RESUMO

Este estudio tiene por objeto enfoca el de analizar la percepción de los usuarios sobre el acceso en la ESF en sus dimensiones geográfica, de organización, socio-cultural y económica. Se ha valorado del proceso con planteamiento cualitativo por medio de entrevista abierta, observación directa y análisis documental en la ciudad de Recife, del estado brasileño de Pernambuco. Los principales problemas han sido: deficiente sistema de referencia, demora en el retorno de los resultados de los exámenes de laboratorio, excesivo número de familias por equipo, dificultad de establecer consultas, gastos con medicamentos. Se han observado facilidades en la relación profesional-usuario así como en la aproximación geográfica de la unidad de salud. La ESF se ha revelado una estrecha puerta de entrada del SUS que merece una observación distinta que adopte como punto de partida las necesidades de los individuos demandantes de sus acciones y también las lógicas que orientan las acciones de los sujetos involucrados en el cuidado.

Palabras clave: Sistema Único de Salud (SUS). Calidad de la atención de salud, acesso y evaluación. Estrategia de Salud de la Familia. Satisfacción del usuario. Atención primaria de salud.

"It is near here, I go there on foot". (user 8, male adult, attender, team A)

"difficulty in scheduling the medical consultation [...]". (user 10, female adult, non-attender, team B)

"We are very numerous, there are many families, so they complain [...]" (professional 1)

Another aspect that was negatively highlighted by users was the emergency care which, in view of their most acute needs, they expect to find in the nearest health unit:

This finding coincides with what was found in the study conducted by Dalmaso (2000), who showed that emergencies are a (repressed) demand that is very frequent at the primary healthcare units. Other authors (Merhy, Franco, 2005; Merhy et al., 2002; Trad et al., 2002) recall that, mainly in the ESF, the lack of this service is one of the main reasons for users' dissatisfaction. This result is, to say the least, curious, in view of the fact that emergency is a service that is already regulated in the ESF, and it is present in the management plan as an additional resource to guarantee the principle of integrality in SUS (Brasil, 2006).

It is in this direction that some authors criticize the structure of the ESF and the insufficiency of primary healthcare (Merhy, Franco, 2005; Cohn et al., 2002; Cecílio, 1997). To these authors, users search for the health service in situations of acute suffering and, when the primary healthcare unit does not respond to their needs, they end up in the emergency services, crowding them with demands that are considered "simple", which might have been solved at the level of primary healthcare. This aspect could be verified by Kovacs et al. (2005), in a study carried out at a pediatric emergency clinic at Recife, in which they observed that the access difficulty in primary healthcare was an important reason for users to search for the analyzed emergency service.

Obstacles after entrance

To some attenders, the obstacle would be in waiting for assistance at the unit, as the fragment below shows:

The explanation lies in the fact that the ESF units have only the collection service; the laboratory analysis is performed at the Municipal Laboratory, which is also responsible for sending the results to the collecting healthcare units. The poor functioning in this other dimension of care (diagnostic support) contributes to disqualify the actions carried out in the assistance dimension.

As for the continuity of care in reference services, it was not regarded a problem by users. The difficulty in scheduling consultations in the local unit (USF) - the entrance door - seems to have been more felt by the population than the difficulty in scheduling consultations with specialists or exams outside the unit's catchment area.

We identified, in this aspect, a certain difference between the discourses of users, professionals and the manager concerning the perception of access. To the professionals and the manager, the access to consultations with specialists constitutes a great obstacle in the ESF, and to some specialties the difficulty is even greater.

Without tackling the polemic discussion that involves the question of problem-solving capacity or of the results of healthcare as a reference element for access (Travassos, Martins, 2004, p.197), it is important to explain that this perception should be seen with caution. First because, as the authors explain, "the population's health does not result directly from the action of the health systems"; second because, in the SIAB Indicators Evaluation Document, produced by Gerência Operacional de Atenção à Saúde (GOAS - Health Care Operational Management) of Sanitary District IV, the contrary was identified: the average of referrals performed by the ESF in 2006 is within what is expected of the studied teams - around 13% in one team and 6% in the other -, in view of the fact that the Ministry of Health recommends to the ESF the referral, to the reference services, of 20% of the assistances at the most. The difficulty perceived by the professionals and the manager seems to be associated with the insufficient number of specialty quotas to each family health unit - a frailty that is closely related to limitations in the referral and counter-referral mechanisms.

These mechanisms are items considered "necessary to the implementation of the Family Health Teams" (Brasil, 2006, p.24) and constitute the "guarantee of referral and counter-referral flows to the specialized services that provide diagnostic and therapeutic support, and also outpatient clinic and hospital support". This problem is associated with the question of the unfinished decentralization of healthcare in the municipality, which still does not exercise the full management of the SUS assistance network, a complex situation in which the large public hospitals are still run by the state or federal governments.

