This study allows for important reflections on the human health policy articulated in the FHS. Although all municipalities in the state of Goiás have implemented PNAISH, only 88.6% ran specific interventions in the last years of the study, confirming the need for investments in strategies that address the specificities of males.
The overall death rate in the male population was higher than that in the female population (59.7% vs. 40.2%), following national and international trends. In addition, 19.3% of deaths in men were due to CSPCs, i.e., preventable diseases that could be resolved in primary care [1, 29-31]. A study conducted in 2017 on the epidemiological profile of male mortality corroborates the results found in this study, indicating a higher proportion of male deaths from preventable causes in the age group of 50 to 59 years. These results may be partly explained by the fact that men prioritize work over prevention as young adults [2].
The present study showed a significant increase in the average FHS coverage in the municipalities, but still far from the recommended value. This growth did not occur uniformly: Some of the municipalities had coverage below 80%, which is therefore reflected in deaths from CSPCs. Similarly, Andrade et al. [32] identified that the growth of FHS coverage in Brazilian municipalities occurs heterogeneously and associated this heterogeneity with financing mechanisms, the size of the population, and the continental size of the country.
The insufficiency of resources transferred by the federal government to municipalities compromises the quality of actions and of health care, forcing managers to focus their efforts on public policies of other demographics that have already shown success and have robust government criteria for evaluations, to the detriment of men’s health policy, thus perpetuating the alienation of men from the health services, consequently raising their vulnerability to illness [33].
The spatial analysis indicated a geographical variation in the pattern of deaths in the municipalities under study and the spatial identification of risk areas for deaths due to CSPCs. This variation may be related to municipalities with low coverage of the Family Health Strategy and/or absence of quality actions related to human health, given that PNAISH is implemented in all municipalities in Goiás. It can also be inferred that this variation is related to the fact that the municipalities of Goiás are heterogeneous, differing from each other in a number of characteristics, such as size, population density (more than half of the municipalities have less than 10,000 inhabitants), level of socioeconomic development, and provision of health services [23]. Thus, it is urgent that we homogenize FHS coverage, as well as take more effective intersectoral actions to promote human health in all municipalities of the state of Goiás.
Our investigation showed that the groups of CSPCs that caused the most deaths were DM, cerebrovascular diseases, SAH, HF, and lung diseases. Several studies have reported results similar to these. This may suggest that men do not seek health care with a focus on disease prevention or that there are failures in primary care [2, 29, 30, 34]. Several of these diseases have been the subject of exclusive public policies instituted by the Ministry of Health within the scope of FHS for more than three decades, such as the fight against noncommunicable chronic diseases, which addresses four main diseases (circulatory, cancers, chronic respiratory diseases, and DM), and the establishment of the National Programme of Pharmaceutical Assistance for SAH, DM, and Asthma, that have targeted other population segments, for example, the elderly [35-37].
Our findings point to a trend towards stability (p > 0.593; β = 1.01) of deaths in general (when all groups were analysed together) due to CSPCs throughout the time studied. The only specific cause of death that showed a falling trend was heart failure. It is important to highlight the increasing tendency of deaths from bacterial pneumonia, asthma, hypertension, epilepsy, kidney and urinary tract infection, and skin and subcutaneous tissue infection and the tendency toward stability of deaths due to DM. The high mortality from these groups of CSPCs in men warns us of the need for a perennial evaluation of the programmes focussed on chronic conditions, which could observe if there is a possible relationship with the quality of the actions taken and the vulnerability of the population segment studied here, associated with the severity of the diseases of these cause groups or pre-existing comorbidities [9, 38-40]. In addition, deaths related to diseases preventable by immunization and sensitive conditions ranked eighth among the 17 groups of CSPCs. Several scholars describe how the National Immunization Programme has expanded and impacted the morbidity and mortality profiles in Brazil, including the eradication of numerous diseases [41].
The data also reveal that there are weaknesses in primary care, which may be linked to the low adherence of men to health services, particularly for preventive actions [13, 21, 33, 42]. Thus, it is necessary to sensitize the male population to self-care and expand the active search for men who have difficulties accessing health services. We believe that diseases preventable by immunization and sensitive conditions should be closely monitored, considering the current public-health impact of SARS-CoV-2 and the anti-vaccination movement.
