Physical therapists in primary health care: analysis of the national register of health service providers

Department of Physical Therapy, Universidade Federal de São Carlos (UFSCar) – São Carlos, SP, Brazil 1 Full professor of the Physical Therapy Department, Universidade Federal de São Carlos (UFSCar) – São Carlos (SP), Brazil. 2 Retired full professor of the Department of Physical Education, Universidade Estadual Paulista “Júlio de Mesquita Filho” (Unesp) – Rio Claro (SP), Brazil. 3 Retired full professor of the Department of Statistics, Universidade Federal de São Carlos (UFSCar) – São Carlos (SP), Brazil. 9 Physical therapists in primary health care: analysis of the national register of health service providers Inserção da fisioterapia na atenção primária à saúde: análise do cadastro nacional de estabelecimentos de saúde em 2010 Inserción de la fisioterapia en la atención primaria de salud: análisis del Registro Nacional de Establecimientos de Salud en 2010 Larissa Riani Costa Tavares1, José Luiz Riani Costa2, Jorge Oishi3, Patricia Driusso1


INTRODUCTION
Primary Health Care (PHC) is characterized as the first health care level, involving a set of actions aimed at enrolled areas 1 .In 1994, the Family Health Program (PSF -Programa de Saúde da Família) was established as a PHC reorientation strategy 2 .The experience in its first decade encouraged the inclusion of PHC in the set of priorities of the Pact for Health in 2006 3 ; in the same year, the National Primary Care Policy (PNAB -Política Nacional da Atenção Básica) 1 was published, promoting the revision of the regulations published in this first period.The expansion, however, was involving mainly the professionals of the multidisciplinary team 1 (doctor, nurse, nursing assistant or technician, and community health agents) and of the oral health team 1 (dental surgeon, dental hygiene technician, and dental office assistant).Teams with other types of professionals were limited, existing according to local dynamics, without a national policy promoting the insertion of other categories into these teams.Seeking to expand the range and scope of PHC, the Family Health Support Center (NASF -Núcleo de Apoio à Saúde da Família) was created in 2008 by the Ministerial Decree no.154/2008 4 , formally inserting other professional categories into the strategy by matrix support (collaborative care).
This insertion into PHC brings challenges for several professions, but mainly physical therapy, which had its origin worldwide at the end of the 19 th century, focused on the treatment of people with physical and functional changes in late phases of health harms or diseases 5 .In Brazil, the profession was developed in the first half of the 20 th century 6 , in a context with high rates of occupational accidents 5 and the need for care to the several individuals with poliomyelitis sequelae 7 , emphasizing the rehabilitation work that was being developed worldwide.In 1969, the profession was regulated by the Decree-Law no.938 8 , under the influence of a concept in which the "post-disease" was a prerequisite for the intervention of physical therapy 6 .In the following years, until the end of the 20 th century, while the country was redirecting the health system towards universality and a strengthened PHC, physical therapy had as main concern the assertion that ensured its space in the Brazilian health scenario, strengthening a specific field of work and remaining until today with the same legal regulations of that time 6 .Despite this trend, some physical therapists started activities in PHC by creating trainee courses with students of the undergraduate course in the cities of Paraíba, Belo Horizonte, Juiz de Fora, and Natal and by directly taking part in the services, gradually approximating the profession to public health actions [9][10][11][12] .From 2000 on, the activities were expanded with the creation of the multidisciplinary residencies in family health.From 2001 on, with the change of the National Curriculum Guidelines for the Course of Physical Therapy (Opinion CNE/ CES 1,210/2001) 13 , the discussion was broadened, with the proposal of a generalist education to work in the prevention, promotion, protection, and rehabilitation of health, in all health care levels, both in the individual and collective spheres.From its publication, the new curricular guidelines encouraged several meetings.Since 2005, two National Forums of Professional Policies were organized by the Federal Council of Physical Therapy and Occupational Therapy (COFFITO -Conselho Federal de Fisioterapia e Terapia Ocupacional), including education issues in their agenda 14 ; in 2006, more than 20 workshops were carried out to implement the curriculum guidelines 14  The approximation of the performance and education of physical therapists to the national health policies is promoting an increase in the number of physical therapists in PHC.According to information available in the website of the Department of Informatics of the Brazilian Unified Health System (DATASUS -Departamento de Informática do Sistema Único de Saúde) 15 , in 2005, there were 3,370 registers of physical therapists in PHC in the CNES.After six years, the number of registers almost tripled, reaching the total of 8,564 in 2011.However, it is important to note that the expansion of physical therapy in PHC is relatively recent, and that its role in this health care level is still under construction.
Thus, one must research the existing experiences to describe how the insertion of physical therapy in PHC is taking place.The existing studies, however, mostly analyze specific actions of a city or region, not presenting the insertion of this professional at the national level.This study aims to describe the distribution of physical therapists in the Brazilian PHC and the ratio of inhabitants per physical therapist in PHC in 2010, to show the situation of this professional in PHC right after the creation of the NASF, characterized as the main policy of expansion of the professional categories involved in the family health strategy.

