Acceso a los servicios de la Atención Primaria de Salud: revisión integradora de la literature

Figueira, Maura Cristiane e Silva; Silva, Wellington Pereira da; Silva, Eliete Maria

doi:10.1590/0034-7167-2017-0441

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REVIEW • Rev. Bras. Enferm. 71 (3) • May-Jun 2018 • https://doi.org/10.1590/0034-7167-2017-0441 copiar

Acceso a los servicios de la Atención Primaria de Salud: revisión integradora de la literature

Autoría SCIMAGO INSTITUTIONS RANKINGS

RESUMEN

Objetivo:

analizar la producción científica que describe la forma de acceso a los servicios de la Atención Primaria de Salud e identificar las poblaciones específicas que tienen acceso diferenciado a los servicios de salud.

Método:

revisión integradora. Para seleccionar los estudios, se utilizaron las bases de datos: PubMed, Scopus, Bireme y Cinahl. La muestra incluyó 22 artículos nacionales e internacionales.

Resultados:

describir sobre el acceso de poblaciones específicas a los servicios de salud, acceso a cuidados primarios por medio de seguros médicos y algunas propuestas para mejorar el acceso.

Conclusión:

el acceso a los servicios es un reto en muchos países y algunas estrategias y políticas son aplicadas para la resolución y perfeccionamiento del cuidado en la atención primaria.

Descriptores:
Acceso a los Servicios de Salud; Atención Primaria en Salud; Sistemas de Salud; Política de Salud; Comunidades Rurales

Authors/journal/country	Objective	Method	Main results
Vargas BAet al.⁽¹⁰10 Vargas BA, Fang H, Garza J, Carter-Pokras O, Wallace SP, Rizzo JA, et al. Variations in healthcare access and utilization among Mexican immigrants: the role of documentation status. J Immigr Minor Health [Internet]. 2012 [cited 2016 Sep 12]; 14(1):146-55. Available from: https://www.ncbi.nlm.ni h.gov /pmc/articles/PMC3256312/pdf/10903_2010_Article_9406.pdf https://www.ncbi.nlm.ni h.gov /pmc/artic... ⁾ (2012) J Immigr Minor Health USA	Identify differences in the access to healthcare services of documented or undocumented Mexican immigrants in the USA.	Quantitative: data from the California Health Interview Survey (CHIS) (population study conducted by telephone). Chi-square tests to determine access.	Documented immigrants are likely to see a physician at least once. Undocumented immigrants excluded from the Patient Protection and Affordable Care Act do not have access to health services.
Santos JCB, Hennington EA⁽¹¹11 Santos JCB, Hennington EA. Nobody gives orders here: the meanings of work and health for settlers from the Landless Rural Workers’ Movement. Cad Saúde Pública [Internet]. 2013 [cited 2016 Sep 12]; 29(8):1595-604. Available from: http://www.scielo.br/pdf/csp/v29n8/v29n8a12.pdf http://www.scielo.br/pdf/csp/v29n8/v29n8... ⁾ (2013) Cad Saúde Pública Brazil	Analyze the lifestyles and meanings attributed by settlers from the landless rural workers' movement (MST - Movimento dos Trabalhadores Rurais Sem Terra) to health and their relationships with labor; identify strategies of health promotion/maintenance.	Qualitative: documentary analysis; community observation; 11 interviews and focus group; content analysis.	The settlers attribute freedom and satisfaction, self-management and autonomy to work, which are considered essential for health. Health access: need to travel to neighboring cities to use services; lack of health care; use of medicinal plants as an alternative due to lack of access.
Moss JA⁽¹²12 Moss JA. Discovering the healthcare beliefs and practices of rural mestizo Ecuadorians: an ethnonursing study. Invest Educ Enferm [Internet]. 2014 [cited 2016 Sep 12]; 32(2):326-36. Available from: http://www.scielo.org.co/pdf/iee/v32n2/v32n2a15.pdf http://www.scielo.org.co/pdf/iee/v32n2/v... ⁾ (2014) Invest Educ Enferm Ecuador	Discover and understand health-related beliefs and practices of mestizo Ecuadorians in rural areas of Ecuador.	Qualitative: semi-structured interviews (28 interviewees) and observation. Leininger's transcultural nursing. Analysis: Qualitative software NVIVO8.	Healer is a primary, secondary or tertiary health resource and/or the use of medicinal plants. They present many needs and multiple barriers in health care.
Santos RC, Silva, MS⁽¹³13 Santos RC, Silva MS. Living conditions and therapeutic paths in a quilombola community in Goiás, Brazil. Saude Soc [Internet]. 2014 [cited 2016 Sep 12]; 23(3):1049-63. Available from: http://www.scielo.br/pdf/sausoc/v23n3/0104-1290-sausoc-23-3-1049.pdf http://www.scielo.br/pdf/sausoc/v23n3/01... ⁾ (2014) Saude Soc Brazil	Investigate the health conditions and therapies of the individuals from two quilombola communities in Goiás.	Quantitative and qualitative: questionnaire with heads of 52 families (188 people); semi-structured interviews with key interviewees and participant observation.	Results classified according to the thematic axes: living conditions, health services, and therapies. They face difficult access to quality basic public health services.
Wunsch S et al.⁽¹⁴14 Wunsch S, Budó MLD, Girardon-Perlini NMO, Garcia RP, Oliveira SG. Care as a commitment of all: a study in a rural settlement. Rev Gaucha Enferm [Internet]. 2014 [cited 2016 Sep 12]; 35(4):65-71. Available from: http://www.scielo.br/pdf/rgenf/v35n4/pt_1983-1447-rgenf-35-04-00065.pdf http://www.scielo.br/pdf/rgenf/v35n4/pt_... ⁾ (2014) Rev Gaucha Enferm Brazil	Learn about healthcare practices in the perspective of families living in a rural settlement in the northwest region of the State of Rio Grande do Sul.	Qualitative: ethnography Observation- Participation-Reflection Model.	Poor rural settlements make it difficult for families to access health services. Families live with scarce service coverage and they use their cultural background for the necessary health care.

