizonte: SES/MG; 2020. [acesso em 2021 jan 2]. Disponível em: https://www.saude.mg.gov.br/images/1_noticias/06_2023/2-jul-ago-set/regionalizacao/1-PDR%202020.pdf.
https://www.saude.mg.gov.br/images/1_not... .

Data collection was carried out from March to May 2021, in official publicly accessible databases. Data were collected regarding 15 variables about the municipalities and, subsequently, these variables were grouped into 4 thematic blocks, according to their type: rural-urban typology, geographic location, social indicators and health indicators. Box 1 contains details of the variables studied, including their grouping into thematic blocks, the year of reference, the source, the date of access, the concept and the cut-off point used in the categorization.

The variable Rural-Urban Typology refers to the geographic classification of municipalities into five typologies: Urban, Intermediate Adjacent, Intermediate Remote, Rural Adjacent and Rural Remote, based on the methodology developed by IBGE¹⁴14 Instituto Brasileiro de Geografia e Estatística. Classificação e caracterização dos espaços rurais e urbanos do Brasil: uma primeira aproximação. Rio de Janeiro: IBGE; 2017. [acesso em 2021 jan 4]. Disponível em: https://www.ibge.gov.br/apps/rural_urbano/.
https://www.ibge.gov.br/apps/rural_urban... , which considers three criteria: population in areas of dense occupation; proportion of population in areas of dense occupation in relation to the total population; and location. The municipalities of the Adjacent Intermediate and Remote Intermediate typologies were grouped into a single typology, called Intermediate. In turn, municipalities belonging to the Remote Rural and Adjacent Rural typologies were grouped into the Rural typology.

The variable Infant Mortality Rate (IMR) was accessed on the Health Surveillance Portal of the State Department of Health of Minas Gerais (SES/MG), Municipal Situation Room, and referred to the year 2018 (box 1). According to the methodology adopted by the Superintendency of Epidemiological Surveillance of SES/MG, for municipalities with a population greater than or equal to 100,000 inhabitants, the IMR was adopted, while for the other municipalities the absolute number was used.

For data analysis, the Statistical Package For The Social Sciences (SPSS)^®, Version 23, was used. The following statistical analyzes were conducted: (1) Prevalence of indicators according to geographic classification and Chi-square test to verify the occurrence of significant associations; (2) Prevalence Ratio using Poisson Regression to estimate the magnitude of associations and (3) Kruskal-Wallis test to compare indicators by municipality type. To perform the Chi-square and Poisson Regression tests, the variables were categorized (box 1).

The present study followed the guidelines and standards of Resolutions No 466/2012¹⁹19 Conselho Nacional de Saúde. Resolução n° 466, de 12 de dezembro de 2012. Aprova as diretrizes e normas regulamentadoras de pesquisas envolvendo seres humanos. Diário Oficial da União. 13 Jun 2013. Seção I:59. and No 510/2016²⁰20 Conselho Nacional de Saúde. Resolução n° 510, de 7 de abril de 2016. Dispõe sobre as normas aplicáveis a pesquisas em Ciências Humanas e Sociais cujos procedimentos metodológicos envolvam a utilização de dados diretamente obtidos com os participantes ou de informações identificáveis ou que possam acarretar riscos maiores do que os existentes na vida cotidiana, na forma definida nesta Resolução. Diário Oficial da União. 24 Maio 2016. Seção I:44. of the National Health Council, which regulate the ethical and legal aspects of scientific research in Brazil. As this is research involving only publicly accessible data, whose information is aggregated, without the possibility of individual identification, the present study did not present in its design the direct participation of human beings and, therefore, there was no obligation to submit to an Ethics in Research Committee for consideration and analysis.

