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Revista Brasileira de Saúde Materno Infantil

versão impressa ISSN 1519-3829versão On-line ISSN 1806-9304

Rev. Bras. Saude Mater. Infant. vol.19 no.2 Recife abr./jun. 2019  Epub 22-Jul-2019 


Children's hospitalizations by sensitive conditions in primary care in the Northeast of Brazil

Márcia Gabriela Costa Ribeiro1

Augusto Cezar Antunes de Araujo Filho2

Silvana Santiago da Rocha3

1-3Programa de Pós-Graduação em Enfermagem. Departamento de Enfermagem. Universidade Federal do Piauí. Campus Ministro Petrônio Portella. Bloco 12. Teresina, PI, Brasil. CEP: 64.049-550. E-mail:



to analyze the temporal evolution of hospitalizations due to sensitive conditions in primary care among children under five years of age in the Brazilian Northeast region.


ecological descriptive study with hospitalizations data from the Sistema de Informações Hospitalares do Sistema Único de Saúde (Hospital Information System from the Public Health System). The admissions rates on sensitive conditions in primary care between 2004 and 2013 were calculated in two age groups: children under one year old and between one and five years of age.


there was a reduction of hospitalization rates in the Northeast, despite the existence of fluctuations in the analyzed period. Bahia and Sergipe presented, respectively, the highest and lowest admission rates (465.14 and220.19 per 10 thousand inhabitants). It has been shown that children under one year old are more affected by sensitive diseases in primary care, presenting a total rate of 709.08 per 10 thousand inhabitants. The main causes of hospitalizations were related to the infectious gastroenteritis group and its complications with a rate of 218.76 per 10 thousand inhabitants.


despite the decrease of hospitalizations due to sensitive conditions in primary care, the Northeast still presents high rates compared to other States, thus, evidencing the need to qualify the services offered through professionals' qualification and the inclusion of health actions for the real necessity in the community.

Key words Primary healthcare; Hospitalization; Morbidity; Child's health


The Atenção Primária à Saúde (APS) (Primary Health Care), a gateway to healthcare networks, refers to a set of promotion, prevention, treatment and rehabilitation actions that have an impact on the population's well-being and development.1 One of the APS pillars in Brazil is the Estratégia Saúde da Família (ESF) (Family Health Strategy) that goes beyond medical care and curative practices, since its actions focus on the family, which is perceived from its physical and social environment, through the established link between the user and the professional, promoting an integral, continuous and qualified care.1-2

The access to these health actions, besides improving the population's quality of life, also reducing the socioeconomic inequalities and contributing to the reduction of hospitalization rates, as well as to the improvement of the health indicators. Despite its importance, in 2013 only 53.4% of the Brazilian households were registered in a family health unit. The study compared the results of the Pesquisa Nacional de Saúde (PNS) (National Health Research) along with the Pesquisa Nacional por Amostras de Domicílios (PNAD) (National Research on Household Samples) carried out by IBGE in 2008.3

Some of the indicators referred to the percentage of households and residents enrolled in a family health unit. The data were analyzed by the sampling weights for the primary sampling units, households and residents. When evaluating the regions of the country, the Northeast had the largest number of registered households with 64.7%, and the lowest in the Southeast with only 46.0%.3 Another study showed that in 2013 the Northeastern region had 73.8% ESF coverage, while in the Southeast, it was 44.5%.4

However, in order for the APS have positive impacts on the population's health indicators, it is necessary, besides the coverage of services, to have quality in care and assistance. One of the ways to evaluate its performance is through the analysis of the hospitalization indicator on sensitive conditions at the primary care (ICSAP).5 The National List had as its conceptual framework model proposed by Caminal-Homar& Casanova-Matutano, in addition to, the referral lists of the municipal and the State health secretariats from the country, as well as the international studies, were used as references.6

This list is divided by groups of hospitalization causes and according to the document number. 221, on April 17, 2008, which can be used as a tool for assessing APS and the health system performance (SUS) in the national, state and municipal levels areas.3,7

The non-resolution of these APS sensitive conditions generates a greater demand for costs, because the cases that could be solved at this care level on lower technological density are transferred to the higher density ones, including hospitalizations. This fact increases expenses, unnecessarily burdens to SUS8 in addition, these sensitive conditions influence the mortality and morbidity rates from different age groups.

The children's population is one of the most vulnerable group to miss out these diseases and its complications, which were observed in studies carried out in Piauí,9 in Rio Grande do Norte10 and in São Paulo,11 in which the majority of infants' death under one year old could be avoided if more effective, qualified and timely health actions were performed during the pregnancy-puerperal period.7,10,11

Understanding the impact that APS has on the population's quality of life and recognizing the importance of a healthy development and growth for the children's lives. This study aimed to analyze the temporal evolution of ICSAP among children under five years of age in the Northeast Region.


