The ESF has been proposed as a priority model for organizing PHC in several aspects, especially in improving accessibility and reducing inequities in less empowered groups of the population17,18. Several studies have found an inverse association between HACSC and ESF coverage19,20. However, in the period studied, ESF coverage in Sergipe remained above 80%, with little variation, suggesting that in this period the effectiveness of PHC can be better assessed by other aspects than ESF coverage. In other words, the changes observed in the period are not due to a change in the supply of the service in terms of population coverage.
In the initial phase of the study, from 2008 to 2014, we observed a decrease in HCASC in Sergipe, which corroborates studies of similar periods in other places such as Goiás (Mid-West region of Brazil) from 2005 to 2015, Pernambuco (Northeast region) from 2008 to 2012 and Espírito Santo (Southeast region) from 2000 to 201421–23. Our research showed a U-curve over time, starting in 2008 with a continued decrease in the HCASC rate until 2011, followed by a stabilization until 2014, the year in which it reached a lower value. From then on, the indicator worsened, with a sharp increase in rates, which, at the end of the period, are similar to the beginning, showing a worsening of the advances achieved. The worsening occurs in all age groups, particularly among children, who have the HCASC rates in 2017 higher than in 2008. Statistical analysis showed that the values found at the end of the period are significantly different from the beginning, indicating that the behavior observed is not the result of random variation. The analysis also shows the aptness of the indicator to describe the outcome of health policies, which is consistent with the conceptual methodological framework that presents it with an indicator of the first level of the health system in all its scope, and not only of the care provided by the health team5,6.
The public policies that preceded and contributed to the performance of the indicator throughout the study period began with the publication of the 2006 PNAB, which marks the transition from PSF to ESF status. Integrative and Complementary Health Practices (also called “Alternatives”) and the National Health Promotion Policy were also important milestones that year. In 2007, the Health at School Programme was created, and in 2008 the Family Health Support Centre (Núcleo de Apoio à Saúde da Família - NASF) was created. In 2011, the second edition of the PNAB, creation of the National Program for Improving Access and Quality of Basic Care (Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica - PMAQ) and creation of the Programs: Requalification of Basic Health Units; Better at Home; Academy of Health; of the teams of Clinic in the Street; of Telehealth Brazil Networks (Telessaúde Brasil Redes); and the review of the National Policy on Food and Nutrition. In 2012, there was the creation of the Basic Care Professional Valuation Program (Programa de Valorização do Profissional da Atenção Básica - PROVAB) and, in 2013, the More Doctors Program (Programa Mais Médicos - PMM) and the substitution of the Basic Care Information System by the e-SUS Basic Care and the Basic Care Health Information System (Sistema de Informação em Saúde da Atenção Básica - SISAB).
This entire set of federal government policies has invested in improving the structure and health process of care, and expanding the accessibility, resulting in better effectiveness of PHC. However, as of 2014, the Brazilian economic crisis had repercussions in the rate of unemployment and increased social inequality, financial cuts, and social instability24, and the indicator began to assume the upward slope of the curve. In this regard, the approval of the Constitutional Amendment 95/2016 that establishes a spending cap in the next 20 consecutive years, along with environmental and educational policies will compromise the sustainability of the SUS and its constitutional premise of universal coverage and other attributes of the PHC24,25. In 2017, there was the third edition of the PNAB, with major setbacks and reformulation in its political orientation, and withdrawal of financial incentives to the ESF, which is why it suffered severe criticism from the Brazilian scientific community25,26.
The most frequent groups of causes in children up to 14 years old were gastroenteritis, asthma, bacterial pneumonia, and ear, nose, and throat infection. There was a significant decrease in gastroenteritis and complications, ranging from 50% of the HCASC in 2008 to 22% in 2017; asthma and pneumonia remained stable in the period. These causes were the same as those found in a study in Minas Gerais, Southeastern Brazil, for children and teenagers27.
A study conducted in Sergipe from 2002 to 2012 on hospital admissions in teenagers showed a 143.1% reduction in HCASC28. In the population of 50 or more years, the most frequent causes were heart failure, cerebrovascular diseases, diabetes mellitus, systemic arterial hypertension, nutritional deficiencies, and angina. A study conducted in Paraná, Southern Brazil, in the range of 60-74 years, presented similar results20. The improvement observed in the indicator before the most pronounced political changes from 2014 onwards was mainly due to more effective attention to the population over 50 years of age. It is notable that even among the very elderly, rates improved a lot, and then worsened. These results show that the exclusion of the elderly in studies that address the HCASC can be a mistake, since it was shown that it responds to the political actions driving the PHC. Thus, we should continue analyzing the indicator with all age groups - consistent with the principles of universality, equity, and integrality of PHC.
This study has its limitations, most dependent on the quality of information, as it uses secondary data, and the fact that SUS, despite being an universal system, has not total coverage of the hospital admissions. So, it is important to emphasize that about 88% of hospital admissions in Brazil are through SUS29. Nevertheless, the SIH-SUS has shown high reliability for the study of HACSC30.