Care flows and comprehensiveness of health care for riverside communities


Maria Kamyla da Silva QueirozI, Ivaneide Leal Ataíde RodriguesII, Laura Maria Vidal NogueiraIII, Ingrid Fabiane Santos da SilvaIV

I Nurse. State University of Pará, Brazil. E-mail: mariak.queiroz@gmail.com
II PhD in Nursing. Professor at the Department of Community Nursing at the State University of Pará. Brazil. E-mail: ilar@globo.com
III PhD in Nursing. Professor at the Department of Community Nursing at the State University of Pará. Brazil. E-mail: lauramavidal@gmail.com
IV Master student in Nursing. Graduate Program in Nursing, State University of Pará, Brazil. E-mail: ingridenfermeir@gmail.com

DOI: https://doi.org/10.12957/reuerj.2018.26706




Objectives: to ascertain whether health care organization in effect on Ilha do Combú complies with the principle of comprehensive health care for its population, and to identify possible gaps in care flows that hinder and interfere with the continuity of treatment for riverside communities. Method: this qualitative study used the action-research method and focus group technique with 30 participants from among service users and health professionals from the island. Data were treated by thematic content analysis of their accounts. The project was approved by the research ethics committee (Opinion No. 1.388.689). Results: from the analysis, three categories emerged: Health service with quality; Difficulty of access to the health service; and Care flows and comprehensiveness. Conclusion: it was observed that factors relating to health service quality and geography intervene in the context of regard for the principle of comprehensiveness, which is conditioned by local region characteristics.

Descriptors: Health care; integrality; nursing; health Service.




The Unified Health System (SUS) is constituted by health promotion, protection and recovery actions and services, implemented directly or indirectly by the federative entities, through the complementary participation of private institutions, organized in a regionalized and hierarchical way1. The term comprehensiveness of care is described in Law 8.080 as an articulated and continuous set of preventive and curative, individual and collective actions and services required for each case at all levels of complexity2.

The National Policy for Primary Care, through accumulated experiences of those involved historically with the development and consolidation of SUS, has updated concepts in politics and advanced in the recognition of a range of team configurations for the different Brazilian populations, among these the creation of fluvial primary health care units (UBSF) and family health strategy (ESF) for riverside populations3.

In the health management of the ESF teams, it is important to democratize the work process in the organization of services through the horizontal spread of knowledge, promotion of multiprofessional and interdisciplinary activities, and renewal of health practices in a comprehensive care perspective in which the appreciation of health care and attention emerges as a basic dimension for the health policy, which is actively developed in services4.

In the face of transformations based on globalization and technological development, the health area has had a great impact when it comes to the need to reformulate its work processes in order to guarantee the effectiveness of services5. Quality has been seen as a primary requirement for economic survival in response to increased consumer demand and also an ethical, legal, and social demand from customers5.

In this context, this study had as objectives: to verify whether the current health care provided in Combú Island complies with the principle of comprehensive health care of its population and to identify possible gaps in care flows that make it impossible to interfere in the continuity of treatment to the riverside community.



Primary care (PC) is understood as the first level of health care in the SUS and the first contact of users, which is guided by the principles of the system, which include comprehensiveness, but employs low density technology, with inputs and equipment necessary for the meeting of priorities defined for local health care, with guarantee of diagnostic and therapeutic, outpatient and hospital support through referral flows and counter-referral to specialized services6.

A key attribute of PC is its definition as the gateway to SUS, aimed at ensuring that most health needs are addressed and at filtering access to other levels. The fulfillment of this function implies accessibility in the geographical, temporal and cultural contexts, use of the service by the users at each new episode, and requirement and accomplishment of referrals of the PC professionals to access specialized care7.

The referral and counter-referral system (RCRS) is the organization mode of the services configured in networks supported by criteria, flows and mechanisms of operation to ensure a comprehensive care to users. In the understanding of the network, it is necessary to reaffirm the perspective of its logical design, which foresees the hierarchy of levels of complexity, facilitating resolute referrals among the different health networks, but reinforcing its central conception of fostering and ensuring links in different dimensions: among health teams, between teams and services, between workers and managers and between users and services/teams6.

