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Revista de Saúde Pública

Print version ISSN 0034-8910On-line version ISSN 1518-8787

Rev. Saúde Pública vol.49  São Paulo  2015  Epub June 09, 2015

http://dx.doi.org/10.1590/S0034-8910.2015049005503 

Original Articles

Lack of access and continuity of adult health care: a national population-based survey

Falta de acesso e de continuidade da atenção à saúde em adultos: inquérito nacional

Alitéia Santiago Dilélio I  

Elaine Tomasi II  

Elaine Thumé III  

Denise Silva da Silveira IV  

Fernando Carlos Vinholes Siqueira V  

Roberto Xavier Piccini IV  

Suele Manjourany Silva II  

Bruno Pereira Nunes II  

Luiz Augusto Facchini II  

IDepartamento de Ciências da Saúde. Universidade Federal de Santa Maria. Palmeira das Missões, RS, Brasil

IIPrograma de Pós-Graduação em Epidemiologia. Universidade Federal de Pelotas. Pelotas, RS, Brasil

IIIPrograma de Pós-Graduação em Enfermagem. Universidade Federal de Pelotas. Pelotas, RS, Brasil

IVFaculdade de Medicina. Universidade Federal de Pelotas. Pelotas, RS, Brasil

VPrograma de Pós-Graduação em Educação Física. Universidade Federal de Pelotas. Pelotas, RS, Brasil


ABSTRACT

OBJECTIVE

To describe the lack of access and continuity of health care in adults.

METHODS

A cross-sectional population-based study was performed on a sample of 12,402 adults aged 20 to 59 years in urban areas of 100 municipalities of 23 states in the five Brazilian geopolitical regions. Barriers to the access and continuity of health care and were investigated based on receiving, needing and seeking health care (hospitalization and accident/emergency care in the last 12 months; care provided by a doctor, by other health professional or home care in the last three months). Based on the results obtained by the description of the sample, a projection is provided for adults living in Brazilian urban areas.

RESULTS

The highest prevalence of lack of access to health services and to provision of care by health professionals was for hospitalization (3.0%), whilst the lowest prevalence was for care provided by a doctor (1.1%). The lack of access to care provided by other health professionals was 2.0%; to accident and emergency services, 2.1%; and to home care, 2.9%. As for prevalences, the greatest absolute lack of access occurred in emergency care (more than 360,000 adults). The main reasons were structural and organizational problems, such as unavailability of hospital beds, of health professionals, of appointments for the type of care needed and charges made for care.

CONCLUSIONS

The universal right to health care in Brazil has not yet been achieved. These projections can help health care management in scaling the efforts needed to overcome this problem, such as expanding the infrastructure of health services and the workforce.

Key words: Adult; Health Services Accessibility; Continuity of Patient Care; Health Inequalities; Equity in Health; Health Surveys

RESUMO

OBJETIVO

Descrever a falta de acesso e de continuidade da atenção à saúde de adultos.

MÉTODOS

Estudo transversal de base populacional com 12.402 adultos entre 20 e 59 anos, residentes em áreas urbanas de 100 municípios de 23 estados brasileiros, nas cinco regiões geopolíticas. Investigaram-se as barreiras no acesso e na continuidade da atenção a partir do recebimento, necessidade e busca de algum atendimento de saúde (internação hospitalar e pronto-socorro nos 12 meses prévios ao estudo; atendimento médico, de outro profissional de saúde e domiciliar nos três meses prévios). A partir dos resultados obtidos na descrição da amostra, apresenta-se uma projeção para os adultos residentes em áreas urbanas no território nacional.

RESULTADOS

A prevalência de falta de acesso aos serviços e aos atendimentos com profissionais de saúde mais expressiva foi de 3,0%, para internação hospitalar, enquanto a menor prevalência foi para atendimento médico (1,1%). A falta de acesso para o atendimento com outro profissional de saúde foi de 2,0%; em pronto-socorro, 2,1%; e domiciliar, 2,9%. Quanto às prevalências, o maior número absoluto de falta de acesso foi para atendimentos de urgência (mais de 360.000 adultos). Os principais motivos foram problemas estruturais e organizacionais, como falta de leito, de profissionais, de ficha/vaga do tipo de atendimento necessário e cobrança pelo atendimento.

CONCLUSÕES

O direito universal à saúde no Brasil ainda não foi alcançado. As projeções podem apoiar a gestão no dimensionamento de esforços dirigidos ao seu enfrentamento, como a ampliação da estrutura física dos serviços e da força de trabalho.

Palavras-Chave: Adulto; Acesso aos Serviços de Saúde; Continuidade da Assistência ao Paciente; Desigualdades em Saúde; Equidade em Saúde; Inquéritos Epidemiológicos

INTRODUCTION

The Brazilian Unified Health System (SUS) is guided by the principles of universal and equal access and aims to provide services based on health needs.20,21

The concept of “access” is complex and multidimensional, and may focus on people’s characteristics, service supply or the relationship between people and services.19 In this study, the concept is a synonym of accessibility, referring to the possibility of using health services when necessary.18 Lack of access is the impossibility of using the service regardless of need, expressing lack of capacity to respond or difficulty in ensuring health care.22

The behavioural model proposed by Andersen and Newman identifies access as one of the mediators of health service use, and indicates four dimensions of access: potential access, referring to contextual factors; realized access, relating to service use; effective access, referring to the care process; and efficient access, focusing on changes in health conditions and satisfaction as a result of the received care.1,18

The mechanisms that regulate the seeking and use of health services need to be understood, such as health needs which do or do not lead to services being sought; when seeking care, demand is generated and this is mediated by the existence or inexistence of the service, the main barrier to access.18 Other barriers are geographic distribution, the availability and quality of human and technical resources and the health care model.20

According to Pereira,16 when health services exist, needs may transform into demand for services and their use. A health need is “any disturbance to health or well-being, from both the patient’s and the health professional’s point of view, capable of resulting in a demand on the health system”. Needs can also be perceived (when they are identified by the individual), or unperceived (when they are only identified by a health professional).16

Even when the need is felt, an individual has “freedom of use” based on the degree of information about choices or, in other words, an individual has a health need but does not seek care owing to personal decisions.18

Continuity of care also deserves attention, and its quality must be evaluated. Continuity is related to the experiences and relationship of a patient with a clinician, as well as coordinated clinical care as the patient moves between different parts of the health service.11 Adequate diagnosis and treatment procedures culminating in user satisfaction would be the desired course for all health care.7,14

The individual’s lack of access to first contact or the lack of continuity of care can be considered indicators of the quality of health services by identifying inadequacies as: shortage of professionals, setting and fixed days for performing programmatic actions shifts.