This is an ecological descriptive study, in which the causes of ICSAP were analyzed in children under five years of age residing in the Northeast region, between 2004 and 2013.

Regarding to sensitive diseases to the APS, a published list was used as basis under the document number. 221 on April 17, 2008, which included the International Diseases Classification categories. The list consists of 19 categories, such as infectious gastroenteritis and complications, iron deficiency anemia, nutritional deficiencies, hypertension, and among others.7

The data from this study were extracted from the Rede Interagencial de Informações para a Saúde (Ripsa) (Interagency Health Information Network) in October 2017, which aims to provide basic data, indicators and analyzes on health conditions and trends.

To compose this study, absolute numbers and hospitalization rates were used for sensitive conditions in primary care, stratified by state, sensitive cause group, and by age group. The hospitalizations were analyzed in two age groups: children less than one year old (birth up to 11 months and 29 days) and children between one year old and less than five years of age (12 months to 59 months and 29 days). After the data was collected, the data was entered on a spreadsheet in the Microsoft Excel 7.0 program.

The censuses were worked on in different decades corresponding from 2000 to 2010. The rates used were collected directly from Ripsa, which uses as an exponential basis, 10,000.12

This study was carried out with secondary data from a public domain platform and on-line and it was unnecessary to submit this study to the Research Ethics Committee, according to the Resolution of the National Health Council of the Ministry of Health, number 510, on April 7, 2016.


Table 1 shows that during the analyzed period the state of Bahia in the Northeast of Brazil has the highest ICSAP rate of children under the age of five (465.14 per 10 thousand inhabitants). Despite the decrease trend of the rates between 2004 and 2009 in Bahia State, thus, there was an increase in the rate in the previous year of 2010. However, Sergipe State obtained the lowest rate (220.19 per 10,000 inhabitants) under the same hospitalization conditions.

Table 1 Hospitalization rate on Sensitive Conditions in Primary Care per 10,000 children under the age of five in the States in the Northeast of Brazil between 2004 and 2013 according to the year of hospitalization. Teresina, Piauí, Brazil, 2017. 

State 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Average annual rate
Alagoas 598.23 555.37 447.72 389.00 330.12 309.42 381.43 285.51 248.92 244.21 378.99
Bahia 545.47 540.15 493.90 464.31 430.60 426.71 546.47 439.74 400.23 363.81 465.14
Ceará 462.10 455.11 419.20 366.36 326.16 334.08 341.91 341.55 280.40 319.46 364.63
Maranhão 340.50 374.70 390.12 338.53 291.02 339.98 423.64 373.41 333.88 368.17 357.40
Paraíba 606.08 630.12 522.86 426.17 382.00 395.92 376.11 280.04 227.50 229.58 407.64
Pernambuco 484.03 476.38 420.29 375.80 329.17 320.39 315.85 294.89 281.26 277.43 357.55
Piauí 579.42 531.90 466.25 377.42 392.35 386.19 507.94 427.50 355.41 342.21 436.66
Rio Grande do Norte 411.49 413.19 344.07 309.16 221.47 239.49 275.01 223.65 195.21 204.72 283.75
Sergipe 386.93 334.88 262.06 215.55 164.98 151.58 195.23 149.12 176.14 165.47 220.19
Total 489.65 484.23 436.29 386.79 346.00 350.91 406.25 346.34 308.28 308.90 386.36

Source: Public Health System IT Department.

Table 2 presents the number and the hospitalization rates in each State in the Northeast of Brazil, in the period studied according to the age group that were analyzed. It was evidenced that children under one year old were more affected by ICSAP, presenting a rate of 709.08 per 10,000 inhabitants.

Table 2 Distribution of the number and the hospitalization rates for Sensitive Conditions in Primary Care per 10,000 children under the age of five in the States in the Northeast of Brazil, according to age group. Teresina, Piauí, Brazil, 2017. 

State < 1 year old 1 to 4 years old < 5 years old
n rate n rate n rate
Alagoas 48942 837.82 75121 318.58 124063 421.67
Bahia 166896 745.17 407206 452.25 574102 510.6
Ceará 95494 728.03 175990 325.38 271484 403.96
Maranhão 71619 606.85 167309 343.89 238928 395.23
Paraíba 39124 703.87 88242 392.15 127366 453.9
Pernambuco 106648 808.92 158955 296.64 265603 397.8
Piauí 34902 694.45 88686 426.36 123588 478.53
Rio Grande do Norte 24713 521.3 50355 263.78 75068 315.01
Sergipe 15406 442.87 27411 195.81 42817 244.98
Total 603744 709.08 1239275 357.83 1843019 427.14

Source: Public Health System IT Department.

