Health and territory: Primary Health Care in Pará – 06/29/2023 – Saúde em Público
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The Unified Health System (SUS) was designed with a decentralized, hierarchical and regionally integrated architecture through health care networks. Within this large system, Primary Health Care (PHC) is the main gateway to the SUS and includes services ranging from health promotion and disease prevention to chronic disease control and palliative care. It is present throughout the national territory, and in the state of Pará, it exists and resists in a complex and diverse reality, marked by specific health demands, territorialities and the Amazonian population profile.
The state of Pará is the second largest Brazilian state in terms of territory with 1,247.6 thousand km², being the most populous in the northern region with 8,442,962 inhabitants, according to recent data from the IBGE. The hydrographic basin of Pará reaches 1.2 million km², whose river network integrates the two largest Brazilian hydrographic basins: Amazon and Tocantins-Araguaia. The state has an extensive ethnic and population plurality, in which different peoples and indigenous communities, quilombolas, riverside communities, extractivists, among others, coexist.
Considering this broad, plural and complex territorial dynamic, how is PHC articulated? First of all, it is important to recognize that access to health is not only linked to a question of geographic access, but also to historical, social, economic and environmental determinants. Regions located in the Legal Amazon, as is the case of Pará and 8 other states, concentrate areas historically characterized as care voids, in which the barriers to accessing professionals and health services are significant and are generally aggravated by precarious basic conditions, such as lack of sanitation, water supply, energy, among others.
Between 2010 and 2021, the state of Pará was one of the states in the Legal Amazon that presented worrying percentages in coverage of the Family Health Strategy. According to data collected from IEPS Data, despite the progressive growth in coverage, which went from 42.9 to 60 in the period, the percentage is still low. In 2021, the state was one of those with the lowest coverage, only ahead of Amapá.
| state | Coverage of the Family Health Strategy in 2021 |
|---|---|
| Tocantins | 93.5% |
| Maranhao | 88.2% |
| Acre | 76.1% |
| Mato Grosso | 74.1% |
| Rondônia | 69.3% |
| amazon | 66.1% |
| roraima | 62.8% |
| For | 60% |
| Amapá | 57.8% |
Percentage of ESF coverage in the states of Northern Brazil in 2021. Source: IEPS Data with data from e-Gestor AB
A recent study by the Institute of Studies for Health Policies (IEPS) also pointed out that the state is the fifth in the country with the highest demand for Family Health teams. The Institutional Study n. 8 of the IEPS also points out that 1,543 additional ESF teams would be needed for the state to reach 100% ESF coverage.
The design of the regionalization of health in the state of Pará, which is divided into 13 health regions, according to the State Secretariat of the State of Pará (SESPA), enabled the decentralization of services and the reduction of geographic barriers. The National Primary Care Policy (PNAB) resulted in significant advances with the creation of specific health teams and equipment for care in rural, riverside or remote locations, such as the Riverside Health and River Health teams for the Legal Amazon and Pantanal. However, even with the advances in SUS functional organization strategies to correct inequalities and the fragmentation of health services, there is still a long way to go to guarantee equity in access to health in Pará.
The way in which the PHC should be organized and act in the face of the singularities that exist in the territories, especially in rural or remote areas, are still highlighted as major challenges for universal health. In the Amazon, despite its heterogeneity, gaps still prevail in policies and studies in the health area dedicated to access in remote regions.
Facing the problem demands the articulation and promotion of different national, municipal and state sectors. In order to build efficient and resolute policies and strategies to improve health in the Legal Amazon, it is necessary to integrate different points of view and actors involved in the SUS, namely health professionals, the population, managers, civil society, the teaching and research institutions and professional associations. Only in this way will it be possible to build interventions with adherence and sustainability capacity, not being limited to actions with verticality in management and with restricted political insertion of states and municipalities.
It is necessary to elaborate exit routes with the perspective that they can induce public policies that meet the constitutional precepts of the SUS. To achieve health for all, it is necessary to develop continuous work to diagnose the reality of the country, or more precisely the different realities of the country, and the elaboration and execution of programs and policies that dialogue with local particularities.
Isabela Ramos is a psychologist, from Pará, consultant at the Institute of Studies for Health Policies (IEPS) and advisor to Doctors Without Borders (MSF) Brazil.
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