Despite the importance of barriers to access to health services and to continuity of care regarding public health and impact on health indicators, studies in this area are incipient. This study aimed to describe lack of access and lack of health care continuity for adults.

METHODS

This study was part of a survey that investigated the access and quality of health services in Brazil. This was a cross-sectional population-based study performed on a sample of 12,402 adults with ages from 20 to 59 years, resident in urban areas of 100 cities in 23 states in the five Brazilian geopolitical regions.9

The sample size was estimated a posteriori based on prevalence rates. The largest sample required had 9,151 subjects, assuming: 0.7% prevalence of lack of access, accuracy of 0.2 pp, and a design effect of 1.2, including 15.0% for losses and refusals. It described the characteristics of continuous care.

The sample representing the adult urban population was located by a multiple level sampling process9,17 that considered population size, census tracts and households. Municipalities were aggregated according to population size and selected systematically. Census tracts were allocated randomly according to the proportion of valid sectors and population size, using the official grid of the 2000 Population Census.a Ten households were visited in each of the 638 sectors selected, “jumping” systematically 30 households from one residence to the next with the aim of finding 17 adults per sector.

All adults resident in the households were eligible to be interviewed. The 55 selected and trained interviewers collected the data using a hand-held device (PDA – personal digital assistant) in 2009. The data was stored on portable computers and transferred to the study headquarters via Internet.

The questionnaire was standardized and pre-tested. It contained socioeconomic and demographic variables as well as variables regarding both public and private health service use.

The respondents were asked if they had received some form of health care recently (hospital admission and accident/emergency care in the last 12 months; care provided by a doctor, other health professional or domiciliary care in the last three months) in order to investigate lack of access. If no, they were asked whether they had needed it, despite not having had care (yes/no). The sequence of questions asked about care provided by a doctor can be exemplified as follows: “In the <last three months>, have you been seen by a doctor?” If no: “Despite not having been seen by a doctor, did you need to be seen by one?” If needed: “Have you sought the care of a doctor in the <last three months>?” If the care of a doctor was sought: “Why were you not seen by a doctor?”. The questions for investigating the other forms of care provision followed the same pattern. Care provided by other health professional referred to top-level professionals, including dentists, psychologists, physiotherapists, dieticians, physical education teachers, speech therapists, social workers and nurses.

The reason for not receiving care and the outcome of the problem were investigated to describe barriers to access. With regard to care provided by a doctor, another health professional or domiciliary care, the respondents were asked whether they had sought care and the reason why they had not sought care. The reason why care was needed was also considered when it was provided by a doctor or domiciliary care.

In order to characterize barriers to care continuity, the respondents were asked about: all forms of care provided, the outcome of the problem after receiving care, whether they had received any explanation about the reason for care being provided, whether they were referred for a follow-up appointment, whether the follow-up appointment took place and the reason why they did not have their follow-up appointment. They were also asked whether they were referred to another service, whether any of these referrals did not take place and the reason why they did not have the care to which they had been referred regarding care provided by a doctor, another health professional or domiciliary care. Exclusively in relation to care provided by a doctor, respondents were asked whether any tests had been requested and the reason for not having them. The term “continuity of care” was used instead of “management continuity”, since part of the visits may refer to a continuum of care throughout life, and part may be related to specific problems.10,11

The descriptive variables were gender (male/female), self-reported skin color (white; black; other – mixed, Asian and indigenous categories), age in years (20 to 29; 30 to 39; 40 to 49; 50 to 59), education in years (none; one to four; five to eight; nine to 11; 12 or more), economic classification as per Brazilian Association of Research Companies (ABEP)b (A and B; C; D and E), per capita income in minimum wages (≤ 0.3; 0.4 to < 1; 1.0 and more), morbidity diagnosed medically (hypertension; diabetes mellitus; nerve problems – yes/no), geopolitical region (MW/N/NE/SE/S) and municipality population size (≤ 30,000; 30,001 to 100,000; 100,001 to 1,000,000; > 1,000,000 inhabitants).

For the purposes of quality control, 5.0% of the interviews were selected randomly to be repeated within three days at most, following the first interview. Hospitalization in the last year and a medical reference hypertension resulted kappa index of 0.77 and 0.73, respectively.

Based on the results obtained by the sample, a projection was provided for the reference population, i.e. adults in urban areas throughout Brazil, based on a total of 92,168,985 inhabitants.c

Analysis was performed using the Stata 12.1 statistics package.

This study was approved by the Research Ethics Committee of the Faculdade de Medicina of Universidade Federal de Pelotas (Process 152/07). All respondents signed an informed consent form.

RESULTS

A total of 13,756 adults were identified. Losses and refusals accounted for 9.8%, resulting in 12,402 individuals included in the study; 55.1% were women and 39.7% self-reported white skin colour. Average age was 37.4 years (SD = 11.5 years) and 31.8% were aged 20 to 29 years.

Approximately 1/3 of the individuals had between nine and 11 years of schooling. Most individuals fell into economic classification C (51.5%) and 42.0% had per capita income > 1 minimum wage. A quarter of the respondents reported medical diagnosis of at least one chronic disease. The highest number of respondents lived in the Southeast (35.4%), in cities with between 100,001 and 1,000,000 inhabitants (39.9%).

About 3.0% were not admitted and did not even have access to hospitalization (223,324 adult Brazilians), among those who self-reported need to be admitted to a hospital. The majority needed to be admitted to a hospital for an emergency surgery (30.0%) or to undergo examinations (20.0%); 40.0% did not admit themselves to a hospital because they thought they did not need to; and 20.0% reported that the outcome of their health problem was worsened (Table 1).

Table 1 Description of barriers to access and continued care based on the indicated need for hospital admission among adults. Brazil, 2009. 

