Trends in the access and use of health services in PHC among Brazilian older adults in the years 2008 , 2013 and 2019

This paper aims to identify the conditions and trends in access and use of primary health care (PHC) services by Brazilian older adults in 2008, 2013, and 2019. We performed a cross-sectional panel study with a descriptive analysis of the percentages and confidence intervals of the variables listed, in which data on the elderly population investigated in the Health Supplement of the 2008 National Household Sample Survey (PNAD) and the 2013 and 2019 National Health Surveys (PNS) were obtained. We initially identified that, while PHC was the primary service sought for care needs, this demand tended to decline in all Brazilian regions, among older women, the 60-69 years age group, and whites. The number of households registered with the USF increased 15.2%; the search for a place, service, or health professional by 4.5%; and the population served by 31.4%. The main factors of non-attendance were not being able to get a vacancy/service ticket and doctor unavailability. A growing trend was observed among those diagnosed with Systemic Arterial Hypertension, Diabetes Mellitus, and multimorbidities among those investigated.


Introduction
The increase in Chronic Non-Communicable Diseases (NCDs) in the epidemiological profile of the Brazilian and global population is one of the most challenging global health problems, especially among older adults.Diseases such as systemic arterial hypertension, diabetes mellitus, and osteoarticular problems that, in more than half of elderly individuals, show multimorbidities (simultaneous occurrence of ≥ 2 or ≥ 3 chronic diseases), cause limitations and incapacity for work and activities of daily living, affect the quality of life for an extended period, and can lead to premature mortality [1][2][3][4] .
In the care of older adults, a fragmented care model with the multiplication of specialized visits, uncoordinated care, non-shared information, increased polypharmacy, repetition of tests, and other procedures, overloads the health system, causes iatrogenic events, and does not adequately meet the users' health needs.Thus, the current Brazilian epidemiological profile demands a model that prioritizes light levels of care, the PHC, with promotion actions, considering the education and active participation of subjects, the prevention and delay of diseases and frailties, and the maintenance of independence and autonomy so that the greater longevity achieved by current generations can be enjoyed with quality of life 5,6 .
The need to strengthen and prioritize PHC revives its relevance in the SUS by being defined as the preferred gateway and communication center with the health care network and reinforces its relevance in securing equality in access and promoting the use of health services 7 .Access is the user's entry into the health service according to the identified individual need.This must have a universal character and promote substantial impacts on health care, such as reducing inequalities, strengthening the SUS, identifying and redirecting actions, through the particularities of population groups, such as older adults, and favoring the proper use of services, which consists of direct or indirect contact with health services, through visits, hospitalizations, preventive actions, and diagnostic tests [8][9][10][11] .
The current reality shows that sociodemographic factors are closely related to the access and use of health services.Thus, it requires a reliable analysis of elderly care, such as possible differences in gender, ethnicity, age, and region of residence 12,13 .In this context, data from the Health Supplement of the National Household Sample Survey (PNAD) and the National Health Survey (PNS) allow an in-depth analysis of the casuistry, considering the most diverse perspectives, from users who did not attempt to enter the service to those who were adequately attended to.
Thus, this study aimed to identify the conditions and trends in the access and older adults' use of Brazilian PHC health services in 2008, 2013, and 2019, identifying the similarities and disparities according to the studied variables in the periods in question.

Methods
This cross-sectional panel study analyzed the historical series of indicators of access and use of health services in the PHC based on data from the Health Supplement of the 2008 National Household Sample Survey (PNAD) and the 2013 and 2019 National Health Surveys (PNS).These national household surveys were conducted by the Brazilian Institute of Geography and Statistics (IBGE) in partnership with the Ministry of Health, and the PNS is a continuation of the PNAD supplements, with greater detail and specificity of methods for the health theme 14 .The PNAD and the PNS are population-based studies representative of the country, large regions, Federation Units, capitals, and metropolitan regions 15 .Data on the elderly population aged 60 years and over were considered for this study.
The indicators were calculated from the common questions in the different surveys (Table 1) used in the questionnaires to guarantee the maintenance of data comparability in the historical series.The variables that referred to the follow-up of treatment by the service/professional, the health service they usually look for when needed, a recent search for health service, type of health service sought, difficulty in accessing the health service, and reason for not receiving care in the last visit were considered to analyze the access and use of health services in PHC, as explained in Table 1.
Morbidity indicators were based on variables prevalence of diabetes mellitus, the prevalence of systemic arterial hypertension, and prevalence of multimorbidities (with the presence of two or more of the following pathologies: chronic spine diseases, rheumatoid arthritis, cancer, diabetes mellitus, asthma/bronchitis, systemic arterial hypertension, heart disease, chronic renal failure, and high cholesterol).PHC coverage was based on the variable registration in the Family Health Unit, as shown in Table 1.
Older adults investigated in the three surveys were characterized by gender, age, and ethnicity/ skin color.The historical series of health profile/ need and access/use indicators were analyzed by frequencies and confidence intervals at the national level and in the large regions, based on es-timates of complex samples.Then, the Wald test with Rao-Scott correction was performed to find differences between the proportions of categorical variables in the PNAD 2008, PNS 2013, and PNS 2019, considering the sample weight and the effect of the design on the calculations.

