Health care provided by SUS : the experience of foreign students Assistência à saúde prestada pelo SUS : a experiência de estudantes estrangeiros

Objective: To analyze the experience of foreign students in health care provided by the SUS services. Methods: Qualitative approach study, with undergraduate and graduate foreign students who used the SUS health services. The interviews were submitted to the technique of content analysis. Results: Emerged three thematic categories: knowledge about SUS, health services used and evaluation of users regarding assistance. User (dis)satisfaction regarding to health services was related to the reception, resoluteness, the time in the waiting room and facilities and difficult access. Conclusions: The study showa the need to clarify the foreign students about systema organization and how to seek service to achieve better resolution.


INTRODUCTION
Since the promulgation of the 1988 Constitution, when for the first time health was guaranteed to the entire population as a duty of state 1 , many achievements have been obtained in order to ensure equal access to the services offered.The new reorganization proposed by the Unified Health System (SUS) universalized the right to health care, pointing to full access to services without any discrimination or exclusion criteria 2 .
It appears from the legal text that the universal right to health transcends Brazilian citizens born or naturalized, as it refers to all human beings.Although the health legislation does not specifically refer to the access of foreigners to SUS, its universal access should be guaranteed to people regardless of nationality.The Foreigner Statute, promulgated by Law No. 6,815, of August  19, 1980 already guarantee to the foreign resident in Brazil enjoy "all the rights granted to Brazilians, under the Constitution and the laws" 3 .
The issue of access to health services is still one of the major obstacles for the population to exercise their right to health, and still one of the biggest challenges of managing 4 .It is believed then that this difficulty also extends to foreign population resident in Brazil and in this case, becomes even greater, because it involves aspects such as prejudice and ignorance of current legislation.
By understanding the accessibility of foreigners to health services provided by the SUS, it was noted that despite the majority of municipal health secretaries have considered that foreigners are entitled to attendance in SUS, restrictive access barriers of this right have been identified, meeting the National Legislation.As examples, the implementation of the Health Strategy for the Family or the need for SUS card for the servicealthough such actions have been created to organize the system, appear as obstacles to the realization of care to foreigners, as they may restrict service to registered users 5 .
From the guarantee, by the foreigners, of access to services offered by the SUS, arouse to reflection on the perception of health care through the SUS paid to foreign students.In an attempt to clarify this issue, it sought to analyze the experience of international students in health care provided by the SUS services.

METHODS
A qualitative approach study, conducted between October 2013 to June 2014, with exchange students enrolled at the State University of Paraíba (UEPB) and registered with the Coordination of Institutional and International Affairs.
The subjects were selected from the following inclusion criteria: to have used at some point during their stay in Brazil and the duration of the exchange, the services of the SUS care network.Although all foreign students have been contacted, only those originating from Timor-Leste met the inclusion criteria and therefore 14 subjects Timorese participated in the study.
Interviews were conducted from semistructured script with the participants and the recording was authorized.After the interviews were transcribed and submitted to content analysis technique proposed by Bardin 6 , following the steps of: transcribing the interviews in full; establishment of a corpus; selection of the record units; and encoding and categorizing of the identified issues.
The research was developed in view of the guidelines of Resolution 466/2012 of the National Health Council (CNS), of Ministry of Health, approving the guidelines and regulatory standards for research involving humanos beings 7 .Thus, the study was approved by the Ethics Committee in Research of the State University of Paraíba, under CAAE Nº 22922013.3.0000.5187.Anonymity was assured for participants and the secrecy of confidential data that could arise during the collection, adopting the initial Est.followed by the sequential number of the interview.

Characterization of subjects
Foreign students coming from Timor-Leste are aged between 20 and 48 years, the graduates (08) aged 20 to 25 years, and the postgraduate students (04) aged between 42 and 48 years.Regarding the gender, eight are male and six female.
Graduating students are enrolled in world language courses (01), dentistry (04), computing (03) and law school (02), with exchange lasting up to five years and $750 salary.Master's students working in Timor as teachers of primary and fundamental level and are enrolled in the Master's courses in Public Health (02) and Masters in Regional Development (02), with exchange lasting up to three years and $850 salary.
Most interviewees used more than once health services, reporting varied causes to use the system.Abdominal pain, symptoms such as nausea and vomiting, allergies and even a surgery to remove benign tumor were cited.

Knowledge about the SUS
In principle, foreigners were questioned about knowledge of health politics in Brazil and ensuring access to these services through the agreement signed for the exchange.They said they know little about SUS, making reference only to the gratuity of the services offered:

Health services used
When asked about what services seek to meet their health needs, foreign students, almost in its entirety, cited Emergency Care Unit (UPA) for the treatment of symptoms such as gastritis, headache, viral infection and peak arterial hypertension.

