New paths for specialized care in the Municipality of Rio de Janeiro, Brazil: results from the Super Centro Carioca de Saúde

Abstract

The Outpatient Regulation System in the Municipality of Rio de Janeiro (MRJ) faced a significant increase in demand for doctor´s appointments, exams, and surgeries between 2020 and 2024. The creation of the Carioca Super Health Center (Super Centro Carioca de Saúde - SCCS) in 2023 aimed to improve access to specialized procedures and reduce waiting times. A descriptive cross-sectional study was conducted based on data available at the Transparency Portal to evaluate the frequency of requests, available slots, authorizations, and waiting times between 2020 and 2024. There was a 3.7-fold increase in requests and a 4-fold increase in authorizations between 2020 and 2024. The SCCS contributed 19% of the total available slots in 2023, especially for imaging and ophthalmology procedures. The mean waiting list decreased by 4% over the period, with a 44% reduction in exam waiting lists and a 39% reduction in average waiting time. However, waiting lists for doctors’ appointments increased by 38%. The expansion of service capacity and the establishment of specialized units like the SCCS were effective in reducing waiting times for exams and surgeries. Nevertheless, the continuous increase in demand, especially for doctor´s appointments, suggests the need for ongoing planning and effective policies for waiting list management and service prioritization.

Key words:
Ambulatory Regulation; Waiting Time; Specialized Care; Public Health System

Resumo

A Regulação Ambulatorial do Município do Rio de Janeiro (MRJ) enfrentou um aumento significativo na demanda por procedimentos entre 2020 e 2024. A criação do Super Centro Carioca de Saúde (SCCS), em 2023, visava melhorar o acesso a procedimentos especializados e reduzir o tempo de espera. Foi realizado um estudo transversal descritivo, a partir de dados de regulação do Portal da Transparência, para avaliar o volume de solicitações, oferta de vagas, autorizações e fila de espera entre 2020 e 2024. Houve um aumento de 3,7 vezes nas solicitações e 4 vezes nas autorizações nesse período. O SSCS contribuiu com 19% da oferta total de vagas em 2023, com destaque para procedimentos de imagem e oftalmologia. A fila de espera reduziu-se em 4%, com destaque para exames, cuja fila caiu 44%, e o tempo médio de espera foi reduzido em 39%. No entanto, a fila para consultas aumentou 38%. A ampliação da oferta e a criação de uma unidade especializada como o SSCS foram eficazes em reduzir o tempo de espera para exames e cirurgias. No entanto, o aumento contínuo da demanda, especialmente por consultas, sugere a necessidade de planejamento contínuo e políticas eficazes para gestão de filas e priorização de atendimentos.

Palavras-chave:
Regulação Ambulatorial; Tempo de Espera; Atenção Especializada; Sistema Público de Saúde

Resumen

La Regulación Ambulatoria de Río de Janeiro (MRJ) enfrentó un aumento significativo en la demanda de procedimientos entre 2020 y 2024. La creación del Super Centro Carioca de Salud (SCCS) en 2023 tenía como objetivo mejorar el acceso a procedimientos y reducir los tiempos de espera. Se realizó un estudio transversal descriptivo basado en datos disponibles en el Portal de Transparencia, para evaluar el volumen de solicitudes, la oferta y autorizaciones de cupos y la lista de espera entre 2020 y 2024. Hubo un aumento de 3,7 veces en las solicitudes y de 4 veces en las autorizaciones. El SCCS contribuyó con el 19% de la oferta total de cupos en 2023, especialmente en los procedimientos de imagen y oftalmología. La lista de espera se redujo en un 4%, con una reducción del 44% en las colas de exámenes y del 39% en el tiempo medio de espera. Sin embargo, las colas para consultas aumentaron en un 38%. La expansión de la oferta y la creación de unidade especializada como el SCCS fueron eficaces en la reducción de los tiempos de espera para exámenes y cirugías. Sin embargo, el aumento de la demanda, especialmente para consultas, sugiere la necesidad de una planificación continua y de políticas eficaces para la gestión de colas y la priorización de los servicios.

Palabras clave:
Regulación Ambulatoria; Tiempo de Espera; Atención Especializada; Sistema Público de Salud

Introduction

In the last decade, the guidelines for organizing the Brazilian health system have included structuring healthcare networks, consisting of three levels of care: from Primary Health Care (PHC) to secondary and tertiary care levels, which correspond to specialized and hospital care.

During this period, PHC has advanced continuously and with a certain stability, based on institutional, qualitative, and financial guidance from the National Primary Care Policy (Política Nacional de Atenção Básica - PNAB)¹ and its successive updates^2-5. By contrast, specialized services were implemented in states and municipalities with no clear policy or definition that would allow for establishing operational and quality guidelines to guarantee comprehensive care that continues to dialogue with other key points in the care network for the continuity of care^6,7. This situation helps to explain a series of bottlenecks that produce negative repercussions for the consolidation of the Unified Health System (SUS) in its universal and comprehensive nature, in the broad expression of the judicialization of health in Brazil, and the excessive waiting times in regulatory systems^8-11.

SUS faces enormous investment and funding difficulties, which have worsened over the last decade, since the impeachment of Dilma Rousseff in 2016, through the approval of Constitutional Amendment 95/2016¹² and the Bolsonaro presidential cycle from 2019 to 2022. This may well explain the discontinuity of several national programs and policies, among which we highlight the Rede Cegonha (Stork Network) and the Mais Médicos (More Doctors) Program, as well as the lack of progress concerning a structuring policy of Specialized Care (SC) during the period.

More recently, with the return of the center-left government of President Luís Inácio Lula da Silva, in addition to the return of programs and policies discontinued from the previous period, the Ministry of Health published the National Policy for Specialized Care (Política Nacional de Atenção Especializada - PNAES), along with its guidelines, dimensions, and structuring axes¹³. The relevance of this policy in the consolidation of SUS and PNAB is highly important, since the guarantee of access to specialized care makes it possible to guarantee the comprehensiveness and effectiveness of PHC.

