Brazil's Unified National Research Articles

Comprehensiveness of practices by Cuban physicians in the More Doctors Program in Rio de Janeiro, Brazil.

The shortage of physicians in remote and underprivileged areas poses an obstacle to universal access and quality of health care. Through the More Doctors Program (PMM), as of 2015, 18 thousand physicians had been incorporated into Brazil's Unified National Health System (SUS) to work in basic care, 79% of whom were Cubans. This article analyzed the comprehensiveness of practices by Cuban physicians in the PMM using a qualitative study in the city of Rio de Janeiro, Brazil, based on interviews with Cuban physicians (24) and a focus group with supervisors of the PMM (4). Comprehensiveness was analyzed in two dimensions: the community-oriented biopsychosocial approach to care and the range of activities in health promotion, prevention, and care. The work by Cuban physicians presents elements that are consistent with the comprehensiveness of practices in primary care, providing a wide range of care and services, in keeping with the health problems' complexity and the plurality of settings. These health workers show outstanding capacity for community interaction, a preventive focus, planning of activities, and positive interpersonal team relations. The study identified attitudes and techniques of solidarity, physician-patient bonding, and community accountability. Challenges were identified in the promotion of participatory practices with communities, the expansion of users' autonomy in clinical decisions, management of psychological problems, systematization of approach tools, and performance of invasive procedures. The study furnishes strong evidence that the PMM, in addition to medical consultations, provides comprehensive health care and contributes to strengthening basic care in Brazil.

Formulação da política de Gestão do Trabalho e Educação na Saúde: o caso da Secretaria Estadual de Saúde da Bahia, Brasil, 2007-2008

The construction of Brazil's Unified National Health System (SUS) has raised a set of challenges for the health sector's administrators and personnel, including issues of work management and continuing education for health workers, in view of the financial, political, and organizational constraints in the process of changing the healthcare model. The current study aimed to analyze the process of formulating the Health Work and Education Management Policy by the Bahia State Health Department. Public policy cycle was used as the theoretical framework. The study analyzed data from institutional documents and records of participant observation by one of the authors. The results include mapping the governmental and nongovernmental stakeholders that participated in the process. The analysis highlights a series of problems in the SUS in Bahia related to work management and health workers' profile, taken as the point of departure for priority-setting in the State Strategic Agenda and Health Plan for 2008-2011.

Análises espaciais na identificação das áreas de risco para a esquistossomose mansônica no município de Lauro de Freitas, Bahia, Brasil

The spread of schistosomiasis mansoni defies efforts by Brazil's Unified National Health System, thus demonstrating the need to reassess endemic control programs in the country. The aim of this study was to demarcate geographic areas at risk of schistosomiasis in Lauro de Freitas, Bahia State, Brazil, and to establish the epidemiological and socioeconomic profile of the disease in this municipality (county). Kernel density estimator exploratory analysis was used for visual identification of areas at risk. Kulldorff & Nagarwalla's spatial analysis was used to obtain statistically significant clusters and to measure risk. These technologies identified four risk areas for schistosomiasis. Clusters identified within the risk areas were characterized by lower socioeconomic conditions. Multiple correspondence analyses showed a distinct profile for positive patients in the primary cluster. The techniques employed here represent an important methodological acquisition for tracking and controlling schistosomiasis in Lauro de Freitas.

A regulação assistencial e a produção do cuidado: um arranjo potente para qualificar a atenção

Healthcare production that assures comprehensiveness and equity has posed a challenge for Brazil's Unified National Health System. The aim of this study was to contribute to the debate on the issue, analyzing an experience with municipal healthcare management using regulation to improve quality of care. We conducted a case study in which data were obtained through direct observation, interviews, written narratives, and document analysis. The research subjects were health services managers and health workers. The results feature the concept of a living network, produced actively by building relations between the health workers in the different services. The study highlights the measures to support the care produced by the teams, based on healthcare regulation and work processes management. The results were expressive in upgrading the care, reducing the waiting lines for the specialties, and increasing the health workers' satisfaction. The key feature in the process was the evident need to enrich (through acts) the technical knowledge with light technologies and active movements by management in the production of care.

