ABSTRACT

The present study aimed at understanding the access barriers of homeless people (HP) in Belo Horizonte city to health services as well as to analyze the employed care strategies from the Belo Horizonte Consultório na Rua (eCR), street clinics’ team view. We report a qualitative study by means of semi structured interviews with 10 workers from two eCR. The investigated HP face protocol and symbolic discriminatory barriers that hamper and impede their rights of access to the health system, besides the Brazil Unified Health System (SUS) equity guidelines. These barriers are related to the social exclusion process to what the homeless people are submitted, marked by multiple and overlapping violences, restricted access to basic rights that are escalated when the use of drugs is reported. Among the strategies to overcome the access barriers are the need to qualify public data on HP, institutional dialogues on the HP access to the SUS, a more permanent education attitudes to demystify thoughts and prejudices, the need to elaborate different flows that take into account the HP’s ways of life, the need of outgoing primary care actions that promote inclusion of the Belo Horizonte HP, as well as strategies that strengthen them with active social participation.

KEYWORDS:
Ill-housed persons; Health services accessibility; Health equity; Vulnerable populations; Qualitative research.

Introduction

The Homeless Population (HP) is a heterogeneous group that has in common extreme poverty, the weakening or rupture of family ties, the lack of conventional housing and the use of public places as housing and sustenance^{11 Ministério do Desenvolvimento Social e Combate à Fome (BR). Rua aprendendo a contar. Brasília, DF: MDS; 2009.}.

The large number of HP in Brazil is the result of the worsening of social issues, especially the rapid urbanization that occurred in the 20th century, with migration to large cities, the formation of large urban centers, social inequality, poverty, amongothers^{22 Ministério da Saúde (BR). Saúde da população em situação de rua: um direito humano. Brasília, DF: Ministério da Saúde; 2014.}. The HP lives in a permanent state of vulnerability, either because they do not have documents (which is indispensable for citizenship), or because they do not have a home, money, fixed employment, caused by not having access to education or because they find it difficult even to receive healthcare^{33 Sotero M. Vulnerabilidade e vulneração: população de rua, uma questão ética. Rev Bioética. 2011;19(3)799-817.}.

There is a shortage of updated public data that quantify and characterize the HP in Brazil, and they are not included in the census data of the Brazilian Institute of Geography and Statistics (IBGE), because it is not a domiciled population. The Institute of Applied Economic Research (IPEA) estimated that, in 2022, there were 281,472 homeless people in Brazil^{44 Natalino M. Estimativa da população em situação de rua no Brasil (2012-2022). Brasília, DF: Instituto de Pesquisa Econômica Aplicada; 2023.}. In May 2023, there were 204,244 homeless people registered in Cadastro Único (CECAD)^{55 CECAD Tabulador do Cadastro Único [Internet]. Versão 2.0 [Brasília, DF]: CECAD; em data] [acesso em 2023 ago 1]. Disponível em: http://cecad.cidadania.gov.br
http://cecad.cidadania.gov.br...} .

To obtain a national overview of the reality of homelessness in Brazil, a national survey on homelessness was carried out in 2009, which identified 31,992 people over 18 years, living on the streets. According to the research, homeless people have difficulties in accessing health services, and more than half of the interviewees said they had suffered discrimination and maltreatment in health services, where they are sometimes considered to have ‘social pathology’, avoiding entering certain spaces because they understand that they will probably be expelled^{11 Ministério do Desenvolvimento Social e Combate à Fome (BR). Rua aprendendo a contar. Brasília, DF: MDS; 2009.}.

The multidisciplinary teams of the Street Clinic (eCR) were created to deal with the different problems and health needs of the HP, given the recognition of the difficulty of access to primary care services^{66 Ministério da Saúde (BR). Portaria Nº 122, de 25 de janeiro de 2011. Define as diretrizes de organização e funcionamento das equipes de consultório na rua. Diário Oficial da União, Brasília, DF. 2011 jan 26; Seção 1.}. The eCRs correspond to a type of extramural care, which seeks to provide comprehensive care, offering on-site healthcare assistance to guarantee care for PSR. The teams make up Primary Health Care (PHC) and circulate in the territories in a vehicle, offering health care adapted to the specificities of a population with important complexity^{77 Londero MFP, Ceccim RB, Bilibio LFS. Consultório de/na rua: desafio para um cuidado em verso na saúde. Interface - Comun Saúde Educ. 2014;18(49):251-60.}.