[...] the whole time that I was sick I went there in UPA [...] (Est. 1). [...] I went there in UPA when I felt pain in the belly and the doctor asked to take exam [...] (Est. 4). [...] I think I'll go back to UPA when I have a fever or cough [...] (Est. 5). [...] from when we arrived, colleagues reported that we are Timorese, foreigners, and we went to this hospital UPA [...] (Est. 11).
It was observed also that some foreign students sought private service in search of medical care and tests:

[...] I went in first UPA and then went to a paid doctor [...] (Est. 1). [...] Many times I paid being free. It takes too long! An examination takes two to three months, that's why I paid [...] (Est. 14).
Students did not have any information about how would be the health care in Brazil, and because they were unaware of SUS care network, foreigners do not follow the hierarchy proposed by the system and understand that the money they receive through the studies may be intended for the payment of medical care.

[...] I do not really know this information because,
according to the information I had from there Timor, the money we receive here is to treat health [...] (Est.1).

Evaluation of users regarding assistance
The evaluation of foreigners about health care in SUS diverged among them, which even made comparisons of health care between Brazil and other countries, as the following excerpts:

[...] I think that has nothing bad, I liked everything[...] (Est. 3). [...] I need always and I'm used to, and I know that that place for me is good[...] (Est. 9). [...] I've been in many countries, I have been in Indonesia, I have been to
Singapore, but in Brazil, some people go to the hospital with pain and will die because the doctor didn't arrive yet [...] (Est.6).
[...] the service is bad; I mean, the system is complicated, I will not say bad, but it is the system of the country.Here it takes long because a lot of people [...] (Est.14).

[...] It has many patients, but has few doctors. [...] Should increase the doctors and nurses, because we need to be seen, because we are suffering. Health is a priority for everything [...] (Est. 11).
The host and listening activities are not unique to a professional category.All professionals who work in the health service and have contact with the user must be committed and The experience of foreign students Barbosa ML, Celino SDM, Carneiro AG, Costa GMC able to welcome.The speech of one of the participants pointed out the importance of acceptance by professionals: [...] for me this is a better service because the professionals there who are all welcoming.It is better care and I managed to 'cross' better this moment [...] (Est.11).
It is important to highlight that although the student show a positive view of the host, this professional action should not be related to kindness or favor, but guided by qualified and resoluteness listening, which did not happen in some cases: On the other hand, the risk rating was reported as a positive aspect for the use of urgent and emergency health services system, it is able to ensure compliance fairly.
[...] I think each one has a disease level.With a more serious condition is attended.I find very interesting this system because there is no one who comes in and goes straight (be attended).Bad! [...] If we have a less severe disease, we will not be attended.We will be seen, but it takes more [...] (Est.8).
[...] and my case too.I went when needed.I went straight, and when I got there, they have a criterion: they give a card with green, red or yellow, to attend fast.They gave me red because it was serious [...] (Est.9).
In the case of resoluteness of the foreign listed needs, part of them pointed out that the used services were resolute, however others expressed dissatisfaction about the solution to your health problem:

DISCUSSION
Given the participation of Brazil in the international scenario performing with increasing emphasis on the economy, increasing exchanges became a reality.However, public health politic proves to be unprepared to receive this demand, as are many foreign reports about barriers faced daily in access to the health system, such as discrimination, disinformation, disrespect for cultural diversity and unpreparedness of professionals for attendance 5 .

