Difficulties in Accessing Medical Surgical Care in the Amazonas

Abstract

Despite over half of Amazonas’s inhabitants residing in rural areas, few specialized health services are available to them. Most advanced health services, including hemodialysis, are concentrated in the state capital, Manaus, leaving those in rural areas without access to proper healthcare. The population of the interior is devoid of units of health. This is partially due to the region’s challenging geography, making it difficult for rural populations to reach Manaus. All surgical hospitals in cities surrounding the capital are publicly funded, with no private healthcare options available in rural Amazonas. The Lancet Commission on Global Surgery, an international initiative, has proposed a model for analyzing the health system, especially the surgical system, to achieve universal access to safe surgery and anesthesia by 2030. Funding is a crucial factor in making this possible and providing better access to healthcare for all. A comprehensive analysis of the health system in the state is necessary to guide public policies, optimize future healthcare investments, and improve access to clinical and surgical treatments for the population.

1. Introduction

In the late 1980s, the “Health Reform Movement” was launched in Brazil to oppose the military dictatorship. As part of this movement, the single health system, known as SUS, contemplated by civil society, is today a successful reform model and an example of a health system for Latin America [1]. It played a crucial role in the re-democratization of Brazil and the restoration of citizens’ rights [2]. Reforms in health system governance and the growth of primary healthcare (PHC) have led to considerable enhancements in health service coverage, accessibility, and outcomes [3, 4, 5].

The Brazilian health system has a mixed coverage, mixing elements from the public and private spheres, not only in terms of service provision but also in terms of funding [6]. It comprises a diverse range of primary, secondary, and tertiary health services. These services are predominantly funded by public financing, with private involvement mainly in the secondary and tertiary sectors. Either companies or users themselves pay for private health plans.

The organization and delivery of health services are divided into Primary care, Secondary care, and Tertiary (hospital) care. The first is the public sector, where the government provides financing and services at municipal, state, and federal levels, including healthcare for military employees. The second sector is the private sector, which includes for-profit and non-profit organizations. These services can be paid for with public funding or directly by the user. The last sector is private health plans, which offer various premiums and tax subsidies. Although distinct, the public and private sectors are interconnected since users can access both, and financing can come from either the government or the user. The private health sector provides additional hospital and outpatient services alongside the public system. Most of the funding comes from public sources, with other private contributions. Health plans are mainly used by employees of both public and private companies [2].

The primary health care model intends to offer universal access, and the Family Health Program (Programa Saúde da Família -PSF) has been the primary strategy for structuring municipal health systems. It consists of a program composed of several primary health care units, containing medical and nursing professionals, distributed among the municipalities, aimed at primary disease care, such as systemic arterial hypertension, diabetes mellitus, and care for pregnant women, among others. The PSF’s primary goal is to organize small health units in each city’s health districts that cater to families and communities. These units focus on preventive measures and health promotion. Additionally, they act as a triage system for secondary and tertiary health levels.

One of the significant challenges in the healthcare system is at the secondary level. This level comprises units responsible for conducting various types of medium and high-complexity exams. These services have a limited supply and are mainly for the private health plan sector [7, 8]. Access to equipment in the public healthcare system is limited, with only 24.1% of computed tomography devices and 13.4% of magnetic resonance devices available for public use. The situation is even more challenging at the tertiary level, where highly complex and costly surgical procedures are performed. Public university hospitals and private hospitals contracted by the government are responsible for providing these services, adding to the challenges [9].

The State of Amazonas is one of the seven states in the North region of Brazil. It is located in the central part of the country’s northern region and is part of the Amazon Biome. It is part of the Legal Amazon, together with the states of Amapá, Acre, Tocantins, Rondônia, Roraima, Pará, north of Mato Grosso, and west of Maranhão. It borders Venezuela and Roraima to the north, Colombia to the northwest, Pará to the east, Mato Grosso to the southwest, Rondônia to the south, and Acre and Peru to the southwest (Figure 1). It is the country’s largest state in terms of land area, covering 1,559,161.682 square kilometers and 62 municipalities. It also has 97% of its forest cover preserved, in addition to about 12% of the total fresh water in the world, being considered therefore the largest freshwater reservoir on the planet [10]. The total population, according to the last census carried out in 2022, is 3,952,262 inhabitants, representing about 2% of the country’s population, who live primarily in urban areas, with more than half (2,054,731 inhabitants) residing in the capital and has the second-lowest demographic density (2, inhabitants per km²) among the Federation Units [11]. This entire population is distributed in 9 health regions, described in Figure 2.

