REVIEW ARTICLE

MANAGEMENT OF HEALTH ACCESS DEMANDS AND BACKLOGS IN PRIMARY HEALTH CARE

GESTIÓN DE LAS DEMANDAS Y REZAGOS DE ACCESO A LA SALUD EN LA ATENCIÓN PRIMARIA DE SALUD

GESTÃO DE DEMANDAS DE ACESSO À SAÚDE E BACKLOGS NA ATENÇÃO PRIMÁRIA À SAÚDE

https://doi.org/10.31011/reaid-2025-v.99-n.supl.1-art.2345

Larayne Gallo Farias Oliveira¹

Lislaine Aparecida Fracolli²

Alfredo Almeida Pina-Oliveira³

Anna Luiza de Fátima Pinho Lins Gryschek⁴

Alexandre Ramiro Pinto⁵

Leticia Aparecida da Silva⁶

Daniela Silva Campos⁷

Denise Maria Campos de Lima Castro⁸

[1] Programa Interunidades em Enfermagem, Escola de Enfermagem da Universidade de São Paulo (USP), São Paulo-SP, Brazil, https://orcid.org/0000-0002-0031-3846

2 Depto. Enfermagem em Saúde Coletiva, Escola de Enfermagem da Universidade de São Paulo (USP), São Paulo-SP, Brazil, https://orcid.org/0000-0002-0936-4877

3 Depto. Enfermagem em Saúde Coletiva, Escola de Enfermagem da Universidade de São Paulo (USP), São Paulo-SP, Brazil, https://orcid.org/0000-0002-1777-4673

4 Depto. Enfermagem em Saúde Coletiva, Escola de Enfermagem da Universidade de São Paulo (USP), São Paulo-SP, Brazil, https://orcid.org/.0000-0001-5012-5977

5 Curso de Enfermagem, Universidade Guarulhos, Itaquaquecetuba, São Paulo-SP, Brazil, https://orcid.org/0000-0001-8237-7327.

6 Programa de Pós-Graduação de Enfermagem (PPGE), Escola de Enfermagem da Universidade de São Paulo (USP), São Paulo-SP, Brazil, https://orcid.org/0000-0003-4831-6525

7 Mestrado Profissional em Enfermagem na Atenção Primária à Saúde, Escola de Enfermagem da Universidade de São Paulo (USP), São Paulo-SP, Brazil, https://orcid.org/0000-0001-8740-6908

8 Mestrado Profissional em Enfermagem na Atenção Primária à Saúde, Escola de Enfermagem da Universidade de São Paulo (USP), São Paulo-SP, Brazil, https://orcid.org/0000-0003-1510-8156

Corresponding Author

Larayne Gallo Farias Oliveira

Av. Dr. Enéas Carvalho de Aguiar, 419 - Cerqueira César, São Paulo - SP, Brazil. 05403-000, +55 (73) 99103-5689, E-mail: larayne@usp.br

Submission: 06-08-2024

Approval: 07-05-2025

ABSTRACT

Introduction: One of the central points of Primary Health Care is access to care. However, several challenges still limit access to health. Therefore, demand management in Primary Health Care is essential to avoid overloading emergency services, promoting the appropriate use of available resources. However, the high demand for health services often exceeds the available supply. This imbalance results in backlogs, which are appointments scheduled for the future, creating a pent-up demand in the present. Therefore, this study proposed to explore the management of demands and backlogs in Primary Health Care and their implications for the quality of care. Method: This was a narrative, bibliographic, and non-systematic review that sought to explore the management of demands and backlogs in Primary Health Care and their implications for the quality of care. Results: The results point to the implementation of advanced queue management technologies, the adoption of new practices, the extension of health unit opening hours, the hiring of more professionals, electronic scheduling systems and the Advanced Access model. Final Considerations: To achieve these objectives, comprehensive strategic planning and continuous training of health professionals are necessary, promoting a more efficient, accessible and user-centered health system.

Keywords: Primary Health Care; Effective Access to Health Services; Access to Primary Care; Health Services Needs and Demand; Health Management.

