Original Research

Provision of specialized care in remote rural municipalities of the Brazilian semi-arid region


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Patty Fidelis de Almeida1
PhD Public Health, Professor *

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Adriano Maia dos Santos2
PhD, Professor

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Lucas Manoel da Silva Cabral3
MSc, Researcher

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Aylene Bousquat4
PhD, Professor

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Márcia Cristina Fausto5
PhD, Professor and researcher


1 Collective Health Institute, Federal Fluminense University, Niterói, RJ, Brazil

2 Multidisciplinary Health Institute, Federal University of Bahia, Vitória da Conquista, BA, Brazil

3 Institute of Social Medicine, State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil

4 Public Health Faculty, University of São Paulo, São Paulo, SP, Brazil

5 National School of Public Health Sergio Arouca, Oswaldo Cruz Foundation, Rio de Janeiro, RJ, Brazil

ACCEPTED: 24 September 2021

early abstract:

Introduction: Specialized care barriers are widespread and multifactorial, with consequences for timely access, health outcomes, and equity, especially in rural contexts. This paper aims to identify and analyze arrangements for providing specialized care in the Brazilian Remote Rural Municipalities (RRM).
Methods: This is a multiple, qualitative case study developed in seven RRM located in the Brazilian semi-arid region. Twenty-two semi-structured interviews were conducted with the public health system managers, complemented by analysis of secondary data from national health information systems. Thematic content analysis was guided by the Integrated Health Service Networks (RISS) attributes related to the provision of specialized care.
Results: Socioeconomic indicators and indicators of availability and accessibility to health services express the context of greater vulnerability of RRM and their respective health regions when compared to states and the country. The analyzed cases do not come close to the RISS constitutive attributes. Various arrangements for the provision and financing of specialized care in the RRM were identified: public provision through an agreement between managers in the health region; health consortia; public provision in the municipality itself or neighboring municipalities; provision in private health services through direct purchase (out-of-pocket); telehealth (very incipient). Such arrangements were unable to respond quantitatively and qualitatively to the demand for specialized care. Providing timely specialized care in an adequate place is not achieved, resulting in a fragmented, low-resolution model. The fragility of regionalized networks, aggravated by underfunding of the Brazilian Unified Health System (SUS), insufficient logistical support, and computerization of health services, contributes to maintaining care gaps and unacceptable travels to be submitted to basic specialized procedures, with more severe effects for people residing in the rural area of the municipalities.
Conclusion: The country’s disorganization or lack of a systemic response based on regionalized health networks generates several care improvisations. The less structured the RISS is, the more informal arrangements are made, with gains for the private sector to the detriment of public health system users.