Acesso à assistência oncológica: mapeamento dos fluxos origem-destino das internações e dos atendimentos ambulatoriais. O caso do câncer de mama

This study analyzes the flow of patients with breast cancer treated in Brazil's Unified National Health System (SUS) by type of treatment (surgery, radiotherapy, and chemotherapy). Hospital and outpatient services networks were identified based on data from the National Information System for Inpatient Care (SIH), and the National Information System for Outpatient Cancer Care, for 2005-2006, using TabWin and TerraView. Health services networks reach most of the country, and few municipalities are not connected to a network. However, treatment is highly concentrated in the largest cities, and even the latter show evidence of service shortages. Furthermore, a large proportion of patients live more than 150 km from the respective service. Network identification is important for planning and improving services distribution, since geographic access is a relevant issue for treatment outcome. Reduction of morbidity and mortality requires early identification, and appropriate and prompt treatment can reduce the impacts of the disease.

Os custos de doenças tabaco-relacionadas para o Sistema Único de Saúde

This study aimed to identify the direct costs of hospitalizations due to three smoking-related groups of diseases - cancer and circulatory and respiratory diseases - in Brazil's Unified National Health System (SUS) in 2005. For cancer, the cost of chemotherapy was also included. The study derived cost estimates using administrative databases, relative risks, smoking prevalence, and smoking-attributable fraction. According to the estimates, smoking- attributable medical expenditures for the three disease groups amounted to R$338,692,516.02 (approximately U$185 million), accounting for 27.6% of total medical expenditures. Considering all hospitalizations and chemotherapy provided by the National Health System, tobacco-related diseases accounted for 7.7% of total medical expenditures. These costs also represented 0.9% of expenditures by federally funded public health services. This study provides a conservative estimate of smoking-related costs and suggests the need for continued research on comprehensive approaches to measure the total burden of smoking for society.

Integração entre vigilância sanitária e assistência à saúde da mulher: um estudo sobre a integralidade no SUS

Comprehensiveness is a key principle in Brazil's Unified National Health System (SUS), approached from various perspectives, including linkage between services. The debate on this principle appears in health care, especially in the area of Women's Health, and in Health Surveillance guidelines. Since both areas target quality of health services, the aim of this study is to analyze the integration between Health Surveillance and Women's Health Care. This is a qualitative case study that interviewed Health Surveillance staff in health services and coordinators of Women's Health services. The findings point to the isolation of Health Surveillance within the health secretariats. The importance of integrating the two areas is cited by Women's Health administrators, but it is difficult to implement. Collaborative relations only occur in emergency situations. The Health Surveillance professionals believe that this lack of integration is due to the fact that women's health issues do not require their participation, and that at any rate they collaborate with the area through health inspections and talks. The study detected difficulties in achieving integration between the two areas, with the persistent challenge of linking health actions, especially with Health Surveillance.

Sustentabilidade financeira e econômica do gasto público em saúde no nível municipal: reflexões a partir de dados de municípios mato-grossenses

Brazil's Unified National Health System is financed according to a model known as fiscal federalism, the fund-sharing rules of the Social Security Budget, Ministry of Health norms, and Constitutional Amendment 29 (EC-29), which links Federal, State, and municipal resources to health. This article discusses the sustainability of public spending on health at the municipal level. Twenty-one municipalities were studied, using municipal budget data. From 1996 to 2006, total current per capita revenues increased by 280% above the accumulated inflation and Gross Domestic Product, varying by size of municipality, which also defined the composition of the municipal budgets. Meanwhile, the budget comprising the basis for EC-29 increased less (178%), thus placing limits on the municipal share of health spending. The results observed in these municipalities are believed to reflect the reality in thousands of other Brazilian municipalities, thus jeopardizing the capacity for municipal investment in health, especially beginning in 2008. The situation may become even worse, considering the repeal of the so-called Bank Transaction Tax (CPMF), Bills of Law 306/08 and 233/08 (currently under review in the National Congress), and the world recession stemming from the U.S. financial crisis.

