Physical therapists in primary health care: analysis of the national register of health service providers

Larissa Riani Costa Tavares José Luiz Riani Costa Jorge Oishi Patricia Driusso About the authors

RESUMO

O objetivo deste estudo é descrever a distribuição de fisioterapeutas na atenção primária à saúde (APS) no Brasil, e analisar a relação do número de habitantes por fisioterapeuta na APS, de acordo com o Cadastro Nacional de Estabelecimentos de Saúde (CNES). Foi realizado um estudo transversal descritivo, a partir de dados do CNES e do Censo Demográfico de 2010. A partir disso, foram identificados 6.917 cadastros de fisioterapeutas na APS, com predomínio na região Sudeste (49%), a qual, em junto com a Sul, foram as regiões com melhores relações de habitantes por fisioterapeuta na APS (aproximadamente 23.000/1), enquanto na região Norte foram observados 32.000 habitantes por profissional. Dos municípios do Brasil, 47% possuem fisioterapeuta na APS, e a análise por porte populacional indicou maior percentual de fisioterapeutas na APS em municípios de pequeno porte (39%) e médio porte (34%). A melhor relação entre habitantes por fisioterapeuta ocorreu nos municípios de pequeno porte do Sudeste (6.948/1), e a pior em metrópoles do Centro-Oeste (371.672/1). Observou-se, ainda, que municípios de pequeno porte apresentam fisioterapeutas apenas na APS, ao passo que, por outro lado, a maioria dos municípios de demais portes possui fisioterapeutas em todos os níveis de atenção.

Descritores
Fisioterapia; Atenção Primária à Saúde; Saúde Pública

RESUMEN

El objetivo de este estudio es describir la distribución de fisioterapeutas en la atención primaria de salud (APS) en Brasil y analizar la relación del número de habitantes por fisioterapeuta en la APS, según el Registro Nacional de Establecimientos de Salud (Renaes) - Cadastro Nacional de Establecimientos de Salud (CNES) en Brasil. Se realizó un estudio transversal descriptivo desde datos del Renaes y del Censo Demográfico de 2010. Desde eso, se identificaron 6.917 registros de fisioterapeutas en la APS, con predominio en la región Sudeste de Brasil (49%), que, junto con la Sur, fueron las regiones con las mejores relaciones de habitantes por fisioterapeuta en la APS (aproximadamente 23.000/1), mientras en la región Norte se observaron 32.000 habitantes por profesional. De los municipios de Brasil, el 47% presentan fisioterapeuta en la APS y el análisis por porte poblacional indicó mayor porcentaje de fisioterapeutas en la APS en municipios de pequeño porte (39%) y medio porte (34%). La mejor relación entre habitantes por fisioterapeuta ocurrió en municipios de pequeño porte de la región Sudeste (6.948/1), y la peor en metrópolis de la Centro-Oeste (371.672/1). Se observó, además, que municipios de pequeño porte presentan fisioterapeutas solo en la APS, mientras que, por otro lado, la mayoría de los municipios de otros portes presenta fisioterapeutas en todos los niveles de atención.

Palabras clave
Fisioterapia; Atención Primaria de Salud; Salud Pública

ABSTRACT

This study aimed to describe the distribution of physical therapists in the Brazilian primary health care (PHC) and the ratio of inhabitants per physical therapist in PHC, according to the National Register of Health Service Providers (CNES - Cadastro Nacional de Estabelecimentos de Saúde). A descriptive cross-sectional study was conducted from CNES and Census/2010 data. In total, 6,917 physical therapists were registered in PHC, and most were located in the Southeast region (49%). Southeast and South were the regions with the best ratios of inhabitants per physical therapist in PHC (about 23,000/1). The North presented a ratio of 32,000 inhabitants/professional. 47% of the Brazilian cities have a physical therapist in PHC. Our analysis by population size indicated a higher percentage of physical therapists in PHC in small (39%) and midsize cities (34%). The best inhabitants/physical therapist ratio occurred in small cities of the Southeast (6,948/1) and the worst, in metropolises of the Midwest (371,672/1). Small cities have physical therapists only in PHC; on the other hand, most cities of larger sizes have physical therapists in all health care levels.