Variable (n) Sample Projection for the urban population (20 to 59 years)b 92,168,985

na % 95%CI n 95%CI
Hospitalized (n = 12,365) 961 7.8 7.3; 8.3 7,189,181 6,728,335;7,757,856
Despite not being hospitalized, a doctor had indicated hospitalization (n = 11,404) 30 0.3      

Barriers to access
Lack of access to hospitalization (n = 991)c 30 3.0 2.0;4.3 223,324 148,882;320,097
Reason for needing to be hospitalized (n = 30)          
Emergency surgery/Operation 9 300 14.7;49.4 76,482 37,476;125,940
Non-emergency surgery/Operation 2 6.7 8.2;22.1 17,081 20,905;56,342
Clinical treatment 7 23.3 9.9;42.3 59,401 25,239;107,839
To have tests/Examinations 6 20.0 7.7;38.6 50,988 19,630;98,407
Other 6 20.0 7.7;38.6 50,988 19,630;98,407
Reason for not being hospitalized (n = 30)
Thought they did not need it 12 40.0 22.7;59.4 101,976 57,871;151,434
No hospital bed available 6 20.0 7.7;38.6 50,988 19,630;98,407
Family or work commitments 5 16.7 5.6;34.7 42,575 14,277;88,464
Afraid 4 13.3 3.7;30.7 33,907 9,433;78,266
Unable to pay 3 10.0 2.1;26.5 25,494 5,354;67,559
No transport available 1 3.3 0.08;17.2 8,413 204;43,850
Other 6 20.0 7.7;38.6 50,988 9,630;98,407
Health problem outcome after not being hospitalized (n = 30)
Got worse 6 20.0 7.7;38.6 50,988 19,630;98,407
Just the same as before 12 40.0 22.7;59.4 101,976 57,871;151,434
Improved a little    
Improved considerably 4 13.3 3.7;30.7 33,907 9,433;78,266
Cured/Problem solved 8 26.7 12.3;45.9 68,069 31,358;117,017

Barriers to continuity of care
Did not receive explanation as to the reason for being hospitalized (n = 915) 799 87.3 85.0;89.4 6,276,155 6,110,804;6,427,128
Discharged from hospital without being referred to a follow-up appointment (n = 935) 401 42.9 39.7;46.1 3,084,159 2,854,105;3,314,212
Did not have the follow-up appointment (n = 534) 110 20.6 17.2;24.3 845,635 706,064;997,520
Reason why did not have follow-up appointment (n = 108)
Date of the appointment not reached yet 59 54.6 44.7;64.2 461,716 377,999;542,897
Did not attempt to make an appointment 33 30.6 22.1;40.2 258,764 186,885;339,945
Unable to go and make the appointment 3 2.8 0.6;7.9 23,678 5,074;66,805
Attempted to make an appointment. but none available 2 1.9 0.2;6.5 16,067 1,691;54,966
No doctor available on SUS and unable to pay for a private doctor 2 1.9 0.2;6.5 16,067 1,691;54,966
Attempted to make an appointment, but no doctor available at that service 1 0.9 0.02;5.0 7,611 169;42,282
Other 8 7.4 3.3;14.1 62,577 27,906;119,234
Opinion about care received (n = 923)          
Very bad 43 4.7 3.4;6.2 337,891 244,432;445,729
Poor 12 1.3 0.7;2.3 93,459 5,032;165,351
Regular 79 8.6 6.8;10.6 618,270 488,864;762,053
Good 448 48.5 45.3;51.8 3,486,753 3,256,699;3,723,996
Very good 341 36.9 33.8;40.2 2,652,808 2,429,943;2,890,051
What happened to the problem after being hospitalized (n = 885)
Got worse 18 2.0 1.2;3.2 143,784 86,270;230,054
Just the same as before 59 6.7 5.1;8.5 481,675 366,648;611,080
Improved a little 140 15.8 13.5;18.4 1,135,891 970,539;1,322,809
Improved considerably 258 29.2 26.2;32.3 2,099,241 1,883,565;2,322,105
Cured/Problem solved 410 46.3 43.0;49.7 3,328,591 3,091,348;3,573,0.23

SUS: Brazilian Unified Health System

a Information is partially unknown for some variables. Differing values may therefore appear.

b Instituto Brasileiro de Geografia e Estatística, Censo Demográfico, 2010.

c The denominator refers to the total of individuals who were hospitalized plus individuals who reported having medical indication for hospitalization but did not have access to it.

Of those adults who were admitted to a hospital, 42.9% were discharged without being referred for a follow-up appointment and 20.6% of those who were referred did not actually have the appointment (4.7% for difficulties within the health service: 1.9% – no appointments available; 0.9% – no doctor available onsite; 1.9% – lack of SUS doctors) (Table 1).

Of individuals seeking accident/emergency care, 2.1% (360,186 people) did not receive it. Almost half (49.0%) gave up waiting to be seen since it took too long and the problem causing them to seek care had got worse in 16.3% of cases (Table 2).

Table 2 Description of barriers to access and continued care based on adults’ self-reported need for accident and emergency care. Brazil, 2009. 

Variable (n) Sample Projection for the urban population (20 to 59 years)b 92,168,985

na % 95%CI n 95%CI
Accident and Emergency Care (n = 12,302) 2,243 18.2 17.6;18.9 16,774,755 16,221,741;17,419,938
Needed care, despite not receiving it (n = 10,059) 49 0.5      

Barriers to access
Lack of access to accident and emergency care (n = 2,292)c 49 2.1 1.6;2.8 360,186 274,428;480,248
Reason why care was not provided (n = 49)          
Waiting time too long, gave up 24 49.0 34.4;63.7 184716 129,678;240,131
Too many people waiting 18 36.7 23.4;51.7 138,348 88,211;194,894
Specialist not available 12 24.5 13.3;38.9 92,358 50,137;146,642
Service refused to provide care 8 16.3 7.3;29.7 61,446 27,519;111,960
No transport available 2 4.1 0.5;14.0 15,456 188;52,776
Other 10 20.0 10.2;34.3 75,394 38,451;129,301
Problem outcome after not receiving care (n = 49)          
Got worse 8 16.3 7.3;29.7 61,446 27,519;111,960
Just the same as before 15 30.6 18.3;45.4 115,353 68,986;171,145
Improved a little 14 28.6 16.6;43.3 107,814 62,577;163,229
Improved considerably 7 14.3 5.9;27.2 53,907 22,241;102,536
Cured/Problem solved 5 10.2 3.4;22.2 38,451 12,817;83,688

