Accessibility of people with disabilities to public health services

ORIGINAL ARTICLE

HILGERT, Adriano Conttri ^[1], SLOB, Edna Márcia Grahl Brandalize ^[2]

HILGERT, Adriano Conttri, SLOB, Edna Márcia Grahl Brandalize. Accessibility of people with disabilities to public health services. Revista Científica Multidisciplinar Núcleo do Conhecimento. Year 04, Ed. 04, Vol. 01, p. 05-27. April 2019. ISSN: 2448-0959, Access link: https://www.nucleodoconhecimento.com.br/health/accessibility-of-people

ABSTRACT

The person with a disability or reduced mobility has limitations that can make it difficult and impossible to move and perform tasks. The right to health is a constitutional commandment, being a right of all and a duty of the State to operationalize public service. The universality and gratuity, integrality and equity of the right to health by the Unified Health System (SUS) affects the entire Brazilian population, but in practice these principles have assumed a utopian role. Accessibility is to ensure that people with disabilities have access to health services, on an equal basis with other people. However, there are difficulties in access. The study aims to analyze the accessibility of people with disabilities to public health services. The method of literature review was used, carried out in specialized and complementary sources, and databases from 2006 to 2017. The concept of access, accessibility and accessibility barriers, legal frameworks, and an analysis of the accessibility and barriers faced by people with disabilities to health services. The results indicated that socio-organizational barriers and geographic barriers interfere in the accessibility of people with disabilities to health services. It is concluded that accessibility is equalization of opportunities in all spheres of life, but different types of barriers make it difficult for people with disabilities to access health services, contrary to the principle of equity of the SUS.

Keywords: Accessibility, People with Disabilities, Health Services, Barriers.

1. INTRODUCTION

The present study addresses the issue of accessibility for people with disabilities, limited to health services.

The interest in the subject of study is justified by its importance for the effective social inclusion of people with disabilities in public health services. People with disabilities or reduced mobility face external and internal difficulties in accessing health services. The Federal Constitution of 1988 dispensed with differentiated treatment for people with disabilities so that they can enjoy their basic right, human dignity. Access to health services is a determinant of quality of life. This study can offer subsidies for changes in the way of thinking about accessibility and the access of people with disabilities to public spaces, with equal conditions. For that, the concept of access, accessibility and accessibility barriers is based, and the look at the legislation.

Access and accessibility are complementary concepts. “Access” represents “degree of fit between clients and the health system”, attributes of “availability” of a service relative to people’s needs. “Accessibility” represents “dimension of access” in relation to “the geographic distribution of services and customers”. (ALBUQUERQUE et al., 2014, p. 183). Accessibility is quality, being “accessible”, where you can get there easily. (LOUGHBOROUGH, 2006, p. 1).

Accessibility barriers are obstacles, architectural or structural, faced by people with disabilities that make social integration difficult. Godoy et al. (2000 apud PAGLIUCA et al., 2007, p. 2) states that it is “possibility and condition of safely and autonomously reaching buildings, furniture, urban equipment, transport and means of communication”.

The difficulty of accessibility for people with disabilities has been changing since 1981, with the establishment of the International Year of Persons with Disabilities (AIPPD) by the UN. In Brazil, Laws nº 7.853/89 and nº 13.146/15, and the National Conferences on the Rights of Persons with Disabilities, promote social integration and a change in attitudes. (BRASIL, 2012, p. 46).

Change has been taking place, but data indicate that 23.92% of the Brazilian population has some type of disability. (IBGE, Demographic Census, 2010).

In view of the above, we seek an answer to the research question: What is the relationship between accessibility and barriers to access for people with disabilities to health services? It is not possible to speak of the right of all, without equality.

The research has as general objective to analyze the accessibility of people with disabilities to health services. And as specific objectives: to point out legal landmarks of accessibility; analyze accessibility; identify types of barriers to accessibility of people with disabilities to health services.

2. THEORETICAL FRAMEWORK

In order to understand accessibility and the barriers that make it difficult for people with disabilities to access health services, this reference analyzes the legal frameworks for accessibility, accessibility and accessibility barriers to health services in the literature.

2.1 LEGAL FRAMEWORKS ABOUT PEOPLE WITH DISABILITIES

The International Year of Persons with Disabilities (AIPPD) is an international milestone in the accessibility of people with disabilities to health services. (LOUGHBOROUGH, 2006, p. 1).

The VIII National Health Conference (CNS) discussed health as a right for all and a duty of the State. Access to health services was affirmed as an “integral and inseparable part of the individual’s general health”, directly related to quality of life. (BRASIL, 1986, p. 7).

The Federal Constitution of 1988 defines “health as a right of all and a duty of the State” (art. 196), constituting the most significant national landmark, as it guarantees universal and equal access to actions for its promotion, protection and recovery of people with disabilities. deficiency. Establishes the Unified Health System, defining action guidelines and responsibilities. It provides specific guidelines for people with disabilities, aiming at facilitating access to collective goods and services and eliminating architectural prejudices and obstacles (art. 227, II, and § 2). The establishment of specific norms is referred to the special law. (BRASIL, 1988).