Results
Older adults interviewed in the PNAD 2008 totaled 26,350, while in the PNS 2013 and 2019, they were 23,815 and 43,554, respectively.Figure 1 shows the distribution of older adults who usually look for PHC, which, despite remaining as the primary service sought, decreased from 53.2% in 2008 to 46.2% in 2019.On the other hand, the results show an increase in the search for public or private emergency care services, ranging from 4.6% in PNAD 2008 to 14.4% in PNS 2013 and 14.6% in PNS 2019, while other types of services had similar numbers over the period.
Table 1 assesses the percentage of older adults who seek PHC, stratified by gender, age group, ethnicity, and region.This assessment identified a decrease in both genders.However, a reduction of almost eight percentage points from the PNAD 2008 to the PNS 2019 in females was observed.The declining demand for PHC is also observed regarding the age group and is more evident in the 60-69 years age group, from 55.7% in 2008 to 47.80% in 2019.
The trend in demand for PHC varies between ethnicity/skin color categories in the period evaluated.Black older adults sought PHC less from PNAD 2008 to PNS 2013, but an increase was observed for PNS 2019.Another highlight is the most significant decrease in white self-declared older adults, from 46.1% to 38.8%, as shown in Table 1.The older adults' demand for PHC also varies by region of residence, with a decline in all regions from 2008 to 2013, a trend that remained in 2019 in the Southeast, while a slight increase was observed in the other regions (Table 1).
Despite the reduction in demand for PHC services, the percentage of households registered in the Family Health Unit (USF) increased considerably, approximately 12 percentage points, from PNAD 2008 to PNS 2013.In contrast, a 4.5% increase was observed in current demand for a health location, service, or professional, and approximately 31 percentage points among users served (Table 2) from 2008 to 2019.
The main reasons for non-attendance by the PHC service remained practically the same: not being able to get a vacancy/service ticket and doctor not available, so that this last sample showed a declining trend of 18 percentage points from 2008 to 2019, as shown in Table 2. Brazilian regions share this trend, highlighting older adults in the Northeast in 2013 (34%) and the Midwest in 2019 (58.9%), who mentioned that they waited too long and gave up on getting access and use of the service as a reason for not attending.In the North in 2008 and 2019 and the Southeast in 2019, respectively, a relevant amount of 34.3% and 25.7% and 20.6% of older adults reported unavailable specialized service or professional as a determining factor for not performing their care (Table 3).
Concerning morbidities, an increasing trend was identified in elderly patients assisted by the PHC diagnosed with arterial hypertension, diabetes mellitus, and multimorbidities, emphasizing an increase of approximately 12 percentage points in the latter, as seen in Table 2.At the regional level, significant differences are shown in Table 3 only in the Northeast and Midwest regions for the diagnosis of hypertension, with an increase of 5 and 7 percentage points, respectively.The number of older adults with diabetes and multimorbidities showed an upward trend in all Brazilian regions, particularly multimorbidities in the South and Southeast, which evidenced a growth of 10.2% and 13.1%, respectively.