Barriers to continuity of care
Did not receive an explanation as to the reason for seeking care (n = 2,126) 1.415 66.6 64.5;68.6 11,171,987 10,819,717;11,507,482
Discharged from the accident and emergency unit without being referred to a follow-up appointment (n = 2,178) 1.854 85.1 83.6;86.6 14,275,317 14,023,695;14,526,938
Did not have the follow-up appointment (n = 324) 92 28.4 23.6;33.6 709,841 589,867;839,811
Reason why did not have the follow-up appointment (n = 91)
Did not attempt to make an appointment 33 36.3 26.4;47.0 257,672 187,398;333,625
Date of the appointment not reached yet 29 31.9 22.5;42.5 226,439 159,714;301,682
Attempted to make an appointment, but no doctor available at that service 5 5.5 1.8;12.4 39,041 12,777;88,020
Unable to go and make the appointment 3 3.3 0.7;9.3 23,425 4,969;66,015
No doctor available on SUS and unable to pay for a private doctor 2 2.2 0.3;7.7 15,616 2,130;54,658
Attempted to make an appointment, but none available 1 1.1 0.03;6.0 7,808 213;42,590
Other 18 19.8 12.2;29.5 140,548 86,601;209,403
Opinion about care received (n = 2,083)          
Very bad 183 8.8 7.6;10.1 1,476,178 1,274,881;1,694,250
Poor 99 4.8 3.9;5.8 805,188 654,215;972,936
Regular 352 16.9 15.3;18.6 2,834,934 2,566,538;3,120,104
Good 1.105 53.0 50.9;55.2 8,890,620 8,538,350;9,259,665
Very good 344 16.5 14.9;18.2 2,767,835 2,415,656;3,053,005
Problem outcome after care was provided (n = 2,158)          
Got worse 48 2.2 1.6;2.9 369,045 268,396;486,468
Just the same as before 341 15.8 14.3;17.4 2,650,411 2,398,790;2,918,807
Improved a little 584 27.1 25.2;29.0 4,545,959 4,227,238;4,864,679
Improved considerably 669 31.0 29.1;33.0 5,200,174 4,881,454;5,535,669
Cured/Problem solved 516 23.9 22.1;25.8 4,009,167 3,707,221;4,327,887

SUS: Brazilian Unified Health System

a Information is partially unknown for some variables. Differing values may therefore appear.

b Instituto Brasileiro de Geografia e Estatística, Censo Demográfico, 2010.

c The denominator refers to the total of individuals who received care in an accident and emergency unit plus individuals who reported needing this type of care but did not have access to it.

The majority (85.1%) provided with accident/emergency care were discharged without being referred for a follow-up appointment and 28.4% of those who were referred did not attend it. Lack of access to follow-up appointments owing to difficulties within the health service (no appointments available (1.1%); no doctor available onsite (5.5%); lack of SUS doctor (2.2%))accounted for 8.8% (Table 2).

Out of all respondents who sought care provided by a doctor, 1.1% did not receive care (n = 49): 353,867 Brazilian adults were estimated not to have had access. The main reason for needing to be seen by a doctor, even though they were not seen, was “because I thought I needed to, I was feeling ill” (80.8%). Reasons relating to health promotion and prevention were reported by 53.9% of the sample: health problem follow-up/monitoring (29.9%), check-up (17.4%), pre-cancerous conditions (4.1%), prostate examination (1.5%) and antenatal appointment (1.0%). Around 70.7% of individuals who reported needing care actually sought it. The main reasons for this were the absence of a doctor (42.6%) and unavailability of appointments (40.4%). When asked why they had not sought care provided by a doctor, 53.4% stated difficulty in getting an appointment on SUS and 9.3% the lack of a doctor. The majority (50.3%) considered that their health problem continued just the same after having been seen by the doctor (Table 3).

Table 3 Description of barriers to access and continued care based on adults’ self-reported need to be seen by a doctor. Brazil, 2009. 

Variable (n) Sample Projection for the urban population (20 to 59 years)b 92,168,985

na % 95%CI n 95%CI
Care provided by a doctor (n = 12,300) 4,241 34.5 33.6;35.3 31,798,300 30,968,779;32,535,652
Needed care, despite not receiving it (n = 8,059) 167 2.1      

Barriers to access
Reason why needed care (n = 167)          
Thought they needed it because felt unwell 135 80.8 74.0;86.5 1,024,370 938,160;1,096,633
Follow-up on health problem 50 29.9 23.1;37.5 379,068 292,858;475,419
To have a check-up 29 17.4 12.0;24.0 220,594 152,134;304,268
To request tests/Examinations 19 11.4 7.0;17.2 144,527 88,745;218,059
To request a prescription 8 4.8 2.1;9.2 60,854 26,623;116,636
Cancer screening (n = 98) 4 4.1 1.1;10.1 51,979 13,946;128,046
To request a medical certificate 3 1.8 0.4;5.2 22820 5,071;65,925
To receive the results of tests 3 1.8 0.4;5.2 22,820 5,071;65,925
Prostate examination (n = 69) 1 1.5 0.03;7.8 19,017 380;98,887
To have an antenatal appointment (n = 98) 1 1.0 0.03;5.6 12,678 380;70,996
Other 12 7.2 3.8;12.2 91,280 48,176;154,670
Lack of access to care provided by a doctor (n = 4,290)c 49 1.1 0.8;1.5 353,867 257,358;482,546
Did not attempt to make an appointment (n = 167) 118 70.7 63.1;77.4 896,324 799,972;981,265
Reason why did not attempt to make an appointment (n = 118)          
Difficulty in getting an appointment on the SUS 63 53.4 44.0;62.6 478,637 394,382;561,099
Afraid/Did not want to 34 28.8 20.9;37.9 258,141 187,332;339,707
Family or work commitments 25 21.2 14.2;29.7 190,021 127,278;266,208
Unable to pay 24 20.4 13.5;28.7 182,850 121,004;257,245
Unable to go and make appointment 18 15.3 9.3;23.0 137,138 83,358;206,154
No doctor available at their usual health service 11 9.3 4.7;16.1 83,358 42,127;144,308
Health complaint got better 5 4.2 1.4;9.6 37,646 12,549;86,047
Other 17 14.5 8.6;22.1 129,967 77,084;198,088
Reason why care was not provided (n = 47)          
No doctor available 20 42.6 28.3;57.8 158,242 105,123;214,704
No appointment available 19 40.4 26.4;55.7 150,070 98,066;206,904
Unable to pay 7 14.9 6.2;28.3 55,348 23,031;105,123
Service closed when care was sought 1 2.1 0.05;11.3 7,801 186;41,975
Problem outcome after not receiving care (n = 167)          
Got worse 17 10.2 6.0;15.8 129,314 76,067;200,310
Just the same as before 84 50.3 42.5;58.1 637,696 538,808;736,583
Improved a little 31 18.5 13.0;25.3 234,540 164,812;320,749
Improved considerably 21 12.6 8.0;18.6 159,741 101,423;235,808
Cured/Problem solved 14 8.4 4.7;13.7 106,494 59,586;173,686