RESUMEN

Introducción: Uno de los puntos centrales de la Atención Primaria de Salud es el acceso a la atención. Sin embargo, varios desafíos aún limitan el acceso a la atención médica. Por tanto, la gestión de la demanda en Atención Primaria de Salud es fundamental para evitar la sobrecarga de los servicios de urgencia y emergencia, promoviendo el uso adecuado de los recursos disponibles. Sin embargo, la gran demanda de servicios sanitarios suele superar la oferta disponible. Este desequilibrio da como resultado retrasos, que son servicios programados para el futuro, creando una demanda atrapada en el presente. Por lo tanto, este estudio se propuso explorar la gestión de las demandas y rezagos en la Atención Primaria de Salud y sus implicaciones para la calidad de la atención. Método: Se realizó una revisión narrativa, bibliográfica y no sistemática, que buscó explorar la gestión de las demandas y rezagos en la Atención Primaria de Salud y sus implicaciones para la calidad de la atención. Resultados: Los resultados apuntan a la implementación de tecnologías avanzadas de gestión de colas, la adopción de nuevas prácticas, ampliación del horario de atención de las unidades de salud, contratación de más profesionales, sistemas de programación electrónica y el modelo de Acceso Avanzado. Consideraciones finales: Para alcanzar estos objetivos es necesaria una planificación estratégica integral y la capacitación continua de los profesionales de la salud, promoviendo un sistema de salud más eficiente, accesible y centrado en el usuario.

Palabras clave: Primeros auxilios; Acceso Efectivo a los Servicios de Salud; Acceso a la Atención Primaria; Necesidades y Demandas de Servicios de Salud; Manejo de la Salud.

RESUMO

Introdução: Um dos pontos centrais da Atenção Primária à Saúde é o acesso ao cuidado. No entanto, diversos desafios ainda limitam o acesso à saúde. Desta forma, a gestão de demandas na Atenção Primária à Saúde é essencial para evitar a sobrecarga dos serviços de urgência e emergência, promovendo o uso adequado dos recursos disponíveis. Contudo, a alta demanda de serviços de saúde frequentemente supera a oferta disponível. Esse desequilíbrio resulta em backlogs, que são atendimentos agendados para o futuro, criando uma demanda represada no presente. Sendo assim, este estudo propôs explorar a gestão de demandas e backlogs na Atenção Primária à Saúde e suas implicações para a qualidade do atendimento. Método: Tratou-se de uma revisão narrativa, bibliográfica e não sistemática, que buscou explorar a gestão de demandas e backlogs na Atenção Primária à Saúde e suas implicações para a qualidade do atendimento. Resultados: Os resultados apontam para a implementação de tecnologias avançadas de gestão de filas, a adoção de novas práticas, extensão dos horários de funcionamento das unidades de saúde, contratação de mais profissionais, sistemas de agendamento eletrônico e o modelo de Acesso Avançado. Considerações Finais: Para alcançar esses objetivos, é necessário um planejamento estratégico abrangente e a capacitação contínua dos profissionais de saúde, promovendo um sistema de saúde mais eficiente, acessível e centrado no usuário.

Palavras-chave: Atenção Primária à Saúde; Acesso Efetivo aos Serviços de Saúde; Acesso à Atenção Primária; Necessidades e Demandas de Serviços de Saúde; Gestão em Saúde.

INTRODUCTION

Primary Health Care (PHC) is the main entryway into the health system. It was created to provide primary care for all health service users, according to foundational principles ¹. When caring for individuals or the collective, some of its attributes stand out, such as the first contact, integral care, care continuity, care coordination, and its longitudinal nature².

One of the main points of PHC is access to care. Having access to health is a fundamental right, enshrined in many countries. It is essential to promote the well being and quality of life of the population³and involves available and accessible services that deliver quality health care, including prevention, diagnosis, treatment, and rehabilitation⁴. This implies the existence of appropriate infrastructure, qualified health workers, and public policies that ensure the equal distribution of resources and health services.

Nevertheless, several challenges still limit the access to health in many different regions⁵. Financial barriers, such as costly treatments and lack of coverage from insurance can prevent people from seeking the care they need^3,5. Moreover, social and economic inequalities also lead to disparities in health access, negatively affecting the ability of many individuals of receiving appropriate care⁶.

Therefore, the quality of health access is one of the main aspects of public health policy, since the demand for health services is often higher than their supply⁷. This imbalance leads to backlogs, that is, to appointments scheduled for future dates, which create a repressed demand in the present⁸.

The management of PHC demand is essential to avoid overload in urgency and emergency services, promoting the appropriate use of the resources available and improving the efficiency of the Single Health System (SUS)⁹. Therefore, the PHC must be able to deal with most health problems of the population, from prevention to the treatment of chronic diseases, including the follow up of acute conditions and health promotion¹⁰.

The efficient management of these demands is essential to ensure that users receive the care they need in a timely manner, while not compromising the quality of the service provided¹¹. In this regard, one of the greatest challenges of SUS regarding access to health is an efficient management of demand and backlogs.