This article aims to analyze the barriers of access of the HP in the SUS, as well as the possibilities of construction of care from the perception of the workers of the eCR. The results presented are part of a master’s thesis^{88 Fraga PVR. “Tá normal! tá normal! a saúde chegou”: etnografia da atuação do Consultório na Rua de Belo Horizonte nas cenas de uso [dissertação]. Belo Horizonte: Fundação Oswaldo Cruz. Instituto René Rachou; 2022. 141 p.} that sought to understand the role of eCR in the street space and public scenes of drug use.

Material and methods

This is a qualitative study, considering that this research format allows a deeper understanding of certain social phenomena, favoring the subjective aspect of social action in view of the configuration of society’s structures. Thus, qualitative methods emphasize the specificities of a phenomenon in terms of its origins and its reason of being^{99 Haguette TMF. Metodologias qualitativas na sociologia. 9. ed. Petrópolis: Editora Vozes; 2003.}.

Semi-structured interviews were conducted with workers from two eCR. The researcher contacted each team during work meetings where she presented the research and invited them to participate. The selection criterion of the workers was to integrate one of the teams that work in the territories of the studied scenes of drug use. Refusal or absence from work during the collection period were defined as exclusion criteria.

Ten interviews were conducted, from October to December 2021, with an average duration of forty minutes. Two professionals from each category (social worker, nurse, harm reducer, art educator and psychologist) of two eCR, who work in the studied scenes of use, participated. The audio of the interviews was recorded, later transcribed, and the material was archived on the institution’s servers.

The names used in this article are fictitious to preserve the anonymity of the participants. The data were analyzed using the Thematic Content Analysis technique^{1010 Bardin L. Análise de conteúdo. Lisboa: Edições 70, 1977. 225 p.}. Content analysis can be understood as a communications analysis tool that makes use of systematic procedures to describe the content of messages.

Initially, the transcribed content was organized by thematic axes; then, the analysis was carried out according to the frequency with which these themes were mentioned and, in a third moment, the cross-sectional analysis was carried out, in which the transcribed content is cut and grouped into the thematic axes initially organized. Among the thematic axes identified, here we intend to discuss an axis that was presented as central: the perception of the workers about the access of the HP to the SUS network.

The interviews aimed to understand the performance of the device with the HP in the scenes of use. During the analysis, it was noticed that access barriers were a recurring theme in the interviews. This topic has become an important element of research, considering the privileged extramural view of the eCR in relation to HP with its on-site performance and its ability to look intramural within public health policy. As health workers, they have a different approach to the HP, based on their prerogative to be a low-demand service, that operate in the street space, which brings a more specific look at this reality. In contrast, they also have a look within the institutionality of the SUS/BH network, considering that they are part of it.

The research was guided by Resolution No. 466/12^{1111 Conselho Nacional de Saúde (BR). Resolução nº 466, de 12 de dezembro de 2012. Aprova as diretrizes e normas regulamentadoras de pesquisas envolvendo seres humanos. Diário Oficial da União, Brasília, DF. 2013 jun 13; Seção I:59.}, of the National Health Council (CNS), which regulates the guidelines and standards on research involving human beings, approved by the Research Ethics Committee of Fiocruz Minas/Instituto René Rachou (CAAE 46888821.0.0000.5091) and by the Research Ethics Committee of the City of Belo Horizonte (CAAE 46888821.0.3001.5140) under registration 4,084,770.

Results and discussion

The eCRs that were part of the research are mostly composed of black women (black and brown). At the time of the interviews, 7 workers had one to two years of experience in the service, as shown in the table 1 below.

For analysis purposes, the barriers were categorized into three types, although sometimes they intersect: discriminatory barriers, protocol barriers and symbolic barriers, which are addressed in each section respectively. Then, results that are not related to the central categories are presented, but are important to think about the possibilities of care found in the topic of building bridges.

