Abstract
Specialized care barriers are widespread and multifactorial, with consequences for timely access, health outcomes, and equity, especially in rural contexts. This article aims to identify and analyze arrangements for providing specialized care in the Brazilian remote rural municipalities (RRMs). This is a multiple-case qualitative case study developed in seven RRMs located in the Brazilian semi-arid region. Twenty-two semi-structured interviews were conducted with the public health system managers, complemented by analysis of secondary data from national health information systems. Thematic content analysis was guided by the Integrated Health Service Network attributes related to the provision of specialized care. Socioeconomic indicators and indicators of availability and accessibility to health services express the context of greater vulnerability of RRM and their respective health regions when compared to states and the country. The analyzed cases do not come close to the RISS constitutive attributes. Various arrangements for the provision and financing of specialized care in the RRM were identified: public provision through an agreement between managers in the health region, health consortia, public provision in the municipality itself or neighboring municipalities, provision in private health services through direct purchase (out-of-pocket), and telehealth (very incipient). Such arrangements were unable to respond quantitatively and qualitatively to the demand for specialized care. Providing timely specialized care in an adequate place is not achieved, resulting in a fragmented, low-resolution model. The fragility of regionalized networks, aggravated by underfunding of the Brazilian Unified Health System, insufficient logistical support, and computerization of health services, contributes to care gaps and unacceptably long travel times for common specialized procedures, with more severe effects for people residing in the rural areas of the municipalities. Brazil's disorganization or lack of a systemic response based on regionalized health networks generates several care improvisations. The less structured the RISS, the more informal arrangements are made, with gains for the private sector to the detriment of public health system users.
Highlights
Specialized care barriers are widespread and multifactorial, with consequences for timely access, health outcomes, and equity, especially in rural contexts
The seven municipalities were distributed over three Brazilian states and comprised five health regions that should provide specialized care actions, mainly in the respective host cities
The results indicate that the analyzed cases were not close to the RISS parameters and attributes, a situation currently found in other Latin American countries, whose health systems are characterized by fragmentation and weak network performance[7]
Summary
Specialized care barriers are widespread and multifactorial, with consequences for timely access, health outcomes, and equity, especially in rural contexts. This article aims to identify and analyze arrangements for providing specialized care in the Brazilian remote rural municipalities (RRMs). Methods: This is a multiple-case qualitative case study developed in seven RRMs located in the Brazilian semi-arid region. Twentytwo semi-structured interviews were conducted with the public health system managers, complemented by analysis of secondary data from national health information systems. Thematic content analysis was guided by the Integrated Health Service Network attributes related to the provision of specialized care. Results: Socioeconomic indicators and indicators of availability and accessibility to health services express the context of greater vulnerability of RRM and their respective health regions when compared to states and the country. Various arrangements for the provision and financing of specialized care in the RRM were identified: public provision through an agreement
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