As for the users, their perception of easy access may be associated with their low expectation in relation to the public services. The delay to receive specialized assistance is already expected by them, and the mere fact of obtaining assistance is already an important satisfaction factor. In this sense, the representations that the users have of the public health services are closely related to their experiences in searching for the assistance they need (Starfield, 2002; Halal et al., 1994). A similar perception was not observed in the study conducted by Escorel et al. (2007), in which the families had a clearer perception of this problem compared to the health professionals, who lacked mechanisms to measure the waiting time and the magnitude of the queues.

The fragment below draws attention again to the question of continuity of care:

This testimony reveals that the responsibility for treating the disease moved to another level of care, together with the responsibility for taking care of the subject, who, from then on, detaches himself from the professional-user relation established in primary healthcare. The focus on a professional's discourse reflects this discussion.

The continuity of assistance in another level of care, when the technologies available in the primary level do not meet users' needs anymore, does not take the responsibility away from the health team to which these users are linked. The systematic follow-up of these users is a daily task in the ESF, and is conditioned to the commitment (to the other) both of the professional who refers and also of the one who receives the patient. According to Escorel et al. (2007), communication and information exchange among professionals is very important for the function of coordination attributed to the ESF and to guarantee continuity of care.

This characteristic of a network of interconnected services with links that give logic and meaning to the hierarchized health system constitutes a fundamental element in the issue that has been discussed in this study, as access without integrality of care limits the universalizing character of the system. In this perspective, it is important to remember the criticism made by Cecílio (1997) against the hierarchy of the healthcare model of SUS: besides the fact that this hierarchy, in practice, does not fully function (for reasons that cannot be explained here, due to the limit of space of this paper), this model is based on the notion of full functioning of a network whose constraints are felt already in the entrance door. Thus, a referral and counter-referral mechanism based on ESF tends to fail in its essential function, which is the guarantee of what Cecílio (2006) has called "amplified integrality".

Sociocultural dimension

The reasons why users attend the healthcare units of this study expressed the priority demand for actions and services related to disease control or cure and/or reduction in some discomfort or indisposition, as the fragment below shows:

According to Cohn et al. (2002), the predominance of users' references to individual and immediate consumption of the service shows that health is hardly seen and based on a collective perspective, situated in the sphere of citizenship. On the other hand, the offer of services presents a similar character, being constituted mainly of healthcare actions. Therefore, it is a pattern of supply and demand in keeping with an understanding of the health-disease process centered on the biomedical model of healthcare, a conception that is fought by the reforming ideals of the Brazilian public health.

As regards the concern about health, this was related, by one of the users, to impossibility of working, or to the difficulty in getting a job due to an illness. This difficulty in having access to a reference service not only maintained but intensified his situation of shortage, both of a job and of treatment.

The mode of insertion of the individuals in the job market - and the degree of freedom that this insertion provides - may constitute an important limit, related: to the material conditions of existence in this society, to the user's attendance at the unit and to the search for the assistance he needs, as can be observed below:

According to Minayo (1999), in the capitalist society, the body represents the "workforce", the only form that the individuals who do not own the means of production have of reproducing themselves, or, in other words, of maintaining their material conditions of survival. Therefore, from this derives a painful existential experience, "representative" of a reality in which the body constitutes the only source that generates goods. This understanding finds echo in other studies. Barbosa and Coimbra Júnior (2000) identified, in a research into schistosomiasis in a rural community of the Brazilian Northeast region, that this disease only started to be considered by the adults as serious when it disabled them from working or made the children be absent from school. Following the same reflection, Bercini and Tomanik (2006), in a study developed with fishermen's wives in the municipality of Porto Rico (Southern Brazil), observed that, among the interviewed women, there was the perception - constituted of meanings and values that belonged to that locality - that a healthy individual is the one with disposition and capacity to work.

The community's participation is one of the fundamental principles of SUS, and implies sharing power and responsibilities when making decisions which, after all, affect all the involved individuals, and whose success, in case it occurs, will be earned by all. Due to this, participation should be stimulated and, above all, promoted by the ESF professionals, as the Ministry of Health (Brasil, 2006) recommends. But, in a context of daily interaction (which is not always pacific) between players in different power positions, with distinct interests and possibilities, the participation idealized by SUS becomes a project which has not been finished yet, as the experience reported below corroborates:

The incipient experience in the field of social participation, both of professionals and users, added to the insufficient qualification of the two groups, draws a conflicting picture in the local sphere, in the very space in which the closest relationships (in all their dimensions) among these players take place.

Economic dimension

Economic issues are almost always highlighted in studies related to access to health services (Elias et al., 2006; Ribeiro et al., 2006; Travassos et al., 2000.). Such studies constantly refer to an inversely proportional relation between the individuals' socioeconomic situation and the possibility of access.

