Water, land, and air: how do residents of Brazilian remote rural territories travel to access health services?

Context of RRM: socioeconomic characteristics and costs of transports

Table 2 presents socioeconomic indicators that are necessary to understand the living conditions in RRM. The national standard and the percentage of the population in extreme poverty and those who are beneficiaries of the federal program that we used as reference show the extreme vulnerability of the cases. The national Gini Index shows the great inequality of income in Brazil. The smaller Gini Index in 18 of the 27 RRM does not indicate greater equality, but only a generalized distribution of poverty. Likewise, the low Municipal Human Development Index of most cases confirms the set of vulnerabilities to which populations in remote rural territories are exposed. Some municipalities have higher values of Gross Domestic Product per capita due to agribusiness and mining activities. Low demographic density, with small and dispersed populations (only in 6 cases with a population above 20 thousand inhabitants), is also a characteristic of the RRM, with important implications for intra and intermunicipal transport.

Table 2 Socioeconomic indicators in Remote Rural Municipalities, Brazil, 2019

Table 3 shows that the monthly per capita income of families was less than US$100 (except in the Central-West). The table, based on the estimated expenditure on fuel by type of transport used (according to climate, geography, and condition of the roads), allows us to infer the magnitude of the impact on the income of families and individuals in the case of trips financed with their own resources, whether internal to the municipality itself (rural area-headquarters RRM) or the headquarter municipality of the health region or capital.

Table 3 Per capita income and estimated travel expenses, rural area—headquarters of the RRM – municipality headquarters of the health region—capital of the state, Remote Rural Municipalities, Brazil, 2019By water, land, and air: means of health transport in RRMElective health transport

The means of transport to access elective health services varied across municipalities and within them. The means used were identified for the following: a) transport to the PCU, specifically, by the populations of the rural area of the RRM and; b) specialized and hospital services provided in other municipalities and used by users in the RRM headquarters and rural areas. In both situations, the means of transport were provided by either the municipal administration or direct expense of users or their families.

As a common characteristic, none of the RRM studied have a structured logistic system for continuous and satisfactory provision of health transport. The transport routes, primarily by land, were often unpaved, especially in rural areas, and vehicles were insufficient, intermittent, and inadequate for the diversity of the population’s needs. Furthermore, the conditions of the roads and the distances to be covered increased the danger of some routes. With the use of motorcycles, the risk of accidents increased. In territories with populations mostly in conditions of a financial shortfall, the elective health transport system was required with considerable frequency and on a large scale due to characteristics intrinsic to the RRM and the location of specialized and hospital services, which were outside of the municipality of residence of the users.

All municipalities had some type of vehicle (minibuses, cars, vans, pickup trucks, boats, among others) funded with their own resources and, therefore, subject to discontinuities arising from budgetary limits and/or management capacity. The less complex municipal ambulances, although considered a modality of urgent and emergency transport, also attended to elective transport in some situation.

In any case, commonly, the provision of transport through municipal resources was primarily intended for users whose socioeconomic vulnerability prevented them from bearing the costs of traveling to health facilities, substantial portion of the population. In one of the cases, it was estimated that, due to the socio-economic conditions of the population, only one in ten residents would be able to pay for transport. In this sense, the funding and determination of priority for the selection of users, generally under the responsibility of the municipal administration, made this resource strongly crossed by clientelist interests.

Specifically, for users traveling to PCU, with rare exceptions, there was no provision of health transport, even to the most remote locations in the rural area of the RRM. Thus, the use of rides on school buses was a recurrent alternative in the territories. As such vehicles did not circulate during school holidays, the flow of users from the rural area to the PHC services located at the headquarters decreased. Another alternative for the residents in rural areas was to travel by foot or drive with their own resources – vehicle, river, animal – ride with neighbors and family members, or be even carried in hammocks with travel that could take up to two days. Aiming at a single cost of transport (outshopping), it was common for users in rural areas to seek health services when they went to the headquarters for other activities (to the bank, lottery stores, market). Thus, they optimize time and resources.

As there is no public transport in the rural area, there was a network of alternative transport for residents of the region, with increased values that compromised the families’ budget. In part of the municipalities where specialized consultations were in the state capital, users were instructed to go to the headquarters the day before on their own, from where the health transport departed. In this situation, it was common for users in rural areas to delay the search for care and seek assistance when affected by acute illnesses or worsening of chronic processes. Sometimes, they used alternatives present in informal subsystems, such as self-medication, teas, and medicinal plants, among others. However, in exceptional cases – bedridden people or people with specific health condition – it was possible to make a vehicle available by the municipal administration to travel from their residence to the health services. In addition, in rural areas, even the contact to request transport was difficult because of the lack of a telephone signal in some areas.