Barriers to continuity of care
Did not receive an explanation as to the reason for seeking care (n = 4,100) 3.035 74.0 72.7;75.4 23,530,742 23,117,364;23,975,918
Appointment ended without tests having been requested (n = 4,159) 2.376 57.1 55.6;58.6 18,156,829 17,679,855;18,633,804
Reason(s) why did not have some of the test(s) requested (n = 526)
Appointment made, but has not happened yet 279 53.0 48.7;57.4 7,229,979 6,643,396;7,830,204
Unable to get tests on the SUS and unable to pay 86 16.4 13.4;19.8 2,237,201 1,827,957;2,701,011
Unable to go and make appointment/Have tests 53 10.1 7.6;13.0 1,377,789 1,036,752;1,773,391
Did not want to 41 7.8 5.7;10.4 1,064,035 777,564;1,418,713
Not available in their city 23 4.4 2.8;6.5 600,225 381,961;886,696
Thought they did not need them 22 4.2 2.6;6.3 572,942 354,678;859,413
Other 82 15.6 12.6;19.0 2,128,069 1,718,825;2,591,879
Appointment ended without being referred to another service (n = 4,178) 3.881 92.9 92.1;93.7 29,540,621 29,286,234;29,795,007
Did not go to some of the referrals (n = 294) 100 34.0 28.6;39.7 767,611 645,696,276;896,298,677
Reason why did not go to some of the referrals (n = 100)          
Appointment made, but has not happened yet 45 45.0 35.0;55.3 345,425 268,664;24,489
Unable to go and make appointment/Have them 12 12.0 6.4;20.0 92,113 49,127;153,522
Unable to get tests on the SUS and unable to pay 11 11.0 5.6;18.8 84,437 42,986;144,311
Did not want to 9 9.0 4.2;16.4 69,085 32,240;125,888
Thought they did not need them 4 4.0 1.1;9.9 30,704 8,444;75,993
Not available in their city 3 3.0 0.6;8.5 23,028 4,606;65,247
Other 22 22.0 14.3;31.4 168,874 109,768;241,030
Opinion about care received (n = 4,027)          
Very bad 107 2.7 2.2;3.2 858,554 699,563;1,017,546
Poor 61 1.5 1.2;1.9 476,974 381,580;604,168
Regular 313 7.8 7.0;8.6 2,480,267 2,225,881;2,734,654
Good 2.169 53.8 52.3;55.4 17,107,485 16,630,511;17,616,258
Very good 1.377 34.2 32.7;35.7 10,875,019 10,398,044;11,351,993
Problem outcome after care was provided (n = 4,000)          
Got worse 41 1.0 0.7;1.4 317,983 222,588;445,176
Just the same as before 1.293 32.3 30.9;33.8 10,270,851 9,825,675;10,747,825
Improved a little 848 21.2 19.9;22.5 6,741,240 6,327,862;7,154,617
Improved considerably 1.046 26.2 24.8;27.5 8,331,155 7,885,978;8,744,532
Cured/Problem solved 772 19.3 18.1;20.6 6,137,072 5,755,492;6,550,450

SUS: Brazilian Unified Health System

a Information is partially unknown for some variables. Differing values may therefore appear.

b Instituto Brasileiro de Geografia e Estatística, Censo Demográfico, 2010.

c The denominator refers to the total of individuals who had care provided by a doctor plus individuals who sought this type of care but did not have access to it.

More than half the adults (57.1%) left the appointment without being referred for tests after being seen by a doctor, 16.4% did not have any tests performed because they were not able to on the SUS or because they were not available in their city (4.4%). Many (92.9%) left the appointment without being referred to care at another service (Table 3).

Of the respondents, 2.0% stated that although they had not received care provided by a health professional other than a doctor, they needed it (representing 246,417 adults). More than half (56.0%) reported not having sought care, especially for the difficulty in getting an appointment on SUS (57.1%). The main reasons why adults did not receive care were the lack of appointments (27.3%) and users being unable to pay for services (24.2%). The majority (61.3%) stated that their health problem remained unaltered (Table 4).

Table 4 Description of barriers to access and continued care based on adults’ self-reported need to have care provided by a health professional other than a doctor. Brazil, 2009. 

Variable (n) Sample Projection for the urban population (20 to 59 years)b 92,168,985

na % IC95% n IC95%
Care provided by professional other than a doctor (n = 12,279) 1,61 13.1 12.5;13.8 12,074,137 11,521,123;12,719,320
Needed care, despite not receiving it (n = 10,666) 75 0.7      

Barriers to access
Lack of access to health professional other than a doctor (n = 1,646) c 33 2.0 1.4;2.8 246,417 178,070;356,141
Did not make an appointment (n = 75) 42 56.0 44.1;67.5 313,972 247,253;378,448
Reason why did not make appointment (n = 42)          
Difficulty in getting an appointment on the SUS 24 57.1 41.0;72.3 179,278 128,728;227,002
Unable to pay 12 28.6 15.7;44.6 89,796 49,294;140,031
Family or work commitments 12 28.6 15.7;44.6 89,796 49,294;140,031
Unable to go and make appointment 9 21.4 10.3;36.8 67,190 32,339;115,542
This type of professional not available at their usual health service 8 19.0 8.6;34.1 59,655 27,002;107,064
Afraid/Did not want to 6 14.3 5.4;28.5 44,898 16,954;89,482
Health complaint got better 1 2.4 0.06;12.6 7,535 188;39,560
Other 2 4.8 0.6;16.2 15,071 1,884;50,863
Reason why care was not provided (n = 33)          
No appointment available 9 27.3 13.3;45.5 67,347 32,810;112,245
Unable to pay 8 24.2 11.1;42.3 59,699 27,383;104,351
This type of professional not available at the service 5 15.4 5.1;31.9 37,991 12,581;78,695
Service closed when care was sought 1 3.0 0.08;15.8 7,401 197;38,977
Other 11 33.3 18.0;51.8 82,148 44,405;127,787
Problem outcome after not receiving care (n = 75)          
Got worse 16 21.3 12.7;32.3 119,421 71,204;181,094
Just the same as before 46 61.3 49.4;72.4 343,687 276,968;405,921
Improved a little 10 13.3 6.6;23.2 74,568 34,004;130,074
Improved considerably 1 1.3 0.03;7.2 7,289 168;40,368
Cured/Problem solved 2 2.7 0.3;9.3 15,138 1,682;52,142