Keywords
Physical Therapy Specialty; Primary Health Care; Public Health

INTRODUCTION

Primary Health Care (PHC) is characterized as the first health care level, involving a set of actions aimed at enrolled areas11. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Atenção Básica. Brasília, DF: Ministério da Saúde; 2006.. In 1994, the Family Health Program (PSF - Programa de Saúde da Família) was established as a PHC reorientation strategy22. Brasil. Conselho Nacional de Secretários de Saúde. Atenção Primária e Promoção da Saúde. Brasília, DF: Conass; 2011. 197 p.. The experience in its first decade encouraged the inclusion of PHC in the set of priorities of the Pact for Health in 200633. Brasil. Ministério da Saúde. Secretaria Executiva. Departamento de Apoio à Descentralização. Coordenação-Geral de Apoio à Gestão Descentralizada. Diretrizes operacionais dos Pactos pela Vida, em defesa do SUS e de gestão. Brasília: Ministério da Saúde; 2006. 76 p.; in the same year, the National Primary Care Policy (PNAB - Política Nacional da Atenção Básica)11. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Atenção Básica. Brasília, DF: Ministério da Saúde; 2006. was published, promoting the revision of the regulations published in this first period. The expansion, however, was involving mainly the professionals of the multidisciplinary team11. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Atenção Básica. Brasília, DF: Ministério da Saúde; 2006. (doctor, nurse, nursing assistant or technician, and community health agents) and of the oral health team11. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política Nacional de Atenção Básica. Brasília, DF: Ministério da Saúde; 2006. (dental surgeon, dental hygiene technician, and dental office assistant). Teams with other types of professionals were limited, existing according to local dynamics, without a national policy promoting the insertion of other categories into these teams. Seeking to expand the range and scope of PHC, the Family Health Support Center (NASF - Núcleo de Apoio à Saúde da Família) was created in 2008 by the Ministerial Decree no. 154/200844. Brasil. Ministério da Saúde. Portaria nº 154, de 24 de janeiro de 2008. Cria os Núcleos de Apoio à Saúde da Família. Diário Oficial da União. Brasília, DF; 4 mar. 2008. Seção 1, n. 43, p. 38-40., formally inserting other professional categories into the strategy by matrix support (collaborative care).

This insertion into PHC brings challenges for several professions, but mainly physical therapy, which had its origin worldwide at the end of the 19th century, focused on the treatment of people with physical and functional changes in late phases of health harms or diseases55. Rebelatto JR, Botomé SP. Fisioterapia no Brasil: fundamentos para uma ação preventiva e perspectivas profissionais. São Paulo: Manole; 1999.. In Brazil, the profession was developed in the first half of the 20th century66. Freitas MS. A atenção básica como campo de atuação da fisioterapia no Brasil: as diretrizes curriculares resignificando a prática profissional [tese]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2006., in a context with high rates of occupational accidents55. Rebelatto JR, Botomé SP. Fisioterapia no Brasil: fundamentos para uma ação preventiva e perspectivas profissionais. São Paulo: Manole; 1999. and the need for care to the several individuals with poliomyelitis sequelae77. Barros FBM. Poliomielite, filantropia e fisioterapia: o nascimento da profissão de fisioterapeuta no Rio de Janeiro dos anos 1950. Ciênc Saúde Coletiva. 2008;13(3):941-54. doi: 10.1590/S1413-81232008000300016
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, emphasizing the rehabilitation work that was being developed worldwide. In 1969, the profession was regulated by the Decree-Law no. 93888. Brasil. Decreto-Lei nº 938, de 13 de outubro de 1968. Provê sobre as profissões de fisioterapeuta e terapeuta ocupacional, e dá outras providências. Diário Oficial da União. 1969., under the influence of a concept in which the “post-disease” was a prerequisite for the intervention of physical therapy66. Freitas MS. A atenção básica como campo de atuação da fisioterapia no Brasil: as diretrizes curriculares resignificando a prática profissional [tese]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2006.. In the following years, until the end of the 20th century, while the country was redirecting the health system towards universality and a strengthened PHC, physical therapy had as main concern the assertion that ensured its space in the Brazilian health scenario, strengthening a specific field of work and remaining until today with the same legal regulations of that time66. Freitas MS. A atenção básica como campo de atuação da fisioterapia no Brasil: as diretrizes curriculares resignificando a prática profissional [tese]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2006..