Discussion
The results show a higher level of access and use of PHC health services by older adults in Brazil over the years analyzed, which could be observed in all Brazilian regions, in both genders, in all age groups, especially women, older adults aged 60-69, those with morbidities, and residing in the Midwest region.
Among these results, more significant disparities were found between the PNAD and the two editions of the PNS, which may be related to methodological issues, such as favoring a more significant sampling plan effect in the PNAD due to the greater number of households included in the sample.It is also noteworthy that the PNS allowed the unlinking of health information from the Continuous PNAD and its inclusion in the SIPD, besides having a specific design and exclusively directed to the collection of health data 15,16 .Thus, conducting a specific health survey probably led to greater precision in the PNS estimates.However, we should consider that, despite these disparities, this research was designed to monitor most of the indicators listed in the PNAD 2008 15 .
The higher number of older adults throughout the surveys reflects the current demographic trend of population aging, with a projected variation of 10.1% to 13.8% in the representation of individuals aged 60 or more in the Brazilian population from 2008 to 2019 17 .This phenome- A decrease in the PHC demand by Brazilian older adults was found in this study despite the increasing level of PHC coverage in all regions over the same period analyzed in Brazil, ranging from 64.32% in 2008 to 70.58% in 2013 and 74.76% in 2019, according to the Ministry of Health 20 .Synchronously with this trend, the search for Urgent and Emergency care units grew, which can be explained by the implementation of Emergency Care Units (UPA) in 2009.The use of health facilities depends, in part, on the per- ceived need by individuals and, considering that the UPAs are intermediary units between primary care and hospital emergencies, it is inferred that many users have started to look directly to the UPA for assistance to the urgent needs.However, many of these needs can be met by PHC 21,22 .
Thus, we observe the establishment of health care unlinked from care longitudinality, health promotion, and disease prevention and, therefore, weakening and lower PHC resolution, with an overload and deviation from the purpose of the UPAs, undermining their care potential.It is noteworthy that the PHC should not be excluded from this care process within the UPA but instead articulated to ensure the longitudinality and coordination of care.Furthermore, the health network must see to the fact that the cura-tive and hospital-centered model is not encouraged to the detriment of health promotion and prevention actions, especially promoted by the PHC and essential to face the more significant burden of NCDs in the contemporary world, ev-idenced by a higher prevalence of diabetes mellitus, systemic arterial hypertension, and multimorbidities 23 .
As in the data of the total population, this health profile of the current elderly population was modified by the changes as mentioned above in the age structure, typical of the demographic transition, associated with economic, social, cultural, and environmental factors, promoting what Omran 24 conceptualizes as an epidemiological transition.This is defined as a reduced morbimortality from infectious diseases and higher relevance of NCDs.Thus, it is essential to consider several simultaneous morbidities (multimorbidities) in meeting this demand 25 .The increase in the prevalence of NCDs in the study represents a trend and may be related to the more significant opportunity for their diagnosis, requiring the strengthening of PHC to meet all the existing demand 26 effectively.
Observing other types of health services, the private ones, data from the National Supplementary Health Agency (ANS) show that the rate of coverage by private health plans increased from 2008 (21.87%) to 2013 (25.4%) while showing a slight reduction in 2019 (24.2%) 27,28 .We can infer that this setting has contributed to the observed reduction, throughout the surveys, in the search for PHC by the most socioeconomically favored strata: white people and residing in the Southeast region.
Regional inequalities are known characteristics in the Brazilian reality and reflect health care inequalities.The North and Northeast regions usually show more unfavorable results for health indicators, such as worse health status assessment, more significant restriction of activities, and lower use of health services 26 .This setting is observed in the result of lower PHC demand in the North region.However, the same finding in the Southeast contradicts the trend of better indicators.This situation in the Southeast can be explained by the lower PHC coverage among Brazilian regions, calculated at 68.84% in October 2020 by the Ministry of Health 20 , and with greater coverage of private plans among older adults, 33.1% in 2015, according to data from the National Supplementary Health Agency 30 , when compared to other Brazilian regions.
Ethnicity/skin color is a significant perspective of inequality, and black, brown, and indigenous individuals have the most unfavorable indicators for schooling, work, and access to goods and services, including healthcare 31 .The findings of this study showed a different result: lower PHC demand by white people, which is due to the methodology used, specifically for this type of establishment.
PHC is a predominantly public service, and it was identified that 99.2% belonged to the SUS in 2017 8 .Therefore, black or brown people are more dependent on the SUS, while a relevant portion of white people has private health plans, which corresponded to 53.1% of white older adults, according to Silva et al. 32 in the Health, Well-being, and Aging Study conducted in the city of São Paulo (SP).This data reflects the reality of health inequalities determined by ethnicity, which is included in the concept of social determinants of health as a structuring factor of social hierarchy, interfering with health, disease, and death outcomes 33 .
The considerable increase in the number of households registered at the USF favors the findings of this study, identifying that the elderly population investigated, when approached about the recent search for health services, sought more health care over the period, and had considerable success in achieving it in 2019.This variable was a trend inversely proportional to the lack of a doctor as a justification in the cases that did not receive care, with more negative numbers from 2008 to 2013 but with a relevant positive outlook in 2019.Therefore, besides the expanded PHC, we can infer that the greater availability of medical professionals contributes to the result of users obtaining care, and these achievements can be explained by the creation and implementation of the Mais Médicos (More Doctors) Program, which aims to reduce regional inequalities arising from the lack of these professionals and strengthening PHC as the coordinating perspective of health care 34 .
Even so, the lack of doctors represents the biggest hurdle to care for the elderly population, with an insufficient number of professionals to meet all the current demands.This reality aggravates the difficult access to the service, as the challenging task of achieving a vacancy or service ticket, possibly due to the reduced number of professionals to meet the existing demand, was the second most frequent reason for non-service in 2008, 2013, and 2019, with a considerable increase in the Northeast, to the detriment of what was seen in other regions.It is noteworthy that the targeting of care through the distribution of service tickets can adversely affect the achievement of access and use of health services because, as Nunes et al. 22 emphasize, this model encourages the culture of long waiting lines before the onset of service opening hours at the UBS, in order to ensure health care and realization of the use of the health service.
Considering that this is a cross-sectional panel study, the limitations were susceptibility to survival bias; also, both surveys, the Health Supplement of PNAD 2008 and PNS, disregarded the population residing in collective institutions, embassies, consulates, and institutionalized people residing in collective households of institutional establishments, such as military personnel in barracks or dependencies of military installations, people deprived of liberty, inmates in schools, orphanages, asylums, hospitals, the religious in convents, and monasteries.However, this is a nationwide study that identifies the conditions and trends of access and use of PHC health services by the elderly Brazilian population.

