A multiprofessional perspective on the principal barriers to universal health coverage and universal access to health in extremely poor territories: the contributions of nursing

Objective: to investigate the knowledge of managers and health professionals, social workers and education professionals regarding the principal barriers to universal health coverage and universal access to health on the part of the extremely poor population; and to point to the contributions made by nursing for the promotion of this right. Method: a qualitative study whose reference was, for ensuring the right to health, the reorientation of the Brazilian Unified Health System (SUS) towards universal coverage and access in these territories. Interviews were held with 27 members of the multi-professional team of a municipality with high social vulnerability. The data were worked on using thematic content analysis. Results: the following were ascertained as the principal barriers to universal health coverage and access to health: failures in the expansion and strengthening of the services; absence of diagnosis of the priority demands; shortage of technology, equipment, and material and human resources; poor local infrastructure; and actions with low resolutive power and absence of interdepartmental policies. Within the multi-professional team, nursing acts in the SUS in unique health actions and social practices in these territories, presenting an in-depth perspective on this harsh reality, being able to contribute with indispensable support for confronting these disparities in universal health coverage and universal access to health. Conclusion: nursing's in-depth understanding regarding these barriers is essential for encouraging the processes reorienting the SUS, geared towards equality in the right to health.


Introduction
In theory, the organization of the health services in Brazil is based on the Federal Constitution of 1998 and on the organic laws of the Unified Health System (SUS). For universal health coverage and universal access to health, in the municipalities, the following are stipulated by the SUS: financial investments, resources, and tripartite management processes, respecting the federal single management and decentralized municipal management, in order to prioritize the ensuring of attendance to the population's needs and their local requirements, taking into account the geographical, biological, social, economic and cultural adversities for care which is comprehensive, fair and inclusive (1) .
The availability or absence of equipment and devices which mediate universal health coverage and access to health in the municipalities is associated with various public services, health services, social work services, education, basic sanitation, productive inclusion and urban infrastructure, which can configure -or not -scenarios which are propitious for actions preventing disease and promoting health, treatment, rehabilitation and protection, favoring situations which can either reproduce or repair the context of poverty; and contribute -or not -to these groups gradually increasing or reducing their distance from achieving justice and citizenship (1)(2) .
Health is a social, physical, biological, psychic, cultural and affective good, which is manifested as a condition of positive well-being when its achievement is mediated through the offering of easily-accessed equipment, facilities and devices, strengthening it in the face of life's challenges. The processes of expansion and broadening in the offering of tools which are compatible with meeting the population's health requirements require, therefore, public policies and actions which are coherent and legitimate for each context. These must be sustainable if they are to progressively meet the population's needs, using efficacious management processes, sufficient financial resources, and a professional team which has been empowered to eliminate the barriers to access to attendance and care and to integral health with fairness.
In this regard, the strengthening of the interdepartmental actions is an essential effort (2) .
Resolution CP 53.14, of 2014, of the Pan-American Health Organization (PAHO), presents the essential requirements for encouraging actions preventing disease, and promoting health, treatment, rehabilitation, protection, and the construction of conditions which are favorable to the assistance and integral care of the population, in particular those groups in social vulnerability, and to create opportunities which ensure them the right to universal health coverage and to universal access to health. In order to analyze these groups' living conditions, it is not enough to identify the causes and consequences which act in this context, reinforcing the processes of inequality and social exclusion. It is necessary to reflect on the reality in these territories, aiming for a society which is more just and righteous, and to ask the question: inequality in what? (3).
In addressing the mismatches present in extremely poor territories, and seeking responses to the main problems and gaps in meeting these subjects' needs, the authors adopted the PAHO resolutions providing information on the principles and guidelines which are considered pillars for the planning and execution of public policies in favor of legitimate and sustainable actions capable of guaranteeing universal health coverage and universal access to health for the population of Latin America, in particular, for the vulnerable groups.
Among the world's population -7.2 billion, in 2015 -836 million were considered extremely poor, surviving on less than $1.25 per day (4) . In Latin America, social inequality is high, as is the proportion of the population which is poor, with 29% below the poverty line, 30% without access to health for financial reasons, and 21% unable to seek attendance due to geographical barriers (5) .
In Brazil, 16.27 million people are poor (8.6%), and the eradication of poverty is a major socioeconomic challenge. The Poverty Line, in Brazil, defines extreme poverty as family income per capita less than or equal to R$77.00 (seventy-seven reais) per month (6) .
In order to define the degree of poverty, one can use unidimensional or multidimensional criteria which are capable of measuring the attendance to these subjects' basic needs. The multidimensional measuring is part of the criteria of privation of income, crucial aspects such as the lack of, or poor access to, the attendance of basic needs, material resources, goods, services, and social support. In the scenarios of extreme poverty, the access to integral healthcare facilitates the achieving of other social rights such as access to education, nutrition, basic sanitation, housing, and social and productive inclusion (7) .

Method
This is exploratory-descriptive qualitative research, Interviews were held with managers and professionals who work in planning and executing public policies at a central and regional level in these territories of extreme poverty. In order to select these subjects, 27 informants were invited. These participated in the research after signing the Terms of Free and Informed Consent (TFIC). and Education Department (SME), in which they work.

Results
The sociodemographic profile of the multi-

Discussion
The universal health coverage provided through the APS in the municipality studied has the capacity to attend only half of the areas covered and of the local population.
These subjects do not represent the families in extreme poverty in the region, who are described as invisible; it is estimated that the number of these subjects is territories of poverty (9)(10) .
The profile and the accounts of the multi-professional health and to the rights to citizenship (9,11)  in the health systems (11)(12)(13)(14)(15) . When the offering of services is limited due to failures in the coverage, the team's work is made difficult, as is the access to health, leading to the APS having a poor resolutive capacity (13) . This study identifies the collective social responsibility established by the multi-professional team in response to the urgent need to promote an effort integrating all the departments in resolving the problems indicated, as suggested in the scientific literature (9)(10)(11)(12)(13)(14)(15) . It is important to undertake further research -testing possible tools for applying in local diagnosis with extremely poor communities, addressing multidimensional instruments for evaluating the obstacles to, and the gains obtained in, universal health coverage and universal access to health -making it possible to indicate sustainable paths for maximizing the resolutive capacity of the APS and ESF in these territories. There is, however, a shortage of such studies in Brazil and worldwide (15)(16)(17) .
The multi-professional team responsible for the municipal public services, in dealing with problems arising from these social inequalities, both knows and experiences in its routine the health needs of these communities in extreme poverty. Among the managers and professionals interviewed, nursing stands out due to its in-depth work and knowledge regarding the barriers which these families suffer in relation to universal health coverage and universal access to health. This knowledge provides nursing with support which is essential for fostering the processes inherent to public policies geared towards the re-orientation of the SUS and towards fairness in the right to health.