Despite this trend, some physical therapists started activities in PHC by creating trainee courses with students of the undergraduate course in the cities of Paraíba, Belo Horizonte, Juiz de Fora, and Natal and by directly taking part in the services, gradually approximating the profession to public health actions99. Gallo DLL. A fisioterapia no programa saúde da família: percepções em relação à atuação profissional e formação universitária [dissertação]. Londrina: Universidade Estadual de Londrina; 2005.)-(1212. Trelha CS, Silva DW, Iida LM, Fortes MH, Mendes TS. O fisioterapeuta no Programa de Saúde da Família em Londrina (PR). Espaç Saúde. 2007;8(2):20-5.. From 2000 on, the activities were expanded with the creation of the multidisciplinary residencies in family health. From 2001 on, with the change of the National Curriculum Guidelines for the Course of Physical Therapy (Opinion CNE/CES 1,210/2001) (1313. Brasil. Conselho Nacional de Educação. Câmara de Educação Superior. Parecer no CNE/CES 1.210/2001, de 7 de dezembro de 2001. Institui as Diretrizes Curriculares Nacionais do Curso de Graduação em Fisioterapia. Diário Oficial da União . Brasília, DF; 10 dez. 2001. Seção 1, p. 22., the discussion was broadened, with the proposal of a generalist education to work in the prevention, promotion, protection, and rehabilitation of health, in all health care levels, both in the individual and collective spheres. From its publication, the new curricular guidelines encouraged several meetings. Since 2005, two National Forums of Professional Policies were organized by the Federal Council of Physical Therapy and Occupational Therapy (COFFITO - Conselho Federal de Fisioterapia e Terapia Ocupacional), including education issues in their agenda1414. Rocha VM, Caldas MAJ, Araujo FRO, Caldas AJ, Batiston AP, et al. As diretrizes curriculares e as mudanças na formação de profissionais fisioterapeutas. Documento apresentado no XVI Fórum Nacional de Ensino em Fisioterapia; 2007 jun. 7-9; Canela, RS. Evento promovido pela Associação Brasileira de Ensino de Fisioterapia.; in 2006, more than 20 workshops were carried out to implement the curriculum guidelines1414. Rocha VM, Caldas MAJ, Araujo FRO, Caldas AJ, Batiston AP, et al. As diretrizes curriculares e as mudanças na formação de profissionais fisioterapeutas. Documento apresentado no XVI Fórum Nacional de Ensino em Fisioterapia; 2007 jun. 7-9; Canela, RS. Evento promovido pela Associação Brasileira de Ensino de Fisioterapia.; in 2007 and 2008, the National Forum of Education in Physical Therapy of the Brazilian Association of Education in Physical Therapy (ABENFISIO - Associação Brasileira de Ensino em Fisioterapia) included the topic “Physical Therapy in Primary Health Care” as its main discussion. Between 2007 and 2016, five versions of the National Congress of Physical Therapy in Public Health (CONAFISC - Congresso Nacional de Fisioterapia em Saúde Coletiva) were carried out, and, in 2016, the XXVI National Forum of Education in Physical Therapy presented the topic “Comprehensive health care and education of physical therapists: reformulation of the National Curriculum Guidelines as a strategy for the (re)qualification of health processes,” after the conduction of state workshops promoted by ABENFISIO to analyze and reformulate the national curricular guidelines of the undergraduate courses in physical therapy.

The approximation of the performance and education of physical therapists to the national health policies is promoting an increase in the number of physical therapists in PHC. According to information available in the website of the Department of Informatics of the Brazilian Unified Health System (DATASUS - Departamento de Informática do Sistema Único de Saúde) (1515. Brasil. Ministério da Saúde. Informações de saúde (TABNET): rede assistencial. [homepage na Internet]. Brasília, DF: Ministério da Saúde; 2008 [citado em 2018 fev. 2]. Disponível em: <Disponível em: https://goo.gl/XrHXpJ >.
https://goo.gl/XrHXpJ...
, in 2005, there were 3,370 registers of physical therapists in PHC in the CNES. After six years, the number of registers almost tripled, reaching the total of 8,564 in 2011. However, it is important to note that the expansion of physical therapy in PHC is relatively recent, and that its role in this health care level is still under construction.

Thus, one must research the existing experiences to describe how the insertion of physical therapy in PHC is taking place. The existing studies, however, mostly analyze specific actions of a city or region, not presenting the insertion of this professional at the national level. This study aims to describe the distribution of physical therapists in the Brazilian PHC and the ratio of inhabitants per physical therapist in PHC in 2010, to show the situation of this professional in PHC right after the creation of the NASF, characterized as the main policy of expansion of the professional categories involved in the family health strategy.

METHODS

A descriptive cross-sectional study was conducted from CNES and Census/2010 data. CNES is the main nationwide information system on health facilities in Brazil. It was created by the Brazilian Ministry of Health in 20001616. Brasil. Ministério da Saúde. Secretaria de Assistência à Saúde. Portaria nº 511, de 29 de dezembro de 2000 [Internet]. Diário Oficial da República Federativa do Brasil. Brasília, DF; 4 jan. 2001 [citado 2018 fev 2]. Disponível em: <Disponível em: https://goo.gl/64oQaS >.
https://goo.gl/64oQaS...
, to help managers with subsidies for implementing health policies and contributing in the areas of planning, regulation, evaluation, control, audit, and teaching/research. It includes information regarding Physical Area, Human Resources, Equipment, and Outpatient and Hospital Services, serving as a basis for other information systems of the Brazilian Ministry of Health. The registration of public and private health facilities and of active professionals is mandatory, as determined by Ordinance no. 511/20001717. Brasil. Ministério da Saúde. Secretaria de Assistência à Saúde. Portaria nº 511, de 29 de dezembro de 2000 [Internet]. Diário Oficial da República Federativa do Brasil . Brasília, DF; 4 jan. 2001 [citado 2018 fev 2]. Disponível em: <Disponível em: https://goo.gl/64oQaS >.
https://goo.gl/64oQaS...
.

The study was approved by the Human Research Ethics Committee of the Federal University of São Carlos, under Protocol no. 386/2009.

