Access to surgical assistance: challenges and perspectives

Objective to characterize the access to surgical assistance in Brazil. Method documentary study, with a quantitative approach, developed from information of the Caixa Preta da Saúde [Health Black Box] database, of the Brazilian Medical Association. Results in the one-year period 3773 cases related to health care in Brazil were recorded. There were 458 (12.3%) records on surgical assistance. Of these, most, 339 (74.1%), involved the lack of access in all regions of Brazil. The main access constraint was the prolonged waiting time for surgery. Other constraints were the excessive waiting for medical appointment with experts, doing examinations and cancellation of surgeries. Conclusion the access to surgical assistance, by users of the Brazilian health system, is not widely guaranteed, reinforcing the need for integrated governmental actions, organization of the health care network, management of health care and human resources to overcome the challenges imposed to achieve the Universal Access to Health and Universal Health Coverage.


Introduction
Surgical condition is essential for prevention of chronic disabilities and mortality (1)(2) . This is because, often, it is the only solution to avoid them in case of injuries, traffic accidents, burns, disasters, violence, obstetrical complications, emergency abdominal and non-abdominal conditions, and others that may significantly affect the quality of life, such as cataract and congenital malformations (1) .
Surgery is at the end of the spectrum of the classic curative model. Thus, regardless of successful prevention strategies, surgical conditions will always be responsible for a significant portion of the burden of disease in a population. In developing countries, in particular, where conservative treatment is not readily available, the incidence of trauma and obstetric complications are high and with significant accumulation of untreated surgical diseases (1) .
However, the access and coverage of essential surgical care, as part of the human right to health, are not widely guaranteed (2)(3) . As a result, surgical pathologies are aggravated, affect the socioeconomic condition of the active population, impair the quality of life, and become potentially lethal (2) .
In addition to improve the quality of life, the quality of surgical interventions, and increase access to surgery, it can assist in achieving the United Nations Millennium goals for 2015; considering that surgery enhances the reduction of child mortality (goal 4) and improves maternal health (goal 5) for obstetric complications treatment. In addition, surgery may contribute to reduce the number of people living in poverty (goal 1), since surgical conditions can keep people outside the labor market (4) .  in Brazil was of 484.74±191.29 days, with regional disparities, according to Table 3. Failure in the schedule process † ---------01 (0.5) ---*F=Frequency. †The name of the user was not on the waiting list for surgery anymore. Coverage should be the main objective and guideline of health systems, and its fundamental premise is the right everyone has to the highest standard of health care (6) .
Moreover, it is a powerful means of promoting health, well-being, and human development (7) .
Regarding the number of records, it was observed that the Southeast region significantly surpassed other regions. This greater potential of use of the tool in this region can be due to the higher population density.
On the other hand, the Northern region, with smaller number of records, has the lowest population density (3.9 people per km²) (8) . Additionally, regarding Internet access in Brazil, there is a marked inequality between regions. Regions with more access, Mid-West, South and Southeast, surpass the North and Northeast regions (9) .  (10) .
Regarding the lack of surgical access, this is not a new problem: health systems worldwide, regardless of the socioeconomic status of the countries, deal with it.
In Brazil, the waiting list for elective surgeries is a reality with regional nuances as to procedures with longer or shorter lists, whether measured in number of patients or waiting time (11) .
We noted that the waiting comprised all the course of the user in the health care network. Considering that the user, due to the presence of signs and symptoms, accesses the network searching for medical care in the basic care. Once acknowledged the need, there is the referral to the specialist in the outpatient care.
After a long process of appointments, research, expert evaluation, and the need for surgical treatment, the user is placed in a waiting list for surgery, which will occur in the hospital care instance (11) .
Similarly, a study conducted to verify the barriers BRL (12) .
In this study, we showed an excessive waiting It should be noted that the prolonged waiting for care occurs when demand is greater than the capacity of the public system. Often, the list reflects the inadequacy of public funding for health. And is one of the main problems of public health systems, being a permanent source of political and social discontent (13) .

Achieve Universal Access to Health and Universal
Health Coverage is a permanent, complex and challenging task (14) . of Universal Access to Health and Universal Health Coverage (6) .
More specifically on access to surgery, we highlight the mutual-aid group of surgeries, government-funded, through allocation of extra resources. The mutual-aid group aims to meet the repressed surgical demands through concentration of efforts of the health services to accomplish a significant number of surgeries in a short time (11) . However, what was supposed to be an emergency strategy has become the modus operandi for access, being a palliative measure, costly to the system and that does not guarantee the access to surgical assistance in a sustainable way, since the extended waiting time in the list for surgery persists, with negative impact on health and quality of life of patients (11) .
In relation to the political and economic aspects, constraints to the access to health in Brazil, we noted that the public investment in health system remains,  (3) .
Therefore, only a systemic change is able to overcome the challenges imposed to achieve the Universal Access to Health and Universal Health Coverage (14)(15) . Thus, it is believed that an integrated approach, which includes endless joint efforts in the political and economic aspects, in the organization of the health care network, management of health services and human resources, will enable to overcome these challenges, in such a way that health and other social rights of Brazilian citizens are widely guaranteed.
Regarding the political aspect, it is imperative that government policies face the challenges related to the macroestructure complexity, so that they can overcome the challenges imposed to health. Thus, for improving health, it is necessary to improve governance, i.e., a greater degree of responsibility of the public sector, less corruption, and assumption that provide the public health system is a constitutional duty of the State (7,14) .
Furthermore, given the social determination of health, the economic crisis and social inequality must confront, education must be improved, the environment must be preserved, and the increasing demands of an ageing population must be met (14) . Equally important, the should be recognized that one of the main obstacles to the integration of the health services network is the prolonged waiting time for the care (16) .
Regarding the organization of the network to surgical assistance, aiming to improve the access and  (16)(17) .
In outpatient level, we recommend instituting careful research about the needs of the users in a waiting list situation, namely: clinical criteria such as health status deterioration, disease evolution, disabling pain, and mobility limitations; socioeconomic criteria concerning the ability to live and work independently, in addition to the emotional aspects. This allows the user the re-evaluation of priority while in the waiting list, and reconducting the family health team, for continuous monitoring (13,17) .
In addition, encouraging the development of guidelines for determining safe and acceptable waiting period, development of prioritization tools of assistance to consider the psychosocial characteristics, definition of responsibilities to operationalize the prioritization process, being a surgeon, nurse or other health professional (17).
Strictly regarding to the management of resources, comparisons show that greater supply of beds, health professionals and health expenses are effective strategies, in long-term, in management of the waiting.
Thus, the ability of the health services can be optimized.
We suggest the payment for productivity, quantitative and qualitative investment in human resources, evidence-based practice support, and use of idle capacity of surgical center on weekends, among others (13,17) .  (15) .
In the field of professional performance, nursing, in partnership with other health professions, must assume the commitment to public health, through the construction and consolidation of the SUS. To make this commitment involves overcoming Cartesian health assistance practices, aiming the completeness of the care, introjecting the premises of health policy in force, incorporate them into your practice, and act in the organization of health care networks, with emphasis on primary health care.
In the field of training, nursing must have the commitment to the construction of values that structure it as a social practice, provided through the interpretative looks of its history and open to the current reality, considering the political, economic and social structure in force in the country, health care models and their coverage, as well as the internal struggles of workers in the process of work and future challenges (19) . Therefore, if Universal Health Coverage is assumed as a government priority and also of health services, it will stimulate the nursing to expand its role in the construction of a system of universal, equitable and complete public health.