Discriminatory barriers: ‘left there and fell, no one saw, only saw at the end of the shift’

Butler points out in her work ‘Precarious Life’ that some lives are “highly protected”, however “other lives will not find such rapid and fierce support and will not even qualify as bereavable”^{1212 Butler J. Vida precária: os poderes do luto e da violência. Belo Horizonte: Autêntica; 2019.(52)}; the framing makes some lives more or less bereavable. For the author, all life is precarious, however she distinguishes the intrinsic precariousness of life from another that is the product of a policy, acting unevenly in some populations.

Pinheiro relates Butler’s idea of framing with the dehumanization of the bodies of sex workers, with emphasis on the denial of the pains experienced by them, since “their pains are not perceived as violence, but as consequences of what they are - women sex workers”^{1414 Pinheiro BO. Vidas precárias: estudo sobre a espiritualidade sem religião vivida por profissionais do sexo em Belo Horizonte [dissertação]. Belo Horizonte: Pontifícia Universidade Católica de Minas Gerais; 2022.(75)}.

Regarding the notion of framing, the author explains:

Under the logic of framing, when faced with the person in a street situation, the subject who sees him decides (by a conscious choice or not) to direct his gaze to these subjects by placing them at the angle of the framing or at the margin of it, outside the edges. Relating the reality presented about sex workers with the HP, a similar context of marginalization and discrimination is perceived when the precariousness experienced is associated with vagrancy, laziness or choice, causing them to be outside the framing of the beings that should be cared for.

It stands out here, according to Pinheiro^{1414 Pinheiro BO. Vidas precárias: estudo sobre a espiritualidade sem religião vivida por profissionais do sexo em Belo Horizonte [dissertação]. Belo Horizonte: Pontifícia Universidade Católica de Minas Gerais; 2022.(80)}

The notion of racial discrimination used by Almeida, that is “the attribution of differentiated treatment to members of racially identified groups”^{1515 Almeida SL. Racismo Estrutural. São Paulo: Editora Jandira; 2021.(32)}, has as a “fundamental requirement the power, without which it is not possible to attribute advantages or disadvantages on account of race”^{1515 Almeida SL. Racismo Estrutural. São Paulo: Editora Jandira; 2021.(32)}.

In this text, the word discrimination is represented as the action of intolerance and prejudice that separates and segregates people or groups, culminating in disadvantages or privileges for individuals depending on the group to which they belong, whether by race, ethnicity, gender, sexual orientation, religion, social situation, disability, among others, recognizing that such practices in health services are known to be factors that hinder health access and care^{22 Ministério da Saúde (BR). Saúde da população em situação de rua: um direito humano. Brasília, DF: Ministério da Saúde; 2014.}.

In this sense, it was used to define as discriminatory barriers the actions developed by public actors that prevent or disqualify offers to the HP driven by prejudices, such as reports of refusal of care; distancing at the time of examining; inadequate care; not touching the subject during the clinical evaluation; demanding that the user return cleaner; failing to indicate a therapy for discrediting adherence^{88 Fraga PVR. “Tá normal! tá normal! a saúde chegou”: etnografia da atuação do Consultório na Rua de Belo Horizonte nas cenas de uso [dissertação]. Belo Horizonte: Fundação Oswaldo Cruz. Instituto René Rachou; 2022. 141 p.}.

In the interviews, several cases were reported that can be related to the notion of discriminatory barriers because they are homeless, however a situation arouses attention due to its severity and negative outcome: the time that the eCR took a user to hospital, later the team received a call from a professional from the Emergency Care Unit (UPA), informing: “there is a man who is here at the door that you brought yesterday, he does not want to stay, he is here at the door, but he cannot stay here at the door”. And Amarilis, one of the interviewees, responds: “No! He can stay wherever he wants. But is he okay? What’s going on?” The UPA professional informed that he could not walk, but had signed a “term of evasion”.