METHODS
A descriptive cross-sectional study was conducted from CNES and Census/2010 data.CNES is the main nationwide information system on health facilities in Brazil.It was created by the Brazilian Ministry of Health in 2000 16 , to help managers with subsidies for implementing health policies and contributing in the areas of planning, regulation, evaluation, control, audit, and teaching/research.It includes information regarding Physical Area, Human Resources, Equipment, and Outpatient and Hospital Services, serving as a basis for other information systems of the Brazilian Ministry of Health.The registration of public and private health facilities and of active professionals is mandatory, as determined by Ordinance no.511/2000 17 .
The study was approved by the Human Research Ethics Committee of the Federal University of São Carlos, under Protocol no.386/2009.
The data from the registers of physical therapists were collected in the CNES database in Brasília, Federal District, in March 2010, making it possible to know the distribution of these professionals right after the implementation of the main public policy of inclusion of physical therapists in PHC.The search included information from the 5,565 cities of Brazil, involving facilities with at least one physical therapist.It is important to note that professionals who work in more than one facility generate one register for each workplace.Thus, more than one register may exist for the same professional.The analyses of this study considered the total number of registers.
The following information were obtained for each facility: type of facility; number of physical therapists; region, federative unit (FU), and city.
The following centers were considered as PHC facilities: health center, primary health care unit, family health support center, fluvial health care unit.The remaining facilities were considered as "Other health care levels," and included: specialized clinic/specialty outpatient clinic; polyclinic; doctor's office; cooperative; psychosocial care center and support, diagnosis, and therapy unit (SADT -Serviço de Apoio Diagnóstico Terapêutico); general hospital; specialized hospital; day hospital; normal childbirth center; emergency room; specialized emergency room; pre-hospital level mobile unit; mixed health unit (which provides both PHC and specialized service (hospitalization and emergency); center for regulation of health services; health secretariat; health surveillance unit; land mobile unit; indigenous health care center; and hemotherapy and/or hematology health care center.
The number of inhabitants of the cities was collected from the results of the Census/2010 18 , using the following classification for the population size 19 : small size: population up to 20,000 inhabitants; midsize: between 20,001 and 100,000 inhabitants; large size: between 100,001 and 500,000 inhabitants; metropolis: over 500,000 inhabitants.Data were analyzed by descriptive statistical techniques.The ratio of physical therapists per 1,000 inhabitants was calculated from the total of registers of physical therapists × 1000/number of inhabitants

Distribution of registers of physical therapists in PHC
In total, 6,917 physical therapists were registered in PHC.Southeast and South accounted for 49% and 16% of the registers, a ratio higher than the population representation of these regions (42% and 14% of the Brazilian population, respectively).North, Midwest, and Northeast accounted for 4%, 6%, and 24% of registers, respectively, with values lower than their population distribution (8%, 8%, and 28%).
This distribution affects the ratio of inhabitants per physical therapist, as Table 1 shows.South and Southeast presented the best ratios, with about 23,000 inhabitants/physical therapist in PHC.The North region presented the worst ratio (58,761 inhabitants/ physical therapist).The distribution according to the population size of the cities indicated a higher percentage in small cities (38%), followed by midsize cities (34%), large cities (17%), and metropolises (11%).The North and Northeast presented an opposite trend, with greater concentration in midsize cities (48% and 45%, respectively).Source: Brasil 20 and Instituto Brasileiro de Geografia e Estatística 18 .
The low number of registers in metropolises results in a ratio six times greater than the one verified in small cities: 76,000 inhabitants/physical therapist in metropolises in contraposition to 12,000 inhabitants/ physical therapist in small cities (Table 2).Small cities in the Southeast presented the lowest ratio (6,948 inhabitants/physical therapist).