Law No. 7,853, 10.24.1989, extends legal support to people with disabilities, providing “on support for people with disabilities and their social integration”. This Law establishes “general norms that ensure the full exercise of individual and social rights by people with disabilities, and their effective social integration. Provides for the accessibility of people with disabilities to health services, establishing priority and adequate treatment, and guaranteeing access for people with disabilities to health services. It also has provisions for the areas of buildings and public roads. (BRASIL, 1989).

The Organic Health Law, Law No. 8,080/90, reaffirms the role of the SUS in the formulation and execution of the training and development policy for human resources for health, as well as the functioning of services, establishing the principle of universal access. (BRASIL, 1990).

Decree No. 3,298-99 defines disabilities and regulates Law No. 7,583/89, provides for the National Policy for the Integration of Persons with Disabilities, consolidating the standards of protection and equalization of opportunities, and “the guarantee of access for person with a disability to public and private health establishments and their adequate treatment under appropriate technical norms and standards of conduct”. (BRASIL, 1999).

Law nº 10.098/00 establishes general norms and basic criteria for the promotion of accessibility (art. 1) and inserts in the items of art. 2, definitions of accessibility, barriers, urbanization element, urban furniture, communication and universal design, among others, are amended by Law No. 13,146, of 06.07.2015. From this perspective, it defines accessibility and barriers, among other elements.

Barriers are classified, according to inc. II, of art. 2 of Law nº 10.098/00, in the wording given by Law nº 13.146/15 in: urban planning; architectural; in transport; in communications and information. The same article defines: elements of urbanization; urban furniture; assistive technology; communication, tactile communication, large characters, multimedia devices, plain language, written and oral, auditory systems, information and communications technologies; and universal design. (BRASIL, 2000).

The Brazilian Standard NBR 9050 (ABNT, 2004), regulates the right to accessibility for people with disabilities in Brazil, based on human and citizenship rights.

The implementation of the National Primary Care Policy (PNAB), by Ordinance No. 648/06, put Family Health “in place of a priority strategy for the organization of Primary Care (AB)”. Accessibility considers the available structure (existence of barriers), proximity of services to the users’ residence. AB has among its foundations: to enable universal and continuous access to quality and resolute health services. (BRASIL, 2006).

For the Brazilian Institute for the Rights of Persons with Disabilities (IBDD), accessibility means being within reach. Adequate space adaptation should consider the movement of a person in a wheelchair, coordinated use of strength or fine motor coordination, “free space in the arm band (0.62 m), height of a maximum of 1.35 m”. (IBDD, 2008, p. 243).

The guarantee of good circulation involves: “regular, firm, non-slip” flooring, “maximum cross slope of 2%”, “tactile signaling”, “bands with different texture and color”, facilitate movement. It also brings “accessibility measures” to circulation and recognizes that total communication “is characterized by the acceptance of various communicative resources”. (IBDD, 2008, p. 249-267 and 306).

The new National Primary Care Policy, launched in 2011, establishes “the Family Health Strategy (ESF) that reorganizes Primary Care in the country, according to the precepts of the Unified Health System (SUS) ”. (BRASIL, 2011).

The Legislative Assembly of the State of Rio Grande do Sul launches a booklet, outlining a path for coexistence with people with disabilities. It recognizes that “the attitude towards people with disabilities” is the main barrier. It brings ways to promote accessibility and reminds us that “lack of accessibility is discrimination, and discrimination is a crime”. (RGS, Legislative Assembly, 2011, p. 17).

Law No. 13,146, of 06.07.2015, Brazilian Law for the Inclusion of Persons with Disabilities, the Statute of Persons with Disabilities, “aiming at their social inclusion and citizenship”, is another significant legal framework. (BRASIL, 2015).

The new ABNT Accessibility Standard, NBR 9050, of 09/11/2015, revises and updates the Accessibility Standard for Buildings, Furniture, Spaces and Urban Equipment, NBR 9050/2004. (ABNT, 2015).

The Brazilian Law for the Inclusion of Persons with Disabilities (LBI), “establishes commands to operationalize the right to accessibility and induces the creation and improvement of technical norms with minimum standards, within the precepts of universal design”, which help to put into practice practice the “right to have rights”. Defines physical and attitudinal accessibility and provision of resources for people with disabilities at events. (SETUBAL; FAYAN, 2016, p. 22 and 174-200).

2.2 ACCESSIBILITY OF PEOPLE WITH DISABILITIES TO PUBLIC HEALTH SERVICES

It reflects on accessibility, as issues involving people with disabilities remain unknown to society. From the institution of the International Year of Persons with Disabilities, accessibility is emphasized. (LOUGHBOROUGH, 2006, p. 1).

The UN decree stimulated a change in attitudes and the emergence of new trends, such as “the replacement of the term architectural barriers with accessibility”. Accessibility “is more than building ramps – although ramps are always key”. (LOUGHBOROUGH, 2006, p. 1-2).

The issue of accessibility lies between need (demand) and satisfaction (availability). Frenk (1985 apud CASTRO et al., 2011, p. 100) defines accessibility “as the product of the relationship between the effective availability of health services and the access by individuals to these services”.