The data from the registers of physical therapists were collected in the CNES database in Brasília, Federal District, in March 2010, making it possible to know the distribution of these professionals right after the implementation of the main public policy of inclusion of physical therapists in PHC. The search included information from the 5,565 cities of Brazil, involving facilities with at least one physical therapist. It is important to note that professionals who work in more than one facility generate one register for each workplace. Thus, more than one register may exist for the same professional. The analyses of this study considered the total number of registers.

The following information were obtained for each facility: type of facility; number of physical therapists; region, federative unit (FU), and city.

The following centers were considered as PHC facilities: health center, primary health care unit, family health support center, fluvial health care unit. The remaining facilities were considered as “Other health care levels,” and included: specialized clinic/specialty outpatient clinic; polyclinic; doctor’s office; cooperative; psychosocial care center and support, diagnosis, and therapy unit (SADT - Serviço de Apoio Diagnóstico Terapêutico); general hospital; specialized hospital; day hospital; normal childbirth center; emergency room; specialized emergency room; pre-hospital level mobile unit; mixed health unit (which provides both PHC and specialized service (hospitalization and emergency); center for regulation of health services; health secretariat; health surveillance unit; land mobile unit; indigenous health care center; and hemotherapy and/or hematology health care center.

The number of inhabitants of the cities was collected from the results of the Census/20101818. Instituto Brasileiro de Geografia e Estatística. Dados do Censo Demográfico de 2010 [homepage na Internet]. Rio de Janeiro: IBGE; 2011 [citado em 2018 fev 2]. Disponível em: <Disponível em: https://goo.gl/pmvQNE >.
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, using the following classification for the population size1919. Centro de Estatísticas, Estudos e Pesquisas. Estudo sobre a presença do Estado nos Municípios de pequeno porte até 20.000 habitantes, de médio porte de 20.000 a 100.000 habitantes e grande porte de 100.000 ou mais classificados por regiões do Estado [Internet]. Rio de Janeiro: Ceperj; em andamento [citado em 2018 fev 2]. Disponível em: <Disponível em: https://goo.gl/JA9V9v >.
https://goo.gl/JA9V9v...
: small size: population up to 20,000 inhabitants; midsize: between 20,001 and 100,000 inhabitants; large size: between 100,001 and 500,000 inhabitants; metropolis: over 500,000 inhabitants. Data were analyzed by descriptive statistical techniques. The ratio of physical therapists per 1,000 inhabitants was calculated from the total of registers of physical therapists × 1000/number of inhabitants

RESULTS

Distribution of registers of physical therapists in PHC

In total, 6,917 physical therapists were registered in PHC. Southeast and South accounted for 49% and 16% of the registers, a ratio higher than the population representation of these regions (42% and 14% of the Brazilian population, respectively). North, Midwest, and Northeast accounted for 4%, 6%, and 24% of registers, respectively, with values lower than their population distribution (8%, 8%, and 28%).

This distribution affects the ratio of inhabitants per physical therapist, as Table 1 shows. South and Southeast presented the best ratios, with about 23,000 inhabitants/physical therapist in PHC. The North region presented the worst ratio (58,761 inhabitants/physical therapist).

Table 1
Distribution of registers of physical therapists in primary health care (PHC) and ratio of inhabitants per professional according to regions and federative units, 2010

The distribution according to the population size of the cities indicated a higher percentage in small cities (38%), followed by midsize cities (34%), large cities (17%), and metropolises (11%). The North and Northeast presented an opposite trend, with greater concentration in midsize cities (48% and 45%, respectively).

The low number of registers in metropolises results in a ratio six times greater than the one verified in small cities: 76,000 inhabitants/physical therapist in metropolises in contraposition to 12,000 inhabitants/physical therapist in small cities (Table 2). Small cities in the Southeast presented the lowest ratio (6,948 inhabitants/physical therapist).

Table 2
Ratio of inhabitants per physical therapist in PHC between the regions of the country, according to the population size of the cities in 2010

Number and percentage of cities with physical therapist in PHC

In total, 47% of the cities have at least one physical therapist registered in PHC, and the coverage in the Southeast (62%) was twice as that of the North (31%), as Table 3 shows. Regarding population size, the highest proportions were observed in the metropolises.

Table 3
Number and proportion of cities with physical therapists in primary health care (PHC), 2010

Table 4 classifies the cities according to the health care levels that offer physical therapy. Most cities had registers in both PHC and other health care levels (38%), followed by cities with registers only in other levels, thus without physical therapy in PHC (34%). The percentage of cities with registers only in PHC represented 28% of the cities with physical therapists.

Table 4
Total of cities with physical therapists according to the health care levels that have this professional in 2010

Concerning population size, most small cities only have physical therapists in PHC (40%), while larger cities also have this professional in other health care levels (Table 4). Among the small cities that have a physical therapist in PHC (1,818), 60% had this professional only in this health care level.

DISCUSSION

The analysis of the distribution of physical therapists in PHC identified a concentration of professionals in the Southeast and South above the population representation of these regions, while in the Northeast, North, and Midwest had concentrations below their population representation. Southeast and South also presented the best ratios of physical therapists per inhabitant and the highest proportions of cities with physical therapists in PHC compared to the total number of cities.