For specialized and hospital services located in other municipalities, the larger the territorial extension, the more was the difficulty in getting around, especially for residents of rural areas. To conduct consultations or specialized examinations, they made two trips to reach there (from the countryside to the RRM headquarters and then to the specialized/hospital services) and two trips to come back, which were sometimes considerably difficult. In some indigenous villages in North Roads, it took up to four days to reach the headquarters of the municipality (about 2000 km away).

In all studied RRM, for long-term treatments (hemodialysis, cancer), some means of transport was guaranteed for the user and a companion, regardless of the financial condition. In these cases, there were vehicles and/or commercial bus tickets paid for by a federal program called Treatment Outside the Home. Even then, the funding of this Program was still insufficient and was often supplemented by municipal resources. Larger vehicles such as vans, available in some wealthier municipalities, served to transport a greater number of users to the locations where continued care was provided.

In addition to the commonly used means, geographic, climatic, socioeconomic, and management specificities present in the RRM, and its territories conditioned various responses and strategies for the provision of means and modes of transport to access elective health services.

For travel to specialized care, in one of the RRM in the North Minas territory, there was a minibus managed by the Intermunicipal Health Consortium. This service, although more costly, was considered safer, as the Consortium was responsible for managing passengers and paying insurance in the event of an accident, which represented a certain amount of legal certainty for the administration. Cars offered by local merchants to the rural population for shopping at the municipality’s headquarters were also used to assist the PHC services.

In a municipality in the Semiarid region, the most viable option was to pay for tickets on intermunicipal buses, whose schedules did not always meet those made in other municipalities. Occasionally, it was “easier” to ensure transport to Salvador (state capital), where commercial buses left at night and arrived in the morning, merely in time for the consultation or examination. In these cases, it was necessary to ensure some type of support in the capital to assist in the mobility of users, especially those from rural areas.

In the Central-West area, the only territory in which all researched municipalities had an average Municipal Human Development Index, with lower percentages of Bolsa Família beneficiaries (Table 2). In this municipalities there seemed to be greater availability of cars, vans, and pickup trucks. Some of these were purchased through parliamentary amendments (federal and state public budget resources legally awarded to parliamentarians for public purposes) mainly to meet the demands of users in the rural area. These resources were used to return to the residence after traveling to the headquarters, travel to specialized services in other municipalities, and transport bedridden people. Such vehicles also served to support the activities of PHC teams, home visits, and sanitary and epidemiological surveillance actions. Therefore, they were not always available to transport users.

In the territory of Matopiba, no specifics were identified in relation to health transport (apart from municipal cars and some vans). It highlighted frequent reports of the administrations and professionals regarding their dependence on their own ambulances, especially on the SAMU (stands for “Mobile Emergency Care Service” in Portuguese) for the transport of users. There were reports of payment for intermunicipal buses for the most vulnerable users (the vast majority), especially in the municipalities belonging to the state of Piauí, which has its specialized health care units located mainly in the state capital.

In the North Waters territory, boats such as “voadeiras” and “rabetas” (small boats with outboard motors), regular boats and water ambulances were used due to geographic and climatic characteristics. In the isolated municipalities (Melgaço, Maués, and Aveiro), there were only cars and other means of land transport at the municipal headquarters. For other areas, only water transport was available. The use of both suffered variations due to extreme climatic conditions in the Amazon. Even municipalities that had public transport (circular buses) or ambulances (extremely frequent) experienced an interruption in circulation due to the need for repairs caused by the precariousness of the roads damaged by the rain. Transport was considered by respondents as the most critical resource for the provision of health services, with the high cost of fuel for river transport being highlighted (Table 3). Both ambulances (more complex structures for emergencies) and common river vehicles were used for elective transport of users; often, part of the route was completed by one or more means of land transport.

In the North Roads, which does not have a water ambulance, in case of trauma, the users themselves sought the service using “voadeiras.” In addition, many journeys by land were interrupted by precarious roads that became impassable (muddy roads) in the rainy season, increasing travel times, costs, and preventing the use of larger-scale transport such as buses. In RRM of North Waters and North Roads, the need for 4 × 4 traction cars and pickup trucks was reported due to road conditions, more frequently when compared to the other territories in the study.