When the team arrived at the unit, the patient had already been taken back inside because he had a significant worsening of the condition. After readmission, he was isolated for suspected tuberculosis and, after two days, died after a fall from the stretcher. According to the UPA team, the patient was found “fallen ... he already had mydriasis, his pupil was dilated, he had no brain response”. And he concludes: “we understand that it was [...] negligence, of care. They didn’t go there, they left him there, and he fell, nobody saw, they only saw him at the end of the shift” (Amarilis).

The situations above dialogue with the findings in the literature and reveal how this population is socially seen by a stigmatized bias^{1616 Teixeira MB, Belmonte P, Engstrom EM, et al. Os invisibilizados da cidade: o estigma da população em situação de rua no Rio de Janeiro. Saúde debate. 2019;43(esp7):92-101. DOI: https://doi.org/10.1590/0103-11042019S707
https://doi.org/10.1590/0103-11042019S70...} , loaded with prejudices^{1717 Valle FAAL, Farah BF, Carneiro Junior N. As vivências na rua que interferem na saúde: perspectiva da população em situação de rua. Saúde debate [Internet]. 2020;44(124):182-92. DOI: https://doi.org/10.1590/0103-1104202012413
https://doi.org/10.1590/0103-11042020124...} , with the resistance of some health professionals to serve them^{1818 Andrade R, Costa AAS, Sousa ET, et al. O acesso aos serviços de saúde pela população em situação de rua: uma revisão integrativa. Saúde debate. 2022;46(132):227-39. DOI: https://doi.org/10.1590/0103-1104202213216
https://doi.org/10.1590/0103-11042022132...} , revealing themselves as the ‘unwanted patient’ of many health services, which generates fear and distrust of users^{1919 Abal YS. Mais que apenas pedras e pedradas. A produção de saúde em cenas abertas de uso de crack, pasta base de cocaína e similares [dissertação]. Cuiabá: Instituto de Saúde Coletiva, UFMT; 2018.} - who know the limitations of access and feel discriminated^{2020 Filho G, Moura J. Humilhação social - um problema político em psicologia. Psicol USP. 1998;9:11-67. DOI: https://doi.org/10.1590/S0103-65641998000200002
https://doi.org/10.1590/S0103-6564199800...} . The release of the patient after the signature of the alleged ‘term of evasion’ indicates a lack of responsibility in relation to the patient who is in the unit.

Corroborating the literature, there were reports of discriminatory situations with the HP aggravated when related to drug use, as occurred in an orthopedic emergency care:

The marginalization of these bodies is due to the (re)production of the stigma to which the HP is subjected, contributing to the construction of a negative image of these individuals. In situations such as the one described, moral convictions loaded with prejudices are attributed, even before listening to the subject’s life story or diagnostic complaints. The aggravation of stigma when it comes to people in harmful drug use comes from a notion of fragility of character, vagrancy or dangerousness^{1616 Teixeira MB, Belmonte P, Engstrom EM, et al. Os invisibilizados da cidade: o estigma da população em situação de rua no Rio de Janeiro. Saúde debate. 2019;43(esp7):92-101. DOI: https://doi.org/10.1590/0103-11042019S707
https://doi.org/10.1590/0103-11042019S70... ,1717 Valle FAAL, Farah BF, Carneiro Junior N. As vivências na rua que interferem na saúde: perspectiva da população em situação de rua. Saúde debate [Internet]. 2020;44(124):182-92. DOI: https://doi.org/10.1590/0103-1104202012413
https://doi.org/10.1590/0103-11042020124...} , driven by a ‘conceptual slippage’ between poverty, madness and dangerous classes that needs to be overcome^{2121 Paiva IKS, Guimarães J. População em situação de rua e Rede de Atenção Psicossocial: na corda bamba do cuidado. Physis. 2022;32(4):1-21. DOI: https://doi.org/10.1590/S0103-73312022320408
https://doi.org/10.1590/S0103-7331202232...} .