PHC backlogs can be considered good or bad. Bad backlog is work that should be carried out in the present, but due to a lack of available time, is delayed into the future¹². According to Mendes¹², this type of backlog is harmful as it leads to an accumulation of demands, overloading SUS and increasing user waiting time. This can lead to delays in diagnosis and treatment, worsening the health results of users¹³.

Good backlogs, on the other hand, involve users that do not wish to receive the service in the same day, and prefer to schedule appointments for future dates, as it is more convenient to them. It also includes users who had a follow-up consultation scheduled, cases in which the health team elaborates a plan to monitor and adjust their treatment as needed¹³. This type of backlog is beneficial, as it enables continuous and personalized monitoring of the user.

Nevertheless, the growing demand for services and the accumulation of backlogs has become a significant challenge, that directly impacts the quality of the care provided to the users¹⁴. Studying these elements allows the identification of bottlenecks and enables solutions that can improve work flow and the efficiency of the services provided.

Furthermore, the inadequate management of demands and backlogs in PHC can lead to long waiting times, health worker overload, and, consequently, to the deterioration of the quality of care. This, in turn, can lead to late diagnoses, inadequate treatment, and the dissatisfaction of users, making public health issues worse¹⁴.

As a result, this study aimed to explore the management of demand and backlogs in PHC and its implications to the quality of care. By doing so, it can provide contributions to more efficient health policies and promote quality, accessible, and efficient care for the population.

METHOD

This is a narrative review, a type of study ideal to describe and discuss the development or the state of the art of a specific topic, from both theoretical and contextual perspectives¹⁵. It involves an analysis of the literature available in books, printed and digital journals, as well as the critical interpretation and analysis of the author. This type of review is essential for continued education, as it allows readers to acquire and update their knowledge about a specific subject in a fast and efficient way.

This is a type of literature review that aims at summarizing and carrying out a critical analysis of existing knowledge on a specific research topic or question¹⁶. Since the narrative review does not use a rigorous and transparent methodology to select and analyze studies, it becomes, in turn, more flexible and exploratory^15,16. It provides researchers with greater freedom to discuss the contributions, gaps, and controversies in literature, enabling a broader and more contextualized perspective on the topic at hand¹⁵.

This review was carried out following the steps: definition of a central question to guide the study; thorough analysis of the publications associated with the topic; collection of data relevant to investigate the management of demand and backlogs in PHC, as well as its implications on the quality of care. Our goal was to identify trends, patterns, and significant information related to the topic, followed by a critical analysis of the data collected.

RESULTS AND DISCUSSION

The access to health services is the result of an interaction between supply and demand⁴. In other words, the alignment between supply (the ability to deliver a service to people) and demand (the number of people who search for said service) determines access⁹. When the supply is sufficient and well-organized enough to meet demand, the access to services tends to be more efficient and effective⁸. However, a mismatch between supply and demand can lead to issues such as long lines, service overload, or even the lack of care to all those who need it⁹.

This interaction is crucial to plan and manage health resources. Understanding the dynamics between supply and demand allows health managers to develop strategies to improve service capability, adjust the services to the needs of the population, and, finally, to ensure a more equal and efficient access to health care.

The supply is the number of people that can be attended in a specific period, being organized by the schedule of the health units and involving all professionals, as well as different service modalities, such as individual in-person consultations, continued care, group sessions, operational groups, groups of peers, remote care, and others¹⁶. The real supply is represented by the number of people that, in a specific time frame, actually search for care from these professionals and receive it¹⁷.

The demand, in turn, is the total number of people who search for care in a certain time frame, be it via phone, e-mail, or in person, in the health units (external demand), in addition to follow-up consultations with the health professionals (internal demand)¹⁸. Demand is not necessarily aligned with supply capacity, which can lead to work backlog, which in turn is reflect in queues¹⁹.

Thus, the implementation of advanced technologies in the management of backlogs and the adoption of new practices, such as reception²⁰ and teleconsultation²¹, were found to be effective in reducing waiting time and improving user satisfaction. These findings reiterate the importance of investing in infrastructure and training health workers for the use of these technologies²².

However, we must consider that health demand management is more than the simple implementation of technologies. It also involves the need for an encompassing strategic planning²³, one that considers the peculiarities of each health unit and the complexities of each population attended²⁴. Thus, an efficient management of health demands can provide significant contributions for a more equal and accessible health system, promoting better results for the health of the population.