The data resemble the results observed in studies that analyzed the distribution of registers of physical therapists in the CNES regardless of the health care level21,22. Several factors were associated with the concentration of professionals in the regions with greater economic development, including socioeconomic and historical factors that affect population distribution, the formation of the health care network, and the allocation of higher education institutions, promoting a higher number of inhabitants, health facilities, and professionals trained in the Southeast and South2222. Tavares LRC, Costa JLR, Oishi J, Driusso P. Distribuição territorial de fisioterapeutas no Brasil: análise do Cadastro Nacional de Estabelecimentos de Saúde: CNES/2010. Conscientiae Saúde. 2016;15(1):61-61. doi: 10.5585/ConsSaude.v15n1.6152
https://doi.org/10.5585/ConsSaude.v15n1....
.

The authors discuss the correlation between the offer of health services, their participation in the national Gross Domestic Product (GDP), and the Human Development Index, noting that the economic influence in the creation of the health system promotes inequality in the distribution of services and has its origin in the historical process of health care in Brazil2222. Tavares LRC, Costa JLR, Oishi J, Driusso P. Distribuição territorial de fisioterapeutas no Brasil: análise do Cadastro Nacional de Estabelecimentos de Saúde: CNES/2010. Conscientiae Saúde. 2016;15(1):61-61. doi: 10.5585/ConsSaude.v15n1.6152
https://doi.org/10.5585/ConsSaude.v15n1....
.

In contrast, DATASUS data from the same period2020. Brasil. Ministério da Saúde. Cadastro Nacional dos Estabelecimentos de Saúde do Brasil. Informações de saúde [homepage na Internet]. Brasília, DF: Ministério da Saúde ; 2018 [citado em 2018 fev 5]. Disponível em: <Disponível em: http://bit.ly/2FLmlL8 >.
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show that the professions of Nurse, Doctor, and Dentist of the Family Health Strategy are better distributed across regions, with prevalence of registers in the Northeast (40%), followed by 30% in the Southeast, 14% in the South, 8% in the North, and 7% in the Midwest.

The greater dispersion of the professions linked to PHC can also be verified in the database of the portal of the department of primary health care2323. Brasil. Ministério da Saúde. Departamento de Atenção Básica. Histórico de cobertura da Saúde da Família [homepage na Internet]. Brasília, DF: Portal da Saúde; 2017 [citado em 2018 fev 5]. Disponível em: <Disponível em: https://goo.gl/tPZQXw >.
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for the year 2010, with the 30,782 family Health teams (eSF - Equipes de Saúde da Família) and 1,250 NASF teams distributed as follows: 41% and 47% in the Northeast, 31% and 30% in the Southeast, 14% and 9% in the South, 7% and 7% in the North, and 8% and 7% in the Midwest, respectively. The updated data of February 2017 indicate the following distribution of the 39,859 eSF and the 4,010 NASF teams: 37% and 43% in the Northeast, 33% and 28% in the Southeast, 15% and 14% in the South, 7% and 7% in the North, and 8% and 7% in the Midwest, respectively2020. Brasil. Ministério da Saúde. Cadastro Nacional dos Estabelecimentos de Saúde do Brasil. Informações de saúde [homepage na Internet]. Brasília, DF: Ministério da Saúde ; 2018 [citado em 2018 fev 5]. Disponível em: <Disponível em: http://bit.ly/2FLmlL8 >.
http://bit.ly/2FLmlL8...
.

Therefore, one can verify that the distribution of physical therapists in the country showed regional differences both in specialized health care levels2121. Costa LR, Oishi J, Driusso P. Distribuição de fisioterapeutas entre estabelecimentos públicos e privados nos diferentes níveis de complexidade de atenção à saúde. Rev Bras Fisioter. 2012;16(5):422-30. doi: 10.1590/S1413-35552012005000051
https://doi.org/10.1590/S1413-3555201200...
), (2222. Tavares LRC, Costa JLR, Oishi J, Driusso P. Distribuição territorial de fisioterapeutas no Brasil: análise do Cadastro Nacional de Estabelecimentos de Saúde: CNES/2010. Conscientiae Saúde. 2016;15(1):61-61. doi: 10.5585/ConsSaude.v15n1.6152
https://doi.org/10.5585/ConsSaude.v15n1....
and in PHC, diverging from other professions that present greater dispersion in PHC. Recent data must be studied to identify whether there was greater equity between the Brazilian regions after a longer implementation period of the NASF.

Our data also show that, regarding population size, most registers of physical therapists in PHC occurred in small cities, followed by midsize cities, large cities, and metropolises. This distribution differs from that of the study2222. Tavares LRC, Costa JLR, Oishi J, Driusso P. Distribuição territorial de fisioterapeutas no Brasil: análise do Cadastro Nacional de Estabelecimentos de Saúde: CNES/2010. Conscientiae Saúde. 2016;15(1):61-61. doi: 10.5585/ConsSaude.v15n1.6152
https://doi.org/10.5585/ConsSaude.v15n1....
that identified all physical therapists with registers in the CNES, in which 36% of professionals were working in metropolises and 28% in large cities, totaling 64%. Physical therapists of midsize cities represented 24% of the total, and those of small cities, only 12% of the professionals.