Results

Of the 853 municipalities in the state of Minas Gerais, 547 (64.12%) are classified as rural, 201 (23.56%) as urban and 105 (12.30%) as intermediate, according to the rural-urban typology. The highest proportions of municipalities classified in the urban typology occurred in the health macro-regions Center (44.55%), South Triangle (37.03%) and North Triangle (33.33%). The health macro-regions East (88.23%), East of the South (84.90%) and Jequitinhonha (83.87%) had the highest proportions of municipalities classified in the Rural typology. Finally, the macro-regions North Triangle (29.62%), Northeast (26.31%) and Northwest (18.18%) had the largest number of municipalities classified as intermediate. Figure 1 shows the spatial distribution of rural-urban typologies in the municipalities of the state of Minas Gerais.

The analysis, considering social indicators in their numerical nature, found a higher average Municipal Human Development Index (MHDI) among urban municipalities (0.72) and a lower average Gini Index among intermediate and rural municipalities (0.47). In turn, the analysis of health indicators indicated that rural municipalities had higher averages for FHC Coverage (98.34%) and Vaccination Homogeneity (63.92%), and lower averages for IMR (0.98), Deaths by Preventable Causes (35.24%) and Prevalence of Malnutrition (4.35%). A lower average number of Hospitalizations for Ambulatory Care Sensitive Conditions (ICSAP) (39.24) was observed among urban municipalities (table 1).

As for social indicators, categorically addressed, it is highlighted that 822 (96.40%) are small/medium-sized municipalities and a total of 771 municipalities (90.4%) have MHDI below the state index (0.731). In relation to health indicators, there was a higher proportion of rural municipalities with FHC coverage above state coverage (527=96.3%); higher proportion of intermediate (105=100%) and rural municipalities (547=100%) with an Infant Mortality Rate equal to/below the state rate; higher proportion of urban municipalities (117=58.2%) with ICSAP equal to/below the state level; 799 municipalities (93.7%) with a Premature Mortality Rate above the state rate; higher proportion of rural municipalities (379=69.3%) with Deaths from Preventable Causes equal to/below the state target; and a higher proportion of rural municipalities (327=59.8%) with Vaccination Homogeneity equal to/above the state target (table 2).

Assessing the Prevalence Ratio (PR), it was found that an MHDI below the state index was more prevalent among intermediate and rural municipalities. In these municipalities, a lower prevalence of FHC coverage below the state level was also identified. Rural municipalities had a prevalence of ICSAP above the state level. In turn, a Premature Mortality Rate above the state rate is less prevalent among rural municipalities; Deaths from Preventable Causes and Prevalence of Malnutrition above the state target are less prevalent among rural municipalities; Vaccination homogeneity below the state target is less prevalent among rural municipalities (table 3).

Discussion

The state of Minas Gerais has a higher prevalence of municipalities in a rural context, based on the IBGE methodology for classifying municipalities by rural-urban typology. This differs from the assessment that considers the resident population by household situation, which indicates that the state’s population lives predominantly in urban areas¹⁶16 Instituto Brasileiro de Geografia e Estatística. IBGE Cidades: Minas Gerais. 2020. [acesso em 2021 jan 2]. Disponível em: https://cidades.ibge.gov.br/brasil/mg/panorama.
https://cidades.ibge.gov.br/brasil/mg/pa... . In this context, the literature points out that the concentration of households in urban areas is a reflection of the urbanization process, occupation of territories and population dynamics, in which more prosperous cities and regions tend to concentrate more population²¹21 Calvo MCM, Lacerda JT, Colussi CF, et al. Estratificação de municípios brasileiros para avaliação de desempenho em saúde. Epidemiol. Serv. Saúde. 2016; 25(4):767-76..