Figure 1.

Map of Amazonas with limits.

Figure 2.

Map of Amazonas distributed by health regions and their municipalities.

The vast expanse of Amazonas state poses significant challenges for its healthcare system. Transportation between cities is primarily through rivers, which can take hours or even days. Small aircraft are also used but are expensive and not accessible to most people. Only a few cities have highways connecting them to the capital [12]. Because of the diverse population distribution in the state, health management requires a resourceful and expensive approach. This involves transporting patients by boats and planes, utilizing telemedicine, and relying on surgical missions.

Although there are hospitals in rural communities throughout the state, there is a need for more advanced facilities for major surgeries and specialized exams, like magnetic resonance imaging [10]. Complex hospital units are limited in their ability to provide essential surgical procedures and emergency surgeries due to a shortage in the surgical workforce. Surgeons, obstetricians, anesthetists, and surgical nurses are particularly affected. Despite their skill, they often lack the necessary equipment to perform complex surgeries. This is due to a lack of specialized professionals, infrastructure, and access to material and financial resources. As a result, service provision is often precarious [13].

For many, access to secondary and tertiary-level hospitals requires days of travel and high transportation costs, which is often unfeasible for a large part of the population.

2. Major health indicators

Brazil is an upper-middle-income country that, despite its universal health coverage scheme, has dramatic regional variations in healthcare access and quality [14, 15]. Within Brazil, the state of Amazonas is one of the poorest states with the most significant challenges in accessing health care, mainly due to limitations in workforce and infrastructure [16]. The state’s inadequate diagnostic services may worsen challenges in providing safe, timely, and affordable care.

The Lancet Commission on Global Surgery (LCGS), an international initiative, has proposed a model for analyzing surgical systems. In its Global Surgery 2030 report, published in May 2015, the Commission describes its vision of universal access to safe surgery and anesthesia and establishes that funding is essential for its viability, providing better access to all [17]. To achieve this level of access, the Commission proposes a two-step analysis method: first, it proposes six indicators to assess the strength of a region’s surgical system—timely access to essential surgical care, number of surgical teams, volume surgery, perioperative mortality rate, protection against impoverishment, and protection against excessive expenses [18]. These indicators aim to quantify the preparation and capacity of the Surgical System and the system’s ability to protect patients against financial risks. Second, the commission proposes structuring the surgical system that considers regional characteristics and contexts in a particular way. The main components of this plan are: 1—infrastructure, 2—workforce, 3—provision of services, 4—information management, and 5—financing [18].

To assess the quality of a healthcare system, a qualitative and quantitative mixed methods Hospital Assessment Tool (HAT) was developed [19]. The HAT tool was developed jointly with the Global Surgery and Social Change Program and the World Health Organization (WHO). The instrument assesses the infrastructure of a surgical system, service delivery, workforce, information management, and funding through hospital interviews, reviews of medical records and surgery books, as well as interviews with unit directors and some providers responsible for surgical care (surgeon, anesthetist, obstetrician, nurse, and hospital managers). An initial HAT pilot project was conducted in Cape Verde, Ethiopia, and India. The tool was then adjusted and validated by 18 experts (Delphi consensus) [20].

The tool has been recently used in Brazil’s largest state, Amazonas, which also has more difficult logistical characteristics, to identify priority areas for system improvement and health policy changes, as perceived by patients and local providers. The tool’s implementation involved a partnership between the University of the State of Amazonas (UEA), Harvard Medical School, and the University of São Paulo (USP). Understanding this region’s deficiencies and strengths helped identify the main gaps in the delivery of medical services in the state.

2.1 Health infrastructure

A peculiar characteristic of the state of Amazonas refers to its geography since it is crossed by several rivers. This makes access to cities very difficult. Because of this, the general infrastructure of hospital units in all cities is quite deficient. We can see a direct reflection of this geography when we observe that all hospital units in these cities (except for the capital) are public, with no private medical assistance at the hospital level outside the capital Manaus.