Authors/journal/country	Objective	Method	Main results
Bond AM, White C⁽¹⁵15 Bond AM, White C. Massachusetts coverage expansion associated with reduction in primary care utilization among Medicare beneficiaries. Health Serv Res [Internet]. 2013 [cited 2016 Sep 12]; 48(6):1826-39. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3876406/pdf/hesr0048-1826.pdf https://www.ncbi.nlm.nih.gov/pmc/article... ⁾ (2013) Health Serv Res USA	Analyze whether expanding coverage for non-elderly adults has affected the use of primary care among Medicare users in Massachusetts.	Quantitative: Medicare database.	Compared to other states, there was a 6.7% increase in visits to a primary health care physician in Medicare and a 7% decrease in population without an annual visit to a primary health care physician.
Dow AW et al.⁽¹⁶16 Dow AW, Bohannon A, Garland S, Mazmanian PE, Retchin SM. The effects of expanding primary care access for the uninsured: implications for the health care workforce under health reform. Acad Med [Internet]. 2013 [cited 2016 Sep 12]; 88(12):1855-61. Available from: http://www3.med.unipmn.it/papers/2014/LWW/2014-01-13_lww/The_ Effects_of_Expanding_Primary_Care_Access_for.22.pdf http://www3.med.unipmn.it/papers/2014/LW... ⁾ (2013) Acad Med USA	Compare Virginia Coordinated Care (VCC) insurance to the Patient Protection (PP) and Affordable Care Act (ACA).	Quantitative: data from VCC. Exposed groups of medical complexity: SpecifCare (1.2%), EpisodiCare (62%), CroniCare (16.4%), ComplexiCare (8.7%).	In the comparison of Virginia Coordinated Care to the Patient Protection and Affordable Care Act, to improve the access, it is necessary to expand the access to primary care services, therapeutic residency for chronic diseases, and the continued training of health professionals.
Cheng TL,Wise PH, Halfon N⁽¹⁷17 Cheng TL, Wise PH, Halfon N. Quality health care for children and the Affordable Care Act: a voltage drop checklist. Pediatrics [Internet]. 2014 [cited 2016 Sep 12]; 134(4):794-802. Available from: http://pediatrics.aappublications.org/content/pediatrics/134/4/794.full.pdf http://pediatrics.aappublications.org/co... ⁾ (2014) Pediatrics USA	Expand ideas on the impact of the Affordable Care Act on the health of American children.	Quantitative: a practical state checklist tool was used.	It was found that the plan coverage does not ensure the availability of primary care to children, the main factors are: difficult accessibility, family non-enrollment, immigration and non-proficiency in English language.
Rhodes K et al.⁽¹⁸18 Rhodes KV, Kenney GM, Friedman AB, Saloner B, Lawson CC, Chearo D, et al. Primary care access for new patients on the eve of health care reform. JAMA [Internet]. 2014 [cited 2016 Sep 12]; 174(6):861-69. Available from: http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1857092 http://jamanetwork.com/journals/jamainte... ⁾ (2014) JAMA Intern Med USA	Analyze the availability of visits to primary health care physicians by state and status of health insurance.	Quantitative: phone contacts were performed from primary care office in 10 American states (11,347 calls were made).	More appointments available for private insurance than for Medicaid. In the states, the calls to schedule a primary care appointment for Medicaid patients were worse than for patients of private plans.
Ortega NA, Rodriguez HP, Vargas BA⁽¹⁹19 Ortega AN, Rodriguez HP, Bustamante AV. Policy dilemmas in Latino health care and implementation of the Affordable Care Act. Annu Rev Public Health [Internet]. 2015 [cited 2016 Sep 12]; 36(18):525-44. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/25581154/ https://www.ncbi.nlm.nih.gov/pmc/article... ⁾ (2015) Annu Rev Public Health USA	Perform a review on health policies and services that affect the Latin immigrants living in the United States and that are relevant to understanding the impact of ACA on the health of this population.	Literature review.	Latin immigrants have worse geographic access to health care in the United States due to migration; because they live in rural areas; or language issues with health professionals. The Affordable Care Act should make preventive care more accessible to Latin immigrants.