On the other hand, despite being the second most populous state in Brazil, behind only the state of São Paulo, Minas Gerais is characterized by having a low demographic density, an extensive area of the territorial unit (586,521.123 Km²2 Barbosa ALNH, Menezes TA, Andrade BC. Demandas por produtos alimentares nas áreas rurais e urbanas do Brasil. Pesqui. Planej. Econ. 2014; 44(3):507-43.) and the largest number of municipalities among Brazilian states (853), most of which are small municipalities¹⁶16 Instituto Brasileiro de Geografia e Estatística. IBGE Cidades: Minas Gerais. 2020. [acesso em 2021 jan 2]. Disponível em: https://cidades.ibge.gov.br/brasil/mg/panorama.
https://cidades.ibge.gov.br/brasil/mg/pa... . Notably, 96.5% of Minas Gerais municipalities have up to 100 thousand inhabitants. When evaluating the number of municipalities with a population of up to 20 thousand inhabitants, the percentage reaches 79%²²22 Nogueira M. As pequenas cidades de Minas Gerais: uma tipologia. Geoingá. 2016; 8(2):38-57.. In such municipalities, generally characterized by having low demographic density and extensive rural areas, but quite different from each other, the biggest challenge is to clearly recognize the limits between urban and rural. This finding emphasizes the need to carry out future studies to investigate the social, economic and cultural context of small municipalities²²22 Nogueira M. As pequenas cidades de Minas Gerais: uma tipologia. Geoingá. 2016; 8(2):38-57..

When it comes to economic and social development, Minas Gerais presents great regional disparities. The North and Northeast mesoregions concentrate most of the municipalities with a low Human Development Index (HDI), while the South, Triangle and Alto Paranaíba mesoregions have a prevalence of municipalities with a high HDI²³23 Gomes FBFF, Lana FCF, Oliveira RC, et al. Indicators of leprosy in the state of Minas Gerais and its relationship with the Municipal Human Development Index and the coverage of the Family Health Strategy. Rev Min Enferm. 2017; 21:e-1063.. The higher average MHDI among urban municipalities and a higher prevalence of MHDI below the state index among intermediate and rural municipalities in Minas Gerais reflects a reality in which, generally, urban municipalities present greater human development when compared to rural. The literature²⁴24 Kassouf AL. Acesso aos serviços de saúde nas áreas urbana e rural do Brasil. Rev. Econ. Sociol. Rural. 2005; 43(1):29-44.,²⁶26 Travassos C, Viacava F. Acesso e uso de serviços de saúde em idosos residentes em áreas rurais, Brasil, 1998 e 2003. Cad. Saúde Pública. 2007; 23(10):2490-502. points out that, in Brazil, the pattern of economic and social inequality that prevails in rural territories determines the living and health conditions of people in these territories. Families in the lowest income brackets reside predominantly in rural municipalities, where the highest illiteracy rates are found among people aged 15 or over and the largest number of households lacking basic sanitation²⁷27 Sarmento RA, Moraes RM, Viana RTP, et al. Determinantes socioambientais e saúde: O Brasil rural versus o Brasil urbano. Tempus, actas de saúde colet. 2015; 9(2):221-35.. Among Brazilian municipalities with a high percentage of rural population, there are those that have the worst MHDI, indexes influenced mainly by the dimensions of income and education²⁸28 Programa das Nações Unidas para o Desenvolvimento. Atlas do Desenvolvimento Humano no Brasil. 2017 [acesso em 2021 fev 18]. Disponível em: http://www.atlasbrasil.org.br/.
http://www.atlasbrasil.org.br/.... .

Regarding FHC Coverage, Minas Gerais presents high coverage rates in all regions, with emphasis on a higher average coverage among rural municipalities and a lower prevalence of coverage below state coverage in intermediate and rural municipalities. The greater insertion of FHC in rural and intermediate municipalities is related to the Ministry of Health’s policy of inducing the expansion of FHC in the neediest regions²⁹29 Andrade MV, Noronha K, Barbosa ACQ, et al. A equidade na cobertura da Estratégia Saúde da Família em Minas Gerais, Brasil. Cad. Saúde Pública. 2015; 31(6):1175-87.. High FHC coverage is related to less inequality in access to health services for populations that have historically been in a situation of greater vulnerability, low income and lower health plan coverage¹¹11 Malta DC, Santos MAS, Stopa SR, et al. Family Health Strategy Coverage in Brazil, according to the National Health Survey, 2013. Ciênc. saúde coletiva. 2016; 21(2):327-38.,²⁹29 Andrade MV, Noronha K, Barbosa ACQ, et al. A equidade na cobertura da Estratégia Saúde da Família em Minas Gerais, Brasil. Cad. Saúde Pública. 2015; 31(6):1175-87..

