INTRODUCTION

<= span style=3D'font-size:12.0pt;line-height:150%;mso-fareast-font-family:"Times N= ew Roman"'>

<= span style=3D'font-size:12.0pt;line-height:150%;mso-fareast-font-family:"Times N= ew Roman"'>Public policies must be created to contribute to the enforcement of laws= , instituting interventions in different sectors of society,= being essential for the <= span class=3DSpellE>achievement of health. Ensuring<= /span> the right of everyone to access health care, including people with disabilities, is still a challen= ge.

<= span style=3D'font-size:12.0pt;line-height:150%;mso-fareast-font-family:"Times N= ew Roman"'> These people have = greater exposure to risk factors, low socioeconomic conditions, little = access to education and health s= ervices, in addition to lack= of information. Thus, they become more vulnerable to the development of diseases, requiring differ= entiated health care due to the peculiarities of their <= span class=3DSpellE>disability.(1)

<= span style=3D'font-size:12.0pt;line-height:150%;mso-fareast-font-family:"Times N= ew Roman"'>In Brazil, 23.91% of the population has a disability, with a highe= r concentration among women, in rural areas, in the north and <= span class=3DSpellE>northeast regions of Braz= il. Being in first place the = visual impairment (18.6%); followed by motor impairment (7.0%), h= earing impairment (5.10%) and mental or intellectual disability (1.40%). As for the age group, 59% of people with disabi= lities belong to the age group between 15 and 64 years old. More than 23.7 million people with d= isabilities of working age are unemplo= yed; more than half of p= eople with disabilities (61.1%) have no education or = have incomplete primary education.(4)

<= span style=3D'font-size:12.0pt;line-height:150%;mso-fareast-font-family:"Times N= ew Roman"'>Most initiatives in the field of health care aimed at this<= /span> audience have still been = isolated and at odds with= the principles of integrality= , equity and qualified and universal access to health, resulting in fragmented and poorly inclusive care.(2)

<= span style=3D'font-size:12.0pt;line-height:150%;mso-fareast-font-family:"Times N= ew Roman"'>The perspective of comprehensiveness and equity in health care in the SUS defines that health = care for individuals occurs according to their needs = (particularities) and articulated= at all levels of complexity of the system.(2,6)= Therefore, they are Speci= fic and effective public health policies are necessary so that this group can have qualified health= care.

<= span class=3DSpellE>Historically, the issue of disability in th= e public sphere was initially understood as “social action” and is now treated from the perspective of citizenship and human rights. L= egal instruments have been est= ablished since then, regulating the constitutional dictates r= elated to this population = segment, including in the area of health.

<= span class=3DSpellE>Throughout the historical trajectory, it= is clear that advances have = been made in relation to = public policies for people with disabilities in Brazil, however, the challenge of = implementing a public health policy cap= able of responding to the health needs of this population = still exists. Given this context, the question is: What challenges need = to be faced to provide health care for people with disabilities?

<= span class=3DSpellE>Therefore, the study aimed to carry out a reflective analysis on health care for people with disabilities.

<= span style=3D'font-size:12.0pt;line-height:150%;mso-fareast-font-family:"Times N= ew Roman"'>As this is a reflective study, with theoretical support from Brazilian public = health policies aimed at this population and from recent publications on the subject, the present work was structured in two reflective axes= that proposed to discuss: The = Network of Health Care for the Person with disabilities= and The issue of accessibility= in public health policies.

<= span style=3D'font-size:12.0pt;line-height:150%;mso-fareast-font-family:"Times N= ew Roman"'>

HEALTH CARE NETWORK FOR PEOPLE WITH DISABILITIES<= /b>

<= span class=3DSpellE>This thema= tic axis raises some reflective questions: Is = health care for people with disabilities restricted to the area of rehab= ilitation? How is the health care network of this clientele organized? What= are the barriers to its implementa= tion? To follow the paths that lead to answering these questions, the foll= owing discussions on the subject are presented.