Médico de família: ser ou não ser? Dilemas envolvidos na escolha desta carreira

A Estratégia Saúde da Família é responsável por reorganizar o Sistema Único de Saúde brasileiro por meio da Atenção Primária. O aumento substancial de programas e vagas para residência em Medicina de Família e Comunidade, ocorrido desde 2002, é uma das estratégias para suprir o crescente mercado de trabalho correspondente. Entretanto, menos da metade dessas vagas são ocupadas. A literatura brasileira apresenta poucas evidências sobre o motivo desta baixa procura. Alguns países que optaram pelo fortalecimento da Atenção Primária em seu sistema de saúde também experimentam uma crise aparente na escolha desta carreira pelos egressos médicos. Neste ensaio, revisamos algumas questões envolvidas nesta escolha, apontando sua complexidade e a necessidade de investigações sistematizadas sobre as motivações dos alunos de graduação em optarem ou não por esta especialidade médica, particularmente no Brasil.

O desafio da descentralização do Sistema Único de Saúde em município de grande porte: o caso de São Paulo, Brasil

Decentralization of Brazil's Unified National Health System (SUS) still poses challenges in large cities. To characterize decentralization as an essentially political process, institutional policy variables, including local management capacity, are determinant for shaping decentralization in each context. Using the government triangle reference to evaluate management capacity, a case study was conducted with the objective of analyzing the system's decentralization in the city of São Paulo, Brazil's largest metropolis. An analysis of selected health system managers and administrative documents identified a trend towards focusing health management at the municipal level in 2005-2008, accompanied by dismantling of local/regional structures in the Municipal Health Secretariat, resulting in technical and policy depletion at these levels. Despite the limits of decentralization, the article emphasizes its power as an operational strategy to achieve the SUS' objectives. The article also stresses the need to resume the health decentralization process in the city of São Paulo, both moving towards local/regional levels and linked to the decentralization of municipal public management.

A reforma sanitária brasileira após 20 anos do SUS: reflexões

This article provides some reflections on the challenges that have arisen during 20 of experience with the implementation of Brazil's Unified National Health System and the significance of Constitutional provisions related to health for both academic research and health sector managers. The article discusses the main issues during these 20 years and how they are currently managed, and concludes by inquiring into the need for reconnecting health sector projects to a broader project for Brazilian society, without which the original proposals for health run the risk of becoming merely managerial ones.

As mudanças na educação médica brasileira em perspectiva: reflexões sobre a emergência de um novo estilo de pensamento

A formação médica atual encontra-se estruturada a partir de um modelo tecnocientífico. No entanto, na contemporaneidade surgem propostas orientadas por um projeto ético-humanista que tensionam esse modelo com vistas a sua transformação. Neste ensaio, considera-se o Sistema Único de Saúde (SUS) como superfície de emergência de novas demandas que alavancam as transformações requeridas na educação médica brasileira. A proposta estabelecida pelas Diretrizes Curriculares do Ensino Médico de 2001 sugere a inserção precoce do aluno em cenários diversificados de ensino-aprendizagem e enfatiza o papel desempenhado pela atenção básica nesse processo. Entende-se que a instituição de novos cenários de prática, a valorização das dimensões psicossocial e antropológica do adoecer e a incorporação de tecnologias relacionais na formação médica possibilitam uma reorientação do olhar sobre os aspectos subjetivos do adoecimento, permitindo uma compreensão ampliada do processo saúde-doença. Considerando que inovações no processo de trabalho possibilitam mudanças na prática clínica e na produção da atenção à saúde, questiona-se a possibilidade de emergência de um novo estilo de pensamento médico.