Number and percentage of cities with physical therapist in PHC
In total, 47% of the cities have at least one physical therapist registered in PHC, and the coverage in the Southeast (62%) was twice as that of the North (31%), as Table 3 shows.Regarding population size, the highest proportions were observed in the metropolises.Concerning population size, most small cities only have physical therapists in PHC (40%), while larger cities also have this professional in other health care levels (Table 4).Among the small cities that have a physical therapist in PHC (1,818), 60% had this professional only in this health care level.Source: Brasil 20 and Instituto Brasileiro de Geografia e Estatística 18 .Note: Pp% -proportion of cities with physical therapists in primary health care compared to the total number of cities in each region and Federative Unit.

DISCUSSION
The analysis of the distribution of physical therapists in PHC identified a concentration of professionals in the Southeast and South above the population representation of these regions, while in the Northeast, North, and Midwest had concentrations below their population representation.Southeast and South also presented the best ratios of physical therapists per inhabitant and the highest proportions of cities with physical therapists in PHC compared to the total number of cities.
The data resemble the results observed in studies that analyzed the distribution of registers of physical therapists in the CNES regardless of the health care level 21,22 .Several factors were associated with the concentration of professionals in the regions with greater economic development, including socioeconomic and historical factors that affect population distribution, the formation of the health care network, and the allocation of higher education institutions, promoting a higher number of inhabitants, health facilities, and professionals trained in the Southeast and South 22 .
The authors discuss the correlation between the offer of health services, their participation in the national Gross Domestic Product (GDP), and the Human Development Index, noting that the economic influence in the creation of the health system promotes inequality in the distribution of services and has its origin in the historical process of health care in Brazil 22 .
In contrast, DATASUS data from the same period 20 show that the professions of Nurse, Doctor, and Dentist of the Family Health Strategy are better distributed across regions, with prevalence of registers in the Northeast (40%), followed by 30% in the Southeast, 14% in the South, 8% in the North, and 7% in the Midwest.
The greater dispersion of the professions linked to PHC can also be verified in the database of the portal of the department of primary health care 23 for the year 2010, with the 30,782 family Health teams (eSF -Equipes de Saúde da Família) and 1,250 NASF teams distributed as follows: 41% and 47% in the Northeast, 31% and 30% in the Southeast, 14% and 9% in the South, 7% and 7% in the North, and 8% and 7% in the Midwest, respectively.The updated data of February 2017 indicate the following distribution of the 39,859 eSF and the 4,010 NASF teams: 37% and 43% in the Northeast, 33% and 28% in the Southeast, 15% and 14% in the South, 7% and 7% in the North, and 8% and 7% in the Midwest, respectively 20 .
Therefore, one can verify that the distribution of physical therapists in the country showed regional differences both in specialized health care levels 21,22 and in PHC, diverging from other professions that present greater dispersion in PHC.Recent data must be studied to identify whether there was greater equity between the Brazilian regions after a longer implementation period of the NASF.
Our data also show that, regarding population size, most registers of physical therapists in PHC occurred in small cities, followed by midsize cities, large cities, and metropolises.This distribution differs from that of the study 22 that identified all physical therapists with registers in the CNES, in which 36% of professionals were working in metropolises and 28% in large cities, totaling 64%.Physical therapists of midsize cities represented 24% of the total, and those of small cities, only 12% of the professionals.
This distribution is probably associated with the hierarchical and regionalized formation of the health system.Considering the large number of small or midsize cities (95% of the total cities in Brazil), most Brazilian cities present insufficient range to accommodate all health care levels in their territory, presenting only PHC facilities, with the offer of specialized levels distributed in micro and macro health regions 24 .
In this context, PHC facilities are likely the only alternative for the insertion of these professionals in small cities and, as the population increases, facilities of other health care levels already exist, and thus physical therapy starts to be mainly concentrated in more specialized levels.
The number of patients with functional changes who need rehabilitation has been increasing, mainly because of the high rates of traffic accidents and violence, the process of population aging, and the increase of chronic degenerative diseases and work-related diseases.In small and midsize cities with absence of specialized care and with difficulties of transportation to centers located outside the city, the pressure for therapeutic care falls on the PHC professional, generating the risk of the propagation of the health care adopted in outpatient clinics and hospitals.
In most large cities and metropolises, physical therapists are registered in all health care levels.Rodrigues 25 points out, however, that the difficulty of transportation to specialized centers, both because of physical and economic limitations, is an obstacle to access, generating a repressed demand for physical therapy.The author also mentions the existence of insufficient vacancies with long waiting lists.Before this repressed demand and the limited number of physical therapists working in PHC in large cities and metropolises (compared to the total number of inhabitants), it is possible that the propagation of outpatient and hospital care is also observed in part of PHC professionals from large urban centers.