Figure 1 shows a reduction in the hospitalization rates, despite the existence of fluctuations in the period of the analysis. Children under the age of one, there was a reduction of 18.6% from 2004 (872.03) to 2013 (709.08). Children aged one to four years old showed a reduction of 8.9% from 2004 (392.82) to 2013 (357.83).

Source: Public Health System IT Department.

Figure 1 Admission rate for sensitive conditions in primary care per 10,000 children under the age of five between 2004 and 2013, according to age group. Teresina, Piauí, Brazil, 2017. 

Hospitalizations for sensitive conditions in primary care occurred mainly due to diseases related to the infectious gastroenteritis group and its complications with a rate of 218.76 per 10,000 inhabitants. Soon after, the respiratory system diseases (bacterial pneumonia, asthma and pulmonary diseases) appeared, totaling 163.75 per 10,000 inhabitants (Table 3).

Table 3 Number and hospitalization rates for sensitive conditions in primary care per 10,000 children under the age of five in the States of Northeast in Brazil by age group. Teresina, Piauí, Brazil, 2017. 

Group < 1 year old 1 to 4 years old < 5 years old
n rate n rate n rate
Preventable diseases due to immunization and sensitive conditions 4,396 5.16 2,999 0.87 7,395 1.71
Infectious gastroenteritis and complications 297,273 349.14 646,649 186.71 943,922 218.76
Anemia 2,592 3.04 3,170 0.92 5762 1.34
Nutritional deficiencies 13,288 15.61 15,526 4.48 28,814 6.68
Ear, nose, and throat infections 4,590 5.39 13,649 3.94 18,239 4.23
Bacterial pneumonias 91,159 107.06 159,668 46.1 250,827 58.13
Asthma 76,483 89.83 293,684 84.8 370,167 85.79
Pulmonary diseases 57,268 67.26 28,288 8.17 85,556 19.83
Hypertension 546 0.64 449 0.13 995 0.23
Angina 94 0.11 37 0.01 131 0.03
Cardiac insufficiency 3,060 3.59 2,665 0.77 5,725 1.33
Cerebrovascular diseases 139 0.16 248 0.07 387 0.09
Diabetes Mellitus 695 0.82 1,818 0.52 2,513 0.58
Epilepsies 6,700 7.87 16,377 4.73 23,077 5.35
kidney and urinary tract infection 16,180 19.0 26,080 7.53 42,260 9.79
skin and subcutaneous tissue infection 9,346 10.98 26,609 7.68 35,955 8.33
Inflammatory disease of female pelvic organs 156 0.18 201 0.06 357 0.08
Gastrointestinal ulcer 913 1.07 858 0.25 1,771 0.41
Diseases related to prenatal and delivery 18,866 22.16 300 0.09 19,166 4.44

Source: Public Health System IT Department.

It is also observed that the North and Northeast regions in Brazil had the highest rates of ICSAP in children under five years of age, respectively, verifying that these regions and the Mid-West presents higher hospitalization rates in Brazil (Table 4).

Table 4 Hospitalization rate for sensitive conditions in primary care per 10,000 children under the age of five by age group, according to the Brazilian geographic region. Teresina, Piauí, Brazil, 2017. 

Region < 1 year old 1 to 4 years old < 5 years old
North 836.52 385.54 473.31
Northeast 709.08 357.83 427.14
Midwest 735.28 308.90 392.59
South 734.00 246.41 339.94
Southeast 605.27 189.99 270.56
Total 688.20 278.71 358.56

Source: Public Health System IT Department.

It should be noted that, when analyzing the occurrence of ICSAP rates by sex, the male children were more affected by these aggravations in the two age groups observed, presenting an overall rate of 456.19/10,000, while the female children presented 397.08/10,000 hospitalizations. This difference was more significant among children under the age of one, with 787.88/10,000 for the male and 627.31/10000 for the girls. Among the children at the age of one to four years, the boys presented a rate of 374.5/1,000 and the girls 340.59/10,000. (Data not tabulated).