A study carried out by Andrade et al.²⁹29 Andrade MV, Noronha K, Barbosa ACQ, et al. A equidade na cobertura da Estratégia Saúde da Família em Minas Gerais, Brasil. Cad. Saúde Pública. 2015; 31(6):1175-87. showed that, in Minas Gerais, there is a regional disparity in FHC coverage, with less insertion of the strategy in the most socioeconomically developed areas. Regarding home visits by FHC teams, the study showed that poorer regions have higher visitation rates, with emphasis on the North region, where 93.16% of homes were visited during the period evaluated. Furthermore, it was pointed out that households with families with lower purchasing power are more visited, indicating more focused coverage on households with lower incomes²⁹29 Andrade MV, Noronha K, Barbosa ACQ, et al. A equidade na cobertura da Estratégia Saúde da Família em Minas Gerais, Brasil. Cad. Saúde Pública. 2015; 31(6):1175-87.. An important dimension of expanding FHC coverage in Brazil is the prioritization of the most vulnerable families, aiming to expand access, include the most needy and reduce health inequities¹¹11 Malta DC, Santos MAS, Stopa SR, et al. Family Health Strategy Coverage in Brazil, according to the National Health Survey, 2013. Ciênc. saúde coletiva. 2016; 21(2):327-38.. Regional disparities are attributed to the diversity of local management processes between municipalities and states. Even with strong induction by the Ministry of Health and states, the organizational processes are varied, which results in large differences in the local implementation of FHC. The differences in FHC coverage between municipalities and regions is a reflection of the health municipalization process¹¹11 Malta DC, Santos MAS, Stopa SR, et al. Family Health Strategy Coverage in Brazil, according to the National Health Survey, 2013. Ciênc. saúde coletiva. 2016; 21(2):327-38..

The literature points out that countries whose health systems are guided by the PHC model have better indicators, including lower infant mortality rates, lower early mortality from preventable causes and higher life expectancy¹¹11 Malta DC, Santos MAS, Stopa SR, et al. Family Health Strategy Coverage in Brazil, according to the National Health Survey, 2013. Ciênc. saúde coletiva. 2016; 21(2):327-38.. However, in Brazil, there is a great disparity in access to health services when comparing urban and rural areas, so that inequality in access is higher and greater in rural areas⁴4 Arruda NM, Maia AG, Alves LC. Desigualdade no acesso à saúde entre as áreas urbanas e rurais do Brasil: uma decomposição de fatores entre 1998 a 2008. Cad. Saúde Pública. 2018; 34(6):e00213816., establishing a reality in which there is a worse healthcare performance in the rural areas¹²12 Pessoa VM, Almeida MM, Carneiro FF. Como garantir o direito à saúde para as populações do campo, da floresta e das águas no Brasil? Saúde debate. 2018; 42(supl1):302-14..

However, it was identified in the present study that, in addition to having better FHC coverage, rural municipalities presented better results for the indicators of infant, premature and preventable mortality, vaccination homogeneity and prevalence of malnutrition in children under two years of age. Urban municipalities, in turn, presented the best results for ICSAP and the proportion of prenatal consultations.