The experience of foreign students
Barbosa ML, Celino SDM, Carneiro AG, Costa GMC Regarding the gratuitousness of care, conquered from the SUS creation as a condition of the principle of universality is in fact clearly recognized by foreign users, but it must be considered that SUS is also home to the doctrinal principles of fairness and integrity to the set of health actions covering a complete and integrated cycle between the promotion, protection and recovery of health, and include the reception and forwarding to reference services 8 .
These principles govern health activities throughout the national territory by the three spheres of government, which makes it a unique system.Despite this, there may be organizational divergence of services between municipalities, observed in the speech of the Est.6 subject, which can be explained by the decentralization that guides the SUS.This principle transfers to municipal management the responsibility from planning, permeating the organization, control, evaluation of activities in health services, as well as manage and run them 8 .
Despite the progress already evidenced from the principles that form the SUS and the evolution of the system itself, it is salutary to recognize the need to look at it critically, in the prospect of finding ways to meet its major challenges, such as social asymmetry created from the large differences in the provision of services, the regional differences of capacity, limitations in systematic processes of qualification of human resources and continuing education in health, strengthening the scientific and technological development in all areas, qualifying social participation, defining priorities based on epidemiological criteria and ensuring funding mechanisms to minimize the increasing social exclusion and promote effectively universal access to health 9,10 .
About the National Health Card, although the understanding as an important tool in access to care, also have a distorted perception of their true purpose -some see it as a way to speed up service, others as a way to reduce the consultation costs (Est.10), which contradicts with statements of understanding that the SUS is a free system.
The National Health Card consists of a unique identification tool for the SUS, which seeks to facilitate the appropriate use of information to guarantee a quality service and contribute to organizing a network of regionalized and hierarchical services, organizing the system of reference and counter in so far that links procedures performed to the user, the professional that held and also to the health facility where they were performed 11 .
It is true that the lack of information provided by the Government on their websites and official informative material constitutes a barrier to the broad understanding of the Brazilian health system.In addition to the lack of preparation of health professionals in this sense, the textbooks are insufficient and do not refer to the rights of the immigrant population.For example, the "Brazilian citizen" expression is repeated several times, and nothing is said about foreign residents in the country 5 .These students do not receive any type of information in the country of origin when they propose to study in other countries and the lack of information is held in Brazil.This aspect encourages inappropriate use of the health system, from enrollment from the SUS card to the misunderstanding about the care network.
It is known that health services in Brazil form a regionalized and hierarchical network, established by Law 8080/1990, and organized according to the degree of technological complexity and using for this purpose, a system of reference and counter of users in the SUS 8 .
The universal, equal and ordered access to actions and health services begins by SUS entrance doors, whether the primary care services, attention to urgency and emergency care, psychosocial care and special open access, which correspond to "health services specific to the care of the person who, in interlocutory reason or employment status, needs special care" 12 .
In the case of primary care, which aims to provide the population with an integral care that impact on their health situation is characterized by a compendium of health actions from health promotion to harm reduction and the maintenance of health, and developed in a way individual and collective.In this sense, it should be as the preferred contact of the users, ie the main entrance of the health care network 13 .
The UPA established by Decree 1601/2011, composes one of the care network services to the urgency, being an establishment of intermediate complexity between the Basic Health Units/Family Health and Hospitalar Network 14 .Thus, it would be the service suitable for the care of the health problems reported by foreign users, who sought these services at an average of two to five times, mostly.
The logic of immediacy that leads to health conception in the biomedical model, in addition to the lack of specific features of each service, results in a higher search of users by UPA in detriment of primary care services, which is a major problem for the organization of health care network 15 .
However, it is essential to broaden the discussion on health services between foreigners and Brazilians, since it can not explain the logic of immediacy only from the lack of knowledge of health services specificities, as it relates to the response capacity of the same.
In the case of the study subjects, the search for UPA may have been motivated by the lack of knowledge of primary care services.For many users, even facing hours in attendance in the UPA, it is preferable to leave with a partial solution than none, although we should also consider that this problem is not restricted to these patients because they are foreigners.In a study conducted in the city of Belo Horizonte, network professionals also complain that users seek basic care in services of higher complexity for not having adequate information on the organization of care network 16 .
The experience of foreign students Barbosa ML, Celino SDM, Carneiro AG, Costa GMC Another study 17 , proved that more than half the children brought to the pediatric emergency department of a university hospital were not referred to primary care units, suggesting that the population of that municipality not predominantly used these services as a gateway to the system.
The lack of knowledge about the network of care is no aspect related only to foreigners but also to Brazilian people.It is essential that public authorities give up of instruments and actions to ensure the care health network compression by both the foreign and the Brazilians.Moreover, the wrong way into the system burdening SUS, hinders resoluteness and reduces user satisfaction regarding attendances.
Another aspect that reduced the satisfaction of the subjects was the recurrence of delay to attend.This aspect relates to, according to them, the lack of doctor proportional to the high number of patients.Also in a study conducted in the cities of São Paulo, Brazilian users of the public health system, despite showing their satisfaction with the service, complained about the need to increase the number of professionals, especially doctors 18 .
This view of users about the need to increase the number of doctors so that care is effective is the remains of the hegemonic medical model, which still influences in health care.However, this model is incomplete and meets the SUS proposals, but there is still, in most of the population served, this view, which further hinders access 19 .
Foreign students also observed other aspects of health care in SUS, as the host and access to services, as well as solving their needs.
Although the user is satisfied with the attendance, it is important to clarify that the host recommended by the Ministry of Health has no relationship with kindness attitudes and favor, but with the consolidation of a service with resoluteness and accountability, ensuring, when necessary, continuity of care 20.The host as an attitude of the user inclusion to health services was established as one of the most relevant guidelines of the SUS Humanization National Policy, presenting itself as a technological tool of intervention in qualified listening, construction bond and consequently guarantee access to services 20 .
The host also assumes the intention to solve the health problems of all users seeking the service, implying that they are all welcomed by health professionals who will perform listening, identifying risks and vulnerability, and be responsible to give an answer to the problem 21 , which was not observed by the speech of the subjects, when the host was difficult even before the user could express their needs.
It is noteworthy, therefore, the importance of qualifying the time the user is in health facilities.It is necessary to form link between team and population, worker and user, questioning the work process and modify the clinic.For a host of solvability, it is indispensable to qualify workers to receive, meet, listen, talk, take decision support and guide users 22 .
The complaint reported in the statements of foreigners has also been reported in other studies with Brazilian users 18,23 .The waiting time and long lines in services hamper access to care, big barrier for this to happen, "in which the wait (temporal dimension), the demand to be resolved (existential dimension) and the solution -or not -of the problem (resolutive dimension) are mixed in the system itself representation with not always guaranteed results" 24:502 .
The risk rating understood by foreign proposes an attendance organization strategy that is not the order of arrival, but the priority of assistance according to the needs of each individual.It is held in emergency services by a nurse, based on protocol and consensus established by the medical staff, assess the severity of each case, ensuring immediate assistance to those worst 25 .
In a study conducted in a UPA Belo Horizonte, it was found that the host with risk rating deconstructed the logic of exclusion, embracing all demand and offering a positive response in the perception of the user, in addition to offering an opportune and punctual assistance and provide better clinical prognosis 26 .
Dissatisfaction of these foreigners do not differ from other studies in the literature with Brazilian users.In a study by household survey in the southwestern region of São Paulo, the problems mentioned by respondents users have not been solved, despite the response capacity of services have shown that they were able to meet the demand 27 .
In research conducted, although of users show satisfaction with the resoluteness of his health problems, evidenced by a long flight path of the respondents, since in a few cases were resolved at the first level of care 28 .
In another study, in the case of the main complaint of the patient, the health services have proved resolute, although users do not always leave satisfied, because demand often does not match the level of assistance that the service is intended 16 .
Gratuity observed by foreign users as a facilitating factor for the return of these to SUS health services presents based on the Federal Constitution, which states that health is the responsibility of the state 1 .In fact, this is a very important feature and verified in the literature as it assists the user access to clinical services, even if there is it takes long in the effectiveness of the attendance 29 .