This distribution is probably associated with the hierarchical and regionalized formation of the health system. Considering the large number of small or midsize cities (95% of the total cities in Brazil), most Brazilian cities present insufficient range to accommodate all health care levels in their territory, presenting only PHC facilities, with the offer of specialized levels distributed in micro and macro health regions2424. Noronha JC, Lima LD, Machado CV. O Sistema Único de Sáude - SUS. In: Giovanella L, Escorel S, Lobato LVC, Noronha JC, Carvalho AI, organizadores. Políticas e sistema de saúde no Brasil. Rio de Janeiro: Editora Fiocruz; 2008. p. 365-394..

In this context, PHC facilities are likely the only alternative for the insertion of these professionals in small cities and, as the population increases, facilities of other health care levels already exist, and thus physical therapy starts to be mainly concentrated in more specialized levels.

The number of patients with functional changes who need rehabilitation has been increasing, mainly because of the high rates of traffic accidents and violence, the process of population aging, and the increase of chronic degenerative diseases and work-related diseases. In small and midsize cities with absence of specialized care and with difficulties of transportation to centers located outside the city, the pressure for therapeutic care falls on the PHC professional, generating the risk of the propagation of the health care adopted in outpatient clinics and hospitals.

In most large cities and metropolises, physical therapists are registered in all health care levels. Rodrigues2525. Rodrigues RM. A fisioterapia no contexto da política de saúde no Brasil: aproximações e desafios. Perspectivas Online. 2008;2(8):104-9. points out, however, that the difficulty of transportation to specialized centers, both because of physical and economic limitations, is an obstacle to access, generating a repressed demand for physical therapy. The author also mentions the existence of insufficient vacancies with long waiting lists. Before this repressed demand and the limited number of physical therapists working in PHC in large cities and metropolises (compared to the total number of inhabitants), it is possible that the propagation of outpatient and hospital care is also observed in part of PHC professionals from large urban centers.

Thus, according to the distribution observed, although the insertion of physical therapists in PHC helps actions of promotion, prevention, and public health of this health care level, it still faces challenges related to outpatient and therapy demand. This risk increases when considering the history of training and performance of physical therapy, with focus on specialized care. Belettini et al. (2626. Belettini NP, Rodrigues F, Cruz TS, Ferreira KC, Tuon L, Coelho BLP. Fisioterapeutas integrantes do Núcleo de Apoio à Saúde da Família do Estado de Santa Catarina: competências e desafios. Fisioter Bras. 2013;14(6):433-8. confirm these statements, identifying that, among the physical therapists working in NASFs of Santa Catarina, the community and NASF team did not clearly know the role of this professional in PHC; 65.2% of them worked in therapeutic groups and 43.7% affirmed spending most of their time in individual care. Souza et al. (2727. Souza MC, Bomfim AS, Souza JN, Franco TB. Fisioterapia e Núcleo de Apoio à Saúde da Família: conhecimento, ferramentas e desafios. Mundo Saúde. 2013;37(2):176-84. describe the following situations: demand, by patients and team, of the continuous presence of the physical therapist in domiciliary care; conflicts in the implementation process because of the difficulty in understanding the work process of the NASF; tendency to perceive the NASF as an outpatient clinic; and a limited perspective about the action of the physical therapist (devices/equipment), associating the practice with hard technology. The same challenge has been reported in studies of other professions2828. Sousa D, Oliveira IF, Costa ALF. Entre o especialismo e o apoio: psicólogos no Núcleo de Apoio à Saúde da Família. Psicol USP. 2015;26(3):474-83. doi: 10.1590/0103-656420140059
https://doi.org/10.1590/0103-65642014005...
), (2929. Nakamura CA, Leite SN. A construção do processo de trabalho no Núcleo de Apoio à Saúde da Família: a experiência dos farmacêuticos em um município do sul do Brasil. Ciênc Saúde Coletiva . 2016;21(5):1565-72. doi: 10.1590/1413-81232015215.17412014
https://doi.org/10.1590/1413-81232015215...
.

Nakamura e Leite2929. Nakamura CA, Leite SN. A construção do processo de trabalho no Núcleo de Apoio à Saúde da Família: a experiência dos farmacêuticos em um município do sul do Brasil. Ciênc Saúde Coletiva . 2016;21(5):1565-72. doi: 10.1590/1413-81232015215.17412014
https://doi.org/10.1590/1413-81232015215...
, in a study involving NASF pharmacists in a city of the South, highlight difficulties in the planning process, lack of clear objectives for the NASF team, and deficiencies in the pharmaceutical services of the city, creating challenges for the structuring of the work process. The authors argue that one of the difficulties is the inadequate description of the work process in the first version of the “NASF Guidelines,” published in the Primary Health Care Journal (Caderno da Atenção Básica) no. 273030. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Saúde na escola. Brasília, DF: Ministério da Saúde ; 2009. (Cadernos de Atenção Básica; n. 27). The version published in 2014 (number 393131. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Núcleo de Apoio à Saúde da Família. Brasília, DF: Ministério da Saúde ; 2014. (Cadernos de Atenção Básica ; n. 39)), however, has a clearer, interdisciplinary, and organizing direction of the work processes for NASF teams, and might bring greater safety in the development of this process.