Barriers to continuity of care
Appointment ended without being referred to another service (n = 1,537) 1.474 95.9 94.8;96.8 11,579,097 11,446,282;11,687,765
Did not go to some of the referrals (n = 61) 25 41.0 28.6;54.3 202,966 141,581;268,807
Reason why did not go to some of the referrals (n = 25)          
Appointment made, but has not happened yet 9 36.0 18.0;57.5 73,068 36,534;116,706
Unable to get tests on the SUS and unable to pay 5 20.0 6.8;40.7 40,593 13,802;82,607
Did not want to 4 16.0 4.5;36.1 32,475 9,133;73,271
Thought they did not need them 3 12.0 2.5;31.2 24,356 5,074;63,325
Unable to go and make appointment/Have them 3 12.0 2.5;31.2 24,356 5,074;63,325
Not available in their city 1 4.0 0.1;20.4 8,119 203;41,405
Other 3 12.0 2.5;31.2 24,356 5,074;63,325
Opinion about care received (n = 1,492)          
Very bad 16 1.1 0.6;1.7 132,816 72,445;205,260
Poor 14 1.0 0.5;1.6 120,741 60,371;193,186
Regular 65 4.3 3.4;5.5 519,188 410,521;664,078
Good 758 50.8 48.2;53.4 6,133,662 5,819,734;6,447,589
Very good 639 42.8 40.3;45.4 5,167,731 4,865,877;5,481,658
Problem outcome after care was provided (n = 1,466)          
Got worse 13 0.9 0.5;1.5 108,667 60,371;181.112
Just the same as before 271 18.5 16.5;28.6 2,233,715 1,992,233;3,453,203
Improved a little 234 16.0 14.1;17.9 1,931,862 1,702,453;2,161,271
Improved considerably 500 34.1 31.7;36.6 4,117,281 3,827,501;4,419,134
Cured/Problem solved 448 30.5 28.2;33.0 3,682,612 3,404,907;3,984,465

SUS: Brazilian Unified Health System

a Information is partially unknown for some variables. Differing values may therefore appear.

b Instituto Brasileiro de Geografia e Estatística. Censo Demográfico, 2010.

c The denominator refers to the total of individuals who received care from a health professional other than a doctor plus individuals who sought this type of care but did not have access to it.

Most individuals (95.9%) who received care were not referred to other services. Around 41.0% of those who were referred did not receive the care to which they had been referred either because they were not able to get this care on SUS (20.0%) or because it was not available in their city (4.0%) (Table 4).

Lack of access to domiciliary care was reported by 2.9% of the adults (representing 126,447 individuals). Transport difficulties (35.5%), being confined to bed (29.0%), blood pressure problems (16.1%) and backache (12.9%) were the most reported reasons for needing to receive domiciliary care. Approximately 3/4 reported not having requested domiciliary care. The majority (47.1%) did not receive care because, even though they sought it, no response was provided by the health service, the health service had no professional available to provide the care (47.1%), or the health service did not provide this kind of care (41.2%). The most mentioned reasons for not seeking domiciliary care were because the health service did not provide this kind of service (68.9%) and there was no professional available to provide it (5.6%). The majority (45.2%) stated that their condition remained the same as before seeking care (Table 5).

Table 5 Description of barriers to access and continued care based on adults’ self-reported need for domiciliary care. Brazil, 2009. 

Variable (n) Sample Projection for the urban population (20 to 59 years)b 92,168,985

na % 95%CI n 95%CI
Domiciliary care (n = 12,281) 560 4.6 4.2;4.9 4,239,773 3,871,097;4,516,280
Needed care at home, despite not receiving it (n = 11,721) 62 0.5      

Barriers to access
Reason why needed care (n = 62)          
Transport difficulties 22 35.5 23.7;48.7 156,074 04,196;214,108
Confined to bed 18 29.0 18.2;42.0 127,497 80,016;184,651
Blood pressure problem 10 16.1 8.0;27.7 70,783 35,172;121,782
Had backache 8 12.9 5.7;23.9 56,714 25,060;105,075
Had leakage/Stroke/Ischaemia 5 8.1 2.7;17.8 35,611 11,870;78,257
Had a mental problem 5 8.1 2.7;17.8 35,611 11,870;78,257
Had rheumatism/Joint problems 5 8.1 2.7;17.8 35,611 11,870;78,257
Had heart problems 4 6.5 1.8;15.7 28,577 7,914;69,024
Had a neurological problem 3 4.8 1.0;13.5 21,103 440;59,352
Needed to get vaccinated 3 4.8 1.0;13.5 21,103 440;59,352
Had diabetes 2 3.2 0.4;11.2 14,069 1,759;49,240
Had been hospitalized in the last three months 2 3.2 0.4;11.2 14,069 1,759;49,240
Had had surgery recently 2 3.2 0.4;11.2 14,069 1,759;49,240
Had cancer 1 1.6 0.04;8.7 7,034 176;38,249
Had injured limbs or back
Lack of access to domiciliary care (n = 577)c 17 2.9 1.7;4.7 126,447 74,124;204,931
Did not request domiciliary care (n = 62) 45 72.6 59.8;83.2 319,183 262,908;365,786
Reason why did not request domiciliary care (n = 45)          
Service does not provide domiciliary care 31 68.9 53.4;81.8 219,917 170,444;261,092
No professional available to provide domiciliary care 25 55.6 40.0;70.4 177,466 127,673;224,705
Health complaint got better 7 15.6 6.5;29.5 49,793 20,747;94,159
Unable to go and make an appointment or request domiciliary care 6 13.3 5.1;26.8 42,451 16,278;85,541
Afraid/Did not want to 5 11.1 3.7;24.1 35,429 11,810;76,923
Service telephone always engaged or not working 2 4.4 0.5;15.2 14,044 1,596;48,516
Service does not have telephone 1 2.2 0.06;11.8 7,022 192;37,664
Other 6 13.3 5.1;26.8 42,451 16,278;85,541
Reason why domiciliary care was not provided (n = 17)          
Sought care but health service did not reply 8 47.1 23.0;72.2 56,738 27,706;8,717,527
Sought care but health service did not have a professional available 8 47.1 23.0;72.2 56,738 27,706;8,717,527
Sought care but health service does not provide this type of care 7 41.2 18.4;67.1 49,631 22,165;8,101,746
Sought care but no appointment available 6 35.3 14.2;61.7 42,523 17,106;7,449,743
No SUS professional available and unable to pay privately 4 23.5 6.8;50.0 28,309 8,191;6,037,069
Sought care but the service was closed 1 5.6 0.1;28.7 6,746 120;3,465,277
Telephone always engaged (n = 17)
Other (n = 17)
Problem outcome after not receiving care (n = 62)          
Got worse 10 16.1 8.0;27.7 70,783 35,172;121,782
Just the same as before 28 45.2 32.5;58.3 198,720 142,885;256,314
Improved a little 11 17.7 9.2;29.5 77,817 40,447;129,696
Improved considerably 10 16.1 8.0;27.7 70,783 35,172;121,782
Cured/Problem solved 3 4.8 1.0;13.5 21,103 4,396;59,352