In the Municipality of Rio de Janeiro (MRJ), the PHC policy gained centrality from 2009 onwards with the Primary Health Care Reform within the scope of the government program called Saúde Presente. Between 2009 and 2016, the reform consolidated the organization of the health system, with PHC as the preferential entry point, with 100% of residents in its territory referred to a family clinic or municipal health center.

Despite the high resolution capacity of the PHC, structured in its essential attributes and resolution of up to 80% of the most common problems of the population¹⁴, the broad access base promoted by the PHC units in MRJ generated a high demand for referrals for specialized care, causing significant bottlenecks in the regulatory systems over time.

This process was intensified by other local and contextual factors that followed this period, such as the dismantling of the Rio de Janeiro PHC system by the previous government, between 2017 and 2020; the city’s financial crisis; the loss of health insurance plans by families; and the impact of the COVID-19 pandemic with the closure of outpatient clinics and worsening health conditions¹⁵.

Another notable aspect in this local context is the serious crisis in federal hospitals that has been ongoing for decades and has gradually reduced the capacity to provide services^16-18. It is said that, historically, specialized care in the Rio de Janeiro State Government has always been heavily dependent on federal hospitals to guarantee access to secondary and tertiary levels of health care for its residents¹⁹.

Data from the Regulatory System (SISREG) Transparency Portal²⁰ and the SISREG Inventory, published in the Official Gazette of the Municipality in 2023²¹, exemplify the size of the political challenge surrounding access to SC in MRJ in 2020. This year, the waiting list for the regulatory system corresponded to 609,575 people, with requests that took up to eight years to be resolved. The average waiting time between the date of referral and the procedure was 160 days this year, with the worst result being for elective surgeries, which reached an average of 259 days. The total number of available procedures was 799,591, just over half of the number available in 2016, which was 1,425,101.

With the assumption of the new municipal management cycle by Mayor Eduardo Paes in 2021, the restructuring of the medium complexity network became a governmental political priority and was included in the Strategic Planning 2021 to 2024²² as an initiative to expand the availability of SC services to SUS users and reduce the waiting time for consultations and procedures in the regulatory system. The concept of a “Zero Waiting list” was also included in the Rio Futuro Plan, 2021 to 2024, and in the Municipal Health Plan, 2022 to 2025. The goal for the four years was defined as the implementation of 21 new specialty and diagnostic centers, including the Carioca Super Health Center (Super Centro Carioca de Saúde - SCCS), a public health complex of the Rio de Janeiro´s municipality, which offers specialized services.

Considering the healthcare bottlenecks for access to SC in SUS and the benefits related to the creation of specialized health centers, a strategy modeled for reorganizing health care in Brazil and ensuring a more integrated and effective approach to health care for the population²³, this article is a case study that seeks to verify the evolution of access to SC in MRJ, based on the analysis of the performance of health indicators, considering the implementation of the SCCS in October 2022. With the recent induction of the Ministry of Health, based on the publication of the PNAES, it is an opportune moment to analyze the management experiences carried out in the regions that can support managers in decision-making regarding the models to be adopted in the implementation of the policy and those that ensure the best results.

Methodology

Study design

This is a mixed methodology study: in the first stage, a documentary analysis was carried to present the process of creation and implementation of the Super Centro Carioca, with the necessary contractual organization and contracted structure (Kingdon Theory). In a second stage, a descriptive observational study was carried out seeking to present the initial results of the SCCS, based on secondary databases of the official SUS information systems used by the Municipal Health Department of Rio de Janeiro, between 2020 and 2024.

In the first stage, official documents were sought to identify the context, actors, and political interests that contributed to implementing the SCCS in the government agenda, namely, Strategic Planning, 2021 to 2024; the Rio Futuro Plan; and the Municipal Health Plan. To survey the adopted management models, our study searched for the official documents referring to the Public Selection Notice for partnerships and the contracts formalized with the Public Authorities. Finally, a survey of the relevant literature was carried out to guide the qualitative analysis of the data and the thematic synthesis of the results.

For the second stage, data from the SISREG was collected from public sources on the MRJ Transparency Portal, assessing the evolution of access to SC in MRJ and the leading role of the SCCS. Among the specialties available in the SCCS, ophthalmology was selected due to its more extensive detail in the analysis, considering: the absence (until then) of an exclusive municipal unit for the large-scale provision of this service; its status as the specialty with the greatest demand in the regulatory system in all the years selected; and, essentially, being a service under municipal jurisdiction.

Characterization of the location

MRJ is located in the southeast region of the country, has an exclusively urban population, and is the second largest in the country, with 6,211,223 inhabitants²⁴. It has 164 neighborhoods, 33 administrative regions, and 10 health districts (called planning areas - PAs)²⁵.

The city has one of the largest healthcare networks in the country, with 240 PHC units, comprised of multidisciplinary teams; local diagnostic resources, to guarantee an expanded portfolio of services; and a SC network, comprised of several health units, including the SCCS (https://doi.org/10.48331/scielodata.GGWFY8).

The SCCS is divided into three health units: the Speciality Center of Rio de Janeiro´s municipality (Centro Carioca de Especialidades - CCE), which provides specialized clinical consultations and treatments; the Diagnostic and Image Treatment Center of Rio de Janeiro´s municipality (Centro Carioca de Diagnóstico e Tratamento por Imagem - CCDTI), which provides diagnostic exams and imaging treatments; and the Eye Center of Rio de Janeiro´s municipality (Centro Carioca do Olho - CCO), which provides all eye healthcare services, from diagnostic exams to complex ophthalmological surgeries and transplants. The 22,000 m² building is located in the Benfica neighborhood, Health District 1.0, in the city center.

Data

Data related to outpatient regulation, such as waiting lists, authorizations, and events, were obtained from the SISREG (Outpatient Regulation System) database of the Ministry of Health. This data is hosted and made available on the SISREG Transparency Portal, developed and maintained by MRJ. For the year 2024, an annual projection was made, considering 5 competencies, from January to May 2024.

