The results are organized into two dimensions. Dimension 1 presents the context of health regions: socioeconomic characteristics (Table 1) and the main flows and distances to specialized care (Fig. 1 and Table 2). Subsequently, dimension 2 presents the health care points and care regulation in RRM: from PHC to specialized care. The corresponding empirical data are synthesised with the main findings and their respective speech fragments.
Table 1
Characteristics of Remote Rural Municipalities, Health Regions, Semi-arid, Brazil, 2019
Local | Population 1 2020 | Area (km²) 2 | Density (inhab./km 2) 2 | Population in rural areas 2 (%) | Extreme poverty2 (%) | PBF beneficiary population 3(%) |
Bahia State | 15.324.591 | 564.732,80 | 27,14 | 27,93 | 12,71 | 51,93 |
Health Region Ibotirama | 196.095 | 28.667,00 | 7,46 | 33,39 | 31,38 | 78,40 |
Ipupiara | 10.157 | 1.055,80 | 9,62 | 35,60 | 23,79 | 76,14 |
Morpará | 8.950 | 2.093,90 | 4,27 | 33,12 | 29,89 | 80,11 |
Health Region Juazeiro | 535.846 | 57.467,30 | 10,74 | 26,58 | 24,84 | 72,51 |
Pilão Arcado | 35.740 | 11.626,60 | 3,07 | 66,44 | 40,90 | 74,87 |
Piauí State | 3.219.953 | 251.611,30 | 12,80 | 34,23 | 13,27 | 58,86 |
Vale Rios Piauí and Itaueiras Health Region | 201.853 | 27.833,10 | 5,39 | 44,55 | 29,42 | 74,81 |
Rio Grande do Piauí | 6.331 | 636,00 | 9,95 | 34,74 | 31,13 | 75,78 |
Brazil | 211.755.692 | 8.516.000 | 23,8 | 15,67 | 6,62 | 21 |
Table 2
Distance between Rural Remote Municipalities to the headquarters of health regions/macro-regions and the state capital, Semi-arid, Brazil, 2019
Place of departure | Health region headquarters (distance/time) | Headquarters of the macro-region health region (distance/time) | Capital (distance/time) |
Ipupiara (BA) | Rural area UR | 281 km (05h:25) | 489 km (08h:12) | 739 km (12h:00) |
Headquarters | 161 km (02h:25) | 369 km (05h:12) | 619 km (09h:00) |
Morpará (BA) | Rural area UR | 108 km (02h:25) | 305 km (05h:05) | 745 km (11h:20) |
Headquarters | 86 km (01h:25) | 283 km (04h:05) | 723 km (10h:20) |
Pilão Arcado (BA) | Rural area UR | 299 km (04h:48) | 299 km (04h:48) | 806 km (12h:40) |
Headquarters | 281 km (04h:08) | 281 km (04h:08) | 788 km (12h:00) |
Rio Grande do Piauí (PI) | Rural area UR | 163 km (03h:00) | Does not apply to the state of Piauí*. | 408 km (06h:20) |
Headquarters | 135 km (02h:00) | 380 km (05h:20) |
Dimension 1 - Context of health regions: socioeconomic characteristics and main flows to specialized care
In Bahia, the health region of Ibotirama is composed of nine municipalities - among them the RRM of Ipupiara and Morpará - and makes up the macroregion of health West, with the municipality of Barreiras as its headquarters, responsible for most of the provision of specialized care services. In Bahia, the health region of Juazeiro is formed by ten municipalities - among them the RRM of Pilão Arcado - and composes the Northern macro-region of health, whose headquarters is the municipality of Juazeiro responsible for most of the provision of specialized care services. This health region borders the states of Pernambuco and Piauí. Finally, the health region of Vale Rios Piauí and Itaueiras, in Piauí, is composed of 28 municipalities - including the RRM of Rio Grande do Piauí - with the municipality of Floriano as the regional headquarters. Still, the largest provider of specialized care is the capital, Teresina.
The socioeconomic and demographic characteristics of the three regions and the respective elected RRMs are summarised in Table 1.
In the four RRM, specialized services should be distributed to contemplate the health needs of the territories according to the design of the health regions (Fig. 1) and provided through the Pactuated and Integrated Programming (PIP). Although the provider was commonly private, the most significant supply was public, especially for specialized consultations and exams.
Some patients go to the regional hospital of Ibotirama, others to the municipal hospital of Barra, and others to Salvador. [...] for example, the municipality of Ibotirama hired a urologist and other doctors from other specialties. Therefore, a private clinic was hired to perform; however, the municipality [to pay] has the correct cost. MRI and orthopedics, the municipality of Barreiras also hired a private clinic and, several times, we outsourced this service and used it. So, it goes from public to public and public to private, at zero cost to the population; zero, so we use the transfer (MM3).
However, the insufficient and disorganized supply by the SUS, associated with the long distances, contributed to various arrangements for the provision/acquisition of SC - direct purchase from the private provider by the municipality, supply through agreements between municipalities, and direct disbursement by the user - in order to somehow fill the gaps in care or shorten the waiting times.