Barriers to continuity of care
Did not receive an explanation as to the reason for seeking care (n = 537) 444 82.7 79.2;85.8 3,506,293 3,357,900;3,637,725
Received care but not referred to any other service (n = 550) 515 93.6 91.3;95.5 3,968,428 3,870,913;4,048,984
Did not go to some of the referrals (n = 35) 4 11.4 3.2;26.7 30,933 8,683;72,449
Reason why did not go to some of the referrals (n = 4)          
Appointment made. but has not happened yet 1 25.0 0.6;80.6 7,733 186;24,932
Unable to get tests on SUS and unable to pay
Thought they did not need them 1 25.0 0.6;80.6 7,733 186;24,932
Did not want to 1 25.0 0.6;80.6 7,733 186;24,932
Unable to go and make appointment/Have them 1 25.0 0.6;80.6 7,733 186;24,932
Not available in their city
Other 1 25.0 0.6;80.6 7,733 186;24,932
Opinion about care received (n = 548)          
Very bad 3 0.6 0.1;1.6 25,439 4,240;67,836
Poor 5 0.9 0.3;2.1 38,158 12,719;89,035
Regular 46 8.4 6.2;11.0 356,141 262,866;466,375
Good 350 63.8 59.7;67.9 2,704,975 2,531,145;2,878,806
Very good 144 26.3 22.6;30.2 1,115,060 958,189;1,280,412
Problem outcome after care was provided (n = 427)          
Got worse 1 0.2 0.006;1.3 8,480 254;55,117
Just the same as before 222 52.0 47.1;56.8 2,204,682 1,996,933;2.408,191
Improved a little 52 12.2 9.2;15.7 517,252 390,059;665,644
Improved considerably 99 23.2 19.3;27.5 983,627 818,276;1,165,938
Cured/Problem solved 53 12.4 9.4;15.9 525,732 398,539;674,124

SUS: Brazilian Unified Health System

a Information is partially unknown for some variables. Differing values may therefore appear.

b Instituto Brasileiro de Geografia e Estatística. Censo Demográfico, 2010.

c The denominator refers to the total of individuals who received domiciliary care plus individuals who sought this type of care but did not have access to it.

Around 93.6% of those who did receive domiciliary health care were not referred to other services, and 11.4% of those who were referred did not reach these other services because they were unable to schedule an appointment (25.0%) (Table 5).

DISCUSSION

The prevalence of lack of access to services and provision of care by health professionals was relatively low and showed little variation. Lack of access was more prevalent (3.0%) for individuals who reported needing hospitalization, whilst individuals who reported needing provision of care by a doctor presented the lowest prevalence (1.1%). The prevalence of lack of access to care provided by a health professional other than a doctor, lack of access to accident/emergency care and lack of access to domiciliary care was 2.0%, 2.1% and 2.9%, respectively.

Data from the 2003 National Household Sample Survey (PNAD) shows that the prevalence of lack of access among adults aged 20 to 64 years who sought health services in the last two weeks was of 2.2%. The 2008 PNAD found 2.8% for this same item.d,e The prevalence rates of this study are similar to those found in PNAD, even though the PNAD respondents’ recollection period was shorter, their age range was greater and more subjects were interviewed than in this study.

A study conducted in the city of Pelotas, Southern Brazil, found a 6.5% prevalence rate of lack of access to a health service in the last month in a sample of adults aged 20 or more. The inclusion of older adults may have led to the higher percentage found by that study.f

Despite being low, the prevalence rates found in this study reach another dimension when they are extrapolated to include all adults living in urban areas in Brazil. Access to a doctor, for example, is estimated to be lacking for more than 350,000 public and private health service users and 360,000 adults are estimated to be without access to emergency care. This is worsened by the service being mainly public. These projections are expected to be useful in supporting health management to calculate the efforts needed to address it, such as scaling up the physical structure of the services and the workforce.

Similarity was found among the reasons for seeking care by both those who did and those who did not manage to access services, with regard to hospitalization, care provided by a doctor and domiciliary care (data not presented). Different from the 2003 PNAD, which found preventive actions to be the main reason for health care provision, our study identified surgical operations and illnesses in general as being the main reasons for needing to be admitted to a hospital or needing to receive health care, like the 2008 PNAD.e

The main reason for lack of access by those seeking health care was structural and organizational problems: lack of hospital beds, charges for services, having to wait a long time to be seen, lack of health professionals, lack of appointments availability and lack of the kind of care needed. Similar aspects were found by the PNAD and by the study conducted in Pelotas, RS, in particular charges for services, unavailability of appointments and lack of doctors.f

Difficulty in getting an appointment on SUS, financial and personal problems and unavailability of services were the reasons for not seeking domiciliary care (72.6%), care provided by a doctor (70.7%) and care provided by other health professionals (56.0%). Lack of access can precede health care seeking, whereby service users identify barriers beforehand. A similar characteristic can be seen in barriers for having tests done.

The 2003 PNAD found that the main barriers to access were financial (23.8%) and long waiting times (18.1%).g Financial and structural problems continue to be significant obstacles to accessing health services. Service users can think it is so unlikely for them to get an appointment at their health centre within a short space of time that the majority do not even try to get one.5

Geographical, financial, organizational, information and cultural barriers to access are an expression of the characteristics of supply that can facilitate or impede people’s ability to use services. Travassos & Castro20 highlight the most important barrier as being the unavailability or physical absence of services and human resources. However, information about such availability, the illness in question and treatment options are also important in facilitating the use of health services, as these factors have an impact on people’s perception of health. Individual perception can also affect use of services, as both the quest for and use of them can be triggered by perceived need.18

Despite the important progress made by SUS, inequalities in universal access still exist. Problems relating to equity and comprehensiveness persist in that structural aspects reported as being the main barriers to accessing health services and ensuring continuity of care.15,23

Longitudinality, i.e. service users being accompanied over time by health professionals, is considered to be a key characteristic of Primary Health Care. However, this concept can also be applied to other levels of care, given that it relates to positive health care results and can be used to assess its quality.7,10