Authors/journal/country	Objective	Method	Main results
Grant R, Greene D⁽²⁰20 Grant R, Greene D. The health care home model: primary health care meeting public health goals. Am J Public Health [Internet]. 2012 [cited 2016 Sep 12]; 102(6):1096-103. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3483945/pdf/AJPH. 2011.300397.pdf https://www.ncbi.nlm.nih.gov/pmc/article... ⁾ (2012) Am J Public Health USA	Summarize the model of nursing home and the evidence of its public health and clinical efficacy.	Qualitative: narrative on the model of nursing home as a means to help PHC achieve the objectives of increasing access to care, reduce disparities and integrate care with public health systems.	The model of nursing home increases access of low-income people and racial/ethnic minorities. Nursing home provides health insurance, transportation, long service hours and integration of the main specialized services.
Jiwa M et al.⁽²¹21 Jiwa M, Othman S, Hanafi NS, Ng CJ, Khoo EM, Chia YC. Healthcare in Asia: a perspective from primary care at the gateway to a continent. Qual Prim Care [Internet] 2012 [cited 2016 Sep 12]; 20(5):17-20. Available from: http://primarycare.imedpub.com/healthcare-in-asia-a-perspective-from-primary-care-at-the-gateway-to-a-continent.pdf http://primarycare.imedpub.com/healthcar... ⁾ (2012) Qual Prim Care Malaysia	Case report on the Asian health system, using the example in Malaysia.	Qualitative: case report on the health system in Malaysia.	The primary health system offered by the government is the main provider of health care. Most Malaysians have excellent access to health care. A significant percentage of residents in the east part of the country and the Aborigines have limited access.
Tan L, Carr J, Reidy J⁽²²22 Tan L, Carr J, Reid J. New Zealand evidence for the impact of primary healthcare investment in Capital and Coast District Health Board. NZMJ [Internet]. 2012 [cited 2016 Sep 12]; 125(1352):7-27. Available from: https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2012/vol-125-no-1352/article-tan https://www.nzma.org.nz/journal/read-the... ⁾ (2012) NZMJ New Zealand	Provide evidence on the effectiveness of investments in primary health care in New Zealand.	Quantitative and qualitative: the effectiveness of investments was measured through the District Health Council, the Capital Council and PHC indicators.	The study observed increased and redistributed primary care and workforce, increased availability of general practitioners, and allocation of community workers to poorer areas. There was also a reduction in outpatient hospitalization and use of emergency services.
Polluste K et al.⁽⁷7 Polluste K, Kasiulevicius V, Veide S, Kringos DS, Boerma W, Lember M. Primary care in Baltic Countries: a comparison of progress and present systems. Health Policy [Internet]. 2013 [cited 2016 Sep 12]; 109(2):122-30. Available from: https://www.ncbi.nlm.nih.gov/pubmed/22964369 https://www.ncbi.nlm.nih.gov/pubmed/2296... ⁾ (2013) Health Policy The Baltic States	Monitor indicators of access to PHC, continuity of care, and aspects of patient experience to discuss the suitability of PHAMEU in comparison to primary care systems.	Quantitative: the study used PHAMEU to monitor primary care activity in Europe (it covered the 27 Member States of the European Union, plus Turkey, Iceland, Norway, and Switzerland).	In Lithuania, the access policy is not well defined. In the Baltic States, the organizations of physicians or patients for care contribute informally to primary care policies. For family medicine, some hours of work should be dedicated to priority appointments. For the comparison of health systems, each country should use its own forms to organize its data.