Utilization of human papillomavirus testing for cervical cancer prevention in a university hospital

This study aimed to evaluate the performance and cost of using polymerase chain reaction (PCR) and hybrid capture in the detection of cervical intraepithelial neoplasia (CIN) in patients with cytological abnormalities (ASCUS/low-grade squamous intraepithelial lesion--LSIL), and the feasibility of implementing these methods in Brazil's Unified National Health System (SUS). Colposcopy gave a negative predictive value of 92.86% and efficiency of 87.8% for diagnosing CIN. The sensitivity of PCR and hybrid capture for detecting CIN was 83.33% and 66.67%, respectively, and the negative predictive value for diagnosing CIN2/CIN3 was 100% and 94.74%, respectively. The annual cost for 80 patients was lower when all patients with ASCUS/LSIL were referred for colposcopy than when HPV testing was performed and those with positive results were referred for colposcopy. Therefore, at present, it is financially unfeasible for the National Health System to implement HPV testing to screen patients with cytological abnormalities (ASCUS/LSIL). However, considering that large-scale use might make such methods cheaper, PCR should be the chosen method, since it is less expensive, more sensitive, and has a high negative predictive value.

Um estudo sobre as filas para transplantes no Sistema Único de Saúde brasileiro

This study analyzes the waiting lines for solid organ transplants in Brazil's Unified National Health System. By using a queuing theory model, we estimate the waiting times for different organs under alternative scenarios. The model reveals the elasticity of various waiting times with respect to arrival and service rates for organ transplantation within the system. Average waiting time for a solid organ transplant is very long and highly elastic in Brazil. The article discusses some important possibilities for reducing such waiting times.

O Sistema de Informação Hospitalar e sua aplicação na saúde coletiva

The objective of this study was to survey the scientific production of applications for data from the Hospital Information System of Brazil's Unified National System (SUS) in analyses of relevant Public Health issues. To find articles published in scientific journals from 1984 to 2003, the authors consulted the SciELO, MEDLINE, and Virtual Public Health Library databases. To locate monographs, theses, and dissertations, the authors consulted the websites of institutions providing Master's and doctoral courses in Public Health. A total of 76 articles were identified for the reference period, and they were classified into five categories with different analytical approaches. Although the Hospital Information System in the SUS has incomplete coverage and there are uncertainties about the reliability of its data, the range of studies showed internal consistency with current knowledge, reinforcing the system's importance and the need to understand its strengths and weaknesses.

Consórcios Intermunicipais de Saúde: o caso do Paraná, Brasil

Inter-municipal health consortia emerged in Brazil's Unified National Health System (SUS) policy in the late 1980s. Municipal health administrators adhered to this strategy with the aim of upgrading health services supplied to the population. This research analyzes the profile of such consortia in Paraná State, focusing on specialized medical care. Data were obtained from reports by the State Health Council and questionnaires sent to all 20 existing municipal health consortia. Governmental Decree no. 1,101 and data published in 2000 on the profile of the health system in Paraná were used as references. Of the 399 municipalities in Paraná State, 81.5% have joined municipal consortia. Specialists are allocated by municipalities (4.4%), the State government (13.6%), or Federal Government (12.8%); another 69.2% are hired by the consortia themselves. The supply of consultations with specialists is either insufficient or inadequately distributed, and there are flaws in the referral and counter-referral system. Municipal health consortia serve as viable instrument for expanding and increasing the capacity of municipalities to supply specialized care, although there is a need for well-defined criteria, planning, and improving of the referral and counter-referral system.

Vigilância epidemiológica no Programa de Controle da Doença de Chagas em Minas Gerais, Brasil (1984-1998)

This paper describes the surveillance phase of the Chagas Disease Control Program in Minas Gerais State. Surveillance was conducted by the County Health Services with community participation in the planning, decision-making, and maintenance processes and is intended to be sustainable in the context of Brazil's Unified National Health System (SUS).