CONCLUSION
It is noticed that the students of Paraiba State University exchange program are unaware of the health care policy in Brazil, even though they have already used, understanding SUS only as the provision of free services and linking to the National Health Card often to the understanding as the system itself or by linking access to health actions to the acquisition card.
The experience of foreign students Barbosa ML, Celino SDM, Carneiro AG, Costa GMC Foreigners also do not recognize in practice the organization of health care services, such as a hierarchical network and therefore seek UPA to meet their diverse health needs, which could be resolved in primary care through the Family Health Strategy.
Dissatisfaction or user satisfaction regarding to health services was related to the reception, resoluteness, the time in the waiting room and facilities, and difficult access.On these aspects, foreigners comprise the host by risk rating, although complain of delay in attendance and resoluteness little service.Gratuity is highlighted as the great facility found for the guarantee of health care, although the bureaucracy is seen as a major failure in the system.
The study has as limitations the lack of literature on the evaluation of health services by foreign, non-use of survey participants from other establishments in the SUS assistance network, getting the perception of limited service in UPA, and the fact that subjects proceed from a single country, represented by only a sociopolitical reality that could present disadvantages against the knowledge of our system compared to other countries.
Nevertheless, the study shows the need for clarification of foreign students when arrive to Brazil to understand the system organization and how to seek care to achieve greater resolution.It must be noted also that can help managers and health professionals to invest in health educationas well as improvement in the reception process and qualified listening, but also points to the research contribution to the migration processes underway in the country.
they do not have the focus on [...] Patients are suffering there and they are chatting.That's a bad thing.On the occasions that I was nervous, I told them that can not be like that [...] (Est.1).[...] One thing that happened is that I went to the hospital [...] with my colleague.It was 7 am and who works there, said this: "There is no spot for you."OnethingI think weird is that it has no spot if you are sick [...] (Est.12).the absence of a qualified reception, the delay was also mentioned by foreign users as a barrier to access to care: It has bureaucracy.In general the system is already so, but in the end solves.The complaint I had at the end was solved [...] (Est.13).[...] I have no way to go back there in the UPA, because I can not solve.It has much delay and bureaucracy [...] (Est.12).[...] I went for six months several times to try to solve my problem and I could not.Only after the university intervened, it was they contacted the hospital and the doctors solved.From the university, they referred me to the Trauma Hospital [...] (Est.14).