Groenewegen PP, Jurgutis A⁽²³23 Groenewegen PP, Jurgutis A. A future for primary care for the greek population. Qual Prim Care [Internet]. 2013 [cited 2016 Sep 12]; 21(6):369-78. Available from: http://primarycare.imedpub.com/a-future-for-primary-care-for-the-greek-population.pdf http://primarycare.imedpub.com/a-future-... ⁾ (2013) Qual Prim Care Greece	Assess the situation of primary care provided to the Greek population.	Qualitative: The assessment of primary care in Greece was conducted using the existing literature, visits to primary care centers and consultations with stakeholders.	Governance is fragmented. There is no system of patient lists; the private payments are high. There are many physicians, but few general practitioners and nurses, and they are distributed irregularly in the country, resulting in difficult primary care access, continuity, coordination and coverage.
Thomas SL, Wakeman J, Humphreys JS⁽²⁴24 Thomas SL, Wakerman J, Humphreys JS. What core primary health care services should be available to Australians living in rural and remote communities? BMC Fam Pract [Internet]. 2014. [cited 2016 Sep 14]; 143(15):1-9. Available from: https://bmcfampract.biomedcentral.com/articles/10.1186/1471-2296-15-143 https://bmcfampract.biomedcentral.com/ar... ⁾ (2014) BMC Fam Pract Australia	Provide a model to policy makers, service providers, and users, determining which primary care services should be available to all Australians.	Quantitative: Delphi's method was used to reach a consensus among 39 specialists (from rural, remote and/or indigenous primary health care) regarding the list of services that should be available. A Liket scale was used to prioritize the services.	High-consensus services were: care to people with diseases and injuries, maternal and child health, disease prevention and oral health, quality and accessibility. For support to services: management/governance/leadership and coordination. Difficult recruitment and maintenance of qualified professionals, in extended infrastructure, quality assurance and accessibility.
Bodenheimer T et al.⁽²⁵25 Bodenheimer T, Ghorob A, Willard-Grace R, Grumbach K. The 10 building blocks of high-performing primary care. Ann Fam Med [Internet]. 2014 [cited 2016 Sep 14]; 12(2):166-71. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3948764/pdf/0120166.pdf https://www.ncbi.nlm.nih.gov/pmc/article... ⁾ (2014) Ann Fam Med USA	Formulate essential elements of primary care, called 'the 10 building blocks' of high-performance primary care.	Qualitative: case study; data were analyzed from health sites on 23 practices of PHC, experience of two researchers as enablers in more than 25 practices, review of existing models and studies on PHC improvements.	The 10 building blocks were: leadership; improvements based on indicators; care services provided by team; partnership between patients and the team; population management; care continuity; quick access; understanding and coordination of care, and proposed models for the future of PHC services.
Aguilera CCE, Brandão AL, Bocater PPM⁽²⁶26 Aguilera CCE, Brandão AL, Bocater PPM. Study on evaluation of dimensions of the Family Health Strategy in the user’s perspective. Physis [Internet] 2014 [cited 2016 Sep 14]; 24(1):127-46. Available from: http://www.scielo.br/pdf/physis/v24n1/0103-7331-physis-24-01-00127.pdf http://www.scielo.br/pdf/physis/v24n1/01... ⁾ (2014) Physis Brazil	Investigate the dimensions that are most valued by users of health services.	Qualitative: focal groups and content analysis.	The results produced in total 17 dimensions. The most frequently mentioned were: service access and availability; work process organization; relationship with health professionals; longitudinality; and link between professionals, users, and care coordination.