Data processing

The pre-processing, exploratory analysis and database linkage steps were performed using the statistical software R, version 4.4.1, with the help of the RStudio software, version 2024.04.2.

To calculate the waiting list, the average number of pending requests (not authorized) each month in the regulatory system was considered. The requests represent the total number of referrals entered into the regulatory system by the doctors of the MRJ PHC. The authorizations represent the total sum of requests entered into SISREG and scheduled by the regulator (authorized). The nomenclatures of the procedures existing in the regulatory system were aggregated according to type in Consultations, Exams, and Surgeries. For the calculation of all variables, requests for return appointments for consultations, exams, and surgeries were excluded, as they were not the first access. Requests from municipalities other than MRJ were excluded.

To calculate the average in-line waiting time and the average difference, in days, between the date of execution (service) and the date of request for all procedures authorized in SISREG was considered.

Theoretical framework

The analysis was based on Kingdon’s multiple streams theory, in which public policy decision-making and the formation of a government agenda depend on the confluence of three major streams: (1) the stream of problems, in which a given problem is identified or recognized by society to assume the public agenda; (2) the stream of proposals or alternatives (policies) to respond to the problem, which requires that these ideas have technical acceptability, reliability of the actors involved, as well as the capacity to cover the costs arising from their implementation; and finally (3) the stream of politics, which configures the political environment favorable to the formation of the agenda²⁶.

This study considered the restructuring of the medium complexity of MRJ, concretized by the implementation of the SCCS, based on a synthesis of the data collected from the different sources, which translate the political flows that determine the formation of this agenda, based on Kingdon’s Theory²⁶.

This study complies with the recommendations contained in Resolution 466/2012 of the National Health Council and uses public, aggregated, anonymized, secondary data, in an aggregation scale by health unit or by type of procedure performed²⁷. Submission to any ethics committee was unnecessary.

Results

The results were structured in two stages: 1) description of the SCCS based on the design, characteristics, and adopted management model; and 2) results obtained to strengthen access to SC in the city of Rio de Janeiro.

The SCCS: the Rio de Janeiro experience in implementing a centralized SC service

The SCCS is a structure linked to the Municipal Health Department of MRJ²⁸. In 2022, public calls were made to hire a Social Health Organization (Organização Social de Saúde - OSS) and a Civil Society Organization (Organização da Sociedade Civil - CSO), which resulted in the formalization of Management Contract No. 008/2022²⁹ for the management, operation, and execution of the health actions and services of the CCO, Collaboration Agreement No. 013/2022³⁰ for the CCE and Collaboration Agreement No. 009/2022³⁰ for the CCDTI.

The management companies were responsible for operationalizing all adaptations and renovations to the existing physical structure, as well as recruiting human resources and service contracts necessary for its full operation. The contracts follow the logic of global budgeting, that is, the transfer value is defined based on the effective cost for the operation of the contracted object, but the transfer of financial resources depends on the fulfillment of quantity and quality targets determined quarterly by the Evaluation Committee, made up of effective employees and appointed by the manager of the Municipal Health Department.

The option to draw up separate contracts for the management of each unit and to adopt management models in partnership with the Third Sector, in light of Law No. 13,019/2014³¹ and Law No. 9,637/1998³², is justified by three reasons^33,34: 1) successful and long-lasting experiences in the application of the model in different municipal health facilities, including PHC units, hospitals, and maternity wards; 2) the speed of implementation of services by these entities, given the commitment made by the mayor of the 2021-2024 management cycle to reduce waiting lists for medium complexity; and 3) the flexibility to modulate the volume of services provided, the planned specialties, the logic of remuneration for the service provided, among others, based on new health demands that may arise and/or by updating the guidelines under the direction of the Brazilian Ministry of Health.

The inauguration was carried out in two stages, with the CCE being the first unit to be inaugurated, on 10/05/2022, and the other two on 02/06/2023. The SCCS became the second largest Health Complex in the city, behind only the Souza Aguiar Hospital Complex, also in MRJ, and the first in several vacancies available in SISREG.

Contrary to a historical process that marked the organization of SC in MRJ and resulted in a large number of polyclinics and hospital outpatient clinics scattered throughout the city, many of which are the result of successive municipalizations of federal units and the legacy of when the city was the headquarters of the Federal District, the SCCS proposal redirects this pattern of strong decentralization towards a logic that becomes one of a concentration of resources. This is because SC presupposes the use of resources with high technological density and professionals with high technical specialization. Thus, seeking to achieve both the operational sustainability of the unit and its financial efficiency, the aim was to concentrate this large productive capital in a health complex, the SCCS.

In addition to the direct provision of health actions and services, the SCCS has three other strategic lines of action associated with its nature as the main SC hub in MRJ: 1) support for professional training with residency programs established in specialties of great interest to municipal public health, such as Ophthalmology and Radiology; 2) matrixing of 28 other diagnostic imaging services that exist in the healthcare network and are directly linked to the SCCS to ensure the standardization of the quality of the service provided and the reports issued; and 3) organization of diagnostic care lines, with the main objective that the patient carries out, whenever possible, in a single location, all the stages of the definitive diagnosis in a quick and timely manner.

Specialized care in Rio de Janeiro: results from the SCCS

Overall, adding up all categories, our study observed an increasing trend in requests (3.7 times), availability (3.2 times), and authorizations (4 times) between 2020 and 2023. Even though that requests have shown growth in all years, 2023 stands out with a 60% increase in requests, when compared to the previous year. The waiting list decreased in the years 2020 to 2022 (55%), growing again in 2023 and 2024. Comparing the total period, the waiting list decreased slightly (4%). As for the average time, a sustained decrease was observed over the years (Table 1).

Table 1
Access to Specialized Care in MRJ based on regulatory data according to consultations, exams, and surgeries, and the availability by type of unit, including the SCCS. Rio de Janeiro, 2020 to 2024.