<= span style=3D'font-size:12.0pt;line-height:150%;mso-fareast-font-family:"Times N= ew Roman"'>The Statute of Persons = with Disabilities, also known = as the Brazilian Law of Inclusion, ensures comprehensive health care for people with disabilities at all levels of co= mplexity, through the SUS, guaranteeing universal and equal access.(5)

<= span style=3D'font-size:12.0pt;line-height:150%;mso-fareast-font-family:"Times N= ew Roman"'>For universal and quality care, it is necessary to conside= r the particularities inhere= nt to people with disabilities. The latter has the right to be= met by the SUS in their basic and specific health needs, through promotion, prevention and rehabilitation actions, including the acquisition of optical resources, orthotics, prostheses and auxiliary = means of mobility.(4)

<= span style=3D'font-size:12.0pt;line-height:150%;mso-fareast-font-family:"Times N= ew Roman"'>The National Health Policy for Persons with Disabilities, institu= ted in 2002, highlights that a person with a disability, in addi= tion to the need for health care specific to their <= span class=3DSpellE>own condition, can also be affected by diseases and injuries common = to other people, thus requiri= ng , from other types of serv= ices besides those strictly related to their disability.(2,6)

<= span style=3D'font-size:12.0pt;line-height:150%;mso-fareast-font-family:"Times N= ew Roman"'>In this sense, another aspect to emphasize is the importance of training professionals who assist this population. There are frequent debates about the professional skills necessary for people with disabili= ties to have their rights to ac= cess these services with= quality guaranteed, especially with regard to the interdiscipl= inary interface.

<= span style=3D'font-size:12.0pt;line-height:150%;mso-fareast-font-family:"Times N= ew Roman"'>The National Health Policy for Persons with Disabilities mentions= the training of human reso= urces to better target he= alth actions. It reinforces th= at all professionals in the family health teams should receive training t= hat enables them to develop actions for preve= ntion, early detection, specific= intervention and adequate= referral of this public.(= 6) This should be considered, as the care for people with disability must be carried out in health care networks according<= /span> to the needs of this population.

<= span style=3D'font-size:12.0pt;line-height:150%;mso-fareast-font-family:"Times N= ew Roman"'>In this context, the Care Network for People with = Disabilities was established wit= hin the scope of the SUS. It is challenging what is pointed out in item III of Article 3 of= Ordinance 793/2012, which defines the general objectives of the network, provi= ding guarantees of articulation= and integration of the points of care of the he= alth networks in the territory, qualifying care by <= span class=3DSpellE>expanding access. (7)

<= span style=3D'font-size:12.0pt;line-height:150%;mso-fareast-font-family:"Times N= ew Roman"'>Studies show that there is a lack of articulation between primary health care teams and the care network for people with disabilities, in addition to barriers within the hospital network, gen= erating consequences in the discon= tinuity of care for people with disabilities. Among the= network's potential, the most cited is the existence of reference rehabilitation services, = on the other hand, the difficulty= of accessing these = services and the precarious training of health professionals and managers to deal<= /span> with the particularities of this public are referred to as the main limitations of the network.(4)

<= span style=3D'font-size:12.0pt;line-height:150%;mso-fareast-font-family:"Times N= ew Roman"'>The integrated articulation of the healthcare network care points in the conte= xt of the SUS often does not hap= pen, as each care point acts exclusively in its own space, as limited and isolated from the others,= generating discontinuity = of care.(3)

<= span class=3DSpellE>Another point that deserves reflection is the one c= ontained in items I and II, of Art. 11, of Ordinance No. 793/12, providing for the organization of t= he Care Network for People with Disabilities within the scope of Prima= ry Care, Specialized Care in Rehabi= litation and of Hospital and Urgency and Emergency Care.= (7)

<= span class=3DSpellE>Previously, health care f= or people with disabilities was restricted to rehabilitation equipmen= t and services, which is ins= ufficient for the health demands of = this clientele. This new= network established by Ordinance No. 793/12 understands that rehabilitation<= /span> centers are necessary as points of attention for specific actions in the health care of people w= ith disabilities, but they are also conceived a= s spaces for articulation w= ith other points of care of the SUS.

