| I work eight hours, so it depends a lot on the day. The normal is until three or four in the afternoon. There are days when we leave early: I leave at two o'clock in the afternoon, three o'clock. That we have to make a house call or something like that, we leave, I leave here and I'm going to make house calls. [...] Personally, it depends a lot on the day. More commonly, I leave here and go to lunch in S. [regional municipality]. I finish seeing patients at 11 o’clock, come back at 1 o'clock, and so on. And when there's a schedule, for example, there's something, there are times when it doesn't stop, and we work straight through. (2MG6MED2 - North of Minas Gerais) |
| So, that's why I tell you, that's why the biggest demand we have in town comes to me, both because of the trust and the quality of care and because I can solve several things without referring patients to someone else. So, for this reason, even the manager, he has a disagreement with me. [...] It's been eight years, ten years, I said: “I'm leaving”. I hadn't mentioned that I would. I had already told some friends that I was leaving. Look, people came in here crying... Then, can you explain to me, how could I leave? Then I got the mayor to give me a day off every fifteen days, so I could visit my family and I'd increase my workload: instead of eight hours, I'd work nine. I said: “it's good, for me it's perfect”. (6BA3MED1 - Semiarid region) |
| They work with cattle, as I told you, they're cattle ranchers and small producers, they live on that, so they live on milk, most of them. They have to pay someone to bring them here to the unit, so they end up not coming, except in extreme cases, you know? So, if there was a place where they could go, a healthcare unit, even with the team assembled, I'm not talking about an emergency. And they came in at nine, nine-thirty, ten and were treated. They didn't have to wait until one o'clock, because sometimes it's like that, the people from town are seen in the morning and the people from the rural areas are seen in the afternoon: they prefer it that way because it isn't as busy in the afternoon. [...] But, for instance, he leaves there at nine-thirty, arrives here at the PHC unit at ten-thirty, eleven o'clock, when it will be closing for lunch. So, you'll have to wait, you'll have to eat. If it had a different schedule and a unit that served the entire rural population at a different time, it would be better for them. (1MT26MED2 -Midwest Vector) |
| But in case of adaptation, it's more like this, they have phones, they call and say: “I'm going with twenty people.” So, the B. community calls and says: “We're going on a boat with forty people, can we go?”. There was a day here where we worked straight through, we didn't even stop for lunch, there were more than fifty people. No, our record was over eighty. Me, the nurse, and the technicians. But it's very much “Bolsa Família”, they have to register. They came in two, three boats. Wow, what a day that was... When it was over, I couldn't even think! (4AM16MED2 - North-waterways) |
| Let's talk about the doctor: he'll come, the car leaves to bring him, he arrives here at half past eight, depending on the road conditions, everything. Where is he going to have lunch here? Did you understand? Then he has to bring his lunch from home, then he'll stop here and have lunch here. He'll stay here at the unit, he'll arrive all the time and: “Oh, doctor, you've got an appointment and such.” So, he doesn't have a break, he doesn't have time to rest every day. Then he'll come back at 1 pm and leave here at five in the afternoon. How are you going to charge a person, a professional, like that? You can't have everything on a "straight" line. Why? Because I get out of here, we're going to make a house call, it's one o'clock! These days I walked for almost an hour and a half. But that's what the need is like here. So, you get attached to the smallest details of “Oh, you have to stick to the schedule.” There's no sticking to a schedule in rural areas, it's not the same service as in town. In town, you can measure hypertensive patients, measure diabetics, at four o'clock in the afternoon you have a group of patients waiting and everything you need to take care of them. That's not the case here, there are days when you have thirty patients in the morning! Am I going to tell them, "Sorry, folks, but I can only see ten of you?" (2MG6MED2 - North of Minas Gerais) |
| Arrangement of work with emphasis on walk-in patients |