Variable		2020	2021	2022	2023	20241
Total (per thousand)
	Waiting List2	335	195	150	212	323
	Requests	720	1,110	1,650	2,650	1,750
	Availability	800	1,180	1,600	2,520	1,810
	Authorizations	582	937	1,450	2,320	1,640
	Average Waiting Time (in days)3	132	110	93	88	81
Consultations (per thousand)
	Waiting List2	108	54.2	48.5	75.9	149
	Requests	233	375	583	879	502
	Availability	244	423	553	759	437
	Authorizations	206	324	522	722	487
	Average Waiting Time (in days)3	139	99	91	94	87
Exams (per thousand)
	Waiting List2	135	77.2	39.5	64.8	75.2
	Requests	334	487	687	1,240	923
	Availability	400	521	705	1,280	1,070
	Authorizations	258	415	602	1,150	878
	Average Waiting Time (in days)3	122	116	84	76	66
Surgeries (per thousand)
	Waiting List2	75.9	48.6	48.7	41.1	57.5
	Requests	94.1	151	235	342	203
	Availability	86.8	133	197	319	188
	Authorizations	69.5	115	189	292	184
	Average Waiting Time (in days)3	151	133	129	106	94.0
Offer from the Super Carioca Health Center (per thousand)4		0 (0%)	0 (0%)	24 (1.5%)	484 (19%)	145 (98)
Rio de Janeiro Center of Specialties4		0 (0%)	0 (0%)	24 (1.5%)	94 (3.7%)	22 (3%)
Rio de Janeiro Eye Center4		0 (0%)	0 (0%)	0 (0%)	91 (3.6%)	24 (3.2%)
Rio de Janeiro Center for Diagnostic and Imaging Treatment4		0 (0%)	0 (0%)	0 (0%)	299 (11.9%)	99 (13.2%)

• Notes: Includes consultations, exams, and surgeries for first-time medical and dental procedures (excludes return visits). Data in a scale of thousands (per thousand) scale, except for waiting times (in days). ¹ Projection for 12 months from partial data up to May/2024; ² Average monthly waiting list; ³ Average time between request and event, in days; ⁴ n in thousand and (%).
• Source: Municipal Health Department of Rio de Janeiro /SISREG Transparency Portal, 2024. Accessed on: October 1, 2024.

The same pattern can be observed in the growth of requests for consultations, exams, and surgeries, of around 3.6-fold between 2020 and 2024. A better performance for exams was observed, where the waiting list was reduced by 44% and the waiting time dropped from 122 days to 66 days. However, the same did not occur with consultations, and the availability of procedures showed the lowest growth among the other categories during the same period, resulting in a 38% increase in the waiting list. For elective surgeries, despite the 3.7-fold growth in availability (the highest among the categories), it is important to note that the relationship between availability and requests changed little between the evaluated years due to the growth in the same pattern in the volume of requests. The SCCS availability represented, in 2023, 19% of the total SC availability in the regulatory system, with emphasis on certain procedures, for which the availability is predominantly from SCCS, such as PET-CT, scintigraphy, panoramic dental radiography, bone densitometry, spirometry, colonoscopy, electroneuromyography, Doppler ultrasounds, biopsies, specific ophthalmological procedures, among others (Table 1).

In 2020, the procedures that represented the biggest bottlenecks totaled 154,660 requests, of which 6% (8,489) were attended to on average within 30 days, while 62% (96,123) of the requests waited more than 180 days. In 2024, these same specialties totaled 87,959 requests, of which 38% (33,554) were resolved within 30 days, 56% within 60 days, 71% within 90 days, and 94% within 180 days. When compared to 2020, there was a 94% reduction in requests that no longer waited more than 180 days to be performed (Figure 1).

Figure 1
Evolution of lines and waiting times for procedures that represented the biggest bottlenecks in the regulatory system in 2020.

The link https://doi.org/10.48331/scielodata.GGWFY8 details the evolution of the waiting list and aggregate waiting time by specialty. It is possible to observe that ophthalmology is the specialty with the longest waiting list in 2020 (17.8%) and 2021 (16.8%). In 2022, there was a proportional reduction to 6.8% of waiting lists, increasing again in 2023 and 2024 (14% and 26.8% respectively). As for the average waiting time, in 2020 it was the specialty with the longest average time (274.3 days), with a gradual reduction in all years, dropping to 71.2 days in 2024.

Access to ophthalmology services at the SCCS

In ophthalmology, there was a significant decrease in the total waiting list between 2020 and 2022, going from 46,300 to 8,620, with a significant increase in 2023 and 2024, reaching 73,500 in the last year. It is possible to observe an increasing trend in the number of requests for ophthalmology by 7.9-fold, going from 75,800 requests in 2020 to 240,000 in 2022, reaching 409,000 requests in 2023, the year of the inauguration of the SCCS. The availability of procedures also increased during the same period, going from 81,900 in 2020, to 344,000 available procedures in 2023, representing 4.2 times more available procedures than in 2020, with a more significant increase in consultations (4-fold), followed by surgeries (4.2-fold) and exams (1.8-fold). The average waiting time for the specialty showed a significant reduction between the first three years evaluated, going from 274 days in 2020 to 74 in 2023. The best performance observed was in ophthalmological consultations, in which there was a reduction of 317 days in the waiting time, going from 381 days in 2020 to 64 in 2023, with a significant growth in consultation requests of 7.4-fold in this segment. For ophthalmological examinations, no substantial changes were observed in availability, requests, authorizations, and waiting lists, despite the significant reduction in waiting time (Table 2).

Table 2
Evolution of access to ophthalmology services according to waiting list, requests, availability, authorizations, and waiting time in the regulatory system. Rio de Janeiro, 2020 to 2024.

