Ligia Giovanella

Saúde da família: limites e possibilidades para uma abordagem integral de atenção primária à saúde no Brasil

The article analyzes the implementation of the Family Health Strategy (FH) and discusses its potential to guide the organization of the Unified Health System in Brazil, based on the integration of FH to the health care network and intersectorial action, crucial aspects of a comprehensive primary health care. Four case studies were carried out in cities with high FH coverage (Aracaju, Belo Horizonte, Florianopolis e Vitoria), using as sources: semi-structured interviews with managers and surveys with health care professionals and registered families. The integration analysis highlighted the position of FH Strategy in the health services network, the integration mechanisms and the availability of information for continuity of care. Intersectoriality was researched in relation to the fields of action, scope, sectors involved, presence of forums, and team initiatives. The results point to advances in the integration of FH to the health care network, strengthening basic services as services that are regularly sought and used as a preferential first contact services, although there are still problems in the access to specialized care. The intersectorial initiatives were broader when defined as integrated municipal government policy for the construction of interfaces and cooperation between the diverse sectors.

Fortalecimento da atenção primária à saúde: estratégia para potencializar a coordenação dos cuidados

OBJETIVO: Descrever e analisar acoes empreendidas em quatro centros urbanos para fortalecer a estrategia saude da familia (ESF) no Brasil. METODOS: Foram realizados estudos de caso em Aracaju, Belo Horizonte, Florianopolis e Vitoria com base em entrevistas semiestruturadas com gestores. Alem disso, foi realizado um estudo transversal com questionarios aplicados a amostras de profissionais e usuarios da ESF. RESULTADOS: Em todos os municipios foram identificadas acoes para fortalecer os servicos de atencao primaria a saude, com destaque para: aumento da oferta de atencao primaria a saude com diminuicao das barreiras de acesso, estruturacao dos servicos de atencao primaria a saude como porta de entrada do sistema, ampliacao da resolutividade (apoio diagnostico e terapeutico, promocao da interlocucao entre equipamentos da rede de servicos para organizar o processo de trabalho, capacitacao, supervisao) e articulacao entre acoes de vigilância e assistencia. CONCLUSOES: Os municipios investigados apresentam experiencias consolidadas de reorganizacao do modelo assistencial com base em uma atencao primaria a saude fortalecida, com potencial para tornar-se coordenadora dos cuidados. Todavia, para efetivar a funcao de porta de entrada e servico de uso regular sao necessarias acoes para equalizar o atendimento das demandas programada e espontânea, sendo que a ultima representa o maior desafio a organizacao do processo de trabalho das equipes. A conquista de apoio e legitimidade para a ESF e um tema pendente. Iniciativas para divulgar a ESF sao necessarias entre a populacao, profissionais de todos os niveis e organizacoes da sociedade civil.

A atenção primária à saúde nos países da União Européia: configurações e reformas organizacionais na década de 1990

During the 1990s, proposals to contain health expenditures and demands raised by changes in the epidemiological profile led to organizational reforms in primary healthcare services in European Union countries, aimed at promoting the coordination of services provided by the various levels of care. Based on a literature review, document analysis, and interviews with key informants, the current study analyzes the institutional configurations for first-level healthcare and discusses the pre-coordination organizational reforms in the European Union countries. First-level outpatient care is provided in these countries through a wide variety of institutional configurations, observing the different financing mechanisms, range of healthcare professionals, range of clinical services provided, and the position occupied by physicians in primary care within the healthcare system. Reforms in the last decade were accompanied by a diversification in the outpatient care organizational models, with an expansion in the clinical, healthcare coordination management, and financing functions of primary care professionals, indicating a process in transition, with a redefinition of the roles played by general practitioners as the leaders of patient care.

Desafios para gestão do trabalho a partir de experiências exitosas de expansão da Estratégia de Saúde da Família

This article discusses the management of the work in Family Health Strategy in four major urban centers. The research includes perspectives from different actors who compose and integrate the network of working relationships in Public Health System through questionnaires with employees of professional categories family health team and interviews with managers and representatives of professional bodies. It is a qualitative-quantitative evaluation study. The dimensions analysed were: insertion and remuneration policies, strategies and qualification of employees. The insertion and remuneration policy highlights the replacement of outsourced frames and hiring by public tender that allows links labor more stable. Other strategies are the establishment of allowance for expertise in areas of greater social vulnerability and the assimilation of specialists in Family and Community Medicine with other experts engaged in secondary services. The political will of municipal Manager to qualify the workforce of family health, maintaining the provision of adequate human resources needs of the health system is a fundamental factor for the consolidation of family health strategy in the face of the low degree of specialization of professionals to work in primary health care.