The RCRS is an administrative mechanism organized in such a way as to allow access to all existing services in the SUS by those who seek basic health units, in which those that are more complex are called referral units. The user assisted in the basic health unit (UBS), when necessary, is referred to a unit of greater complexity in order to receive the care needed. At the end of the call, the patient must be counter-referred - the professional should refer the user to the unit of origin for the continuity of care6.



This is a qualitative study guided by the action-research method, which allows for the resolution of a collective problem, in which the participants are involved cooperatively8. We considered Resolution 466/12 of the National Health Council and the project was approved by the Research Ethics Committee of the State University of Pará under Opinion No. 1,388,689. The participants signed the Informed Consent Form. The interviews were coded for professionals and users, with the letters P and U respectively, as well as the sequential number of interviews (P1...U1...).

Participants were twenty users of the health service, from both sexes, aged more than 18 years, who had been living on the Combú Island for at least five years and attended in the ESF of the Island, and 10 health professionals: a physician, a nurse, three nursing technicians and five community health workers (CHW), who had been working on the Island for at least one year and were working during the period of data production. We developed the focus group technique, a group interview modality in which participants discuss on a particular topic through the encouragement of the researcher9.

Three weekly meetings were held at the UBSF of Combú Island, from February to March 2016, with two groups of 15 participants. The following topics were discussed: quality of health service; difficulty of accessing health services; care flows and the comprehensiveness of care, taking into account the interests of the participants and following a previously prepared script by the researchers. A field diary was also used.

The corpus for thematic analysis10 was composed of the transcriptions of the discussions triggered in the meetings and of the records of the field diary. After the transcriptions, the exploratory reading was carried out, identifying similar topics in occurrence and co-occurrence according to the objectives proposed for the study, which culminated in the emergence of three categories.



The categories that emerged after the treatment of the information were named: Quality and health service; Difficulty in accessing health services; and Care flows and comprehensiveness.

They will be presented and discussed below.

Quality and health service

This category discusses perceptions of the participants regarding the health service and quality, showing that they are very similar.

For most users, the quality of the health service is characterized by the availability of qualified professionals, the availability of tests and consultations, as well as adequate physical structure. They found that this is not their reality, since the most of them cannot even carry out tests immediately in view of the great difficulties for performing specific tests, which can only be carried out outside the island:

It means to have skilled employees, enough physicians and nurses for each area and, mainly, medicines. (U1)

Quality health care means to offer a good structure; it means we can do our tests right here, without having to wait so long, because we suffer with it...(U9)

In health services, quality comes from three dimensions: structure, process and outcome. The structure involves the financial, physical, human, material and equipment resources needed for medical care. The process refers to activities involving health professionals and users, including diagnosis, treatment and ethical aspects of the relationship between health team and patient. The result corresponds to the final product of the care provided, considering healthcare, satisfaction of the standards and expectations of the users11.

The PC health unit should have a minimum physical structure that includes spaces for nursing services, medical consultations, a waiting room suitable for users, among others, besides being equipped to guarantee quality care to the population under its coverage area, allowing it to manage its health problems12.

These aspects were also highlighted by the professionals, as they mentioned that a quality service needs elements that encompass from the reception to the complete solution of the problem. In this sense, they referred to welcoming as a prime factor to qualify the service, since the way the users are received reflects their level of satisfaction with the service provided, and the professional takes the role of welcoming and giving a positive and resolute response to their health problems.

They also mentioned the lack of tests and drugs in the unit as conditioning factors for dissatisfaction, since users often do not have the resources to commute to perform tests and/or purchase medicines, which directly influences the success and/or continuity of therapeutic behaviors, since access to medicines depends on their availability, the people's purchasing capacity and their geographical accessibility13:

[...] the service will only be considered great when it really meets the citizens in what they need and the service in what it should meet. (P1)

[...] the quality health service has to have specialized tests. (P4)

Quality health care means to be well seen, being welcomed, having good physicians, people actually trained to work, having medication [...]. (P7)

The challenges these professionals face in providing quality assistance in the Island, meeting the principle of comprehensiveness, are many. The role of the health team in riverside areas requires the development of skills, such as the performance of specific procedures (surgical, diagnostic and therapeutic), referrals to other professionals in urban centers, interpretation of tests without expert opinions (radiographs, for example) and the initial management of emergencies (clinical, surgical and psychiatric). These teams working in isolated units are reduced and lack a greater resolving power, since they have to work in extreme conditions, dealing with the lack of basic materials and instruments to perform simple procedures14.