The effective availability of health services occurs “when the availability of health services is analyzed in the face of the resistance presented by the environment to this availability”. Investigating obstacles to accessibility to health services “provides subsidies for health planning, structuring and improving services” (CASTRO et al., 2011, p. 100).

The inclusion in the Constitutional Text of “universal access as a right, with the SUS in the Laws of the Republic”, makes Brazil the only country in Latin America to include such a provision in its Constitution. (PAIM, 2013, p. 2). However, the Unified Health System (SUS), based on the principles of universal access to health services at all levels of care, equity and comprehensive care, in practice “has assumed a utopian role”. Gaps make accessibility broader than “the availability of resources at a given time and place”. (SANTANA, 2013, p. 1).

A review study with quantitative and qualitative research, considered that in order to achieve the principles of the SUS, “it is essential to know the main barriers that make this access unfeasible”. The reviewed studies pointed out architectural, socio-organizational and communicational barriers as the most mentioned barriers. (ÁFIO et al., 2013, p. 02356).

Cunha (2010 apud SANTANA, 2013, p. 1) states that the accessibility of people with disabilities to health services occurs according to “the possibility for people to use all services, available according to their needs, in all attention levels. From this perspective, accessibility is treated in two dimensions: geographic and socio-organizational. The geographic dimension is related to “the distance and travel time of users to reach health services, including travel and other costs”; and the socio-organizational dimension of accessibility, “to all the characteristics of the offer that can facilitate or hinder people’s ability to use the services”. Accessibility is “the feature of supply, access to the way people perceive accessibility”. (ALBUQUERQUE et al., 2014, p. 183).

The concept of accessibility goes through the notion of disability, and “it presupposes a variety of concepts such as defect, disease, disability, limitation, exclusion and suffering, thus making its exact determination difficult”. (BERNARDES et al., 2009, p. 31-38 apud AZEVEDO et al., 2015, p. 320).

For Wagner et al. (2010 apud AZEVEDO et al., 2015, p. 320), “it is common for people with disabilities (PD) to face limitations in their daily life”, due to accessibility difficulties, which can impair their occupational, cognitive and psychological development, and contributing to social exclusion”.

2.3 BARRIERS TO ACCESSIBILITY TO HEALTH SERVICES

The accessibility difficulties faced by PDs in accessing health services are varied and involve types and forms of barriers.

2.3.1 TYPES OF ACCESSIBILITY BARRIERS

Urban, architectural, transport, communication and information barriers that make accessibility difficult are classified by Law No. 10,098. (BRASIL, 2000). There are other elements, urban, architectural and communication, which add more obstacles to roads and public spaces, making physical displacement and social coexistence of people with disabilities difficult.

Vasconcelos and Pagliuca (2006, p. 495-496) take a look at access to the interior of health institutions and state that, in practice, the conditions of access and displacement within the health facilities show the absence of the required conditions, “as standards and measures that aim to provide people with disabilities with better and more adequate conditions of access and displacement”.

The Ministry of Health confirms “data from the World Health Organization (WHO), according to which, of the 10% of disabled people, only 2% receive assistance”. (VASCONCELOS; PAGLIUCA, 2006, p. 495).

Corde (2002 apud VASCONCELOS; PAGLIUCA, 2006, p. 495) states that “the difficulties for people with physical limitations to access public health services are particularly perceived in the journey from home to care institution”.

Carvalho and Avelar refer to Law No. 10,098/2000, and state that “barriers correspond to any obstacle that harms or prevents safe access to facilities in a given location” by people with disabilities. They add specificities: “barriers can be architectural and urban and are present on public roads and spaces for public use”. The architectural constructions, “which remain in the internal installations of public and private buildings”; and architectural in transport and communications, “which make it difficult to carry out the respective activities”. (CARVALHO; AVELAR, 2010, p. 466).

Canazilles talks about social or cultural barriers created by man. Among these, he places attitudinal and architectural barriers. Attitudinal barriers are related to “people’s behavior, prejudice, the greatest factor that hinders the social integration of PD”, they appear in the form of excessive pity. Architectural barriers are all over the urban space (streets, parks, buildings), sidewalks that do not have continuity, lack of awareness of their collective use. “Any of these barriers causes anxiety and frustration, determining in practice a process of incapacitation of the person with a disability, when internalizing the public gaze, of prejudice”. (CANAZILLES, 2010, p. 4).

Cunha and Vieira-da-Silva (2010, p. 726) consider that “accessibility to health services represents an important component of a health system when the process of seeking and obtaining care takes place”. Accessibility to health services is an additional feature to the availability of a service in a specific place and time.

Donabedian (1988 apud CUNHA; VIEIRA-DA-SILVA, 2010, p. 727) observes that the two dimensions of accessibility are in continuous interaction, in such a way that the functioning of services interferes with geographic accessibility. Primary Care should function as the gateway to other levels of care, seeking a greater degree of resoluteness of actions.

Based on the characteristics of the geographic and socio-organizational dimensions, a single case study showed that “the expansion in the offer of services explains the improvement in geographic accessibility”. However, “obstacles related to the way of organizing health services persist”, revealing that accessibility is “influenced by the organizational characteristics of the health units” that represent “the different professional profiles and local management”, for example, when within the basic network there is “absence of protocols for scheduling, welcoming and user care” (CUNHA; VIEIRA-DA-SILVA, 2010, p. 736).