Health professionals are also influenced by this imaginary^{1616 Teixeira MB, Belmonte P, Engstrom EM, et al. Os invisibilizados da cidade: o estigma da população em situação de rua no Rio de Janeiro. Saúde debate. 2019;43(esp7):92-101. DOI: https://doi.org/10.1590/0103-11042019S707
https://doi.org/10.1590/0103-11042019S70...} and, often, since the patient’s report on drug use there is hostility in the clinical conduct of care. Case of a pregnant woman who sought the health center and the professional of the unit said

Some discriminatory barriers identified in the interviews were the lack of commitment to the care of people, “when we go to accompany a person in the clinic, the person [care professional] talks looking at us [eCR worker], does not look at the person [patient], as if the person were not there” (Amarilis); they refuse care, saying “return with the Street Clinic” (Amarilis), determining the presence of eCR as a precondition for care.

It is noteworthy that these discriminatory actions towards the HP do not concern individual choices of professionals in isolation, on the contrary, they correspond to the social imaginary related to homeless people, the result of a social process of segregation and social exclusion. Such actions are disconnected from SUS’ guidelines and go against the technical regulations of the Ministry of Health that provide for equity and guarantee broad, simplified and safe access^{2222 Casa Civil (BR). Decreto Nº 7.053 de 23 de dezembro de 2009. Institui a Política Nacional para a População em Situação de Rua e seu Comitê Intersetorial de Acompanhamento e Monitoramento, e dá outras providências. Brasília, DF: Diário Oficial da União, Brasília, DF. 2009 dez 24; Seção 1.}.

Protocol barriers: ‘They prefer to go with us, because we arrive breaking some barriers’

Among the situations of denial of access identified in the interviews, there were bureaucratic and protocol justifications, such as: lack of identity document, SUS card, proof of residence, absence of fixed residence, vacancy time in the unit’s schedule for divergent service of the ways of life of the HP or a condition to care only with the presence of an eCR^{1616 Teixeira MB, Belmonte P, Engstrom EM, et al. Os invisibilizados da cidade: o estigma da população em situação de rua no Rio de Janeiro. Saúde debate. 2019;43(esp7):92-101. DOI: https://doi.org/10.1590/0103-11042019S707
https://doi.org/10.1590/0103-11042019S70... ,1818 Andrade R, Costa AAS, Sousa ET, et al. O acesso aos serviços de saúde pela população em situação de rua: uma revisão integrativa. Saúde debate. 2022;46(132):227-39. DOI: https://doi.org/10.1590/0103-1104202213216
https://doi.org/10.1590/0103-11042022132... ,2121 Paiva IKS, Guimarães J. População em situação de rua e Rede de Atenção Psicossocial: na corda bamba do cuidado. Physis. 2022;32(4):1-21. DOI: https://doi.org/10.1590/S0103-73312022320408
https://doi.org/10.1590/S0103-7331202232... ,2323 Valle FAAL, Farah BF. A saúde de quem está em situação de rua: (in)visibilidades no acesso ao Sistema Único de Saúde. Physis. 2020;30(2):e300226. DOI: https://doi.org/10.1590/S0103-73312020300226
https://doi.org/10.1590/S0103-7331202030...} .

We named as protocol barriers the actions of denials of access of the homeless person in public health services under justifications related to the infrastructure of the services, protocols, flows, routines, registrations, schedules and other motivations related to the organization of the services. We do not intend here to invalidate the need to establish flows and protocols, including understanding the importance of systematizing processes to guarantee access to SUS. However, the difficulty of the network in reviewing the protocol processes to guarantee the right of access of the HP from an equity perspective is questioned.

The legislation provides for comprehensive health care for families and individuals in situations of vulnerability or social and personal risk, and must be given regardless of the presentation of documents^{2424 Casa Civil (BR). Lei Nº 8.742 de 7 de dezembro de 1993. Dispõe sobre a organização da Assistência Social e dá outras providências. Diário Oficial da União, Brasília, DF. 1993 dez 8; Seção 1.}. Refusal for health care in these cases is a situation of violation of rights, either by disinformation or deliberately.

