Health supply and demand in Primary Care – 07/21/2023 – Saúde em Público

Talking about access, reception and work processes in Brazilian Primary Care (AB) is always challenging, whether from the perspective of professionals, management or users. On the one hand, the demand for health services is only increasing, especially with regard to Chronic Non-Communicable Diseases (NCDs) — whether due to the progressive aging of the population, or due to the dammed-up demands since the Covid-19 pandemic. On the other hand, the health offer is insufficient, since Brazil still does not have universal coverage in AB.

All this results in already known problems: people arriving at the unit before opening hours to ensure service, irritation with queues and delays. At the limit, there are reports of inappropriate practices and misconduct by citizens, such as the “sale” of places in the queue for assistance. After all, how is it possible to offer a resolutive service if the care pressure is always high and there is no time for planning?

Changing this reality requires a joint effort by management and health professionals. It is necessary to develop “lightweight” technologies that look at social, behavioral and organizational aspects, gradually improving team actions and processes; “hard” technologies are also needed, which are based on physical, material and digital components, such as improvements in the ambience of the units and in the computerization of primary care services. These combined technologies facilitate the work process, the self-management of the family health teams and the ability to carry out efficient clinical management, prioritizing the health offer to the territories and individuals who need it most.

An additional challenge to consider for the success of interventions is the progressive digitization of health. It is necessary to combine the organization of access and reception flows in PC with the perspective of advancing digital health, since there is an immediate concern with the inclusion of the population that accesses this service, which we call the “Daniel Blake dilemma”. In the film “I, Daniel Blake” (2016), by Ken Loach, an English gentleman is constantly denied access to social security benefits for various reasons, such as lack of digital literacy. This dilemma illustrates how digital tools, which hypothetically make services simpler, more efficient and more accessible, can act against the basic principles of universality, integrality and equity, which underlie systems such as the SUS, and basic care routines, such as user embracement.

To avoid excluding large portions of the population from primary care, the computerization of services must be subsidized by the participation of the health team and users, with the aim of integrating and informing all actors involved in the process. That is, if there is the possibility of scheduling consultations, procedures or teleservices using applications, for example, it is necessary to train the health team to interact with the population and facilitate this access, following the territorial and community logic of primary care as a vector to achieve social and digital transformation.

With that in mind, the Qualifica AB project, built by the Institute of Studies for Health Policies (IEPS) and the Recife Health Secretariat (SESAU), with the support of Umane, is co-creating a model that structures the routine of welcoming citizens in basic health units based on dialogue with professionals and managers. The objective is to achieve the best possible work process based on the reality of each health team in the capital of Pernambuco.

The model proposed by Qualifica AB involves four steps. The first consists of mapping the flow of people in Basic Health Units (UBS). The second aims to study what are the main demands that arrive at the door of the health unit and in the offices, understanding the profile of the population that accesses the service and the reasons for seeking the UBS. In this regard, it is important to say that the “no demand” for UBS is also relevant. For mapping, tools were developed that allow the analysis of demand by type, day of the week, hours and clinical condition of the user.

The third step involves analyzing the current reception process through the collected data, establishing new interventions, protocols and flows based on minimum parameters established by the Health Department of Recife. The fourth and final step seeks to assess the changes based on process indicators co-created with local managers.

There are several ways of thinking about reception: advanced access, agenda sharing model (carve out), or receptions carried out by the day team, by the reference team, or even collectively. Municipal administrations often decide to adopt a single model for all teams and Units, regardless of the particularities of each territory. On other occasions, health teams are lost in the midst of so many theoretical models for welcoming citizens.

Qualifica AB’s innovation lies in not focusing on ready-made models, but betting on the study of demand and the strengthening of work processes, with internal pacts of the teams to increase the health offer (such as collective consultations, groups, intersectoral referrals). This is one of the guidelines of the project to build strategies that are attentive to the demands of each health unit and reduce access barriers within this very challenging process.

Agatha Eleone is a Public Policy Analyst at IEPS. Caio Rabelo is Project Manager at IEPS; and Maria Heloisa Lira Rodrigues dos Santos is a Resident in Collective Health at IMIP.

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