Geographical and socio-organizational variables make it difficult to access health services, even in those units indicated as having satisfactory performance, architectural and environmental barriers limit the existential space and discourage the community integration of people with disabilities. (CANAZILLES, 2010, p. 5). Mainly, if found frequently and making it difficult for the “wheelchair user” to move around. (PESSANHA, 2010, p. 2).

For a descriptive field study, “displacement difficulties”, refer to “the lack of adaptations that facilitate this displacement both on the path and in the internal space of health services”, constitute “as a barrier to geographical accessibility to health services”. (AMARAL et al., 2012, p. 1837).

The same study revealed that users (PD) of health services indicated “inadequacy of care facilities”, USF units “installed in improvised houses”, do not meet the needs of users. The “architectural barriers do not guarantee safe travel for people with disabilities, who use the rented car to travel to health services”, for 80% of these users “who live on a monthly minimum wage, this factor is yet another factor”. barrier to displacement”. (AMARAL et al., 2012, p. 1837).

According to NBR 9050/04, in urban space and in places of access to health services, physical, architectural or environmental barriers are “obstacles to the proper use of the environment” and health resources. There are also communication barriers, information difficulties faced by people with disabilities about the places where communication systems are available, in their surroundings, in hospitals, clinics and basic health units. These barriers can be “visual, lighting and/or additive”, lack of urban and internal signage in buildings, absence of legends. Interpersonal, written and virtual communication is hampered by the lack of dialogue. (ELALI et al., 2012, p. 1-2).

They also mention social barriers and attitudinal barriers. Social barriers influence “social inclusion/exclusion processes”, isolation. Attitudinal barriers generated “by the attitudes and behaviors adopted by individuals”, such as the “improper use of spaces reserved for people with disabilities or reduced mobility”, “cars parked on the sidewalk, blocking the directional tactile floor” and access ramps. (ELALI et al., 2012, p. 2).

Another review study showed architectural and socio-organizational barriers such as “delay in care and absence of doctors” and “ineffective communication of health professionals and their lack of training”. (ÁFIO et al., 2013, p. 02357).

A review study involving articles published in the last 14 years, on the accessibility of PD to health services, in the elements: home/hospital route, access to the surroundings and interior of hospitals and access to sanitary facilities, evidenced as the greatest difficulty for people with disabilities “the infrastructure aspects of hospital environments”, do not offer accessibility to move freely, do not observe the legislation. The conclusion is that there is a need for many changes in hospitals for the effective “accessibility of people with disabilities”. (CIPRIANO; MONÇÃO, 2013, p. 14-15).

The inaccessibility to Primary Care services is an ethical problem, “the universality proposed by the SUS, to be real, must contemplate the intention and effectiveness, problems that require the “humanization of care, accessibility is part of this humanization”. (SILVA et al., 2013, p. 576).

For Alves et al. (2012 apud SILVA et al., 2015, p. 40), accessibility to health services must be considered under two aspects: “the socio-organizational dimension, which characterizes the offer of the service and the geographical dimension that is associated with the distance and displacement”. There are many difficulties in the UBS regarding the adequacy of structures for people with disabilities. Even the most recent constructions for UBS “receive negative criticism for not guaranteeing free access to people”. (FACCHINI et al., 2009 apud SILVA et al., 2015, p. 40-41).

The evaluation of the architectural conditions of a UBS, in São Luís de Montes Belos – GO, showed disagreement with the norms of NBR 9050/04. These are floors, handrails and toilets, which do not meet the psychophysiological needs of users with physical disabilities or reduced mobility, limiting safe use. (SILVA et al., 2015, p. 54).

Another study pointed out that “inadequacies in accessibility have been the most important reason why people with disabilities do not seek care from health services”. Limitations in the access and assistance of health professionals due to “difficult management, lack of adequate material and training”. The perception is that accessibility “is not only the use of services, but it is the knowledge of professionals, adequate equipment, adequate transport and that they have equal opportunities for all citizens”. (VARGAS et al., 2016, p. 8).

3. METHODS

The study developed is a literature review, an integrative review, based on evidence. (SOUZA et al., 2010, p. 103). It combines studies with different methodologies, provides subsidies to integrate the results of studies or research questions, “contributing to the deepening of the knowledge of the investigated topic” (MENDES et al., 2008, p. 759).

The steps to carry out this integrative review included: identification of the research question; literature search/establishment of inclusion and exclusion criteria; data collection procedures; results analysis procedures; discussion of results; integrative synthesis.

a) Research question: What is the relationship between accessibility and barriers to access for people with disabilities to health services?

b) Literature search/Inclusion and exclusion criteria: The literature search required reflection on two aspects of the research: b.1) type of articles to be included in the review; b.2) legislation, technical standards and measures that enable accessibility to health services.

The literature search was carried out in May and June 2017, involving review articles and originals available in full online; published from 2006 to 2017, using the descriptors: accessibility, people with disabilities, health services and barriers, in an isolated and combined form. To locate the articles to be included in the review, journals and specialized journals indexed in databases were used: Scielo and Google Search.