Variable		2020	2021	2022	2023	20241
Total
	Waiting List (thousand)2	46	26	8	24	73
	Requests (thousand)	75.8	142	240	409	251
	Availability (thousand)	81.9	170	226	344	225
	Authorizations (thousand)	74.5	132	217	341	268
	Average Waiting Time (in days)3	274	226	123	74.0	71.0
Consultations
	Waiting List (thousand)2	22	6	4	15	55
	Requests (thousand)	40.4	77.9	155	297	183
	Availability (thousand)	51.6	110	143	240	164
	Authorizations (thousand)	48.4	75.2	149	247	204
	Average Waiting Time (in days)3	381	231	105	64.0	78.0
Exams
	Waiting List (thousand)2	11	15	86	255	190
	Requests (thousand)	15.8	24.3	19.4	16.3	8.67
	Availability (thousand)	9.68	15.4	25.1	17.2	8.63
	Authorizations (thousand)	6.88	16.4	19.5	13.8	7.52
	Average Waiting Time (in days)3	291	388	157	32.0	29.0
Surgeries
	Waiting List (thousand)2	13	5	5	8	18
	Requests (thousand)	19.7	40.0	65.5	95.6	59.4
	Availability (thousand)	20.6	44.7	58.1	87.0	51.9
	Authorizations (thousand)	19.2	40.7	49.4	79.6	56.2
	Average Waiting Time (in days)3	192	125	119	96.0	78.0

• Notes: Includes consultations, exams, and surgeries for medical and dental procedures. ¹ 12-month projection based on partial data up to May/2024; ² Average monthly waiting list; ³ Average time between referral by family doctor and event, in days.
• Source: Rio de Janeiro Municipal Health Department/SISREG Transparency Portal, 2024. Accessed on: October 1, 2024.

Table 3 shows a comparison between the average times for performing exams, consultations, and surgeries before and after the implementation of the SCCS. The years 2021 and 2022 were considered for the classification before the SCCS, and the years 2023 and 2024 for the classification after the SCCS. It was observed that for all statistical groups, there was a reduction in the time in days, but only the exams showed statistical significance.

Table 3
Comparison between Average Waiting Times before and after SCCS regarding Statistical Group. Rio de Janeiro, 2020 to 2024.

Variable		Before SCCS 2020 to 20221	After SCCS 2023 and 20241	p-value2
Average Completion Time (in days)
	All groups	102 (96)	85 (77)	0.2
	Consultations	95 (103)	91 (80)	0.8
	Exams	100 (121)	72 (70)	0.003
	Procedures	131 (147)	100 (84)	0.8

• Notes: ¹ Average (SD); ² Wilcoxon rank sum test. Before the SCCS, the classification considered the years 2020 to 2022, and after the SCSS, the classification considered the years 2023 and 2024.
• Source: Authors.

In June 2020, the average time for the ophthalmology specialty was 379 days, with a downward trend until February 2022 and remaining stable until January 2023, with an average time between 90 and 100 days. The SCCS began to perform consultations and procedures as of January 2023, representing 16.6% of all events performed in ophthalmology in MRJ and offered by the regulatory system, with the highest proportion in December 2023, reaching 36% of all events in ophthalmology in the Rio de Janeiro health network. Since its implementation, the SCCS has represented an average of 27.52% of all events in ophthalmology. In the same period, the average time to perform these events, which was 99 days in January 2023, was on average 55.64 days (95%CI 46.13-65.15) (Graph 1).

Graph 1
Evolution of the average time in Ophthalmology at MRJ according to the percentage of supply at the Super Carioca Health Center, 2020 to 2024.

The information on available procedures and waiting time by type of surgery and examination in ophthalmology is included in the link: https://doi.org/10.48331/scielodata.GGWFY8.

Discussion

The present study’s analysis demonstrated a significant increase in the volume of requests and authorizations, and a decrease in the average waiting time between 2020 and 2024 in the MRJ Outpatient Regulation System. However, the waiting list, despite an initial decrease, grew again in 2023 and 2024. The increase in the number of requests can be explained in part by the increase in the number of PHC teams in the MRJ between 2020 and 2024. In January 2020, the number of complete teams was 927, rising to 1,355 in May 2024, an increase of nearly 46%. The increase in teams occurred in a sustained manner (927 in Jan/2021, 1,050 in Jan/22, 1,225 in Jan/23, and 1,295 in Jan/24)³⁵, which explains the high demand for the analyzed procedures. Although the expansion of available procedures and the creation of specialized units improve access to public health systems, the continued increase in demand may partially offset these advances^36,37. Furthermore, this increase in requests may be due to the expansion of available procedures, since before this expansion, the supply of ophthalmology services was carried out in contracted clinics, in smaller numbers, and without the same quality offered by the SCCS.

In addition, the years 2020 and 2021 were marked by a decrease in the performance of elective procedures and consultations worldwide, especially in-person visits due to COVID-19. After the pandemic, there was a significant increase in global outpatient visits, driven by the increase in the volume of follow-up visits for patients with chronic conditions³⁸. Graph 1 shows a significant drop in the average waiting time for consultations, exams, and surgeries in ophthalmology in March/2020, with a rapid recovery in subsequent months and a sustained downward trend from October/2020 onwards.

The management of waiting lists in public health systems is a critical issue in several countries, and decreased waiting times are strongly linked to an increasing capacity of available procedures, but this also depends on improvements in resource management efficiency and case prioritization³⁶. In this sense, the inauguration of the SCCS reflects this reality, since the expansion of capacity was decisive in reducing waiting times for critical procedures, such as exams and surgeries, but the growth in demand for consultations, for example, prevented a significant reduction in the waiting list.

Specifically in the case of consultations, the 38% increase in the waiting list between 2020 and 2024 causes concern, especially considering that the availability of hospital beds did not keep up with the growth in requests. A study conducted by Kreindler³⁹ shows that the high demand for consultations, especially in public systems, is related to the growing need for PHC services, which often represent the gateway to specialized treatments. He emphasizes that delays in first access can have adverse consequences, including worsening health conditions, which increases pressure on the system over the long term.