<= span style=3D'font-size:12.0pt;line-height:150%;mso-fareast-font-family:"Times N= ew Roman"'>People with disabilities need differentiated and continuous care, which implies the ex= istence of a care network with more interaction between the di= fferent levels and preparation of professionals, especially those in primary care, to welcome and meet the demands of daily care and, when necessary, = make referrals.⁽⁸⁾

= The perception of people with = disabilities that they are not adequate= ly treated regarding t= heir health specificities is an= other worrying component.= (9) Despite the advances achieved by the SUS in recent years, the difficulty in o= vercoming the intense fragmentation of actions and services is still evid= ent. of health. The Care Network for People with Disabiliti= es is a healthcare network un= der construction, where= there is a gradual process of in= corporation of its guidelines in the care of people with disabilities.

= Despite the guarantees defined in these public policies, there are still inequalities that can aggravate = the vulnerable situation of <= span class=3DSpellE>this population segment. A more effective presen= ce of the State is necessary to guarantee this policy, as well as changes in the behavior<= /span> of society, in addition to the training of health professionals for an interdisci= plinary action.

THE QUESTION OF ACCESSIBILITY IN PUBLIC HEALTH POLICIES

= Pervading aspects related to health is the issue of accessibility. In this<= /span> sense, two questions arise: Are the human and = physical resources of the health se= rvices prepared to assist = people with disabilities? What are the main barriers faced by this public in accessing health services?

= To answer these questions, it is important to understand= that accessibility to health services is directly related to the consolidation of SUS principles. Because= it concerns the resolutene= ss of services so that= the offer is sufficient to meet the needs of the population at the time of demand= for care.

= Accessibility to health services has been reported in research as one of the main problems related to = care for people with disabilities. = Several barriers limit the = care provided to these health = users, including professional at= titudes and failures in communication, even physical access to health services= .(10-11)

= Architectural barriers on public roads = and buildings, which impede or hinde= r accessibility to the health service, are some o= f the difficulties experienced by people with disabilities. Access difficulties are also part of the patient-health professional interaction, as sensory deficiencies contribute t= o attitudinal barriers in t= he context of this interaction.(9)

= As primary care is theoretically the gateway to the public health system, this is possibly the first instance where people with disabilities w= ill receive care. However, there is a difficulty in obtaining this <= span class=3DSpellE>access.

= Researches that aimed to assess the physi= cal accessibility of primary health care units in municipalities in the N= ortheast region showed that = the access of people with physical d= isabilities or with reduced mobility to these services is a= challenge, since there ar= e still physical, architectural and furniture barriers. Results show that access to the interior of the health unit building is = via stairs, ramps and inaccessible floors. Partially accessible doors in relation to width and absence of phys= ical obstacles, countertop furniture, seats, drinking fountains and inaccessible public telephones.^(10-11)

The concept of access to health services is cons= idered as the freedom to choose services and their availability<= /span> when seeking care. It can<= /span> also be understood as the association between s= ome elements called availability, acceptability and information and is increasingly<= /span> confused with the concept= of equity in health.(11) Access and accessibility to health actions and serv= ices have similar meanings and relate to ability to obtain health = care when needed, easily= and conveniently.