The search for legislation, technical standards and operational measures for accessibility to health services required a prior analysis and identification of the most significant legal frameworks, involving laws, technical standards and accessibility measures. The period covered was from 1986 to 2017. Google Search, websites and portals were used to locate the legislation.

For sampling, the following procedure was adopted: Inclusion criteria: a) for Articles: review articles and originals available in full online; published in the period from 2006 to 2017; Portuguese language; theme focused on accessibility and barriers for people with disabilities to health services. b) for Legislation: conventions; laws; technical standards and operational accessibility measures, among other data. Exclusion criteria: a) for Articles: repeated articles in the databases; non-compliance with the time frame (2006-2017); foreign language; non-compliance with the study theme. b) for Legislation: conventions, laws, technical standards and operational measures unrelated to the topic and which do not constitute significant legal frameworks and/or relevant information.

c) Procedures for data collection/description of the quantity found in the searches: For the review articles, the isolated search for the descriptor “accessibility” and the combined search for the descriptors were used as search strategies in the databases: “ accessibility”, “people with disabilities”, “health services”; and “accessibility barriers”, “people with disabilities”, “health services”, and for Scielo, the Boolean operators (and, or) were used. In this search, 46 articles were found, identified by titles. Strategies were used for legislation, such as the search for international conventions, Brazilian laws on accessibility, commented laws, as well as technical standards and operational measures of accessibility, in Google Search, on federal and state government websites, to identify legal frameworks. most significant for the change of consciousness and a new look at accessibility in Brazil. 16 laws, technical standards and operational measures were selected.

The selection of studies was based on the criteria of exclusion and relevance or inadequacy of data in the collection. In the articles, after reading the abstract and texts, 27 articles were excluded, totaling 19 articles for integrative review. In the selection of legislation there were no exclusions, encompassing 16 legal documents for analysis and use as subsidies in the discussion of the integrative review.

d) Procedures for analyzing the results: The analysis of the selected studies, in relation to the research design, was based on Mendes et al. (2008), Souza et al. (2010) and Girandil and Santos (2011). The analysis and synthesis of data from the articles are presented in a descriptive way, bringing together the knowledge produced.

e) Discussion of results: interpretation and synthesis of results.

f) Presentation of the integrative review: it contains relevant and conclusive information about the study carried out.

4. RESULTS

The final sample of this review consisted of 19 scientific articles, selected by the previously established inclusion and exclusion criteria. Table 1 (ANNEX A) shows the specifications of each article collected in the Scielo, Google Search, websites and portals databases.

46 review and original articles were found. The refinement by titles and reading of the abstract and content analysis showed that 19 articles were relevant, which were read in full. The focus of the reading was centered on the barriers of accessibility of people with disabilities to public health services. Table 1 shows that 19 review and original articles were analyzed, with the Google Search database presenting the largest number of publications, as studies from various websites and portals are indexed there, mainly from universities and the federal and state government.

Table 2 (ANNEX B) presents the legislation raised as a subsidy for the discussion of the results, in a total of 16 legal and technical documents, including laws, technical standards and operational accessibility measures.

In all, the integrative review included the analysis of 35 publications, including articles and legal frameworks for the accessibility of people with disabilities to public health services used as subsidies in the discussion of the results.

5. DISCUSSION

The integrative literature review determined the current knowledge on the issue of accessibility for people with disabilities to health services. The evidence found on accessibility among the authors reveals that there is an awareness among them that “accessibility is a right. It’s more than building ramps.” Prejudice and discrimination limit this right, imposing on people with disabilities to live with the limitations imposed by society. The accessibility of people with disabilities is influenced by the organizational characteristics of health units. The SUS fulfills a utopian role by presenting accessibility gaps. The inaccessibility of health services is considered an ethical problem that requires the effectiveness of the SUS and not only attention (LOUGHBOROUGH, 2006; CANAZILLES, 2010; CUNHA; VIEIRA-DA-SILVA, 2010; PESSANHA, 2010; SANTANA, 2013).

The Federal Constitution of 1988 is the only Constitution in Latin America to include “universal access as a right” in the text, meaning that the SUS, which is also part of the Constitutional Text, must prioritize the services it offers and make accessibility more comprehensive (PAIM, 2013). Access should provide comfort, security and autonomy to people with disabilities in the search for health services.

There are several barriers to accessibility that indicate the evidence raised. In summary, there are geographic, architectural, urban and environmental, organizational, attitudinal, communication and information, physical, social, external and internal barriers, evidenced by difficulties and problems of displacement, furniture, prejudice, lack of communication, sidewalks, ramps, chairs , toilets, signage, service, due to failure to comply with the normative precepts of current legislation (CUNHA; VIEIRA-DA-SILVA, 2010; ELALI et al., 2010; PESENHA, 2010; CASTRO et al., 2011; AMARAL et al. , 2012; CIPRIANO; MONÇÃO, 2013).