In the municipality, there is a guideline for the dispensation of medication for undocumented HP, however, the HP continues to face protocol barriers justified by bureaucratic aspects that reinforce the institutional violence arising from the bureaucracy of health services^{2525 Santos IT, Prado Júnior RR, Tajra FS, et al. Experiências de acesso à saúde bucal de mulheres em situação de rua. Saúde debate. 2023;47(136):83-95. DOI: https://doi.org/10.1590/0103-1104202313605
https://doi.org/10.1590/0103-11042023136...} . An important aspect pointed out by the workers is the need for a differentiated ‘calculation’ in the clinical conduct of care to the HP, considering their ways of life:

The relationship of the health professional with the user of the services can be established as a power relationship, where technical knowledge overlaps with the user’s knowledge, either in the relationship with the eCR or with the other teams of the SUS network. Sometimes, there is a risk of disregarding the immediacy that permeates the logic of life of the HP^{2626 Engstrom EM, Lacerda A, Belmonte P, et al. A dimensão do cuidado pelas equipes de Consultório na Rua: desafios da clínica em defesa da vida. Saúde debate. 2019;43(esp7):50-61. DOI: https://doi.org/10.1590/0103-11042019S704
https://doi.org/10.1590/0103-11042019S70...} . About these behaviors misaligned with the ways of life of this population, Amarilis reports:

The ways of life of the HP are often related to the search for daily survival (what to eat today, where to sleep today, how to protect oneself today). Therefore, their needs and their daily lives need to be guiding in the construction of care protocols, thinking in a health network that knows the needs of this population. The inflexibility of schedules for consultation may be incompatible with living on the street^{2525 Santos IT, Prado Júnior RR, Tajra FS, et al. Experiências de acesso à saúde bucal de mulheres em situação de rua. Saúde debate. 2023;47(136):83-95. DOI: https://doi.org/10.1590/0103-1104202313605
https://doi.org/10.1590/0103-11042023136...} , making access unfeasible.

Regarding protocol barriers, the eCR have an important role in mediating the relations between the HP and the services:

As much as there are differences between protocol barriers and discriminatory barriers, both result from prejudice and disregard of the ways of life of the HP.

Another striking aspect of the interviews are the noises found in the relationship between the eCR and the workers of other services, either by leading the patient considered ‘unwanted’ - by generating more work demands for the team that receives it - or by the interventions that the eCR need to make at some moments to be able to guarantee the access of the HP to other care.

It is noticed that, even composing the care network of SIS/BH, often the subjects accompanied are seen by other services as ‘patients of the Street Clinic’, with little commitment to the construction of shared care. It is necessary to demarcate that

Symbolic barriers: ‘We’ve been waiting for you’

With regard to health care processes, although there is no physical-spatial distance from health services, it is clear that homeless people, especially those who attend the scenes of drug use, have great resistance and avoid approaching territorial-based health services, including in situations of pain and acute suffering^{1616 Teixeira MB, Belmonte P, Engstrom EM, et al. Os invisibilizados da cidade: o estigma da população em situação de rua no Rio de Janeiro. Saúde debate. 2019;43(esp7):92-101. DOI: https://doi.org/10.1590/0103-11042019S707
https://doi.org/10.1590/0103-11042019S70...} .

An aspect that causes astonishment is the refusal to seek health services, with several reports of situations in which the subjects expect the return of the eCR on Monday.

Situations such as this can be considered symbolic barriers to access, when, even before having a denial of access in a specific service, the person deduces that they will not be well served and avoids entering public spaces from an expectation of expulsion¹1 Ministério do Desenvolvimento Social e Combate à Fome (BR). Rua aprendendo a contar. Brasília, DF: MDS; 2009.. In the literature, there are records of feelings of low self-esteem on the part of the HP, feelings of shame, comparissons to garbage^{1717 Valle FAAL, Farah BF, Carneiro Junior N. As vivências na rua que interferem na saúde: perspectiva da população em situação de rua. Saúde debate [Internet]. 2020;44(124):182-92. DOI: https://doi.org/10.1590/0103-1104202012413
https://doi.org/10.1590/0103-11042020124...} , showing the reproduction of stigmas that are internalized and contribute to the distance from health services.

