Table 5 Summary of results and expressive statements, according to challenges to the provision of specialized care in remote rural municipalities, semi-arid region, Brazil, 2019

[Challenge 4] Manager needs to negotiate discounts with private clinics

I think that is a great challenge for the manager. He [health secretary] was a social assistance secretary and knows each person’s profile and tries somehow to filter and prioritize those who are low-income: both economic and clinical triage. If someone can wait, he goes for a normal appointment; however, he tries to help by financing the specialist for low-income people who cannot afford it; that is how it works (Municipal health manager 2).

[Challenge 5] Direct purchase of private services by the public manager strengthens the private network

[...] the municipalities structure specialized care services by hiring professionals. Then, professional go there and provide the service. So, the municipalities do not get paid for it because they do not have a service that SUS can accredit, and everything depends very much on the municipal counterpart (Regional manager 1). [...] It would take six months to have a visit and return with the tests. So, some patients go to SUS for the first visit. When the doctor asks for the tests, they go to the clinic, pay, and then return to show the results to the [SUS] doctor (Regional manager 3). [Specialized care] is much more private in small municipalities. The larger municipalities can have a more adequate structure, as they can resort to some accreditation. However, the management is public and, in the cases of small municipalities, we still have this issue of company contracts, or contracting with private companies or professionals (State manager 1).

[Challenge 6] Faced with large distances, it was often cheaper for the patient to pay out-of-pocket than to travel to the neighboring municipality to receive public care

[...] we have a covenant with the public laboratory of the hospital in Ibotirama. However, people go there, pay the bus fare to collect blood there, the fare is the money for all the tests or the ultrasound. Sometimes, it’s not worth it. Sometimes, people have [public] vacancies, but they prefer not to use them. Then, we can pay it here [in the municipality], through the private laboratory, because it is cheaper even for us (Municipal health manager 2).

[Challenge 7] RRM managers had to offer a supporting point for patients to stay in capitals during treatment

There is a support house in Salvador; several municipalities have an agreement with that house. They have one in Barreiras; some already have one, those municipalities further away have a support house (Regional manager 1). Every municipality has an Out-of-Home Treatment (OHT) car, which they send for treatment outside the municipality. They both come here (health region headquarters) for hemodialysis and other treatments in Salvador (Regional manager 2).

[Challenge 8] The appointment scheduling center was located in the health secretariats at the headquarters of the RRMs

The patient goes through primary care, gets a referral for that specialty, then goes to the secretariat, where he is scheduled in the regulation system; and then, he is referred (Municipal health manager 8)

[Challenge 9] CHWs informed about the appointment scheduling and the delivery of the results of specialized tests

Because some individuals have no way to come [to schedule], the health worker brings the copy of the document. When we make the appointment, we contact them, and usually, when it is a place where people do not have a telephone, the health worker takes it and informs the patient (Municipal health manager 7)

[Challenge 10] The use of telehealth was incipient

[...] There’s very little access to Telehealth. Although the Telehealth staff comes here [to the health region], it has already been in some municipalities, training with professionals. However, we still feel that there is still not much access [...] internet [in health units] is also a challenge (Regional manager 2). [...] we have implemented [telehealth]; however, it does not work [...] we do not have it for consulting, only for training and capacity building (Regional manager 3).