The team working in the Combú Island aims, among other aspects, to meet the population under their responsibility, although they often need to use the units of Belém to complement its service and solve the health problems of the population. For them, the imaginary of the ideal health service is undone, when they depend on secondary services to give continuity to the treatment of the users, since both will face the difficulty of access to specific tests due to the lack of specialist physicians and even due to the delay to schedule tests. These factors challenge and frustrate them, as they often fail to solve the population's health problems.

In riverside populations, even more than in urban centers, primary care is sometimes the only gateway to the SUS, including emergency situations. In this sense, the availability of adequate transportation must be taken into account, as well as the qualification and valorization of the PHC to act in the most diverse situations, since it is the community's first contact with the local health service15.

The health team committed to its coverage population generates a greater degree of reliability and the professional-user relationship occurs in a harmonic way. It was identified that the population recognizes the effort of the professionals who work in the island to conduct the process of health care with quality because, even without all the necessary conditions, they do it with dedication, often not seen in other places.

In this way, the welcoming goes beyond receiving the user in the unit; it permeates the whole process of care, guaranteeing access to the services provided. Welcoming refers to qualified listening of users' health problems, giving them a positive response and being responsible for solving their problem, thus increasing the capacity of the team to use the potential of the different members thereof16. The accountability for the health problem goes beyond the service itself; it also refers to the necessary link between the service and the user population.

Difficulty in accessing health services

In this category, we discuss the main difficulties that users and professionals face daily to reach the health service.

In this aspect, the majority of users report that the lack of transportation is the factor that makes it more difficult for them to reach the health units, together with the economic factors, namely the lack of financial resources to use transportation, when it is available, both in the Island and to commute to Belém.

Basic health care should be easily accessible to the population and is referred in the Charter of the Rights of Users of the SUS, which guarantees all citizens access in an organized manner and, as a priority, through PC health services, near the place of residence of users7,17.

In this category, we addressed only the geographical dimension, which corresponds to the location of the health services that can be measured by the linear distance between the latter and the patients' households. Access is a complex concept that has several dimensions: organizational, social and geographical, which are interrelated18.

The distance stands out as one of the critical factors that limit the access of the riverside residents both to the health unit of the Island and to the urban perimeter of Belém, in addition to hindering the home visits of the professionals. When questioned about the greater difficulty of access to services, they highlighted the lack of regular transportation, besides the incompatibility of medical consultations with transportation schedules, among others:

[...] it's complicated because we cannot go all the time; there is no transportation available to get things done. (U4)

I think it's transportation, because sometimes there is no boat to take us there. (U7)

One of the difficulties is the transport, considering that users have the river as the only road, through which they move in search of care. Travels in small boats, similar to speedboats, are limited by natural factors that hinder or impede such trips, such as climatic and maritime conditions, which bring risks, as well as economic factors, because not all families have transportation or conditions to keep a boat.

Climatic phenomena and the river's flood and ebb-flow pattern make it difficult for river users to reach the unit and for health care teams to provide care, which reveals a great inequality of access to health services when compared to urban areas19.

For all professionals working on the Island, transportation is one of the factors that makes it more difficult for users to access the UBSF, and for professionals to access users' households:

There is no transportation, so we organized a care schedule for the person to come that day and according to the established programs, but they do not manage to follow it; they end up hitchhiking with some neighbor on another day. (P2)

[...] we do not manage to make the visit properly because some places are far, and the speedboat has no protection. (P3)

Thus, part of the care is not performed efficiently due to lack of transportation; home visits become impaired since the distance between the homes is great. Also for the professionals, the available means of displacement are the speedboats, which put their lives at risk and often increase their expenses due to the fuel of these boats, so that they can develop their activities.

We must highlight the political dimension that guides access, as a State responsibility, which must be guaranteed by the planned distribution of service network resources, considering the geographic location of the unit and the availability of the services that comprise it, according to the population's needs20. The implementation of a Fluvial Electoral Transportation System would guarantee better access to servicesand facilitate home visits, offering to professionals and users safety and access to the Island.