A favorable aspect in this dimension was the availability of medicines at the healthcare unit. However, in spite of the fact that the USF pharmacy is stocked on a monthly basis, it does not receive the amount of medicines that corresponds to the need of all users. This makes the search for medicines become a process that requires agility, because the guarantee is for those who arrive first (before they end). Thus, at the same time it was a facility - because, although in small amounts, the medicines are provided at the unit, which is nearby and makes the medicines available for people to fetch them - expenditures on medicines was also a serious difficulty for some users. The deep condition of social injustice to which these individuals are submitted (which already excludes them from access to other goods and products which are indispensable to the maintenance of life and health) deprives them, on a daily basis, of the right to incur this expense:

The discourse of all the professionals revealed the deep knowledge they seem to have of the reality of shortages which is recurrently experienced by the users, whose problems are reflected on the demands to the unit. There is also the feeling of impotence and distress in view of such a cruel reality, degrading of the human condition. In this sense, we highlight the discourse below:

Living in a situation of permanent contact with pain and so many material shortages makes the working environment become complex, as well as the personal and professional interrelations which are processed in the daily working routine. Thus, "institutional symptoms" are produced, such as communication failures or excessive ideologization in defense of the SUS, as mentioned by Campos (2005). It is important to reflect that the understanding of healthcare should always be viewed within the context of the labor relations, of the peculiarities of the work of the care producers (Deslandes, 2005).

Some professionals' discourse about the expenses users must incur when they are referred to other services, belonging or not to the municipal health network, reveals another reality, as shown by the example below:

These discourses reflect the mode of organization of the health services network; they refer to the principle of decentralization with hierarchization and regionalization of the services network. The chronic situation of social exclusion in which the great majority of the SUS users lives hold this model in check when it reveals that it is not articulated to another network - that of social services, including services of income generation. This aspect is fundamental, because this network meets other needs (health needs) linked with people's way of earning their living, with people's precarious material conditions of existence, which result from a scenario of injustices and social inequalities. These aspects have been worrying the set of social players engaged in making public health effectively accessible to all the Brazilians.

Conclusions

This study aimed to evaluate the access to healthcare in the SUS based on the perception of users of the Family Health Strategy, triangulating and confronting it with the point of view of the manager and of health professionals. It was observed that the existence of services, associated with the expansion of the coverage of primary healthcare, although important, does not imply effective access. Due to this, the organizational change arising with ESF has an important implication in the organization of the health system, because primary healthcare was regulated as the privileged form of access, assuming the function of restructuring the entire care model and reorganizing the assistance practices.

In the present study, the analysis of access brought to light aspects of healthcare in Brazil that are already known. The relevant issue, however, is the fact that problems related to access in the ESF reveal the existence of obstacles in the system that may compromise its entire structure of organization and functioning. Moreover, it may imply the exclusion of millions of individuals whose precarious life conditions already deprive them of many citizenship rights.

Elements that facilitate and hinder the access were identified. The facilitating ones were: the working hours, receptiveness and the proximity of the USF services.

1 organizational dimension:

(i) delay to schedule a consultation; (ii) poor functioning of the referral and counter-referral system, compromising the access to specialists; (iii) excessive number of people enrolled in the teams' areas; (iv) delay, at the waiting room, to receive assistance; (v) delay to receive test results; (vi) ESF's low capacity to solve problems, particularly due to the absence of assistance to simple emergencies, implying overloading the services of medium and high complexity.

2 sociocultural dimension:

(i) professionals' and users' lack of preparation concerning the organization and execution of joint actions; (ii) low capacity to visualize the collective perspective of health, situated in the field of citizenship.

3 economic dimension:

(i) expenses on medicines and other inputs.

The ESF, as a strategy to promote the access of people with complex social needs to the health actions and services, proved to be a narrow entrance door, deserving to be evaluated with a more critical look that takes into account the situations that particularize the individuals who request its actions, and services organization based on the subjects' needs.

COLLABORATORS

supervised the investigation, the elaboration of the instruments and data collection, analyzed the data and helped to write the paper.

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i Address: Av. Santos Dumont, 508, apto. 403. Aflitos, Recife, PE, Brasil. 52.050-050.
1 Based on Azevedo (2007); non-financed research approved by the Research Ethics Committee of Fiocruz/CPqAM.
2 When it was created, in 1994, the Family Health Strategy was called Programa Saúde da Família (PSF - Family Health Program).
3 The concept of access is not a consensus in the literature, and the employed terminology is also variable. In the present study, access and accessibility are considered synonymous, and the term access is predominantly adopted.
4 All the quotations have been translated into English for the purposes of this paper.