These symbolic barriers can easily be perceived in the discourses from Íris, who mentions a set of public health equipment in the territory, with ample hours of service to the public in the open door modality. This includes CERSAM AD (in Belo Horizonte corresponds to the Psychosocial Care Centers for Alcohol and Drugs - CAPS AD), the Health Center and the UPA, located between 240m to 350m from the living space of these subjects who, even so, are unable to access them in order to have their rights to health effective.

There was a report about a critical situation presented with a user who experienced a conflict with trafficking. She was in the park, fingers parted by a machete cut, there was tissue rupture and a deep wound with bone exposure. The user had been tortured after being accused of putting salt in commercialized cocaine. The team tried to mobilize her to be assisted in the UPA 350m from the site, however, even in the face of a serious situation, the user did not accept. Faced with the refusal and severity of the injury, eCR chose to dress and monitor the wound on the street, even though it was aware that the offer of care in the situation was far from ideal, but understood that it was the possible care from the perspective of harm reduction. It is understood that this refusal may also be motivated by the fear of calling the police, as it is an episode of violence and an illicit activity.

The situations reported reveal similarities in the scenes of use in Belo Horizonte/MG with the one portrayed in Cuiabá/MT, where

It is noteworthy that these symbolic barriers are not related to something imaginary. They allude to a refusal or distancing of homeless individuals from health services, an expression of the real prejudice suffered throughout life when accessing public establishments^{11 Ministério do Desenvolvimento Social e Combate à Fome (BR). Rua aprendendo a contar. Brasília, DF: MDS; 2009.}. Repeated access barriers foster symbolic barriers that result in lack of trust, dissatisfaction with services and, consequently, withdrawal and distancing from public health services.

The access barriers found in the researched context are related to the conception of Filho and Moura ²⁰ about social humiliation as a modality of anguish, resulting from the traumatic impact of class inequality. Humiliation for the poor (here situated in the context of the HP) is a reality felt in daily life as imminent, always lurking, and the feeling of not having rights, of looking despicable and disgusting is imposed on them, as beings that no one sees.

Thus, the access barriers identified from the perspective of the workers sometimes intersect and resemble each other, since the factors that generate them are based on the same basis, the process of social exclusion.

Despite all the impasses presented, there is no intention in this article to fall into a fatalism, as if there were no production of networked health care. Although this article focuses on the critical points related to access barriers, possible outputs built on a daily basis collectively, in a network, were identified for the realization of the right to health of the HP.

Building bridges: ‘That’s our job, bridging’

The workers pointed out the eCR as “a service that arrives with the body as no service arrives” (Tulipa), which arrives in places where other services do not arrive and this arrival becomes possible from the link built by the device with the territories.

Relating the context of the research with the literature on the performance of eCR in the country as a more fluid device, which adapts to the reality of the subjects, it becomes evident “the contrast of the view of those who see the scene from the highway, from inside a car, and those who enter the scene”^{2828 Brito C, Silva LN. População em situação de rua: estigmas, preconceitos e estratégias de cuidado em saúde. Ciênc saúde coletiva. 2022;27(1):151-60. DOI: https://doi.org/10.1590/1413-81232022271.19662021
https://doi.org/10.1590/1413-81232022271... (157)}.

The displacement of these teams and the direct approach to the user in the place and the way he is, without prejudgments, allows an approximation of reality that demystifies stigmas and generates a tendency to erase discomforts since the establishment of a bond^{1616 Teixeira MB, Belmonte P, Engstrom EM, et al. Os invisibilizados da cidade: o estigma da população em situação de rua no Rio de Janeiro. Saúde debate. 2019;43(esp7):92-101. DOI: https://doi.org/10.1590/0103-11042019S707
https://doi.org/10.1590/0103-11042019S70... ,1818 Andrade R, Costa AAS, Sousa ET, et al. O acesso aos serviços de saúde pela população em situação de rua: uma revisão integrativa. Saúde debate. 2022;46(132):227-39. DOI: https://doi.org/10.1590/0103-1104202213216
https://doi.org/10.1590/0103-11042022132... ,2828 Brito C, Silva LN. População em situação de rua: estigmas, preconceitos e estratégias de cuidado em saúde. Ciênc saúde coletiva. 2022;27(1):151-60. DOI: https://doi.org/10.1590/1413-81232022271.19662021
https://doi.org/10.1590/1413-81232022271...} .