It is estimated that this fact may be related to greater FHC coverage in rural municipalities, as well as the difficulties imposed on the expansion of FHC in larger municipalities. The literature³⁰30 Castro MC, Massuda A, Almeida G, et al. Brazil’s unified health system: the first 30 years and prospects for the future. Lancet. 2019; 394:345-56. points out that federal subsidies for financing PHC are more effective in smaller municipalities, which depend more on federal resources than larger municipalities. In fact, small municipalities, with low levels of human development²⁸28 Programa das Nações Unidas para o Desenvolvimento. Atlas do Desenvolvimento Humano no Brasil. 2017 [acesso em 2021 fev 18]. Disponível em: http://www.atlasbrasil.org.br/.
http://www.atlasbrasil.org.br/.... and almost always in rural contexts, generally have little financial autonomy³¹31 Caetano CCR, Ávila LAC, Tavares M. Relation between the government transfers, own tax collection and education index of the municipalities of the state of Minas Gerais. Rev. adm. pública (Online). 2017; 51(5):897-916. and are highly dependent on transfers of resources from other federative entities (states and the Union) to carry out health actions³²32 Massardi WO, Abrantes LA. Dependência dos municípios de Minas Gerais em relação ao FPM. Revista de Gestão, Finanças e Contabilidade. 2016; 6(1):173-87..

Evidence indicates that mortality in general is related to socioeconomic and healthcare factors³³33 Soares RAS, Moraes RM, Vianna RPT. Mortalidade infantil no contexto da ruralidade brasileira: uma proposta para a superação da invisibilidade epidemiológica e demográfica. Cad. Saúde Pública. 2020; 36(8):e00068718.,³⁴34 Silva VA, Moura FR, Esperidião F, et al. Desigualdades socioeconômicas: uma análise sobre os determinantes da taxa de mortalidade infantil nos municípios brasileiros. Rev Bras. Estud. Reg. Urb. 2019; 13(1):73-97.,³⁵35 Kropiwiec MV, Franco SC, Amaral AR. Factors associated with infant mortality in a brazilian city with high Human Development Index. Rev. paul. pediatr. 2017; 35(04):391-98.,³⁷37 Malta DC, Saltarelli RMF, Prado RR, et al. Preventable deaths within Brazil’s Public Health System in a population from 5 to 69 years old, 2000 – 2013. Rev. bras. epidemiol. 2018; 21:e180008.. In Brazil, the decline in mortality trends is related to increased access to health services, but is also attributed to the improvement in general living conditions, reduced inequalities and investments in social income distribution programs³⁷37 Malta DC, Saltarelli RMF, Prado RR, et al. Preventable deaths within Brazil’s Public Health System in a population from 5 to 69 years old, 2000 – 2013. Rev. bras. epidemiol. 2018; 21:e180008.,³⁸38 Victora CG, Aquino EM, Leal MC, et al. Maternal and child health in Brazil: progress and challenges. Lancet. 2011; 377:1863-76..

Therefore, socioeconomic inequalities and the use of health services have a direct influence on mortality. The worse performance of urban municipalities in relation to the mortality indicators evaluated (IMR, mortality and mortality from preventable causes) may be related to the large number of people living in precarious conditions in urban agglomerations, the lack of or insufficient health services in these locations and the difficulty in accessing the service network for the resident population³³33 Soares RAS, Moraes RM, Vianna RPT. Mortalidade infantil no contexto da ruralidade brasileira: uma proposta para a superação da invisibilidade epidemiológica e demográfica. Cad. Saúde Pública. 2020; 36(8):e00068718.,³⁹39 Castro ALB, Andrade CLT, Machado CV, et al. Condições socioeconômicas, oferta de médicos e internações por condições sensíveis à atenção primária em grandes municípios do Brasil. Cad. Saúde Pública. 2015; 31(11):2353-66.,⁴⁰40 Almeida LS, Cota ALS, Rodrigues DF. Sanitation, Arboviruses, and Environmental Determinants of Disease: impacts on urban health. Ciênc. saúde coletiva. 2020; 25(10):3857-68..

