José Mendes Ribeiro

Methodological concerns and recommendations on policy consequences of the World Health Report 2000

Celia Almeida MDa, Paula Braveman MDc, Marthe R Gold MDd, Celia L Szwarcwald DrPhb, Jose Mendes Ribeiro MDa, Americo Miglionico MSe, John S Millar MDf, Silvia Porto PhDa, Nilson do Rosario Costa PhDa, Vincente Ortun Rubio PhDg, Malcolm Segall MRCPh, Barbara Starfield MDi, Claudia Travessos MDb, Alicia Uga PhDa, Joaquim Valente MDa and DrFrancisco Viacava MDb/ a National School of Public Health, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil/ b Health Information Department, Center for Scientific and Technological Information, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil/c Department of Family and Community Medicine, University of California, San Francisco, USA/d Department of Community Health and Social Medicine, City University of New York Medical School, New York, USA/e Consultant to Ministry of Health, Montevideo, Uruguay/ f Canadian Institute for Health Information, Ottawa, Canada/ g Department of Economics, Universitat Pompeu Fabra, Barcelona, Spain/h Health Unit, Institute of Development Studies, Sussex, UK/ i Johns Hopkins Medical Institutions, Baltimore, USA

Atenção ao pré-natal na percepção das usuárias do Sistema Único de Saúde: um estudo comparativo

This was a comparative cross-sectional study among public prenatal care users in conventional outpatient health services and family health services, aimed at assessing perception and quality differences between the two models of health services organization according to Ministry of Health guidelines. A total of 203 pregnant women from 22 municipalities in five regions of the country were interviewed while waiting for prenatal consultation. Besides soliciting the womens opinions, we checked for possible advantages in innovative family care services in issues like access and commitment. Data revealed approval by users for key aspects related to care and consultation in both types of public facilities and suggest consistent primary care policies. Low coverage in dentistry (18.9%), gynecological preventive tests (39.6%), and HIV tests (52.6%) indicates policy obstacles. Comparatively, family health services received significantly greater approval by women on issues like quality of the last visit (p = 0.0432), maternity hospital access (p = 0.0106), vaccination schedules (p = 0.0023), drug delivery (p = 0.0053), blood glucose tests (p = 0.0309), nursing visit (p = 0.0469), and home visits (p < 0.0001).

Conselhos de saúde, comissões intergestores e grupos de interesses no Sistema Único de Saúde (SUS)

Health councils have developed in Brazil in keeping with arrangements under the 1988 Constitution, and the logic of their political consensus has expanded among interest groups relevant to public policy. Collegiate bodies, such as intergovernmental commissions, represent an extension of that logic to executive relationships and also express political intermediation by expertise, following the tradition of the European Welfare State. The state technical bureaucracy has thus developed a remarkable role in policy-making and in State-level modeling of interest groups. This article argues that such collegiate bodies should be analyzed through State action and defines two models for health councils. One, the vocal political model, is characterized by a prevalence of outspoken denunciation and an overload of demands on the political agenda. The other, the consensus model, expresses self-limitation amongst interest groups in drafting demands. These models are not hierarchically fixed and are usually linked to the political platforms of interest groups participating in the collegiate bodies.

Desenvolvimento do sus e racionamento de serviços hospitalares

Analisamos o sistema de saude brasileiro em perspectiva comparada. A migracao de clientelas de renda media para operadoras pre-pagas privadas aproxima o caso brasileiro do norte-americano. A producao de servicos hospitalares no SUS demonstra importante reducao da oferta agravada pelo crescimento demografico e por expectativas definidas por disposicoes constitucionais. A reducao e seletiva e concentrada em servicos obstetricos e de clinica medica e nos servicos privados lucrativos. Para se garantir acesso equitativo e necessario: ampliacao de gastos publicos; reducao dos gastos por desembolso direto; reformas organizacionais; ampliacao da capacidade de governo.Analisamos o sistema de saude brasileiro em perspectiva comparada. A migracao de clientelas de renda media para operadoras pre-pagas privadas aproxima o caso brasileiro do norte-americano. A producao de servicos hospitalares no SUS demonstra importante reducao da oferta agravada pelo crescimento demografico e por expectativas definidas por disposicoes constitucionais. A reducao e seletiva e concentrada em servicos obstetricos e de clinica medica e nos servicos privados lucrativos. Para se garantir acesso equitativo e necessario: ampliacao de gastos publicos; reducao dos gastos por desembolso direto; reformas organizacionais; ampliacao da capacidade de governo.