[...] to what extent Juazeiro is able to meet all this demand. Sometimes, this demand cannot be met [...]. Say that there is specialized care for all our demands. In the maternal-infant network, we do not have very great fragility in orthopaedics, and cardiology is also very complicated (RM3).
The public service is very outdated and cannot meet what the entire population wants. There has been a lot of private health care, and we understand that we are being well served here. The mayor has significantly focused on [public] health; however, the private sector has stood out. Perceiving that most of the exams, both quantity, and price, are in the private sector in Irecê, then, Ipupiara sends a lot to Irecê, there are even vans that make the line weekly. The fare is expensive; however, it pays off for the population because everyone who goes there likes the private service (MM1).
Although the headquarters of the RRM concentrated the primary health services, a large portion of the population lived in rural areas in dispersed territories, thus requiring frequent travel to access some continuity between different levels of care.
The distances between municipalities are vast, making it very difficult for the population to access health services, especially in terms of medium and high complexity problems. For us to structure this flow here in the region is very challenging. Moreover, within the municipality itself, we have municipalities that some locations are more than 100 km from the headquarters (RM1).
For Morpará and Ipupiara, located in the same health region, the main supply cities via pacts were Barra, Ibotirama, Barreiras, and Salvador. In turn, the municipality of Irecê stood out for the supply of private services that were purchased directly by the municipal manager, without pacts.
For Pilão Arcado, the main cities of supply via pact were Juazeiro and Salvador. The municipality of Remanso also presented itself as the headquarters of the regional SAMU and reference in the reading of preventive slides for cervicouterine cancer. The municipality borders the state of Piauí and has a sizeable territorial extension. Therefore, for some localities in the rural area, the population moved to municipalities of neighboring states, even for PHC care. Because it is a city on the interstate border, Petrolina, in Pernambuco, was a vital hospital reference, especially for orthopedics.
On the other hand, in Rio Grande do Piauí, the references were concentrated in Floriano and, mainly, Teresina (state capital).
[...] our territory is in a transitional location, where the care gap in the center-south is enormous. The only reference hospital for medium and high complexity is located here in our territory, which is the hospital of Floriano. [...] now, the consultations [with specialists], generally, are in Teresina [...] because there is a specialty that only has two, three professionals for the entire state, so it cannot be enough (GR2).
For the four RRMs, the distances between the place of residence of the user and the health care points for SC were the most significant organizational barriers. Although it met the logic of scale and scope, this issue of spatial distribution paradoxically imposed inequities on vulnerable populations and the neediest municipalities.
For example, we spent nine months with a pregnant woman, and she did only one exam, and that was it! Because she had this difficulty of access; a pregnant woman, with nausea; she had all the difficulty in the world to go and do these exams [at the headquarters of the health region]. So, we spent nine months with this pregnant woman without a blood count because the mother could not afford to pay [the fare] (GM6).
Thus, the populations in rural areas of the RRM needed to travel to the municipal headquarters and then go to the municipalities that provided specialized services. In this sense, the precarious road conditions, usually unpaved in rural areas, reinforced the geographical barriers to healthcare facilities.
Dimension 2 - Health care points and care regulation in RRM: from PHC to specialized care
For cases of urgency and emergency, there was an emergency care facility at the municipal headquarters of the RRM that served for the evaluation and stabilisation of the clinical condition and subsequent referral to referral services. Such care units operated continuously, with the support of a team composed of doctors, nurses on duty, and auxiliary staff. In the case of doctors, several times, they were the same ones who worked in the PHC units, i.e., they accumulated the functions of PHC general practitioner and the on-call physician as a way to increase the income and, consequently, this strategy also worked as a mechanism to attract professionals. However, there was a reduction in the workload in PHC units, which were deprived of doctors on duty shifts.
Some specialized public procedures were occasionally offered in the municipalities themselves in a very segmented way. Morpará provided consultation with a psychiatrist and ultrasonography (in a PHC unit), laboratory tests, and electrocardiogram (in the emergency service). Informal agreements with doctors who had more than one specialty were made such that, even if they were contracted for only one type of specialty, they could also support other needs (for example, a psychiatrist who treated cardiology in Ipupiara).
In Ipupiara, some specialties (psychiatry, orthopaedics, ultrasonography, and radiography) were offered in the municipality through direct purchase from private doctors/clinics to make up for the shortage via PIP. In addition, the gap in the SUS table (value paid to the provider versus quantity contracted/agreed) compromised the supply expectation. It generated the need for purchase by the municipal treasury (inequity for poorer municipalities and more vulnerable populations). Thus, Ipupiara complemented (according to the health secretary's criteria) the SC for users (socioeconomic and clinical criteria) who urgently needed it through direct payment to the private provider. The manager also negotiated discounts with private clinics and referred the patient who would make the direct disbursement.