In view of the existing barriers to the accessibility of people with disabilities to health services, the evidence in the review studies analyzed and in the legislation, indicate a wealth of provisions to guarantee the accessibility of these people with safety, autonomy and comfort, as well as to criminalize prejudiced attitudes. and in the presentation and dissemination of technical standards and operational measures for buildings, furniture, spaces and urban equipment, as well as in defining what constitutes accessibility, access and barriers (CONSTITUIÇÃO, 1988; LEI 7.853/1989; LEI 10.098/2000; NBR 9050/2004; IBDD, 2008 NBR 9050/2015; LAW 13.146/2015; LBI/2016). Awareness is needed in promoting accessibility for people with disabilities to health services.

Accessibility has two interrelated dimensions, geographic and socio-organizational, when the socio-organizational dimension fails, the functioning of services interferes and reduces geographic accessibility, hence the existence of so many barriers of accessibility of people to health services. In the mismatch of these dimensions lies the relationship between accessibility and so many barriers to accessing health services. Evidence found in Cunha and Vieira-da-Silva (2010), and which responds to the research problem, what is the relationship between accessibility and barriers to access for people with disabilities to health services? Considering that in some regions of the country, the lack of service, planning, management and management reaches 80%, evidenced by the lack of seats Pagliuca et al. (2007). Because, according to Albuquerque et al. (2014), the The socio-organizational dimension concerns all the characteristics of the offer that can facilitate or hinder people’s ability to use the services.

6. CONCLUSION

The analysis of the available literature on barriers to accessibility of people with disabilities to health services showed that accessibility is equalization of opportunities in all spheres of life. There are difficulties in the accessibility of health services, contrary to the principle of equity of the SUS, which must reach all citizens and encourage changes in attitudes and respect for human diversity.

Accessibility is a right. The legislation contains clear provisions for the elimination of barriers and accessibility measures that, if adopted, facilitate the access of people with disabilities to public spaces, buildings, furniture and health services. But the reality of the health system still presents difficulties that prevent the effectiveness of assistance to people with disabilities. The lack of accessibility also affects Primary Care, both in the socio-organizational and geographical dimensions, associated with distance and displacement.

In practice, it became evident that barriers to accessibility to health services exist because the socio-organizational dimension of accessibility has gaps, lack of planning, organization of actions, management and effectiveness in policies aimed at SUS. Responding to the research problem, it is necessary that the two dimensions of accessibility are in interaction, so that the accessibility of people with disabilities to health services is not reduced, under penalty of harming the dignity of the person.

It is concluded that the objective of the work, to analyze the accessibility of people with disabilities to health services, was achieved.

Finally, it can be said that when information is not available to everyone, and simple changes are not made, barriers to accessibility for people with disabilities are created. In addition to the State, it is up to society to develop accessibility initiatives and offer security and autonomy to people with disabilities. Although accessibility has been standardized, constituting a matter of international treaties and inserted in the Constitutional Text and in special laws, it remains a challenge for the realization of social integration.

It is not possible to speak of equality as a right for all without accessibility being operationalized and health services offering autonomy, security and possible comfort, for those who enjoy them, with dignity.

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______. Presidência da República. Conselho Nacional de Saúde. Lei nº 8.080, de 19 de setembro de 1990. Condições para a promoção, proteção e recuperação da saúde. Diário Oficial da União, Brasília, 20.09.1990. Disponível em: <http:// conselho.saude.gov.br/ legislacao/lei8080_190990.htm>. Acesso em: 25.05.2017.

______. Presidência da República. Casa Civil. Decreto nº 3.298, de 20 de setembro de 1999. Regulamenta a Lei nº 7.583/89. Diário Oficial da União, Brasília, 21.12.1999. Disponível em: <https://www.planalto.gov.br/ccivil_03/decreto/D3298.htm>. Acesso em: 20.06.2017.

______. Presidência da República. Casa Civil. Lei nº 10.098, de 19 de dezembro de 2000. Estabelece normas gerais e critérios básicos para a promoção da acessibilidade das pessoas portadoras de deficiência ou com mobilidade reduzida. Diário Oficial da União, Brasília, 20.12.2000. Disponível em: <www.planalto.gov.br/ ccivil_03/LEIS/ L10098.htm>. Acesso em: 20.06.2017.

______. Ministério da Saúde. Secretaria de Atenção à Saúde. Portaria nº 648, de 28 de março de 2006. Política Nacional de Atenção Básica. Brasília: MS, 2006. Disponível em: <http://dab.saude.gov.br/docs/legislacao/portaria_648_28_03_2006. pdf>. Acesso em: 10.06.2017.

______. Ministério da Saúde. Secretaria de Atenção Básica. Portaria n. 2488, de 21 de outubro de 2011. Política Nacional de Atenção Básica. Brasília: MS, 2011. Disponível em: <www.cosemssp.org.br/ downloads/PNAB.pdf>. Acesso em: 19.06.2017.

______. Presidência da República. Secretaria Nacional de Promoção dos Direitos da Pessoa com Deficiência. Avanços das Políticas Públicas para as Pessoas com Deficiência: Uma análise a partir das Conferências Nacionais. Brasília: SNPDPD, 2012. 63 p. Disponível em: <https:www.pessoacomdeficiencia.gov.br/app/sites/…/ livro-avancos-politicas-publicas-pcd.pdf>. Acesso em: 21.06.2017.