One of the terms used to refer to the functions of eCR is the fact that the service is established as a bridge between the street and the other SUS’ devices. As much as many users do not access their rights in territorial-based health services, with the presence of eCR “[they] have the information, they see the white blouse passing by, [they know] that it is city hall equipment, from health and that, if they need it, they will go” (Lírio). Situations such as those described reveal the importance of the action proposed by the Ministry of Health of a mobile device that serves in loco in these historically neglected territories, with the potential to expand users’ access to health and other social rights with the health network and intersectoral network.

The fact that it presents itself as a low-demand service, with a certain informality, which arrives in a friendly way with the offer of harm reduction inputs, escapes the imagination related to health workers in white coats, with formal language, prescriptive conduct and, perhaps, even cold from a relational point of view. The possibility of transit through the territory, the ingenious management skills of the technicians and the expanded offer of care that go beyond only the curative logic (with harm reduction actions and art education), considering the perspective of integrality of the SUS, allows access and care to the extent that users allow.

The relationships established with the network are sometimes complex and generate the need for daily dialogue between the devices of the SUS network.

It has the potential to minimize the deleterious effects of the performance of health services, even causing constraints to question the discrimination and lack of assistance of the HP ²⁸.

Bonding, dialogue and listening are important tools for the performance of the service, used as a care and bonding strategy:

Goldblum^{2929 Goldblum AS. Acesso ao cuidado em saúde: a percepção de pessoas atendidas pelas equipes de Consultório na Rua no Município do Rio de Janeiro [dissertação]. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz; 2020.} discusses the importance of the care actions used by the eCR of Rio de Janeiro/RJ following an inverse logic to promote access according to the specificities of the users, with no expectation that the user adapts their characteristics to the service. Acting in a low-demand and high availability perspective involves being an access service with or without scheduling, with the non-requirement of documentation, as well as the availability to welcome the intoxicated subject, not demanding to be abstainers, presenting itself as a service that facilitates the access of the user who, historically, encounters a lot of barriers when seeking a health service.

The power of the eCR is perceived as a network-articulating health service, which proposes care in an expanded perspective, considering principles such as subjectivity and autonomy. The service has a possibility of adapting to the reality of the HP due to its mobile infrastructure, often subverting the necessary, but rigid, health protocols.

Final considerations

This research, carried out within the scope of SUS, corresponds to an instrument of reflection on the work process, indicating possible improvements to the system, with the possibility of supporting public policies that qualify access from the perspective of equity.

Regarding municipal management to reduce protocol barriers, it is important that there are institutionalized alignments for the situations already provided for in national and municipal regulations, as well as the establishment of specific flows and protocols for the HP, considering their ways of life to guarantee access and timely care, with wide dissemination within the network.

Permanent health education actions can prove to be a strategy to reduce discriminatory barriers, seeking to demystify stigmas and guide workers. The actions need to contemplate the harm reduction guidelines of the SUS (integrality, universality and equity), as well as reaffirm the non-negotiability of the professional performance of the public-servants in line with the guidelines of the Ministry of Health and the National Policy for the Homeless Population.

With regard to symbolic barriers, based on the recognition of primary care as care coordinator, especially in Belo Horizonte, which has 81.2% coverage of the Family Health Strategy^{3030 Secretaria Municipal de Saúde (BH). Relatório Anual de Gestão. Belo Horizonte: Prefeitura Municipal; 2018.}, it is recommended to build extramural action to recognize this population in its assigned territory. Also, make it possible to link HP with the services, in addition to the working of the eCR. It is also important to strengthen the social participation of the HP - such as the creation of the National Movement of the Street Population in the 2000s, in the face of growing indignation at violence and the denial of rights^{22 Ministério da Saúde (BR). Saúde da população em situação de rua: um direito humano. Brasília, DF: Ministério da Saúde; 2014.} - and its representation in social control, in Health Councils and Conferences.

References

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