Municipalities with adequate FHC coverage and greater integration of this strategy in the community may have better conditions for monitoring families in PHC¹¹11 Malta DC, Santos MAS, Stopa SR, et al. Family Health Strategy Coverage in Brazil, according to the National Health Survey, 2013. Ciênc. saúde coletiva. 2016; 21(2):327-38.,²⁹29 Andrade MV, Noronha K, Barbosa ACQ, et al. A equidade na cobertura da Estratégia Saúde da Família em Minas Gerais, Brasil. Cad. Saúde Pública. 2015; 31(6):1175-87.. Family planning and prenatal monitoring actions have the potential to reduce infant and maternal mortality. Health promotion actions enable changes in lifestyle habits, interfering with the emergence of chronic conditions³3 Martins-Silva T, Vaz JS, Loret de Mola C, et al. Prevalence of obesity in rural and urban areas in Brazil: National Health Survey, 2013. Rev Bras Epidemiol. 2019; 22:E190049.. In turn, monitoring and adequate management of chronic conditions can reduce premature deaths from preventable causes¹¹11 Malta DC, Santos MAS, Stopa SR, et al. Family Health Strategy Coverage in Brazil, according to the National Health Survey, 2013. Ciênc. saúde coletiva. 2016; 21(2):327-38.,²⁹29 Andrade MV, Noronha K, Barbosa ACQ, et al. A equidade na cobertura da Estratégia Saúde da Família em Minas Gerais, Brasil. Cad. Saúde Pública. 2015; 31(6):1175-87..

In Brazil, despite adequate vaccination coverage at national and state levels, vaccination historically still does not reach the entire target population. In municipalities, coverage is heterogeneous, lower in the highest socioeconomic groups, as well as in the lowest. At the individual level, low coverage is related to the level of knowledge, attitudes and practices regarding vaccination actions⁴¹41 Braz RM, Domingues CMAS, Teixeira MAS, et al. Classification of transmission risk of vaccinepreventable diseases based on vaccination indicators in Brazilian municipalities. Epidemiol. Serv. Saúde. 2016; 25(4):745-54.,⁴²42 Gontijo TL, Oliveira VC, Almeida NA, et al. Análise da cobertura vacinal contra influenza no estado de Minas Gerais. Cienc. Enfermería. 2017; 23(3):69-75.. At the municipal level, low coverage may also be related to the coordination of municipal services in immunization actions, so that several factors may be involved, such as the supply of immunobiologicals, the population’s access to them, the identification of priority areas, the adopted immunization strategy, among others⁴¹41 Braz RM, Domingues CMAS, Teixeira MAS, et al. Classification of transmission risk of vaccinepreventable diseases based on vaccination indicators in Brazilian municipalities. Epidemiol. Serv. Saúde. 2016; 25(4):745-54.,⁴²42 Gontijo TL, Oliveira VC, Almeida NA, et al. Análise da cobertura vacinal contra influenza no estado de Minas Gerais. Cienc. Enfermería. 2017; 23(3):69-75.. In Brazil, due to the large territorial extension and the variability of vaccination coverage between regions, homogeneity of coverage between vaccines is also assessed. This measure allows us to estimate the proportion of immunobiologicals whose coverage targets were achieved in municipalities or even states over a period of time⁴¹41 Braz RM, Domingues CMAS, Teixeira MAS, et al. Classification of transmission risk of vaccinepreventable diseases based on vaccination indicators in Brazilian municipalities. Epidemiol. Serv. Saúde. 2016; 25(4):745-54..

Minas Gerais has the complex challenge of achieving desirable and homogeneous vaccination coverage in all of its 853 municipalities and, historically, has achieved the minimum vaccination coverage target for the population of children and the elderly⁴²42 Gontijo TL, Oliveira VC, Almeida NA, et al. Análise da cobertura vacinal contra influenza no estado de Minas Gerais. Cienc. Enfermería. 2017; 23(3):69-75.. In the state, the variation in vaccination coverage in municipalities is associated with FHC coverage and population size⁴²42 Gontijo TL, Oliveira VC, Almeida NA, et al. Análise da cobertura vacinal contra influenza no estado de Minas Gerais. Cienc. Enfermería. 2017; 23(3):69-75.. Population size and vaccination coverage have an inverse association, with municipalities with larger populations generally having lower vaccination coverage⁴¹41 Braz RM, Domingues CMAS, Teixeira MAS, et al. Classification of transmission risk of vaccinepreventable diseases based on vaccination indicators in Brazilian municipalities. Epidemiol. Serv. Saúde. 2016; 25(4):745-54..

