| Coverage and (un)availability of services |
“Coverage is 90%. Some of the more distant populations are uncovered. In periods of vaccination, for instance, we will now be having the measles campaign, we go to communities and take the opportunity and bring a physician and a nurse with us, who are here from the municipality seat. [...] Last the time the vaccine went there, they left at 4 in the morning and got to the community almost 9 a.m.” (13GM1). |
| “In the region of Várzea, Riverside ESF, we have three communities without coverage, and they’re big communities. We have four communities in the river region, which makes up seven. In the land region we have two communities not covered, two communities that are covered. Almost ten communities where the population has no health agent assistance.” (13GM2) |
| “The units should be closer, but we have a problem in our region, which is distances. I can’t put a UBS in each community, I’m not going to have 114 UBS and I can’t maintain 114 units, so our big problem is territorial dispersion.” (12GM2) |
| Adaptations of the PNAB guidelines to the Amazon reality: multiple and synchronous formats of primary healthcare organization |
“We have a full team there, with doctor, dentist, nurse, where they work according to the riverside population, but with some differences. Because after all our Amazon region is different from the rest of the country. You cannot take everything of the decision at face level. Sometimes you need to make an organizational arrangement there to see if things actually flow any better.” (16GM2) |
| “We end up adapting the working of the unit to help these people who arrive from riverside areas, from rural areas. So much so that we set aside forms for them, we usually reserve four spots for professionals to visit these people from rural areas, more urgent cases. So we make this difference so they are visited and if they come at that time and there is no way we can find a place for them in the morning, I leave them scheduled for the afternoon.” (16GM1) |
| “If the technician has a doubt, something he can sometimes solve it there, he calls us and we guide him - no, wait a little longer”, or “do this, wait another couple of hours, ok? Now, when it is childbirth, or a big cut, or an accident, something like that, or a stroke, or a heart attack, anything, then he will not even contact us. He sends the patient straight on and only then he calls us to say there is a patient with this and that coming our way, so we can prepare support to receive the patient. (14GM2) |
| “Since we do not have health units in the rural area, how do I work with them [EqSF]? I work in an itinerant fashion, so once a month these teams, each in its region, each team covers a territory. They take a boat, it is a doctor, two nurses and nursing technicians, so they stop at each community and cover the whole area, so two teams work in a boat in an itinerant way the entire month, the rest of the days when they are not in the area, they are working here at the Basic Unit, here in the urban area, visiting these people who come from the rural areas. Until we can build the health unit for those regions and manage to transfer those teams there for good.” (16GM1) |
| “The fluvial UBS is a special thing that came to [state], which actually changes the issue of riverside populations in the hinterlands. It’s something that really changes people’s lives.” (17GM1) |
| “We don’t take just one [vaccine] to the [UBSF], we take all of them. So we also take anti-rabies for public health surveillance to apply to cats and dogs, when we pass by we vaccinate them too. Then there is the capture guys [bats]; Social Welfare goes with the Bolsa Familia thing for registration, updating. We also help them with weighing, height measuring, vaccination. There’s also the whole esthetic part that also goes, there’s the notary people who go to make their documents.” (14GM2) |
| “The community health agent is in charge of health guidance, promotion and prevention. For us at the Secretary’s Office, they are our eyes in the community, because we are very far from their reality, they are there, they actually get to see the community, and it is through the health agent that information gets to users, vaccination day, doctor’s day, PCCU offer day, the day their prenatal exams are scheduled, they do the scheduling.” (12GM2) |
| “The role of community health agents is to do house calls [...], he’s the maximum health authority in a community, so if someone’s sick, he hopes the health agent will medicate him, he waits that access comes through him [...] I always tell them a well-oriented population gets ill very rarely.” (16GM1) |