______. Presidência da República. Casa Civil. Lei nº 13.146, de 6 de julho de 2015. Estatuto da Pessoa com Deficiência. Diário Oficial da União, Brasília, 07.07.2015. Disponível em: <www.planalto.gov.br/ccivil_03/ _ato2015-2018/2015/lei/>. Acesso em: 21.06.2017.

CANAZILLES, K. S. A. Acessibilidade urbana – Barreiras arquitetônicas e sociais do portador de necessidades especiais. 19.10.2010, 5 p. Disponível em: <http://w ww.lerparaver.com/lpv/acessibilidade-…>. Acesso em: 18.06.2017.

CASTRO, S. S. et al. Acessibilidade aos serviços de saúde por pessoas com deficiência. Rev. Saúde Pública, São Paulo, v. 45, n. 1, p. 99-105, 2011.

CARVALHO, A. M.; AVELAR, S. A. Barreiras arquitetônicas: Acessibilidade aos usuários. Revista Enfermagem Integrada, Ipatinga, Unileste, MG, v. 3, n. 1, p. 465-475, jul./ago. 2010.

CIPRIANO, C. D. C.; MONÇÃO, M. M. Acessibilidade ao portador de limitação física: aspectos externos e internos do ambiente hospitalar. Estação Científica (UNIFAP), Macapá, v. 3, n. 1, p. 01/17, jan./jun. 2013.

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INSTITUTO BRASILEIRO DOS DIREITOS DA PESSOA COM DEFICIÊNCIA. Inclusão social da pessoa com deficiência: medidas que fazem a diferença. Rio de Janeiro: IBDD, 2008. 312 p.

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ANNEXES

ANNEX A

Table 1. Articles found in Scielo, Google Search, websites and portals on integrative review.

Author/Article Title	Year	Considerations/Theme
1. Loughborough, W. Accessibility is a right, not a privilege.	2006	Critical study. Accessibility is a right. It’s more than building ramps.
2. Vasconcelos, LR; Pagliuca, LMF. Mapping the accessibility of people with physical limitations to basic health services.	2006	Exploratory-descriptive study. They note that the external architecture makes access difficult or impossible. Sidewalks contain obstacles. Most units, inadequate furniture at the time.
3. Pagliuca, LMF et al. Accessibility and physical disability: identification of architectural barriers in internal areas of hospitals in Sobral, Ceará.	2007	A quantitative study points to physical barriers in the external areas of hospitals, 50% of stairs and ramps do not have handrails, 33% seats and 80% counters do not comply with the legislation.
4. Canazilles, KSA. Urban accessibility – Architectural and social barriers for people with special needs.	2010	It analyzes the behavior of society in relation to prejudice, the bearer and its limitations and the architectural barriers that prevent accessibility, concludes that the problem is also to live with the limitations of the prejudiced society.
5. Carvalho, AM; Avelar, AS. Architectural barriers: Accessibility to users.	2010	They carry out quantitative research, discuss and state that the barrier according to Law 10.098/00 is any obstacles that hinder or prevent safe access to facilities and sites. They use NBR 9050/04 as a beacon.
6. Cunha, ABO; Vieira-da-Silva, LM. Accessibility to health services in a municipality in the State of Bahia, Brazil, under full system management.	2010	They carry out a case study which reveals that accessibility is influenced by the organizational characteristics of health units, the profiles of professionals and management. They cite Donabedian, according to which the two dimensions of accessibility are in constant interaction, the functioning of services interferes with geographic accessibility.
7. Elali, AG et al. Psychological Accessibility: Eliminating “physical” barriers is not enough.	2010	They address the universal design and the types of barriers according to the technical standards there are architectural, urban or environmental barriers. It deepens the concept of barrier and refers to attitudinal, communicational, physical and social barriers.
8. Pessanha, POL. The poor view of “people with disabilities”.	2010	It exhibits and criticizes the prejudice and discrimination of people with disabilities. Failure to comply with regulatory precepts makes it difficult for wheelchair users to move around.
9. Castro, SS et al. Accessibility to health services for people with disabilities.	2011	A qualitative study points out that the journey to the health service shows diversity in terms of the user going alone or accompanied. The accessibility difficulties offered by health services indicate delays in care, parking problems, lack of ramps, elevators, chairs, contrary to the principle of equity of the SUS.
10. Amaral, FLJ et al. Accessibility of people with disabilities or permanent mobility restriction to SUS.	2012	A descriptive field study pointed out difficulties in displacement – lack of adaptations that facilitate locomotion. People with disabilities pointed out inadequacies of service locations, architectural barriers and sidewalks do not guarantee safety.
11. Áfio, ACE et al. Access of people with disabilities to health services.	2013	In a literature review, the results pointed out as the main barriers for any type of disability the lack of parking, ramps, wheelchairs, adequate toilets, signage, delay in service, absence of doctors and ineffective communication.
12. Cipriano, CDC; Monção, MM. Accessibility for people with physical limitations: external and internal aspects of the hospital environment.	2013	In a literature review, they identified external and internal accessibility barriers, due to infrastructure aspects of the environments, which do not offer accessibility for free transit – ramps, stairs, floors, handrails, doors, toilets. Changes are needed for effective accessibility.
13. Paim, JS. Accessibility and quality of care.	2013	The inclusion in the Constitutional Text of “universal access as a right, with the SUS in the Laws of the Republic”, makes Brazil the only country in Latin America to include such a provision in its Constitution.
14. Santana, R. SUS and accessibility for people with disabilities.	2013	SUS has assumed a utopian role. Gaps make accessibility broader than availability of resources at a given time and place.
15. Silva, DM et al. Man’s Accessibility to Primary Care Services: An Approach to the Bioethics of Protection.	2013	Inaccessibility is an ethical problem, the universality proposed by the SUS needs not only attention, but effectiveness.
16. Albuquerque, MSV et al. Accessibility to health services: an analysis based on Primary Care in Pernambuco.	2014	In a descriptive study, they talk about the two dimensions of accessibility: geographic and socio-organizational. The socio-organizational refers to all the characteristics of the offer that can facilitate or hinder people’s ability to use the services.
17. Azevedo, TR et al. Physical accessibility of people with disabilities in public hospitals.	2015	In a descriptive, exploratory and quantitative study, hospitals showed irregularities in relation to the physical structure recommended by NBR 9050/04.
18. Silva, DCN et al. Accessibility for people with physical disabilities or reduced mobility at UBS Jonas Manoel Dias in São Luís de Montes Belos, GO.	2015	In a quantitative and descriptive study, it states that accessibility must be considered under 2 aspects: geographical and socio-organizational, which characterize the displacement associated with the offer of the service
19. Vargas, S. C. et al. Health care for people with disabilities in public health services: a bibliographic study. University of Santa Cruz do Sul, 2016.	2015	In a literature review, they point out that accessibility is a result of the availability of health professionals and services. Accessibility is also knowledge of professionals.ANNEX B