Children health care evaluation (0-5 years) according to users' perceptions in the Family Health Strategy of Teresópolis, Rio de Janeiro State

O PSF representa um dos principais programas publicos em saude no Brasil, cobrindo em 2006 um total de 5.601 municipios (91,8%). O estudo avaliou o PSF do municipio de Teresopolis (RJ) por meio da percepcao e das informacoes prestadas pelos responsaveis por criancas na faixa de 0-5 anos e que utilizam estes servicos, por meio de questionarios aplicados aos responsaveis nos proprios modulos de atendimento ou em visitas domiciliares. Resultados foram comparados entre areas urbanas e rurais e diferencas significativas foram observadas para determinados itens e elevado vinculo da clientela ao programa e uma percepcao predominantemente positiva sobre o estado de saude das criancas. O acesso se mostrou adequado segundo os criterios utilizados quando se refere ao atendimento de rotina. Os pontos criticos observados incluem baixa cobertura de visitas domiciliares, dificuldades na realizacao de exames solicitados e no fornecimento regular de medicamentos. As areas rurais apresentaram um numero elevado de criancas que trataram condicoes agudas em casa sem assistencia medica. A satisfacao manifestada pelos usuarios quanto aos medicos, aos agentes de saude, aos profissionais de enfermagem e ao conjunto dos servicos foi elevada. A clientela nao visitada por agentes de saude apresentou menor acesso a distribuicao de medicamentos.

Syringe exchange programs in Brazil: preliminary assessment of 45 programs

The present study aims to evaluate the current operation of Brazilian syringe exchange programs (SEP). After consulting national and regional networks of people working in projects/programs aiming to reduce drug-related harm, we identified 134 potential participant programs. Unfortunately, only 45 SEPs answered a survey, even after repeated attempts. The survey addressed: coverage, funding, procurement of basic supplies, managerial capacity, and the local political environment. Findings were triangulated with in-depth interviews with key informants. The main findings included: satisfactory adherence to the initiatives and adequate documentation, but deficiencies in terms of coverage and monitoring, and uneven procurement of resources. Program personnel work mostly on a provisional basis, despite the efforts of local coordinators. Most programs are funded by the National STDs/AIDS Program. A comprehensive agenda aiming to improve current operations should include: concerted efforts to improve local and regional databanks, incentives/sanctions toward full accountability of initiatives carried by the programs, and a genuine culture of monitoring and evaluation.

Consórcios de saúde: estudo de caso exitoso

Local Health Consortia have been used as alternatives and innovative models for improving health care provision. They are closely linked to the strategy aimed at regionalizing health care in Brazil and are in keeping with the health sectors administrative reform process, seeking greater efficiency, rationality, and quality in the supply of services to the population. In the development of such forms of cooperation, we view some consortia as weak structures with a short lifespan, while others have survived for considerable lengths of time. This case study on the Penápolis Consortium, the oldest in Brazil (having lasted for 14 years), examines the dynamics of cooperation and the reasons for its sustainability. Its formation is a mixture of restructuring the regional supply and the entrepreneurial spirit of its leaders, along with State incentives. The Consortiums local capacity to solve cases with quality care and flexible management has proven to be an important factor. Participants share the important notion that the operational rules are fair, and the reasons for its success stem from the collective perception of reasonably symmetrical political gains as the result of political cooperation.

Descentralização, AIDS e redução de danos: a implementação de políticas públicas no Rio de Janeiro, Brasil

This paper assesses how decentralization of resources and initiatives by the Brazilian National SDT/AIDS Program has impacted the transfer of funds for programs to prevent HIV/AIDS among injecting drug users in Rio de Janeiro, Brazil (1999-2006). The effects of the decentralization policy on Rio de Janeiros Syringe Exchange Programs (SEPs) are assessed in detail. Decentralization effectively took place in Rio de Janeiro in 2006, with the virtual elimination of any direct transfer from the Federal government. The elimination of direct transfers forced SEPs to seek alternative funding sources. The structure of local SEPs appears to be weak and has been further undermined by current funding constraints. Of 22 SEPs operating in 2002, only two are still operational in 2006, basically funded by the State Health Secretariat and one municipal government. The current discontinuity of SEP operations may favor the resurgence of AIDS in the IDU population. A more uniform, regulated decentralization process is thus needed.

Participatory evaluation in health programs: a proposal for the Adolescent Health Care Program

This article presents a model for participatory evaluation of the Adolescent Health Program (PROSAD) in Brazil. The study focuses on the concept of participation, with a review of internationally validated planning methodologies (RAP, logFRAME, ZOPP, PCM) and the programmatic characteristics of PROSAD. The proposed model comprises 4 steps, involving the constitution of the analytical matrix, a self-evaluation workshop, a summary of results, and graphic representation. The model promotes participatory practice in health program management by using techniques that allow a workshop to be held in 70 minutes (mean time), producing results that are recognized and easily grasped by the local team.

Reforma do Estado e mudança organizacional: um estudo de hospitais públicos

O trabalho analisa o processo de difusao da agenda da reforma no Estado, tomando como caso o setor saude. Apresenta as estrategicas e a configuracao politica publica orientada para a ampliacao da flexibilidade administrativa. Estudando organizacoes especificas, identifica as tendencias de desenvolvimento, indicando os estrangulamentos e potenciais de cada modelo assim como as condicoes para a sua adaptacao e imitacao. Enfatiza a reforma do setor saude sob o ponto de vista do desenho organizacional, reconstruindo as engenharias institucionais mais relevantes relacionadas as experiencias de flexibilidade administrativa. Para identificar os arranjos da flexibilizacao da gestao da forca de trabalho, descreve os padroes organizacionais, os criterios de selecao de pessoal, as formas de planejamento, avaliacao e supervisao e assinala os possiveis efeitos no acesso e utilizacao dos servicos publicos.