These hospitals generally provide clinical, surgical, obstetric, and pediatric care. In some cases, such as in the city of Careiro da Várzea, located close to the capital and with an estimated population of 30,846 people, only primary health care is provided, with no capacity to perform surgical procedures (Figure 3).

Figure 3.

Basic health unit working as a hospital.

Our study shows that district hospitals in low- and middle-income countries often experience water, oxygen, and electricity shortages, whereas our findings indicate better infrastructure [21, 22, 23]. According to the survey conducted, almost 95% of the hospitals located in the Amazonas interior are equipped with piped water and a consistent supply of electricity. However, only one hospital provides channeled oxygen, while others rely on cylinders. Essential radiology services are available 24/7 in 83.3% of the hospitals, while half of the units always have ultrasound services available [13]. Computed tomography or magnetic resonance imaging equipment is available in only one hospital [24].

The biggest problem found regarding infrastructure refers to the number of hospital beds. Among the 18 hospitals surveyed, there were a total of 620 beds available, with an average of 34 beds per hospital (ranging from 4 to 102). None of the hospitals included in the study had an intensive care unit (ICU). Most hospitals had 1–2 operating rooms (as shown in Figure 4). Three hospitals (16.7%) had no operating rooms [13].

Figure 4.

Typical remote hospital operating room.

2.2 Medical workforce

From 1970 to 2011, the population of physicians grew by 530% in Brazil. In that same period, the Brazilian population grew by 104%. The speed of evolution of the doctor/inhabitant ratio will be further accelerated with current government policies that have considerably increased the number of medical vacancies [25].

In 2011, a resident of the capital of any state in the South and Southeast had four times more doctors than a resident of any other region in Brazil. The federal government publicizes that the problem is the general lack of doctors in Brazil, expressed in a single rate for the entire country. But the problem is another: the inequality in the distribution of physicians, with a super concentration of physicians in the private sector and different cities and regions [26].

The differences stand out even more when the capitals are separated from the cities in the interior and when the population strata group municipalities. For example, 65.9% of Brazil’s physicians practice in capitals, while only 24% of the national population lives there [27]. An extreme example is that of Amazonas, where 93.1% of doctors are found in the capital, Manaus, which, in turn, is home to just over half of the approximately 4 million inhabitants of the state. Likewise, only 56% of practicing physicians in the North completed residency training, compared to 78% of physicians working in the country [27]. Of the 4844 doctors in Amazonas, 4508 are in the capital, and 336 (6.9%) serve 62 municipalities spread over an area of 1.57 million km². Doctors from Amazonas represent 1.1% of the total number of doctors in the country [28].

In Brazil, the government’s health scheme (SUS) is one of the world’s largest public health care systems, aiming to provide universal health coverage to all Brazilians [27]. However, the major problem is related to the workforce at regional levels. Availability of specialist care varies by region, as only 56% of physicians in the North complete specialist training compared to 78% in the Southeast [15, 27].

In Amazonas, when analyzing the data collected directly in the hospitals of each city, it is notable that the workforce, especially in the surgical specialties (surgeon, anesthesiologist, and obstetrician), is the biggest problem. The surgical workforce across the state of Amazonas remains limited, with a density in the sampled regions of 6.4 per 100,000 compared to a target of 20 per 100,000 [17]. This density is lower than Brazil’s overall density of 34.7 per 100,000 and interestingly, it is much lower than the modeled estimate for the northern region of 18.42 and for the state of Amazonas itself which is 23.82 per 100,000 inhabitants, highlighting the need for validated assessments at the local level [15, 29]. Some of these differences could be explained by the fact that 90% of the surgical workforce is concentrated in Manaus, the state capital, while in the rest of the country, just over 50% of the surgical workforce is focused on the state capitals [29].

Surgical workforce shortages, particularly in resource-poor environments, often lead to healthcare providers performing procedures without adequate training. Due to a lack of anesthesiologists, some surgeons perform anesthesia for their operations. Another observation was that there are some situations where non-surgeons routinely practice surgery and non-physicians perform procedures, often needing more training or supervision.

2.3 Service delivery

It is possible to make important considerations regarding the available supply of health services in Brazil. The majority of hospital services are privately owned: 62% of establishments with hospitalization and 68% of beds in the country. An even greater concentration is observed in relation to units providing diagnostic and therapeutic support services—SADT (92%). In contrast, most outpatient units (78%) are state-owned [6].