The more positive performance in exams reveals the effectiveness of targeted investments and the creation of specialized units. The reduction in the exam waiting list by 44% and the average waiting time from 122 to 66 days, between 2020 and 2024, is in line with a study³⁹ that shows that the creation of units focused on performing diagnostic exams, with specific management capacity, can significantly reduce waiting times. The centralization of specialized exams in the SCCS appears to have been an effective strategy to mitigate bottlenecks, as demonstrated by the fact that the unit was responsible for 19% of the available procedures offered in 2023 in the MRJ.

Another point to be discussed is elective surgery, which, despite the 3.7-fold increase in the number of available procedures, did not show a significant improvement in the relationship between availability and requests. It was observed that the management of waiting lists for elective surgeries is particularly challenging in public systems due to the complexity of scheduling and performing procedures that require a large infrastructure⁴⁰. The equivalent increase in requests for surgeries at MRJ suggests that, despite the expansion in availability, the continued pressure for these procedures prevents a more significant improvement in waiting times. Nevertheless, surgeries, such as “Ophthalmology-retinopexy”, have been able to eliminate the waiting list since 2021.

In ophthalmology, the 7.9-fold increase in requests between 2020 and 2023, accompanied by a reduction from 274 to 74 days in the average waiting time, highlights the positive impact of targeted investments. Studies, such as that conducted by Cazabon et al.⁴¹, suggest the effectiveness of interventions focused on high-demand areas, such as ophthalmology, where population aging increases the prevalence of diseases, including cataracts and glaucoma. The creation of the CCO was essential to meet the growing demand and reduce waiting times, especially for consultations, which fell from 381 to 64 days.

The decrease in waiting times observed in the study must be multifactorial. First and foremost, it is due to the increase in the availability of beds, resulting from the implementation of the SCCS service in MRJ. In addition, the management model with decentralized regulation from the PHC allows that, as the PHC network grows, the capacity to regulate outpatient procedures increases proportionally. Since the implementation of the family medicine residency in 2011, the MRJ has trained more than 100 new family doctors each year, favoring the qualification of the network both in terms of resolution and the quality of requests, allowing for better regulation, given that it is possible to observe that most requests are authorized, which can reflect in proper referrals.

These findings are also comparable to international experiences that indicate that the combination of efficient management, centralization of specialized services, and increased supply capacity is an effective strategy to reduce waiting lists and waiting times in public systems. In the United Kingdom, for example, the National Health Service (NHS) has managed to significantly reduce waiting times for elective surgeries by introducing waiting targets and expanding specialized units. However, as demonstrated in MRJ, the expansion of demand for health services imposes the need for investments in infrastructure and more effective management strategies to regulate access⁴².

In the construction of the political agenda, three forces (flows) converged to make this problem of long waiting times a priority. Link https://doi.org/10.48331/scielodata.GGWFY8 demonstrates the elements identified in defining the agenda ‘Restructuring the SC: the SCCS’ between 2021 and 2024, of which the following stand out: 1) the high number of patients waiting in the regulatory system for long periods, influencing public discourse throughout the electoral process and public opinion of various segments of society, such as the mainstream media and justice agencies, such as the Public Prosecutor’s Office and the Public Defender’s Office, associated with the post-pandemic period; 2) the absence of other solutions within the available resources that would be more effective than implementing the SCCS and the political strategy to operationalize the creation of the city’s public health system; and finally 3) for the newly elected mayor, it was a political opportunity to stand out in his third term, taking advantage of the population’s need to implement something new in favor of the municipal SUS system and that would create its own brand in the health area, to be explored in future electoral cycles. It is important to note that the window of opportunity also included the contribution of extra resources resulting from the concession of the Rio de Janeiro State Water and Sewage Company, which allocated R$ 5.4 billion to the City of Rio de Janeiro, between 2021 and 2024, and which helped to finance investments in new equipment.

Conclusion

Improving quality and access in such areas as ophthalmology, outpatient surgery, and complementary diagnostic tests is a challenge in any part of the world, including in countries like the Netherlands, where the culture values the parsimonious use of resources, a strict adherence to clinical guidelines, and the perception of the importance of leadership in health³⁶.

Managing waiting lists and creating guidelines to help prioritize care are aspects in which the Center has been successful. Managing the continuous improvement of the quality provided will be a great challenge³⁷.

The results of this study show that, although there has been significant progress in expanding the availability of hospital beds and reducing waiting times, especially after the inauguration of the SCCS, the growing pressure for care in the MRJ outpatient regulation system continues to be a challenge. The waiting list, despite having been reduced in some categories, has grown again in others, highlighting the need for planning and ongoing management strategies to meet the needs of the population.

Comparative studies^38-44 suggest that the expansion of specialized services and the creation of units focused on complex exams and procedures are promising solutions to reduce bottlenecks, but these interventions need to be complemented by policies that consider the exponential increase in demand for consultations and surgeries.

Our study reinforces the need to maintain the centrality of PHC in the city of Rio de Janeiro, whose attributes of first contact and coordination of care are crucial for the organization of the healthcare network. When mature, the resolution rate tends to be greater, and medical referrals are better forwarded, avoiding redundant requests and wasted resources. In the future, it will be essential for the outpatient regulation system to invest not only in greater availability, but preferably to be integrated within the PHC electronic medical record. The coordination between care points, the publication of care protocols, triage mechanisms, and prioritization are important requirements to ensure that the progress achieved is sustainable over the long term, as well as to ensure the financial sustainability of specialized health services.