Thus, according to the distribution observed, although the insertion of physical therapists in PHC helps actions of promotion, prevention, and public health of this health care level, it still faces challenges related to outpatient and therapy demand.This risk increases when considering the history of training and performance of physical therapy, with focus on specialized care.Belettini et al. 26 confirm these statements, identifying that, among the physical therapists working in NASFs of Santa Catarina, the community and NASF team did not clearly know the role of this professional in PHC; 65.2% of them worked in therapeutic groups and 43.7% affirmed spending most of their time in individual care.Souza et al. 27 describe the following situations: demand, by patients and team, of the continuous presence of the physical therapist in domiciliary care; conflicts in the implementation process because of the difficulty in understanding the work process of the NASF; tendency to perceive the NASF as an outpatient clinic; and a limited perspective about the action of the physical therapist (devices/equipment), associating the practice with hard technology.The same challenge has been reported in studies of other professions 28,29 .
Nakamura e Leite 29 , in a study involving NASF pharmacists in a city of the South, highlight difficulties in the planning process, lack of clear objectives for the NASF team, and deficiencies in the pharmaceutical services of the city, creating challenges for the structuring of the work process.The authors argue that one of the difficulties is the inadequate description of the work process in the first version of the "NASF Guidelines," published in the Primary Health Care Journal (Caderno da Atenção Básica) no.27 30 .The version published in 2014 (number 39 31 ), however, has a clearer, interdisciplinary, and organizing direction of the work processes for NASF teams, and might bring greater safety in the development of this process.
The Ordinance GM no.154, of January 24, 2008 4 , which determined the creation of the NASF in the modalities 1 and 2 and set the criteria for their implementation, included only part of the Brazilian cities, and small cities were those that faced more obstacles.From these difficulties, the Ordinance no.3,124, of December 28, 2012 32 redefined the parameters for linking modalities 1 and 2 to the family health teams and/or primary health care teams for specific populations, and created modality 3, to enable the universalization of these teams to all Brazilian cities.This Ordinance was supplemented by Ordinance no.548, of April 4, 2013 33 , which sets the financing value of the Variable Primary Health Care Wage (Piso da Atenção Básica Variável) for the three NASF modalities.Thus, future prospects bring the possibility of expanding the number of covered cities and the number of professionals working in PHC.
The problems addressed by this study, however, take place not only in the Brazilian health care system.International organizations such as the World Confederation for Physical Therapy (WCPT) and associations of physical therapists of the United Kingdom, Canada, Scandinavia, Australia, New Zealand, and Spain have discussed the role of physical therapy in this health care level, drawing attention to its still limited performance in PHC 34 .
Regarding the Spanish health system, Paz 34 points out that the insertion of this profession started in 1987 by the creation of "rehabilitation units" located in PHC, which emerged to solve problems of accessibility to physical rehabilitation services, under the same professional regulation until then directed to physical therapists of specialized care and with a hospital-oriented training.
Given these factors, the first actions of physical therapists in the Spanish PHC propagated the actions of tertiary health care, which are inadequate to the primary level, thus putting promotion and prevention aside 35 .In 1990, the law regarding physical therapy in PHC is released 34 .In 2003, Europe passes through a unification of the professional training curricula, including aspects of community physical therapy 36 and, in the same year, the WCPT creates the Declaration of Principles of PHC, approved at the 15 th General Meeting of WCPT.
With the training and legislative developments, since the beginning of the insertion of physical therapy in Spanish PHC until now, a significant evolution has been identified in health promotion and disease prevention, including physical therapists no longer as a mere element to reduce demands for the specialized services, but as an important part in creating a comprehensive health care process 34 .
Similar developments have been taking place in other countries, accompanied by training and legislative adjustments.Finland is the country in which the figure of the physical therapist is well regulated in PHC, with the integration of this professional to the team work in health centers and with the best ratio of inhabitants per physical therapist in European PHC 36 .
The Brazilian physical therapy, thus, has been expanding its insertion in PHC, and part of the problems it has been facing are common to most countries.With the changes brought by the new curricular guidelines of the undergraduate course in physical therapy and with the increasing inclusion of these professionals in projects to reorient the practices of training and continuing education of health professionals, such as the National Program of Reorientation of the Professional Training in Health (Pró-Saúde -Programa Nacional de Reorientação da Formação Profissional em Saúde), multidisciplinary residencies, specialization courses, Program of Education by Work for Health (PET Saúde -Programa de Educação pelo Trabalho para a Saúde), National Program of Technology for Health (Programa Nacional de Telessaúde), and introductory courses for family health teams, it is possible that, in the near future, the insertion of these professionals in PHC will be a reality in the country 2 .This search for training adjustments must be accompanied by legislation and regulations that establish the role of this professional in the teams, especially when considering that the latest resolution on the professional practice of physical therapists dates back to 1987 6 , before the creation of SUS.
It should also be noted the need to increase the number of physical therapists, considering that more than half of Brazilian cities do not have this professional in PHC.This need is particularly highlighted in the North, Northeast, and Midwest, which have about 70%, 65%, and 60% of their cities without physical therapists in PHC, besides presenting the highest ratios of inhabitants per professional.These figures point out that regions far from the South-Southeast axis still have a limited insertion of physical therapists, especially in smaller cities.The difficulty of inserting professionals in these places is common in health professions, as Campos et al. 37  Although 79% of large cities have a physical therapist in PHC, their number of professionals must also be increased, because this number is low compared to the total number of inhabitants, resulting in the worst ratios of inhabitants/physical therapist identified.
Finally, the increase in the number of physical therapists must reach, in addition to PHC, more complex health care levels, ensuring specialized support and a ratio of inhabitants/professional that allows greater participation in PHC actions.