Users of riverside communities in North Waters and North Roads, whose transport was by the river and who did not have boats or “rabetas,” depended exclusively on transport provided by the municipality or community support (relatives and neighbors). Another aspect was the lack of security, as there have been reports of accidents with women in small boats where several other users were traveling, in which women’s hair got stuck in the engine, and they ended up being scalped. For these populations, the Fluvial PCU was one of the ways to take assistance to places of difficult access, minimizing the problem of long distances. The Fluvial PCU was usually moored in central communities with a larger number of families and residents of adjacent communities coming to the vessel for service.

The acquisition of vehicles through resources of federal and state parliamentary amendments was a common procedure. Nevertheless, the cost of drivers, repairs for poor road conditions, and fuel was municipal. Such critical resources collaborated to the discontinuity of the provision of elective transport to the population.

In these cases, the use of vehicles from other sectors such as education, social assistance, and agriculture or requests from social assistance resources to pay for tickets for users and their companions were common.

The assessments of the difficulty in providing elective transport, either health transport or common transport, were unanimous. Occasionally, transport represented a greater challenge than the provision of the health service itself, with even more unfavorable differences for the dispersed population in the interior/rural areas of the RRM. Table 4 presents expressive statements by key respondents that show the challenges and arrangements for the provision of some means of health transport in the RRM. To maintain anonymity, respondents were identified by acronyms that correspond to their category and the state to which they belong, both related to the respective research territory.

Table 4 Summary of “expressive statements” about the challenges for access to health transport, Remote Rural Municipalities, Brazil, 2019Urgent/emergency transport

The municipalities, roughly speaking, had logistics solutions through adequate vehicles to stabilize and/or reverse the troubling situation intended for the transport of people in urgent and emergency cases.

The major means of transport for emergencies is the SAMU of a regional nature. The SAMU, financed through federal and state resources, has mobile prehospital care, with services authorized by doctors in regional regulatory centers located in some municipalities, comprising the State Urgent and Emergency Networks.

For political reasons, not necessarily health ones, some managers wanted to have the SAMU headquarters in the municipality itself, as they considered that they would have easier access to ambulances, although some acknowledged that there was no necessary structure for that. In general, the SAMU ambulances met the needs of the headquarters, with greater difficulties in serving rural areas. For areas with restricted access, the combination between common and adapted transport that move patients to a SAMU ambulance was prevalent, reducing travel time. In some territories, during rainy seasons, residents often do not have access to the SAMU, which, together with PHC professionals, improvised transport in more serious cases.

The municipalities also had their own ambulances, which were less complex but often could not travel along the local roads, roads without pavement, and muddy or drought (sand) roads. It was suggested that ambulances should also have four-wheel drive, as, at certain times of the year, these vehicles were stuck on the roads and could not complete the journey to the health service. In a municipality in Matopiba, municipal ambulances remained in locations far away from the headquarters for emergency calls. In the North Minas and Semiarid regions, the car that took the team to the rural PCU could also be used for emergency transport. In the Semiarid region, another way to guarantee transport was the accreditation of private cars belonging to rural residents to transport emergency cases that could not be conveyed by the SAMU. In North Waters, there were ambulances adapted in boats – water ambulances – for crossing rivers, but they were almost always insufficient to meet the demand of the riverside population. In municipalities in the Amazon region, it was common for the health units (PCU or other health services) located in more distant and isolated areas to have transport (car or speedboat) to take users to the municipal headquarters in urgent and emergency cases.

In rare and extremely serious cases, normally in the Amazon region, air transport was used in small planes but with considerably high costs and generally hired from private companies. It was estimated that air transport had an average cost of R$15,000,00 (US$3,622) between one of the municipalities in North Waters and the location with better assistance resources.

Figure 2 summarizes the means of elective and emergency transport identified in the study by territory and the distances/time between the rural area— headquarters of the RRM—and the headquarters of the health region—the capital of the state, based on secondary data and information from managers and health professionals. It was observed that some trips in water or land vehicles exceeded 1000 km, which is more than 20 h in the North Waters and North Roads territories.

Fig. 2figure 2

Means of elective and emergency transport according to place of departure, distance, and estimated travel times, Remote Rural Municipalities, Brazil, 2019

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