A study carried out by Souza et al.⁴³43 Souza NP, Lira PIC, Fontbonne A, et al. (Mal)nutrition and the new epidemiological trend in a context of development and inequalities. Ciênc. saúde coletiva. 2017; 22(7):2257-66. showed that malnutrition is present in all regions of Brazil, with more emphasis on two areas of hunger (North and Northeast regions) and three areas of malnutrition (South, Southeast and Central-West regions). When comparing nationwide surveys from the 1970s, 1980s and 1990s, a decline in malnutrition in the country was observed, with emphasis on the reduction of approximately 72% in average height in children. The greatest variations were observed in urban areas compared to rural areas, which characterizes malnutrition as a result of socioeconomic inequalities in Brazil⁴³43 Souza NP, Lira PIC, Fontbonne A, et al. (Mal)nutrition and the new epidemiological trend in a context of development and inequalities. Ciênc. saúde coletiva. 2017; 22(7):2257-66..

Regarding the prevalence of malnutrition in children under 2 years of age, in Minas Gerais, there was a lower prevalence of rural municipalities in the group of municipalities that presented an indicator above the state target. In other words, considering the target established by SES/MG for the prevalence of malnutrition in children under 2 years of age, which is less than 4.82%, most of the municipalities that had a result above the state target are made up of urban and intermediate. This result may be related to greater FHC⁴⁴44 Mourão E, Gallo CO, Nascimento FA, et al. Temporal trend of Food and Nutrition Surveillance System coverage among children under 5 in the Northern Region of Brazil, 2008-2017. Epidemiol. Serv. Saúde. 2020; 29(2):e2019377. coverage, as well as improved living conditions in rural municipalities, reduced inequalities and investments in social income distribution programs⁴³43 Souza NP, Lira PIC, Fontbonne A, et al. (Mal)nutrition and the new epidemiological trend in a context of development and inequalities. Ciênc. saúde coletiva. 2017; 22(7):2257-66., but needs to be better investigated in due course.

Higher ICSAP in rural municipalities may be related to the low implementation of FHC in some locations and the inefficient provision of exams and consultations by specialists, which compromises the monitoring of chronic conditions⁴⁵45 Macinko J, Mendonça CS. Estratégia Saúde da Família, um forte modelo de Atenção Primária à Saúde que traz resultados. Saúde debate. 2018; 42(esp1):18-37.. The long distances to the nearest regional centers, combined with the existence of roads without asphalt paving, geographic barriers and the lack of public transport, are also competing factors that can make it difficult for patients to access exams and specialized consultations¹²12 Pessoa VM, Almeida MM, Carneiro FF. Como garantir o direito à saúde para as populações do campo, da floresta e das águas no Brasil? Saúde debate. 2018; 42(supl1):302-14.,⁴⁶46 Smith MW, Owens PL, Andrews RM, et al. Differences in severity at admission for heart failure between rural and urban patients: the value of adding laboratory results to administrative data. BMC Health Services Research. 2016; 16:133..

The scientific literature points out that differences in ICSAP rates in urban and rural locations can be attributed to differences in access to timely outpatient care and also to decisions made at the time of admission. Patients from rural areas who present clinical conditions that do not justify hospitalization may be admitted as a precaution. After the patient has traveled long distances, and faced with the uncertainty that they will have access to health treatment at another point of care in the network, some doctors adopt the position of admitting these patients with conditions that could be managed and treated in PHC⁴⁶46 Smith MW, Owens PL, Andrews RM, et al. Differences in severity at admission for heart failure between rural and urban patients: the value of adding laboratory results to administrative data. BMC Health Services Research. 2016; 16:133..