CONCLUSION
Southeast and South were the regions with most physical therapists registered in PHC.Small cities were the main locations with the insertion of these professionals, and most registers of physical therapists were identified only in PHC, without the support of specialized care.The worst ratios of inhabitants/physical therapist in PHC were observed in metropolises.Less than half of the Brazilian cities presented a physical therapist in PHC, and the proportion of places that do not have this professional is still high.
Before the low number of professionals in PHC and without the proper support of the specialized levels, the development of interventions that broaden and strengthen the work of physical therapists both in PHC and in specialized services is greatly important to ensure the appropriate development of actions for each health care level.The interventions must include health and professional training policies, as well as rules and regulations concerning the professional practice of physical therapists.
; in 2007 and 2008, the National Forum of Education in Physical Therapy of the Brazilian Association of Education in Physical Therapy (ABENFISIO -Associação Brasileira de Ensino em Fisioterapia) included the topic "Physical Therapy in Primary Health Care" as its main discussion.Between 2007 and 2016, five versions of the National Congress of Physical Therapy in Public Health (CONAFISC -Congresso Nacional de Fisioterapia em Saúde Coletiva) were carried out, and, in 2016, the XXVI National Forum of Education in Physical Therapy presented the topic "Comprehensive health care and education of physical therapists: reformulation of the National Curriculum Guidelines as a strategy for the (re)qualification of health processes," after the conduction of state workshops promoted by ABENFISIO to analyze and reformulate the national curricular guidelines of the undergraduate courses in physical therapy.

Table 1 .
Distribution of registers of physical therapists in primary health care (PHC) and ratio of inhabitants per professional according to regions and federative units, 2010

Table 2 .
Ratio of inhabitants per physical therapist in PHC between the regions of the country, according to the population size of the cities in 2010

Table 4
18assifies the cities according to the health care levels that offer physical therapy.Most cities had Source: Brasil20and Instituto Brasileiro de Geografia e Estatística18.

Table 3 .
Number and proportion of cities with physical therapists in primary health care (PHC), 2010

Table 4 .
Total of cities with physical therapists according to the health care levels that have this professional in 2010 18urce: Brasil20and Instituto Brasileiro de Geografia e Estatística18.* Primary Health Care Facilities: health center, primary health care unit, family health support center, fluvial health care unit.** Facilities of other health care levels: specialized clinic/specialty outpatient clinic; polyclinic; doctor's office; cooperative; psychosocial care center and support, diagnosis, and therapy unit (SADT -Serviço de Apoio Diagnóstico Terapêutico); general hospital; specialized hospital; day hospital; normal childbirth center; emergency room; specialized emergency room; pre-hospital level mobile unit; mixed health unit; center for regulation of health services; health secretariat; health surveillance unit; land mobile unit; indigenous health care center; and hemotherapy and/or hematology health care center.
and Brasil 38highlight in the report of the National Seminar on Scarcity, Provision, and Insertion of Health Professionals in Remote and Vulnerable Areas (Seminário Nacional sobre Escassez, Provimento e Fixação de Prof issionais de Saúde em Áreas Remotas e de Maior Vulnerabilidade).