The Ordinance GM no. 154, of January 24, 200844. Brasil. Ministério da Saúde. Portaria nº 154, de 24 de janeiro de 2008. Cria os Núcleos de Apoio à Saúde da Família. Diário Oficial da União. Brasília, DF; 4 mar. 2008. Seção 1, n. 43, p. 38-40., which determined the creation of the NASF in the modalities 1 and 2 and set the criteria for their implementation, included only part of the Brazilian cities, and small cities were those that faced more obstacles. From these difficulties, the Ordinance no. 3,124, of December 28, 20123232. Brasil. Ministério da Saúde. Portaria nº 3.124, de 28 de dezembro de 2012. Redefine os parâmetros de vinculação dos Núcleos de Apoio à Saúde da Família (NASF) Modalidades 1 e 2 às equipes de Saúde da Família e/ou Equipes de Atenção Básica para populações específicas, cria a Modalidade NASF 3, e dá outras providências [Internet]. Diário Oficial da União . Brasília, DF; 3 jan. 2013 [citado em 2018 fev 5]. Disponível em: <Disponível em: https://goo.gl/eJ98Na >.
https://goo.gl/eJ98Na...
redefined the parameters for linking modalities 1 and 2 to the family health teams and/or primary health care teams for specific populations, and created modality 3, to enable the universalization of these teams to all Brazilian cities. This Ordinance was supplemented by Ordinance no. 548, of April 4, 20133333. Brasil. Ministério da Saúde. Portaria nº 548, de 4 de abril de 2013. Define o valor de financiamento do Piso da Atenção Básica Variável para os Núcleos de Apoio à Saúde da Família (NASF) modalidade 1, 2 e 3 [Internet]. Diário Oficial da União . Brasília, DF; 5 abr. 2013 [citado em 2018 fev 5]. Disponível em: <Disponível em: https://goo.gl/15XTPh >.
https://goo.gl/15XTPh...
, which sets the financing value of the Variable Primary Health Care Wage (Piso da Atenção Básica Variável) for the three NASF modalities. Thus, future prospects bring the possibility of expanding the number of covered cities and the number of professionals working in PHC.

The problems addressed by this study, however, take place not only in the Brazilian health care system. International organizations such as the World Confederation for Physical Therapy (WCPT) and associations of physical therapists of the United Kingdom, Canada, Scandinavia, Australia, New Zealand, and Spain have discussed the role of physical therapy in this health care level, drawing attention to its still limited performance in PHC3434. Lourido BP. Entre lo ideal y las realidades: la fisioterapia en la atención primaria domiciliaria [tese]. Balears: Universitat de les Illes Balears; 2007..

Regarding the Spanish health system, Paz3434. Lourido BP. Entre lo ideal y las realidades: la fisioterapia en la atención primaria domiciliaria [tese]. Balears: Universitat de les Illes Balears; 2007. points out that the insertion of this profession started in 1987 by the creation of “rehabilitation units” located in PHC, which emerged to solve problems of accessibility to physical rehabilitation services, under the same professional regulation until then directed to physical therapists of specialized care and with a hospital-oriented training.

Given these factors, the first actions of physical therapists in the Spanish PHC propagated the actions of tertiary health care, which are inadequate to the primary level, thus putting promotion and prevention aside3535. Vaquero AIT. Classificación de actividades del fisioterapeuta de Antención Primária. Fisioterapia (Madr, Ed impr). 1997;19(1):97-114.. In 1990, the law regarding physical therapy in PHC is released3434. Lourido BP. Entre lo ideal y las realidades: la fisioterapia en la atención primaria domiciliaria [tese]. Balears: Universitat de les Illes Balears; 2007.. In 2003, Europe passes through a unification of the professional training curricula, including aspects of community physical therapy3636. Arribas MJD. Fisioterapia comunitaria [proyecto docente]. Madrid: Universidad Complutense de Madrid; 2007. and, in the same year, the WCPT creates the Declaration of Principles of PHC, approved at the 15th General Meeting of WCPT.

With the training and legislative developments, since the beginning of the insertion of physical therapy in Spanish PHC until now, a significant evolution has been identified in health promotion and disease prevention, including physical therapists no longer as a mere element to reduce demands for the specialized services, but as an important part in creating a comprehensive health care process3434. Lourido BP. Entre lo ideal y las realidades: la fisioterapia en la atención primaria domiciliaria [tese]. Balears: Universitat de les Illes Balears; 2007..