There is a lack of information about the need for or indication by health professionals to have follow-up after care, about the need to have tests and the need to be referred to another health professional. Despite that, continuity of care and assessment of the service user’s condition can result in more accurate diagnosis and more efficacious treatment, in addition to optimizing referrals to specialists and the performance of more complex procedures. The same can be observed regarding the prescription of tests and medication, especially about the lack of access to some of these procedures during health care provision.7

Most users stated that the received care was good or very good in spite of the barriers to continued care. On the other hand, 30.5% of those receiving care in accident and emergency units considered it to be regular/poor/very bad and this was the worst service in the opinion of respondents. This degree of dissatisfaction was higher than that found by PNADs in 2008 (13.5%), 2003 (14.0%) and 1998 (2.4%)e,h for any kind of care. For satisfied users, satisfaction is associated with service use, i.e., those who have access to services and for whom this experience is positive, tend to use services more.13 Most individuals who manage to use health services feel satisfied, despite significant inequities.

User satisfaction can be understood based on conceptual models. It may be limited to a checklist or be observed from the perspective of the theory of discrepancy, whereby levels of user satisfaction are predicted from the difference between expectations and the perception of the experience the user has. Furthermore, the theory of embodiment states that satisfaction is the difference between what is desired and what is obtained.8

People seek emergency service care owing to greater assurance of access (24h care – “open doors”), problem-solving and being able to have examinations and tests then and there.2,6

The degree of user satisfaction, apart from being an important indicator of health service quality and access, is also a tool that enables service managers to evaluate and monitor the health system.12Problems affected by barriers to access can be less severe. However, when comparing this with the answers given by those to whom care was provided, no significant differences were found.

In a context of high prevalence of chronic diseases among adults, most of them seek care in order to cope with their health problems rather than to cure them. Therefore, regular contact with a health service provider can influence behavioural change and better treatment adherence, aim of staying healthy and having better quality of life.4,i

There are few studies describing and quantifying barriers to accessing health care and its continuity. This study analyzed when respondents last received health care, which varied between three months and one year. These periods were used to minimize bias in the respondents’ recollections of what happened.3 Other positive features are the low percentage of subjects lost to the study in relation to the estimated sample size, sample size and comprehensiveness, and its being nationally representative, as well as its use of primary data.

The low proportion of individuals without access to health services and care hampered the precision of the analysis. Stratified or adjusted analysis could help to understand the most affected social groups. It can also contribute to the adoption of measures and policies to reduce inequalities, in addition to increasing the efficiency of the health system and scaling up access to services and their quality. Despite the low prevalence rates found, when these proportions are projected and applied to the entire Brazilian adult population living in urban areas, many individuals do not access the health system or have continued health care.

The importance of the access and continuity of health services is increasing in national and international literature. Most studies defines service use as a synonym of access and do not investigate adequately lack of access and continuity of care.

Quantifying lack of access and continuity of health actions and service supply throughout the national territory helps its magnitude to be recognized, assisting in the definition of strategies for controlling them in the health system.

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Research supported by the Brazilian Ministry of Health (Process 23110.010118/2007-89).

a Instituto Brasileiro de Geografia e Estatística. Censo brasileiro de 2000. Rio de Janeiro; 2000 [cited 2010 mar 10]. Available from: http://www.ibge.gov.br/home/estatistica/populacao/censo2000/default_prim_resultados.shtm

b Associação Brasileira de Empresas de Pesquisa (ABEP). Critérios de classificação econômica Brasil. São Paulo (SP); 2003 [cited 2014 jan 21]. Available from:http://www.abep.org

c Instituto Brasileiro de Geografia e Estatística. Censo brasileiro de 2010. Rio de Janeiro (RJ); 2010 [cited 2014 jan 21] Available from: http://censo2010.ibge.gov.br/

d Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional por Amostra de Domicílios - PNAD: acesso e utilização dos serviços de saúde 2003. Rio de Janeiro (RJ); 2005 [cited 2014 Dec 8]. Available from: http://www.spm.gov.br/arquivos-diversos/.arquivos/integra_saude_ibge_2003

e Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional por Amostra de Domicílios - PNAD: um panorama da saúde no Brasil: acesso e utilização dos serviços, condições de saúde e fatores de risco e proteção à saúde 2008. Rio de Janeiro (RJ); 2008 [cited 2014 Dec 8]. Suplemento. Available from: http://www.ibge.gov.br/home/estatistica/populacao/panorama_saude_brasil_2003_2008/

f Nunes BP. Acesso aos serviços de saúde em adolescentes e adultos na cidade de Pelotas - RS [dissertation]. Pelotas (RS): Universidade Federal de Pelotas, Departamento de Medicina Social; 2012.

g Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional por Amostra de Domicílios - PNAD: acesso e utilização dos serviços de saúde 2003. Rio de Janeiro (RJ); 2005 [cited 2014 Dec 8]. Available from: http://www.spm.gov.br/arquivos-diversos/.arquivos/integra_saude_ibge_2003

h Instituto Brasileiro de Geografia e Estatística. PNAD - Pesquisa Nacional por Amostra de Domicílios - PNAD: acesso e utilização dos serviços de saúde 1998. Rio de Janeiro (RJ); 2000 [cited 2014 Dec 8]. Available from: http://www.ibge.gov.br/home/estatistica/populacao/trabalhoerendimento/pnad98/saude/saude.pdf

i Macinko J, Dourado I, Guanais FC. Doenças crônicas, atenção primária e desempenho dos sistemas de saúde: diagnósticos, instrumentos e intervenções. Washington (DC): Banco Interamericano de Desenvolvimento; 2011 [cited 2015 Feb 13]. (Textos para Debate). Available from: http://apsredes.org/site2012/wp-content/uploads/2012/06/Publica%C3%A7%C3%A3o-BID.pdf

Received: April 6, 2014; Accepted: September 23, 2014

Correspondence: Alitéia Santiago Dilélio. Departamento de Medicina Social – UFPEL. Av. Duque de Caxias, 250 3º andar Fragata. 96030-001 Pelotas, RS, Brasil. E-mail: aliteia@gmail.com

Basead on the doctoral thesis of Alitéia Santiago Dilélio, titled: “Acesso e Utilização da Assistência Médica Ambulatorial ao Adulto na Rede de Serviços de Saúde do Brasil”, presented to the Graduate Program in Epidemiology of Universidade Federal de Pelotas, in 2014.

The authors declare no conflict of interest.

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