Final considerations
The current epidemiological transition in Brazil could be ratified with the identification of a growing trend in the prevalence of systemic arterial hypertension, diabetes mellitus, and multimorbidity between the PNAD 2008 and PNS 2019 data, reaffirming the need for monitoring and mobilization to achieve the goals agreed in the Plan for fighting chronic non-communicable diseases 2011-2022.
The PHC is one of the essential mechanisms for coping with NCDs.The increased registration of the USFs, associated with greater demand and service at this level of care, reinforces the relevance of consolidating the PHC to qualify health care for Brazilian elderly population to promote healthier older adults.
In line with this considerable expansion of PHC in this study, identifying the increase in access to and use of PHC health services in all Brazilian regions, it is possible to list the relevant role of the various policies that promote elderly health care, affecting the assurance of access to and use of health services positively, and monitoring these older adults in any region of the country, as identified in this research.

Collaborations
VAC Cesário and TCO Mendes worked in planning, data collection, interpretation of results, and drafting the text.MM Santos participated in the study planning, analysis, interpretation, and writing of the results.PRB Souza Júnior participated in the study analysis, interpretation, and writing of the results.KC Lima contributed to the theoretical-methodological planning.All authors performed a critical review and approved the final version of the manuscript.

Chart 1 .
Questions presented in the different surveys.

Table 1 .
Percentage of older adults seeking PHC.stratified by gender.age group.ethnicity/skin color.and region in Brazil.2019.
Source: National Household Sample Survey(2008).National Health Survey 2013 and 2019.Figure 1.Distribution of older adults who usually seek PHC in Brazil, 2019.Source: National Household Sample Survey (2008).National Health Survey 2013 and 2019.ization, resulting in increased life expectancy, and continued with the declining fertility rates from the 1960s.Thus, these factors affected the population's age structure and a more significant proportion of older adults, so that the United Nations (UN) considers the current period from 1975 to 2025 as the Age of Aging 18,19 .

Table 2 .
Temporal description of variables related to morbidities, access, and use of health services in the Brazilian elderly population, 2019.

Table 3 .
Temporal description of variables related to morbidities, access, and use of health services in the Brazilian elderly population, by geographic region, 2019.

Table 3 .
Temporal description of variables related to morbidities, access, and use of health services in the Brazilian elderly population, by geographic region, 2019.