Similar developments have been taking place in other countries, accompanied by training and legislative adjustments. Finland is the country in which the figure of the physical therapist is well regulated in PHC, with the integration of this professional to the team work in health centers and with the best ratio of inhabitants per physical therapist in European PHC3636. Arribas MJD. Fisioterapia comunitaria [proyecto docente]. Madrid: Universidad Complutense de Madrid; 2007..

The Brazilian physical therapy, thus, has been expanding its insertion in PHC, and part of the problems it has been facing are common to most countries. With the changes brought by the new curricular guidelines of the undergraduate course in physical therapy and with the increasing inclusion of these professionals in projects to reorient the practices of training and continuing education of health professionals, such as the National Program of Reorientation of the Professional Training in Health (Pró-Saúde - Programa Nacional de Reorientação da Formação Profissional em Saúde), multidisciplinary residencies, specialization courses, Program of Education by Work for Health (PET Saúde - Programa de Educação pelo Trabalho para a Saúde), National Program of Technology for Health (Programa Nacional de Telessaúde), and introductory courses for family health teams, it is possible that, in the near future, the insertion of these professionals in PHC will be a reality in the country22. Brasil. Conselho Nacional de Secretários de Saúde. Atenção Primária e Promoção da Saúde. Brasília, DF: Conass; 2011. 197 p..

This search for training adjustments must be accompanied by legislation and regulations that establish the role of this professional in the teams, especially when considering that the latest resolution on the professional practice of physical therapists dates back to 198766. Freitas MS. A atenção básica como campo de atuação da fisioterapia no Brasil: as diretrizes curriculares resignificando a prática profissional [tese]. Rio de Janeiro: Universidade do Estado do Rio de Janeiro; 2006., before the creation of SUS.

It should also be noted the need to increase the number of physical therapists, considering that more than half of Brazilian cities do not have this professional in PHC. This need is particularly highlighted in the North, Northeast, and Midwest, which have about 70%, 65%, and 60% of their cities without physical therapists in PHC, besides presenting the highest ratios of inhabitants per professional. These figures point out that regions far from the South-Southeast axis still have a limited insertion of physical therapists, especially in smaller cities. The difficulty of inserting professionals in these places is common in health professions, as Campos et al. (3737. Campos FE, Machado MH, Girardi SN. A fixação de profissionais de saúde em regiões de necessidades. Divulg Saúde Debate [Internet]. 2009 maio [citado em 2018 fev 5];(44):13-24. Disponível em: <Disponível em: https://goo.gl/6huxtM >.
https://goo.gl/6huxtM...
and Brasil3838. Brasil. Ministério da Saúde. Secretaria de Gestão do Trabalho e da Educação na Saúde. Relatório síntese - Seminário Nacional sobre Escassez, Provimento e Fixação de Profissionais de Saúde em Áreas Remotas de Maior Vulnerabilidade. Brasília, DF: Ministério da Saúde ; 2012. highlight in the report of the National Seminar on Scarcity, Provision, and Insertion of Health Professionals in Remote and Vulnerable Areas (Seminário Nacional sobre Escassez, Provimento e Fixação de Profissionais de Saúde em Áreas Remotas e de Maior Vulnerabilidade).

Although 79% of large cities have a physical therapist in PHC, their number of professionals must also be increased, because this number is low compared to the total number of inhabitants, resulting in the worst ratios of inhabitants/physical therapist identified.

Finally, the increase in the number of physical therapists must reach, in addition to PHC, more complex health care levels, ensuring specialized support and a ratio of inhabitants/professional that allows greater participation in PHC actions.

CONCLUSION

Southeast and South were the regions with most physical therapists registered in PHC. Small cities were the main locations with the insertion of these professionals, and most registers of physical therapists were identified only in PHC, without the support of specialized care. The worst ratios of inhabitants/physical therapist in PHC were observed in metropolises. Less than half of the Brazilian cities presented a physical therapist in PHC, and the proportion of places that do not have this professional is still high.

Before the low number of professionals in PHC and without the proper support of the specialized levels, the development of interventions that broaden and strengthen the work of physical therapists both in PHC and in specialized services is greatly important to ensure the appropriate development of actions for each health care level. The interventions must include health and professional training policies, as well as rules and regulations concerning the professional practice of physical therapists.

ACKNOWLEDGMENTS

The authors thank the Department of Primary Health Care (Departamento de Atenção Básica) and the coordination of the CNES - Brazilian Ministry of Health.

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  • Department of Physical Therapy, Universidade Federal de São Carlos (UFSCar) - São Carlos, SP, Brazil

  • Finance source: Nothing to declare

  • Approved by the Human Research Ethics Committee of the Universidade Federal de São Carlos, under Protocol no. 386/2009.

Publication Dates

  • Publication in this collection
    Jan-Mar 2018

History

  • Received
    12 May 2016
  • Accepted
    10 Dec 2017
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