I think that is a great challenge for the manager. He [health secretary] was a social assistance secretary and knows each person's profile and tries, in a way, to filter and prioritize those who are low-income. Both economic and clinical filtering, if a person can wait, he goes for a normal appointment; however, the low-income person, who cannot afford it, tries to help by financing the specialist; that is how it works (MM2).
Pilão Arcado offered some specialized services in the municipal hospital and complemented, equally, in the local private network (radiography, ultrasonography, and electrocardiography). Moreover, Rio Grande do Piauí offered a collection of laboratory tests in the territory. However, the laboratories were in Floriano (hired through PIP) and offered cardiology and ultrasonography with their own resources.
Thus, in the vacuum of SUS, specialist doctors went to the RRM and offered consultations, procedures, and exams for direct payment of the users or sold them to the municipal public entity. Such private offers were intermittent and residual in the set of needs of the population, mainly due to the socioeconomic conditions of the vast majority of the inhabitants and budget limits of the RRM. However, the direct purchase by the municipal manager seemed, contrastingly, to stimulate the private network.
[...] the municipalities structure EY services by hiring professionals. Then, the professional goes there and provides the service. Subsequently, the municipalities do not get paid for it because they do not have a service that SUS can accredit, which is very much in the municipal counterpart (RM1).
[...]to have a consultation and return with the exams, it would take six months. Then, some patients go to SUS for the first consultation; when the doctor asks for the exams, they go to the clinic, pay, and then return to show the [SUS] doctor (RM3).
In small municipalities, [specialized care] is much more private, the larger municipalities can have an adequate structure, they can resort to some accreditation, but the management is public and, in the cases of small municipalities, there is still this issue of company contracts, or contracting with private companies or professionals (SM1).
Another contradiction, as a result of the long trips to the provider, was that, in some cases, it was more advantageous for users to acquire the procedure/consultation by direct disbursement when offered by the private initiative in their city residence or the closest municipality. Not coincidentally, the RRM, when possible, offered procedures in their own territory or bought from neighbouring providers (outside the pact) because it was less expensive than having health transportation and, in some cases, accommodation. This organizational logic contributed to the strengthening of the private provider and split the network modelling.
As the population is impoverished, then, SUS schedules and the closest one is Floriano. Therefore, it is challenging for the population to access because it depends on paying for a van to go and come back. So, it is not even worth paying for a blood count, summary [of urine], because you have to pay 50 reais, at least, of passage. Then, I went to Floriano, talked to some laboratories, and formed this partnership; we do the collection here to facilitate access. The secretariat takes this material there and brings the results (RM7).
The lack of vacancies for SC was a reality in all three health regions. It affected all the municipalities indiscriminately; however, they seemed to be more harmful to the RRM since they concentrated more significant difficulties of geographical access and more vulnerable populations.
As, many times, SC and long-term care offers are located in the respective state capitals, all the RRM offered a support house for patients' stay. The users received the Out-of-Home Treatment (OHT) benefit; however, the total value of the federal transfer of the program to the municipality did not meet the need; additionally, the managers supplemented most of it with their own money.
There is a support house in Salvador; several municipalities have an agreement with that house. They have one in Barreiras; some already have one, those municipalities further away have a support house (RM1).
Every municipality has an OHT car, which they send for treatment outside the municipality. They both come here (headquarters of the health region) for haemodialysis and other treatments in Salvador (RM2).
In all municipalities, the appointment scheduling centres centralized in the health secretariats mediated access to the SC. Information about the appointment scheduling period was often provided informally to the population. The community health agent (CHA) played an essential role in providing information on appointment scheduling and the results of specialized tests, especially in rural areas.
The patient goes through primary care, gets a referral for that specialty, then goes to the secretariat, where he is scheduled in the regulation system; and then is referred (MM8).
When the user could get an appointment in the SC, the clinical information was brought by the patient himself since there was no integrated information system. One of the few exceptions was the high-risk prenatal care in Ipupiara, with flow and counterflow between the municipality and the hospital in Barreiras.
Some systems work as a reference, such as high-risk prenatal care. In this case, we can have a bigger link, a greater strength in the network [...] has a flow and essential information, both outbound and return (MM2).
There was unreliability in the counter-referral system, and the main informants about the health condition and history of consultations were the patients. The CHAs shared this information with the PHC team (hospital discharge, the performance of procedure, therapeutic plan, etc.).
Because some individuals have no way to come [to schedule], the health agent brings the copy of the document; when we make the appointment, we contact them, and usually, when it is a place where the individual does not have a telephone, the health agent takes it and tells the patient (MM7).
Despite the enormous difficulties in access to SC and provision of health transport in none of the RRM, there was the systematic use of telemedicine and the units were partially computerized. Additionally, there were unreliable communication services by telephone and internet availability, especially in the rural areas, i.e., contrary to the needs of remote territories.
[...] access to Telehealth is very little, although the Telehealth staff comes here [in the health region], and has been in some municipalities, training with professionals. However, we still feel that there is still not much access [...] internet [in health units] is also a difficulty (RM2).
[...] we have implemented [telehealth]; however, it does not work [...] for consulting we do not have, only for training, for capacity building (RM3).