| People here don't have the habit of making an appointment. I've tried, but it doesn't work. Because, according to them, it's a custom and it doesn't work. Right from the start, I was seeing twenty-eight patients, thirty in one morning. I decided on my own to slow down, because once it happened, I realized I was seeing patients too quickly. At the PHC unit, you listen, discuss their problem, hear things you don't need to hear. Given the kind of workload I was having, I couldn't do it. [...] As I told you, there are days when I see four extra patients. On peak days, which are Mondays, sometimes I even squeeze in twenty because the person comes here and says “I live in the countryside, I live far away, there's no way I can come back tomorrow” and we keep on seeing them. We make the schedule here. I've already tried scheduling an appointment and it doesn't work. (5AC11MED2 - North-roads) |
| We're more or less organized. It's just that we didn't have a doctor, just one doctor. Then the doctor from the rural area was covering the urban area. Then another doctor arrived, also from the [More Doctors] Program, who is from the urban area. It's still a little like that today, we treat everybody. But the scheduled [appointments], in this case, are mostly related to prenatal care and child care. [...] It is, at any time [service to people who live in the countryside]. There's no such thing as: “No, we'll give the file at eight o'clock in the morning.” It doesn't work that way. Because like the people around here say: “I hopped in my boat and made it here by ten.” (4AM17MED1 - North-waterways) |
| At first, I even wanted to stay at the downtown PHC unit, which is easier to organize. You work at one place and all. You can say: today is the day of “hyperdia” [hypertension and diabetes], today is the day of pregnant women. Here I can't do that, because if I did, then... there would be no access. So, my appointments are always walk-in. (3MA25MED2 - Matopiba) |
| These rural patients are very difficult. For example, usually, a 15-year-old girl is doing her second prenatal care check-up for her second child. When she gives birth, from the hospital, let's say, she has the baby today, and if she's discharged the following day, she goes straight back to the countryside. She'll only come back if she's got post-partum pain or the baby's sick. Even if she's told: “You have to come back and do the follow-up.” Most of them will only come back if they feel bad or the baby feels bad, otherwise, they don't come back. (4AM17MED1 - North-waterways) |
| Well, here we deal with walk-in appointments. But I tell many of them, "Come back next week." I myself tell them next week, the hypertensive patients that I saw and treated, that took medicine: "I want to see you here next week, please. I want to see you here.” They come. [...] Yes, a follow-up, but guided like this: “I want you to come back.” The rest are walk-in appointments. I don't have a specific number of patients, it's all walk-in appointments. (3TO19MED2 - Matopiba) |
| The problem is we don't provide only the service that we're supposed to do, understand? Because we come here to work as a PHC unit and we're forced to work as a PHC unit and an emergency care service. It turns out we don't do either one right. In my opinion, it's like barking at the moon. We don't promote health care, but there's also no way we can be said to provide urgent and emergency support. The time I would have to provide health care, I'm worried about seeing emergency care patients, helping walk-in patients. (3TO19MED1 - Matopiba) |
| Primary care is touch and go because we have nowhere to send these things I’m telling you about. That daily rush of patients, you can’t make an appointment or fail to see a group of hypertensive patients. […] The main advances? Look, I can’t talk about advances, but it’s not that difficult to work here. Everything we need, management provides. The main advance I’d like to see and doesn’t happen is being able to work with primary care, which we can’t. From my point of view, it’s because there is no emergency service. (1MT26MED2 - Midwest Vector) |
| Arrangement of work with emphasis on walk-in patients |
| The communities around here get assistance in the form of visits and lectures for health promotion, we know what's going on. When diarrhea and viruses start to break out, we know what's happening in the nearest locations. I don't know what happens in the ones farther away. So, in the places close to us, the community health care center works, people have the habit of going there, where the team knows the people, knows the patients, the patients’ families, which is how it should be. But it's only in the radius around here. (6BA1MED2 - Semiarid region) |
| Here in this unit, it's the one with the least adherence to this type of organization. They always want to see the doctor. They show up when they feel sick, otherwise they stay away. [...] This follow-up, we often have to do it at home, go to the patient's house to check their blood pressure, see the medicine, get the medicine, say: "You have to keep the medicine separated!". Even so we often hear: “Oh, she's not taking it.” We go back again because if we wait for them to come here, adherence is difficult. (2MG6MED2 - North of Minas Gerais) |
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Source: Adapted from Bousquat et al.