| “[...] in the rural area we reduce this number because the territorial expression to carry out visits is larger. Sometimes riverside people are not just in villages, they are alone in that place, then to get to the next house it is another I do not know how many minutes by rabeta, they use the rabeta a lot. Each community health agent has his own rabeta. [...] The rabeta and the fuel are provided by the municipal government, but we don’t get any resources for this from the state government, nor from the federal government.” (14GM2) |
| Challenges for guaranteeing access to primary healthcare |
| Financing and offer of services of primary healthcare |
“The first of them [challenges] is the sub funding of the health sector. [...] and all those issues I mentioned during the interview: professionals’ commitment to primary healthcare, geographical barriers. It [sub funding] prevents us from working the way we would like to. [...] No matter how much the municipal government does, it is still not enough. [...] So the financial part, it says a lot about how health will behave.” (16GM2) |
| “We have the financial issue that we’d like to do much more, but we’re stuck. The logistics in our municipality is very complicated, [...] assembling a vaccination campaign requires a lot of money. To get there you need a voadeira, a boat, nobody is going to vaccinate and back. The team spends five to seven days there. For colonies, you need a car or a motorbike, and then you spend money on ice, food, daily fees for employees who need to be paid, [...] (13GM2) |
| “I just got back from a fluvial UBS trip of 16 days. 30,000 reais of fuel for 16 days of travel. I receive 90,000 from the Ministry of Health. On those 16 days I spent 120,000 in drugs and consumables, plus professionals, more than 10,000 in food and cleaning material. This trip cost me about 200,000 reais.” (17GM1) |
| “They bought the ambulances, delivered the ambulances and they’re working just fine. Then the fuel and the person driving the ambulance, the municipal government pays for those. He managed the amendment to buy them only, right, so the municipal government maintains them. We noticed a big improvement.” (14GM2) |
| “The mother of health is our UBSF. Professionals of our own region drew the plant, with everything we needed to help the entire riverside population [...] until the Federal Government came and [municipality] was one of those contemplated. [...] Almost all the money [sent by the Ministry of Health] goes on drugs and professionals.” (14GM2) |
| Provisionment and fixation of professionals |
“[...] now what would really make things move on would be the enabling of the fluvial UBS or the enabling of these strategies in the rural areas. It is just that we also think it is not feasible to enable rural area strategies because resources are too low to keep professionals there and also for us to find physicians, nurses who want to live, to reside in the rural areas, especially those that are so hard to reach. It’s very complicated.” (14GM2) |
| “It also ended up taking a financial burden off the shoulders of the municipal government. Because now instead of paying 15 or 16 thousand, I am paying R$ 2,500. The rest is paid by the Ministry of Health. When the doctor knows that his salary is paid by the Ministry of Health, they work without the fear of not being paid. This makes it more attractive for them to come to the municipality. But I think this program has come to improve things a lot. Today we say that primary healthcare is not possible without Mais Médicos.” (17GM1) |
| Geographical Access and mobility for healthcare |
“Our greatest difficulty at [municipality] is the issue of childbirth, and one of our fights is that we want a mixed unit to be structured for natural birth, but then you’d need equipment, a professional on call, because these transfers usually happen at night [...] They [the population] question this situation a lot. [...] Unfortunately, due to this delay and to the condition of the road, some babies ended up dying. This is why the biggest fight of [municipality] is to improve this service at the mixed unit [...].” (18GM1) |
| “We have the financial issue that we’d like to do much more, but we’re stuck. The logistics in our municipality is very complicated, [...] assembling a vaccination campaign requires a lot of money. To get there you need a voadeira, a boat, nobody is going to vaccinate and back. The team spends five to seven days there. For colonies, you need a car or a motorbike, and then you spend money on ice, food, daily fees for employees who need to be paid, [...] (13GM2) |
| So is there an ambulance at the UBS? A: The ambulance did not work very well at the community [rural 1] because of the road. It would get bogged down, break down, it was not sturdy enough. To get there you need sturdy pick-ups. We have had cases of going to pick up a patient and the ambulance got bogged down, another car had to go there from here to help it. (15GM2) |