In turn, larger municipalities with better socioeconomic indicators have a greater health care park, with a greater offer of health, professional and exam services, both in the public and private sectors, in addition to having a higher percentage of people with private health plans. Urban areas, historically, have a greater and better offer of health services⁴4 Arruda NM, Maia AG, Alves LC. Desigualdade no acesso à saúde entre as áreas urbanas e rurais do Brasil: uma decomposição de fatores entre 1998 a 2008. Cad. Saúde Pública. 2018; 34(6):e00213816.. These factors together can influence ICSAP, as people will be better able to manage and treat clinical conditions considered to be a PHC approach in the FHC itself or in other outpatient services¹²12 Pessoa VM, Almeida MM, Carneiro FF. Como garantir o direito à saúde para as populações do campo, da floresta e das águas no Brasil? Saúde debate. 2018; 42(supl1):302-14.,⁴⁵45 Macinko J, Mendonça CS. Estratégia Saúde da Família, um forte modelo de Atenção Primária à Saúde que traz resultados. Saúde debate. 2018; 42(esp1):18-37.,⁴⁶46 Smith MW, Owens PL, Andrews RM, et al. Differences in severity at admission for heart failure between rural and urban patients: the value of adding laboratory results to administrative data. BMC Health Services Research. 2016; 16:133.. This same context can influence prenatal rates, establishing better prenatal indicators in urban municipalities⁴⁷47 Mario DN, Rigo L, Boclin KLS, et al. Quality of Prenatal Care in Brazil: National Health Research 2013. Ciênc. saúde coletiva. 2019; 24(3):1223-32..

For the purpose of evaluating these results, improvements in the general living conditions of the population³³33 Soares RAS, Moraes RM, Vianna RPT. Mortalidade infantil no contexto da ruralidade brasileira: uma proposta para a superação da invisibilidade epidemiológica e demográfica. Cad. Saúde Pública. 2020; 36(8):e00068718., such as economic and social conditions, reduction of inequality and investment in social income distribution programs³⁷37 Malta DC, Saltarelli RMF, Prado RR, et al. Preventable deaths within Brazil’s Public Health System in a population from 5 to 69 years old, 2000 – 2013. Rev. bras. epidemiol. 2018; 21:e180008.,³⁸38 Victora CG, Aquino EM, Leal MC, et al. Maternal and child health in Brazil: progress and challenges. Lancet. 2011; 377:1863-76.,⁴³43 Souza NP, Lira PIC, Fontbonne A, et al. (Mal)nutrition and the new epidemiological trend in a context of development and inequalities. Ciênc. saúde coletiva. 2017; 22(7):2257-66., can also be considered. Therefore, it is considered that more comprehensive studies are needed to elucidate aspects of access to health services and the population’s living conditions not covered in this study.

Recommendations for health managers at the three governmental levels: promoting the consolidation of FHC in unfavorable contexts, such as remote rural locations and urban clusters; implementation of actions aimed at integrating PHC and Health Surveillance; strengthening PHC with a view to offering problem-solving services (trained professionals and offering exams and procedures at UBS); the financing of multi-professional FHC teams with the aim of having greater resolution; articulation of the service network to guarantee access to other levels of care in cases that exceed the management and resolution capacity of PHC, with emphasis on Specialized Outpatient Care and; the establishment of intersectoral actions on issues that go beyond the health sector but that impact the living and health conditions of the population.

The results of this study should be interpreted with caution, given the limitations of the adopted design. The main limitation of ecological studies is the impossibility of relating exposure and outcome at the individual level (ecological fallacy). In turn, crosssectional studies only describe associations between variables, without the possibility of establishing causality. The limitations inherent to the secondary databases consulted must also be mentioned, which depend on the nutrition, completeness and updating guaranteed by the originating bodies. However, despite such limitations, the topic researched is very relevant to public health and presents useful information to managers and researchers about health care in different municipal contexts, identified within the typologies proposed by IBGE.

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