Esmaeili R et al.⁽²⁷27 Esmaeili R, Hadian M, Rashidian A, Shariati M, Ghaderi H. Family Medicine in Iran: Facing the Health System Challenges. Glob J Health Sci [Internet] 2015 [cited 2016 Sep 12]; 7(3):260-6. Available from: http://www.ccsenet.org/journal/index.php/gjhs/article/ view/40702/23471 http://www.ccsenet.org/journal/index.php... ⁾ (2015) Glob J Health Sci Iran	Understand the perspectives of Iran's political decision-makers and health system on the implementation of family medicine in urban areas of the country.	Qualitative: interviews with policy makers of five main organizations in family physician project (27 interviews). Method: framework for data analysis.	The perspectives indicate the family medicine project implementation will support physician visits, extended care and the creation of reference networks. They understand family medicine improves financial and geographical access to health.
Reeve C et al.⁽²⁸28 Reeve C, Humphreys J, Wakerman J, Carter M, Carroll V, Reeve D. Strengthening primary health care: achieving health gains in remote region of Australia. Med J Aust [Internet]. 2015 [cited 2016 Sep 15]; 202(9):483-7. Available from: https://www.mja.com.au/system/files/issues/202_09/ree00894.pdf https://www.mja.com.au/system/files/issu... ⁾ (2015) Med J Aust Australia	Assess the impact of a service model of PHC using key performance indicators in health and the association with increased use of health care in a remote region of Australia.	Quantitative: document analysis, evaluated according to the National Key Performance Indicators for Aboriginal and Torres Strait Islander for PHC, with non-parametric trend test, Stata version 10 (StataCorp).	The study observed that the increase of political and structural actions resulted in increased primary care activity, thus reducing the flow of urgent services. A general increase was observed in the access to primary care services, especially by peripheral communities.
Takamura A⁽²⁹29 Takamura A. The present circumstance of primary care in Japan. Qual Prim Care [Internet]. 2015 [cited 2017 Feb 12]; 23(5):262-6. Available from: http://primarycare.imedpub.com/the-present-circumstance-of-primary-care-injapan.pdf http://primarycare.imedpub.com/the-prese... ⁾ (2015) Qual Prim Care Japan	Present an investigation into the history of primary care in Japan and show current problems and situations.	Qualitative: case report that addresses the "Primary Care in Japan" in terms of History of Primary Care, Medical System and Medical Education.	Currently, the Japanese government is trying to introduce the General Practitioner / Family Physician (GP/FP) to improve cost-effectiveness ratio and provide better care to the population. They propose to change the medical education training model to prioritize primary care.
Larye S, Goede H, Barten F⁽³⁰30 Laryea S, Goede H, Barten F. Moving toward universal health coverage: a review of comprehensive primary health care in Suriname. Rev Panam Salud Publica [Internet] 2015 [cited 2017 Feb 20]; 37(6):415-21. Available from: http://www.scielosp.org/pdf/rpsp/v37n6/v37n6a07.pdf http://www.scielosp.org/pdf/rpsp/v37n6/v... ⁾ (2015) Rev Panam Salud Publica Suriname	Provide an overview of the development and implementation of comprehensive primary health care in Suriname.	Literature review: three articles selected and analyzed.	There is a shortage of studies on this theme. Partial views of primary care are observed in the country and examples of practice. Focus on the service network is observed in the country side to improve rural access, training the community members for support.

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[1] CORRESPONDING AUTHOR: Maura Cristiane e Silva Figueira E-mail: mauracsf@gmail.com