References

• ¹ Brasil. Ministério da Saúde (MS). Portaria nº 648, de 28 de março de 2006. Dispõe sobre a revisão de diretrizes e normas para a organização da Atenção Básica para o Programa da Saúde da Família (PSF) e o Programa de Agentes Comunitários de Saúde (PACS). Diário Oficial da União 2006; 28 mar.
• ² Brasil. Ministério da Saúde (MS). Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2017; 21 set.
• ³ Brasil. Ministério da Saúde (MS). Portaria nº 2.979, de 12 de novembro de 2019. Institui o Programa Previne Brasil. Diário Oficial da União 2019; 13 nov.
• ⁴ Brasil. Ministério da Saúde (MS). Portaria nº 930, de 15 de maio de 2019. Institui o Programa "Saúde na Hora", que dispõe sobre o horário estendido de funcionamento das Unidades de Saúde da Família. Diário Oficial da União 2019; 17 maio.
• ⁵ Brasil. Ministério da Saúde (MS). Portaria nº 2.488, de 21 de outubro de 2011. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes e normas para a organização da Atenção Básica, para a Estratégia Saúde da Família (ESF) e o Programa de Agentes Comunitários de Saúde (PACS). Diário Oficial da União 2011; 22 out.
• ⁶ Ribeiro SP, Cavalcanti MLT. Atenção Primária e Coordenação do Cuidado: dispositivo para ampliação do acesso e a melhoria da qualidade. Cien Saude Colet 2020; 25(5):1799-1808.
• ⁷ Freire MP, Louvison M, Feuerwerker LCM, Chioro A, Bertussi D. Regulação do cuidado em redes de atenção: importância de novos arranjos tecnológicos. Saude Soc 2019; 29(3):e190682.
• ⁸ Martinelli NL, Scatena JHG, Castro ML, Soares NRF, Charbel SC, Souza NFS, Medeiros ARS, Souza DPO. Análise da estruturação da Rede de Atenção à Saúde no estado de Mato Grosso, Brasil, no contexto da Regionalização. Cien Saude Colet 2023; 28(2):585-598.
• ⁹ Melo EA, Gomes GG, Carvalho JO, Pereira PHB, Guarabira KPL. A regulação do acesso à atenção especializada e a Atenção Primária à Saúde nas políticas nacionais do SUS. Physis 2021; 31(1):e310109.
• ¹⁰ Chaves LA, Andrade EIG, Santos AF. Configuração das Redes de Atenção à Saúde no SUS: análise a partir de componentes da atenção básica e hospitalar. Cien Saude Colet 2024; 29(6):e18392022.
• ¹¹ Costa KB, Silva LM, Ogata MN. A judicialização da saúde e o Sistema Único de Saúde: revisão integrativa. Cad Ibero Amer Dir Sanit. 2020; 9(2):149-163.
• ¹² Brasil. Emenda Constitucional nº 95, de 15 de dezembro de 2016. Altera o Ato das Disposições Constitucionais Transitórias, para instituir o Novo Regime Fiscal, e dá outras providências. Diário Oficial da União; 2016.
• ¹³ Brasil. Ministério da Saúde (MS). Portaria nº 1.604, de 18 de outubro de 2023. Institui a Política Nacional de Atenção Especializada em Saúde (PNAES), no âmbito do Sistema Único de Saúde. Diário Oficial da União 2023; 18 out.
• ¹⁴ World Health Organization (WHO). Primary health care on the road to universal health coverage: 2019 monitoring report. Geneva: WHO; 2020.
• ¹⁵ Silva BZ. Pela DesCrivelização da saúde: reflexões sobre a crise da saúde no Rio de Janeiro-RJ e seu agravo na pandemia. Physis 2020; 30(3):e300308.
• ¹⁶ Marques J, Galdo R. Relatório sobre os hospitais federais do Rio expõe crise e falta de gestão [Internet]. O Globo; 2023 [acessado 2024 nov 20]. Disponível em: https://oglobo.globo.com/rio/noticia/2023/04/relatorio-sobre-os-hospitais-federais-do-rio-expoe-crise-e-falta-de-gestao.ghtml
  » https://oglobo.globo.com/rio/noticia/2023/04/relatorio-sobre-os-hospitais-federais-do-rio-expoe-crise-e-falta-de-gestao.ghtml
• ¹⁷ Lucchese B, Schiavinato G. Faltam 10 mil profissionais em hospitais federais do RJ e há leitos ocupados por 'pacientes fantasmas', diz relatório [Internet]. g1; 2023 [acessado 2024 nov 20]. Disponível em: https://g1.globo.com/rj/rio-de-janeiro/noticia/2023/04/26/faltam-10-mil-profissionais-em-hospitais-federais-do-rj-e-ha-leitos-ocupados-por-pacientes-fantasmas-diz-relatorio.ghtml
  » https://g1.globo.com/rj/rio-de-janeiro/noticia/2023/04/26/faltam-10-mil-profissionais-em-hospitais-federais-do-rj-e-ha-leitos-ocupados-por-pacientes-fantasmas-diz-relatorio.ghtml
• ¹⁸ Prado A, Haidar D. Greve dos hospitais federais do RJ: funcionários relatam falta de insumos e exames adiados [Internet]. g1; 2024 [acessado 2024 nov 20]. Disponível em: https://g1.globo.com/rj/rio-de-janeiro/noticia/2024/05/30/greve-dos-hospitais-federais-do-rj-funcionarios-relatam-falta-de-insumos-e-exames-adiados.ghtml
  » https://g1.globo.com/rj/rio-de-janeiro/noticia/2024/05/30/greve-dos-hospitais-federais-do-rj-funcionarios-relatam-falta-de-insumos-e-exames-adiados.ghtml
• ¹⁹ Campos CEA, Cohn A, Brandão AL. Trajetória histórica da organização sanitária da Cidade do Rio de Janeiro: 1916-2015. Cem anos de inovações e conquistas. Cien Saude Colet 2016; 21(5):1351-1364.