It is noteworthy that the deaths occur at an economically active age in a target demographic covered by a specific policy, indicating an important socioeconomic and cultural impact on the state of Goiás, demonstrating the need to disseminate appropriate actions in an organized and planned manner according to the analysis of the health situation of these locations and the health care network. In this sense, the encouragement of intersectorality and transversality between existing public health policies could help minimize mortality rates among young adult men [9, 21, 33, 42].
The unprecedented nature of government policies for men in Brazil and other countries, by emphasizing the health of men, shows institutional barriers related to cultural issues and models of health care for men. According to several studies, the male population cites obstacles to the use of health services, the shame of exposing oneself, impatience in waiting for care, the lack of time, and the failure of the health care system to resolve their health needs. The fact that men still do not feel a part of the health services and do not see primary care as a gateway to health services are also factors to be considered. In addition, the centralized management of services, inadequate training of health professionals, the lack of appropriate training to provide quality health care, and the fragmentation of services provided to men have been cited [9, 10, 13, 21, 33, 43]. Thus, it is imperative that the FHS formulate a men’s health policy to ensure it is the men’s first health-care contact and that it develop strategic actions to address the male audience by sensitizing them to the health service and self-care to make them realize the health service and make use of the actions offered [9, 10, 21, 42, 44]. Countries such as Ireland and Australia have bet on strategies to sensitize men regarding their well-being and health services, developing continuous training on "Human Health" for health professionals in general and primary-care nurses specifically, which may explain the success of its policy [45, 46].
The present study showed that there was no relationship between mortality rates due to CSPCs in the investigated population of the municipalities and FHS coverage, although this coverage increased by an average of 6% per year during the study period. A priori, the data are surprising and lead us to question the effectiveness of the FHS. However, there is a body of evidence that proves the effectiveness of the FHS [14, 15, 20, 47]. Therefore, it is necessary to consider that numerous factors in this evaluation contributed to the fact that men remain invisible in and through health services, ranging from individual vulnerabilities to social and programmatic vulnerabilities.
On the other hand, relationships were found between FHS coverage and mortality rates due to CSPCs in the groups of diseases preventable by immunization and sensitive conditions; infectious gastroenteritis and complications; nutritional deficiencies; ear, nose, and throat infections; asthma; angina; epilepsy; kidney and urinary tract infections; infections of the skin and subcutaneous tissue; and gastrointestinal ulcers. Discussions of this topic should include that access to the health system can be an important barrier for men in the care of their chronic conditions, whereas they can be assisted when the malady is acute [13, 17, 18, 20, 21]. A study considered a reference correlated the increase in FHS coverage with the tendency to reduce mortality rates from preventable causes of people under 75 years of age in both sexes. According to the authors, it is essential to expand the provision of primary health care, coupled with strong local governance to impact mortality rates, to obtain improvements in health outcomes in terms of reducing avoidable mortality rates [48].
The discontinuity of policies and structural changes in already consolidated programmes needs to be mentioned, since in Brazil, from 2016 to the present, a period of great political and economic fragility has been arisen from changes in labour rules and threats to the SUS [49, 50]. The Prevent Brazil Programme, established in November 2019 by the Ministry of Health, which establishes a new funding model for primary health care, highlights some of these losses. The establishment of this funding model threatens the FHS because it starts to consider registered people instead of registered teams, in addition to not favouring the implementation of actions specific to a given territory or population [51, 52]. It is believed that the evolution of the legislation of the SUS and its funding, the institution of new forms of team models for primary care, and the impacts of the current pandemic can discourage the inclusion of the attributes of the FHS, compromising health care and thus, causing health indicators to rise [49, 50, 51]. It seems appropriate that society as a whole be positioned to protect the current Brazilian health system and that there be advances in studies that evaluate the impact of PHC on the health levels of the population.
An important limitation of this study is the existence of underreporting of deaths and incorrect inputs into the mortality information system, which can interfere with the reliability of the data produced. A strength of the study is the fact that it evaluates deaths due to CSPCs in men aged 20 to 59 years, a vulnerable group on which there is too little research, but which is the targe of the most recent government policy of the SUS, which still lacks consistent evaluations.