The total number of hospitalizations for ICSAP was 1,843,019, considering the period and the age groups analyzed, there was a 26.7% reduction in the hospitalization rates between 2004 and 2013, which corroborates other researches carried out in Brazil, which have shown reductions in children's hospitalization rates.13-15 It is known that these hospitalizations cause damage to the governmental public vaults, as to individuals and to society.16 In this perspective, this reduction is beneficial, since it avoids unnecessary expenses as well as the social burden of morbidity.17 This may be related to the accomplishment of previously performed procedures in services of greater complexity at an ambulatory level18 and also, the improvement in the access conditions, the effectiveness in the assistance provided by the APS, the increase in the coverage of the ESF and the improvement in the social conditions that have been observed in recent years.17-20

In the other hand, Bahia State presented the highest rate of ICSAP during the analyzed period, which may be justified by the fact that this State has the highest population density and the greatest territorial extension among the Northeast States, which can become difficult to cover the APS services.21 In 2013, only 58.5% of the households in Bahia were registered in the family health units.3

It is worth noting that the coverage of APS services is not the only factor that justifies the high rates of PHCS in Bahia. As for, Piauí State, despite having more than 80% of the residents enrolled in the ESF teams, also presents a high ICSAP rate compared to other States in its region. Thus, other dimensions must also be taken into consideration, such as insufficient financial support to guarantee universality and integrality on care, professional qualification, availability and location of services.22

Despite the improvements mentioned above, the Northeast Region, when compared to other regions in the country, has the lowest consultation rates, the greatest difficulties in accessing the health services, and other important elements such as: high illiteracy rates and low sewage coverage.23 In addition, the context in which individuals live also interferes with the process of illness, since social determinants, such as education, employment, income, basic sanitation, affect the population's health.24 Therefore, this reality reveals that more investments should be made in the APS in order to reduce the ICSAP, as well as the population's living conditions since they have an impact on the individual's health.20

It should be reaffirmed that the reduction of child morbidity and the severity of problems that compromise child's health is closely related to the quality of the services offered by the ESF.20 However, in spite of the reduction in the ICSAP, there are still cases of diseases that could be avoided if there were more effective actions from the APS. This is the case of gastroenteritis and respiratory diseases, which are also strongly associated to socioeconomic and environmental circumstances.17

In this study, gastroenteritis were the most impacting conditions for hospitalizations of children under the age of five during the decade reported, corroborating results from other regions in the country, such as the South and the Southeast.5,25 It is known that housing conditions, such as access to basic sanitation and running water are factors that influence the occurrence of these diseases. However, the performance of primary health services has an impact on its prevention, since part of the gastroenteritis is of mild intensity. Thus, low complexity technologies adopted by the APS are effective in preventing such infections, such as oral rehydration therapy, oral human rotavirus vaccine, the use of anti-parasitic, as well as family-oriented health education actions.26 Therefore, it is necessary to have a greater resoluteness of teams which includes, not only the cure of diseases, but the minimization of its complications.27

The respiratory system diseases were also important causes of hospitalization of children under the age of five in the Northeast region, which is in accordance to the reality of the country.5,13,15,25 It was observed that among this group of diseases, asthma was the most frequent among children under five years old. Because it is a disease that combines genetic, environmental and other factors, the APS professionals must act, especially in the modifiable factors, through actions of promoting, preventing and controlling the affection.28 Although this group has a greater biological susceptibility, hospitalizations could be avoided, in the context of the APS itself, through the early identification of signs and symptoms. In addition, the teams have resources to prevent and treat other respiratory diseases through the use of low-tech measures such as immunizations and antibiotics.26

A discreet difference was observed between the ICSAP rates among males and females. Similar results were found in another study that investigated the APS related to hospitalizations in Cuiabá-MT State, in which the male children accounted for 55.1% of the hospitalizations,13 corroborating, also, a study carried out in Montes Claros-MG State, which affirms that male children are the ones who get most ill and use the health services.29 On the other hand, a study carried out in Salvador city which investigated death and hospitalizations for asthma for over a decade, showed that male children were the most hospitalized, although females had a higher rate of deaths.30

Thus, in order to reduce child morbidity from preventable causes, more significantly, it is necessary to reorganize the healthcare model, promoting changes and strengthening in primary care, in order to make the APS more effective and qualified to reduce the ICSAP.8,19

As a limitation of this study, it should be mentioned that the use of secondary data may present problems regarding to the quality of information sources due to underreporting and classification errors.

Finally, it is worth noting that despite the importance to increase the coverage on the APS services, this is not the only factor that influences the quality of these services, since the Northeast still maintains high rates of ICSAP when comparing to other regions in the country. It is noteworthy that children under one year old are still more affected by this group of diseases, despite immunization programs and a great number of consultations in the first year of life. Therefore, the need to qualify the service offered, based on the professionals' training and awareness of, focusing not only on the number of services, but the quality of assistance given to the individual. This includes health actions aimed to the real needs of the community, as well as a closer bond between the professional and the subject, aiming for the active participation in its health-disease process.


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Received: June 20, 2018; Revised: April 24, 2019; Accepted: April 30, 2019

Contribuições dos autores

Ribeiro MG and Araujo Filho ACA - collection and analysis of the data as well as in the article design. Rocha SS - guided the preparation of the article from selecting the theme to the final revision. All the authors have approved the final version of the manuscript.

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