• ²⁰ Secretaria Municipal de Saúde do município do Rio de Janeiro. Subsecretaria Geral. Portal da Transparência SISREG [Internet]. 2024 [acessado 2024 out 15]. Disponível em: https://web2.smsrio.org/minhasaudeRio/#/.
  » https://web2.smsrio.org/minhasaudeRio
• ²¹ Rio de Janeiro. Prefeitura do Rio de Janeiro. Diário Oficial do Município do Rio de Janeiro. Coordenação Geral do Complexo regulador. Inventário SISREG - Regulação Ambulatorial - ano 2023 (até agosto). Ano XXXVII, n.º 140. Rio de Janeiro; 2023. p. 264-267.
• ²² Rio de Janeiro. Prefeitura do Rio de Janeiro (PCRJ). Plano Estratégico Rio Futuro: Plano estratégico 2021-2024. Rio de Janeiro: PCRJ; 2021.
• ²³ Mendes EV. As redes de atenção à saúde. Brasília: OPAS; 2011.
• ²⁴ Instituto Brasileiro de Geografia e Estatística (IBGE). Censo Demográfico 2022: resultados [Internet]. Rio de Janeiro: IBGE; 2023 [acessado 2024 out 22]. Disponível em: https://www.ibge.gov.br/estatisticas/sociais/populacao/9103-censo-demografico-2022.html.
• ²⁵ Instituto Pereira Passos. Prefeitura do Rio. Rio em Síntese 2024 [Internet]. [acessado 2024 ago 14]. Disponível em: https://www.data.rio/pages/rio-em-sntese
  » https://www.data.rio/pages/rio-em-sntese
• ²⁶ Kingdon JW. Agendas, alternatives, and public policies. 2ª ed. New York: Longman; 2003.
• ²⁷ Rio de Janeiro. Prefeitura do Rio de Janeiro. Minha Saúde Rio: dados transparência [Internet]. [acessado 2024 out 22]. Disponível em: https://web2.smsrio.org/minhasaudeRio/#/dados-transparencia
  » https://web2.smsrio.org/minhasaudeRio/#/dados-transparencia
• ²⁸ Rio de Janeiro. Prefeitura do Rio de Janeiro. Super Centro Carioca de Saúde [Internet]. [acessado 2024 out 22] Disponível em: https://supercentro.prefeitura.rio/.
  » https://supercentro.prefeitura.rio
• ²⁹ Rio de Janeiro. Subsecretaria de Promoção, Atenção Primária e Vigilância em Saúde. Contrato de Gestão nº 08 de 2022. Diário Oficial 2022; XXXVI(31):60.
• ³⁰ Rio de Janeiro. Secretaria Municipal de Saúde do Rio de Janeiro. Subsecretaria de Promoção, Atenção Primária e Vigilância em Saúde. Instrutivos dos termos de colaboração [Internet]. 2022 [acessado 2024 out 23]. Disponível em: https://saude.prefeitura.rio/ctgos/instrutivos-dos-termos-de-colaboracao/subpav/.
  » https://saude.prefeitura.rio/ctgos/instrutivos-dos-termos-de-colaboracao/subpav
• ³¹ Brasil. Lei nº 13.019, de 31 de julho de 2014. Estabelece o regime jurídico das parcerias entre a administração pública e as organizações da sociedade civil. Diário Oficial da União 2014; 31 jul.
• ³² Brasil. Lei nº 9.637, de 15 de maio de 1998. Dispõe sobre a qualificação de entidades como organizações sociais e dá outras providências. Diário Oficial da União 1998; 18 maio.
• ³³ Costa NR, Silva LMV, Ramos CL, Carvalho AI, Lima LD, Andrade CLT. A implantação em larga escala da Estratégia de Saúde da Família na cidade do Rio de Janeiro, Brasil: evidências e desafios. Cien Saude Colet 2021; 26(6):2075-2082.
• ³⁴ Liu X, Hotchkiss DR, Bose S. The effectiveness of contracting-out primary health care services in developing countries: a review of the evidence. Health Policy Plan 2008; 23(1):1-13.
• ³⁵ Rio de Janeiro. Subsecretaria de Atenção Primária e Vigilância em Saúde. Secretaria Municipal de Saúde do Rio de Janeiro. Distribuição de equipes [Internet]. [acessado 2024 out 23]. Disponível em: https://subpav.org/aps/cnes
  » https://subpav.org/aps/cnes
• ³⁶ Pereira LH, Côrtes MI. Gestão da qualidade e acesso a cuidados de saúde em países desenvolvidos: o caso da Holanda. J Health Manag 2020; 34(2):145-160.
• ³⁷ Farias MG, Oliveira PM. Gestão de listas de espera na saúde: desafios e boas práticas. Rev Bras Saude 2019; 38(4):212-225.
• ³⁸ Siciliani L, Borowitz M, Moran V. Waiting Time Policies in the Health Sector: What Works? OECD Publishing; 2013.
• ³⁹ Kreindler SA. The Politics of Patient Wait Times: Public Policy and Health Care Waiting Lists. Toronto: University of Toronto Press; 2016.
• ⁴⁰ Pendrith C, Nayyar D, Chu C, O'Brien T, Lyons OD, Agarwal P, Martin D, Bhatia RS, Mukerji G. Outpatient visit trends for internal medicine ambulatory care sensitive conditions after the COVID-19 pandemic: a time-series analysis. BMC Health Serv Res 2022; 22(1):198.
• ⁴¹ Cazabon S,. Managing High Demand in Ophthalmology Services: Global Approaches to Reducing Backlogs. Eye 2019; 33(3):383-390.
• ⁴² MacCormick AD. Reducing Diagnostic Waiting Times Through Process Optimization. J Healthc Manag 2020; 65(3):173-185.
• ⁴³ Sobolev B. Scheduling Elective Surgery in a Publicly Funded Health System. Health Syst 2019; 8(1):34-45.
• ⁴⁴ National Health Service (NHS). Elective Care Recovery: A Strategic Plan for the NHS. NHS; 2021.

• Chief editors:
  Maria Cecília de Souza Minayo, Romeu Gomes, Antônio Augusto Moura da Silva

Publication Dates

• Publication in this collection
  11 Aug 2025
• Date of issue
  July 2025

History

• Received
  24 Oct 2024
• Accepted
  29 Jan 2025
• Published
  31 Jan 2025