Source: The author (2017)

ANNEX B

Table 2. Legislation, technical standards and operational accessibility measures.

Legislation	Year	Considerations/Theme
1. National Health Conference, 8, Brasília. Final report.	1986	It discusses health as a right for all and a duty of the State.
2. Constitution of the Federative Republic of Brazil, of October 5, 1988.	1988	It defines that health is everyone’s right and a duty of the State and guarantees universal and equal access to actions for the promotion, protection and recovery of people with disabilities.
3. Law No. 7,853, of October 24, 1989.	1989	Support for people with disabilities and their social integration
4 Law No. 8080, of September 19, 1990.	1990	Establishes conditions for the promotion, protection and recovery of health.
5. Decree No. 3,298, of September 20, 1999.	1999	It defines the deficiencies and regulates Law nº 7.583/89, providing for the National Policy for the Integration of Persons with Disabilities, consolidating protection norms.
6. Law No. 10,098, of December 19, 2000.	2000	Establishes general rules and basic criteria for promoting accessibility for people with disabilities or reduced mobility.
7. ABNT. NBR 9050: accessibility, buildings and furniture.	2004	Establishes that the right to accessibility for people with disabilities is based on human and citizenship rights, regulated in Brazil by NBR 9050/04.
8. Ordinance No. 648, of March 28, 2006.	2006	Approves the Primary Care policy, based on enabling universal and continuous access to quality and resolute health services.
9. Brazilian Institute for the Rights of Persons with Disabilities. Social inclusion of people with disabilities: measures that make a difference.	2008	Discusses and reflects on operational measures that make a difference in the social inclusion of people with disabilities.
10. Brazilian Institute of Geography and Statistics (IBGE). 2010 Demographic Census.	2010	It points out that 23.92% of people with disabilities in Brazil.
11. Ordinance no. 2488, of October 21, 2011. National Primary Care Policy.	2011	Launches the new Primary Care Policy, instituting the Family Health Strategy (ESF), which reorganizes Primary Care.
12. Legislative Assembly of Rio Grande do Sul. Tips for Living with People with Disabilities, [Booklet].	2011	Launches a booklet, tracing a path for coexistence with people with disabilities.
13. Advances in Public Policies for People with Disabilities: An analysis from the National Conferences.	2012	It proposes the promotion of permanent campaigns to raise awareness and enlighten society and implement initiatives by establishments that meet the accessibility requirements in accordance with current legislation.
14. Law No. 13,146, of July 6, 2015.	2015	Establishes the Statute of Persons with Disabilities.
15. ABNT NBR 9050 – 2015 version.	2015	Establishes a new Accessibility Standard for Buildings, Furniture, Spaces and Urban Equipment.
16. Brazilian Law for the Inclusion of Persons with Disabilities – LBI, [Law No. 13.146/2015, Commented].	2016	It brings several guarantees of accessibility in buildings, communication and urban environment, relating the person’s disability to the environment in which he lives.

Source: The author (2017)

^[1] Specialist in Public Health with an emphasis on Family Health, Graduated in Pharmacy from the Integrated Regional University of Alto Uruguai e das Missões (URI), Santo Ângelo campus.

^[2] Specialist in Science Methodology and Higher Teaching, Quality Audit and TCC Advisor at the International Faculty of Curitiba – FATEC/FACINTER, Obstetric Nursing and Nursing Degree from UFPR.

Sent: April, 2018

Approved: March, 2019