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Table 4 Summary of results and expressive statements, according to challenges to the provision of specialized care in remote rural municipalities, semi-arid region, Brazil, 2019

From: Challenges to the provision of specialized care in remote rural municipalities in Brazil

Dimension 1

Summary of challenges

Expressive statements

[Challenge 1] Public manager is the main buyer and payer of specialized services for the population

Some patients go to the regional hospital of Ibotirama, others to the municipal hospital of Barra, and others to Salvador. [...] for example, the municipality of Ibotirama hired a urologist and other doctors from other specialties. Therefore, a private clinic was hired to perform, but the municipality pays a specific agreed value. Concerning MRI and orthopedics, the municipality of Barreiras also contracted a private clinic and we outsourced this service and used it several times. So, we have public to public and public to private, at no cost to the population; no cost, meaning we use funds transferred to us (Municipal health manager 3).

[Challenge 2] Scarce supply and long distances contribute to different arrangements for the provision/acquisition of specialized care

[...] to what extent Juazeiro can meet all this demand. Sometimes, this demand cannot be met [...]. If we say that there is specialized care for all our demands, well, there isn’t. Orthopedics is our great weakness in the mother and child network, and the situation is very complicated for cardiology as well (Regional manager 3). The public service is very outdated and cannot meet what the entire population wants. There has been a lot of private health care, and we understand that it is well served here. The mayor has significantly focused on [public] health; however, private health care has stood out. Perceiving that most of the tests, both quantity and price, are in the private health care in Irecê, then, Ipupiara sends a lot to Irecê. We have even weekly vans making this trip. The fare is expensive; however, it pays off for the population because everyone who goes there likes the private health care service (Municipal health manager 1). Municipalities are very distant from each other. This hinders people’s access to health services, especially regarding medium- and high-complexity problems. It is very challenging for us to structure this flow here in the region. Moreover, within the municipality, some municipalities have locations that stand more than 100 km from the headquarters (Regional manager 1). [...] our territory is in a transitional location, where the care gap in the center-south is enormous. The only reference hospital for medium- and high-complexity is located here in our territory, which is the Floriano hospital. [...] now, the visits [with specialists] are generally in Teresina [...] because some specialties only have two or three professionals for the entire state, so it cannot be sufficient (Regional manager 2).

[Challenge 3] Inequalities to vulnerable populations and the neediest municipalities

For example, we spent nine months with a pregnant woman, and she did only one test, and that was it! Because struggled to access; a pregnant woman, with nausea; she had all the difficulty in the world to go and do these tests [at the headquarters of the health region]. So, we spent nine months with this pregnant woman without a blood count because the mother could not afford to pay [the bus fare] (Municipal health manager 6).