Another important measure to expand service capacity is increasing the working time of health units²⁵. By providing attention in the evenings, health units can deliver their services to more users, especially those who cannot visit them in office hours. This flexibility is essential to ensure that all have access to health services when needed, reducing overload in peak hours and increasing user satisfaction.

An example of these strategies is the Programa Saúde na Hora (the Health on Time Program), implemented by the Ministry of Health²⁶. The goal of this program is to expand access to PHC services by expanding the working hours in Family Health Units (FHU); The units that adhere to this program are active from 60 to 75 hours a week, functioning during the evening and weekends. This significantly increases their ability to provide care and brings direct benefits to the population.

The program also encourages the hiring of health workers, ensuring that teams are large enough to deal with the increased demand. Furthermore, the Health on Time Program reorganizes the work process within the units, optimizing the use of available resources and improving the efficacy of care²⁶.

Similarly, the implementation of electronic scheduling systems can revolutionize the allocation of PHC resources²⁷. These systems enable an efficient and organized scheduling of appointments, avoiding overload and distributing the users better throughout the day²⁸. Thus, it becomes possible to reduce the waiting time of users, make better use of the facilities, and ensure that health workers are available whenever and wherever they are needed.

Additionally, the Advanced Access model (AA) is an innovative approach to manage health care demand and supply, as its focus is providing care at the time patients need it, without long waits¹³. Unlike traditional scheduling systems, in which appointments are often scheduled weeks in advance, the AA allows users to get consultations in the same day or the next¹⁵. This can be achieved with an efficient management of care capacity, adjusting the supply and scheduling to the fluctuations in demand^5,12. With this approach, health workers can respond faster to the needs of users, improving their satisfaction and clinical outcomes.

It is true, however, that implementing AA requires significant changes in the organization and workflow of health units²⁹. Oliveira and Fracolli³⁰ argue that a careful planning is necessary to balance the workload, avoiding idleness or work overload. The health team must be prepared to provide both routine consultations and respond to emergencies, adapting to its daily demand³¹.

Furthermore, users must be educated in regard to the new system, to ensure that they use the services efficiently. When well implemented, the AA not only improves the operational efficiency of health units, but also promotes user-centered care, reducing waiting time and increasing the necessary access to care^29,30.

FINAL CONSIDERATIONS

The investment in advanced technologies, such as electronic scheduling systems and telemedicine, along with innovative practices such as the Advanced Access model, were found to be promising strategies to reduce waiting times and increase user satisfaction. Backlog management is also essential, as it enables health units to identify backlog and resolve it fast, preventing any issues from becoming worse. Additionally, extending working hours in the health units and hiring more professionals are important measures to increase care capacity. To reach these goals, a broader strategic planning is required, as well as the continuous training of health workers, promoting a more efficient, accessible, and user-centered health system.

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Funding and Acknowledgements:

This study was supported by the Coordination for the Improvement of Higher Education Personnel – Brazil (CAPES) – Funding Code 001.

Authorship criteria (authors’ contributions)

Conception and/or planning of the study: Oliveira, LGF; Fracolli, LA. Data collection/analysis and/or interpretation: Oliveira, LGF; Fracolli, LA; Pina-Oliveira, AA; Gryschek, ALFPL; Pinto, AR; Silva, LA; Campos, DS; Castro, DMC. Writing and/or critical review of the content: Oliveira, LGF; Fracolli, LA; Pina-Oliveira; AA, Gryschek, ALFPL; Pinto, AR; Silva, LA; Campos, DS; Castro, DMC. Final approval of the final version: Oliveira, LGF; Fracolli, LA; Pina-Oliveira; AA, Gryschek, ALFPL; Pinto, AR.

Declaration of conflict of interest

“Nothing to declare.”

Scientific Editor: Ítalo Arão Pereira Ribeiro. Orcid: https://orcid.org/0000-0003-0778-1447

Rev Enferm Atual In Derme 2025;99(supl.1): e025064

Atribuição CCBY

As a result, this study aimed to explore the management of demand and backlogs in PHC and its implications to the quality of care. By doing so, it can provide contributions to more efficient health policies and promote quality, accessible, and efficient care for the population.

METHOD

The program also encourages the hiring of health workers, ensuring that teams are large enough to deal with the increased demand. Furthermore, the Health on Time Program reorganizes the work process within the units, optimizing the use of available resources and improving the efficacy of care26.

The program also encourages the hiring of health workers, ensuring that teams are large enough to deal with the increased demand. Furthermore, the Health on Time Program reorganizes the work process within the units, optimizing the use of available resources and improving the efficacy of care²⁶.