National surgical volume is an important parameter to assess the quality of medical services provided and correlates with maternal mortality rates MMRs. The countries with a surgical volume above 5000/100,000 have the lowest MMR [18, 30]. Simply measuring the total volume of surgeries performed does not ensure that necessary surgeries are carried out safely and on time. However, it is generally assumed that countries with higher surgical volumes also have higher rates of emergency and essential procedures [31].

In Brazil, the public sector alone performs 4337 surgical procedures per 100,000 people, which is close to the suggested minimum of 5000 procedures/100,000 [15]. It is crucial to examine the quality and case mix of surgeries, as well as personnel appropriateness. In particular, selective overprovision of surgeries such as Cesarean section [32, 33, 34] may be harmful to patients and draw resources away from the provision of other necessary procedures.

The low concentration of specialist physicians is reflected in the low volume of consultations and surgical procedures performed in remote hospitals in the interior of the state. The average number of surgical procedures performed in the capital Manaus is about 60 times greater than in the rest of the municipalities, much lower than the target proposed by one of the LCoGS indicators, which is 5000 operations per 100,000 people [13, 18]. This demonstrates the almost total dependence of the state on the capital for surgical care.

2.4 Health information management

Since SUS was implemented, several tools have been built to meet the Public Health demand, constructed by collecting data from the various information systems. The main tool comes with the creation of DATASUS in 1991, whose data provides concrete justifications for a series of public policies in health. The information acquired from the different systems of information comes with creating a department where it is possible to store large amounts of data, which can support public health policies [35].

Health Information Systems (SIS) are instruments that, through the processing of data collected in health services and other places, support the production of information for a better understanding of problems and decision-making within the scope of policies and care in health [36]. In Brazil, when these systems have national coverage, they are called national data sources under the management of the Unified Health System (SUS), SIS with national coverage or national base, with custody of the data and software maintenance usually under the responsibility of the Ministry of Health [37].

An important point identified in the evaluation of data directly in the units was the observation of information that differed from that found in the database of the Ministry of Health (Datasus) [24], such as, for example, the description of surgical procedures performed in the hospital unit of the municipality of Careiro da Várzea, which functioned only as a basic health unit, not performing any surgical procedure. This highlights the importance of this database and the need for proper feeding of this database.

2.5 Financing

In Brazil, the financial transfer to health service providers is carried out by the level of government responsible for its management, which may be municipal, state, or federal. Assessing the quality of a healthcare system involves considering general healthcare spending as one of the main factors. The total health expenditures in Brazil are similar to those in other Latin American countries. However, public spending needs to be improved for such a broad health system, leading to an overwhelming burden on the users [1]. When we compare public health expenditures, Brazil has one of the lowest proportions, around 46%, while Latin America and the Caribbean average 51.28%. In upper- and middle-income countries, these expenses rise to 55.2%, and the Organization for Economic Cooperation and Development countries recommends that these expenses should be around 60%. It is important to note that although private health plans can compensate for low investment in public health, they can also be a significant financial burden for families, accounting for approximately 50% of private health expenses [38].

Regardless of which sphere performs the payment, SUS uses the same information system for Outpatient Services (SIA) and another for the Hospital Information System (SIH). Although the payment for the service provided is decentralized, in the specific case of hospital admissions, the processing of information by SUS is carried out centrally by DATASUS. Thus, the entire public system uses a single price list, defined by the Ministry of Health, for payment to health service providers [39].

In Amazonas, most remote hospitals receive funding from the government, varying according to hospital production and surgical procedures performed in the units. Therefore, there are no direct expenses for the user. However, costs such as commuting, abstaining from work, and purchasing medication cannot be measured using the tool (HAT). In most developing countries without a public health system, the expense of surgery acts as a roadblock for people looking to receive prompt surgical treatment. It is a significant factor in their decision not to seek medical attention [40, 41, 42, 43].

3. Conclusions

To ensure that the population of Amazonas outside of Manaus has access to safe, timely, and affordable healthcare, it is essential to evaluate health indicators at the state level and develop a plan for implementing public health policies. This is especially important given the unique geosocial makeup of Amazonas and the limited state authority on health. It is also important to assess hospital infrastructure in remote areas to identify areas for improvement and understand the barriers the remote population faces in accessing surgical care.