In turn, the Convention on the Rights of Persons with Disabilities refers to accessibility as a tool for people with disabilities to achieve t= heir autonomy in all aspects o= f life. It is noteworthy th= at accessibility must be guaranteed= not only to the physical environment, but also to the means of = information and communication. S= ince, the absence of adaptations= that promote accessibility= came to be considered as an act of discrimination due to d= isability.(12)

Access with equity should be a constant concern in health care, as a pri= nciple of justice based on the premise that it is nece= ssary to treat each person according to their= need.(11)

It is worth noting that the Brazilian Association of Technical Standards (A= BNT NBR 9050), based on the principles of universal design, establishes access= ibility standards that must be followed and adopted in buildings, spaces, urban furniture and equipment and means of transport. Thus, it aims to provide as many people as possible, = regardless of age, height or mobility= limitation, the safe use of the = environment or equipment.(13-14)

However, even with the current legislation, the process = of adhering to the norms of = accessibility to public places still keeps a slow = pace. The most recent constructions designed to= house public agencies, such as basic health units, are s= till the target of complaints from users with disabilities f= or presenting unsatisfactory = conditions that do not guarantee free= access to all people.(10) The la= ck inclusion in health services implies a reduction in care, contr= ibuting to the reduction of educational activities for = the promotion, prevention and mainte= nance of health for this populat= ion segment.

= The issue of accessibility is also addressed in the Stat= ute of Persons with Disabiliti= es when mentioning the right<= /span> to assistive technology, as a form of accessibility to information, autonomy and inclusion.(5)

= Among the Assistive Technology r= esources, the materials and products= that favor autonomous performance in routine activities stand out; al= ternative communication devices; com= puter accessibility features; mobility aids; orthotics = and prostheses; resources tha= t favor the practice of sports and participation in leisure activities; acc= essories that enable mobility in vehicles; in addition to = aids to expand the visual and auditory function.(15)

= Also on this subject, the National Plan for the Righ= ts of Persons with Disabiliti= es – Living Without Limits = Plan has among its guidelines the promotion of access, development and innovation in assistive technology, wit= h the objective of expanding th= e development of such products and investment in research in the area.(16)

= Knowing that assistive technology can be related to the quality of life of people with disabilities, insofar as it facilitates activities, it is important t= hat its use be incorporated in= to health care and education practices.

FINAL CONSIDERATIONS

<= span class=3DSpellE>Ensuring quality of life, accessibility and <= span class=3DSpellE>rights for people with disabilit= ies requires beyond projects and research. Effective legislation and public policies aimed at those with limitations, whether phys= ical, mental, auditory, visual and/or multiple, are essential.

<= span style=3D'font-size:12.0pt;line-height:150%;mso-fareast-font-family:"Times N= ew Roman"'>The situation of health care for people with disabilities in Brazil still presents a poorly inclusive profile, with disarticulation and discontinuity of actions.= The Unified Health System, for over = twenty years, has been emphasizing the concept o= f comprehensiveness and equity in care delivery to the population, but still with limitations in the organization and = operation of health care for people with disabilities.

<= span style=3D'font-size:12.0pt;line-height:150%;mso-fareast-font-family:"Times N= ew Roman"'>From the reflections raised, it is observed that Brazil ha= s experienced many ye= ars of struggle for the incorporation of the rights of people with = disabilities, obtaining various f= orms of benefits such as rights to education, accessibili= ty and information, having an expressive value in combating inequalities . = However, there is still a contradiction, because even with legislation that contemplates the rights of people with = disabilities, there is still a gap between the legal discourse and practical life, as people with disabilities do not fully enjoy the rig= hts of citizenship achieved.

<= span style=3D'font-size:12.0pt;line-height:150%;mso-fareast-font-family:"Times N= ew Roman"'>A network that guarantees co= mprehensive health care for people with disabilities needs to have articulated= actions and services that= favor partnerships between the various= services and actors in the network, adequate funding<= /span>, in addition to the commitm= ent and training of professionals and managers of health.

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Corresponding= author

Adriana Sousa Carvalho de Aguiar.

Endereço completo: Deusdedit Costa Sousa, 55. Bairro: Cocó

CEP: 60.192-460

Telefone: +55 (85) 9 96158002
E-mail: adriana.aguiar@aluno.= uece.br =

Submission: 2021-05-07<= /span>

Approval: 2021-06-10