The expansion of the PC takes into account that services of this nature should be close to the population and easily accessible21. However, although the universalization of health care is constitutionally assured and the expansion of the ESF has greatly contributed to this goal, the organizational barriers to access to the primary care network are still a central problem for the consolidation of SUS in our country22.

Care flows and comprehensiveness

It discusses the participants' perception on the functioning of RCRS, a key factor to meet the principle of comprehensiveness, providing continuity of treatment, as well as the maintenance and recovery of the health status.

The users revealed difficulties with the referral, since they were faced with crowded units and little supply of service, making it difficult to schedule specialized consultations and tests. They affirm that this situation interferes in the diagnosis and recovery, leading to the aggravation of diseases. Comprehensive health care remains a major challenge as it requires combining dimensions of life for disease prevention and health recovery23.

It was found in the testimonies that the RCRS does not work in practice, given the great difficulties that clients face when looking for health services in the capital:

[...] we compete with a unit that is already crowded; there is a great when it comes to referral. (U6)

It would be good if we were referred directly and there we would do all the tests as soon as we arrived. (U13)

[...] and the physician sends us to Belém, but when we get there nothing works. (U10)

The issue of comprehensiveness of care should not be seen only in terms of the organization of available resources, but especially of the flow of the user to access health services. To guarantee comprehensiveness, it is necessary to make changes in the production of care from the primary and secondary care network, emergency services and other levels of care, including hospital care17.

The integration between the health teams of the ESF in the care network is an essential condition for the teams to exercise their sanitary responsibility through the population of the territory-area. Although PC has a resolvability of around 90% of health problems, the flow of users to the care units of the other levels and to the support system is essential for the comprehensive care and recognition of the integrative role of the population of the ESF into this care network24.

When care flows do not work, the user is left with no direction on the network, which aggravates the health problem. The failure of care flows can be perceived in the RCRS itself, which does not work according to the foreseen, since it is based on the Regionalization Master Plan, which aims, among other objectives, to establish mechanisms and inter-municipal referral and counter-referral flow, in order to guarantee the comprehensiveness of care and the population's access to services, according to their needs25.

This aspect was also highlighted by the professionals, in pointing out difficulties with the RCRS, since, in addition to limited access to consultations and tests, there is no return of the counter-referral to the professional, which makes it difficult for physicians to work on the Island, since users return without knowing how to report what happened in the specialist consultation:

I have never seen a counter-referral in three years of service, never! (P2)

[...] the service, here, we do it; we do not manage to do the referrals, as some specialties do not exist in the network. (P3)

Both the specialized consultations and the tests referenced from here sometimes take even years! (P8)

In the context of hierarchy, it is perceived that these systems are fragmented, and are (dis)organized through a set of health care units that do not communicate with each other and, consequently, are incapable of paying continuous attention to the population. PC does not communicate fluidly with secondary care and these two levels also do not communicate with tertiary health care26.

The ESF team is concerned to provide comprehensive care to users, even in the absence of a regionalized referral and counter-referral network. From the moment that continuity of care is interrupted, there is a predominance and strengthening of the classic model of health care, based on the biomedical model, which essentially seeks a solution to the signs and symptoms presented by individuals, to the detriment of comprehensive care27.

The better structured is this flow between services, the greater its efficiency and effectiveness. Its non-effectiveness can be considered an important deficiency in the SUS context, since it compromises the continuity of care provided28. Thus, this system presents itself in a fragmented way, with difficulties in access, discontinuity of care, compromising the comprehensiveness of care, without adequately responding to the demands of health needs29.



Aspects related to the quality of the health services and to the geographic localization are intervening factors in the attention to the principle of comprehensiveness, probably due to the geographic characteristics that are part of the daily life of users and professionals.

The health care services on the Island are not able to meet the differentiated needs of the riverside population, nor to the principle of comprehensiveness, since the professionals have no elements to perform certain procedures due to the limitation of human and material resources, which evidences the lack of a more complete health service.

The regular operation of the care flows could allow better integration between the service network, offering users a quality service. The desired effectiveness implies factors that depend not only on the professionals but also on the commitment of the managers and directors of the units, aiming to guarantee the resolution and comprehensiveness of the assistance.

The small number of participating professionals is a limitation of this study, which prevents the generalization of the findings. However, this research draws attention to the need to expand and qualify health actions in the context of special populations.



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