Avaliação da atenção básica pela perspectiva dos usuários: adaptação do instrumento EUROPEP para grandes centros urbanos brasileiros

Satisfaction with health care is a multidimensional concept that considers aspects such as access, organization and professional-user interaction. The aim of this study was to adapt and apply an instrument in the Family Health Strategy (FHS) to assess user satisfaction with Primary Health Care (PHC) based on the European Task Force on Patient Evaluation of General Practice Care (EUROPEP), which refers to user satisfaction wth general and family medicine services. The instrument consists of five dimensions of satisfaction: relationship and communication, medical care, information and support, continuity and cooperation, and organization of services. The study was divided into phases: review and adjustment of the instrument and application to a representative sample of users of the FHS in Rio de Janeiro. The averages of the proportions of answers for each indicator were calculated to analyze the results. Relationship and communication between professionals and users received the best evaluation and Organization of Services eceived the worst appraisal. Regarding education level, good self-perceived health and more elderly were more satisfied. The instrument proved to be easy to apply, can be routinely used for monitoring of the FHS, and is a tool for the institutionalization of evaluation.

Regional governance: strategies and disputes in health region management

OBJECTIVE To analyze the regional governance of the health systemin relation to management strategies and disputes. METHODOLOGICAL PROCEDURES A qualitative study with health managers from 19 municipalities in the health region of Bahia, Northeastern Brazil. Data were drawn from 17 semi-structured interviews of state, regional, and municipal health policymakers and managers; a focus group; observations of the regional interagency committee; and documents in 2012. The political-institutional and the organizational components were analyzed in the light of dialectical hermeneutics. RESULTS The regional interagency committee is the chief regional governance strategy/component and functions as a strategic tool for strengthening governance. It brings together a diversity of members responsible for decision making in the healthcare territories, who need to negotiate the allocation of funding and the distribution of facilities for common use in the region. The high turnover of health secretaries, their lack of autonomy from the local executive decisions, inadequate technical training to exercise their function, and the influence of party politics on decision making stand as obstacles to the regional interagency committee’s permeability to social demands. Funding is insufficient to enable the fulfillment of the officially integrated agreed-upon program or to boost public supply by the system, requiring that public managers procure services from the private market at values higher than the national health service price schedule (Brazilian Unified Health System Table). The study determined that “facilitators” under contract to health departments accelerated access to specialized (diagnostic, therapeutic and/or surgical) services in other municipalities by direct payment to physicians for procedure costs already covered by the Brazilian Unified Health System. CONCLUSIONS The characteristics identified a regionalized system with a conflictive pattern of governance and intermediate institutionalism. The regional interagency committee’s managerial routine needs to incorporate more democratic devices for connecting with educational institutions, devices that are more permeable to social demands relating to regional policy making.

A posição da Estratégia Saúde da Família na rede de atenção à saúde na perspectiva das equipes e usuários participantes do PMAQ-AB

O artigo analisa a posicao da Estrategia Saude da Familia na rede de atencao a saude sob a perspectiva das 16.566 equipes de Saude da Familia e dos 62.505 usuarios participantes do Programa Nacional para Melhoria do Acesso e da Qualidade da Atencao Basica em 2012. Os resultados indicam que as equipes atuam cada vez mais como porta de entrada preferencial, atendendo a demandas diversas e exercendo a funcao de filtro para a atencao especializada. Contudo, persistem importantes barreiras organizacionais para acesso, os fluxos estao pouco ordenados, a integracao da APS a rede ainda e incipiente e inexiste coordenacao entre APS e atencao especializada.

Listas de espera em sistemas públicos: da expansão da oferta para um acesso oportuno? Considerações a partir do Sistema Nacional de Saúde espanhol

The paper discusses the issue of waiting times based on a study of Spains National Health System (Sistema Nacional de Salud, SNS), focusing on the national context, management issues and local practices. Observation visits and interviews with health personnel and managers conducted in the metropolitan areas of the Autonomous Communities of Madrid, Andalusia, Catalonia and Basque Country were complemented by secondary data and a review of the literature. There is unanimity as to the positive results of the SNS, but cutting waiting times seems to be one key aspect requiring improvement. Two directions were identified for complementary measures: guaranteed maximum waiting times in the macro-social sphere associated with local measures to increase service integration and primary care resolution rates. The peculiarities of the Spanish decentralisation process and the existence of economic, political and health profession corporate interests were mentioned as factors hampering waiting list regulation, transparency and management. A comprehensive approach to this issue shows the need to shift discussion from waiting list monitoring and/or expanded supply to guaranteed timely access. That is the quality differential that primary care-oriented systems must bring to public health systems.

The financial crisis and health care systems in Europe: universal care under threat? Trends in health sector reforms in Germany, the United Kingdom, and Spain

The paper analyzes trends in contemporary health sector reforms in three European countries with Bismarckian and Beveridgean models of national health systems within the context of strong financial pressure resulting from the economic crisis (2008-date), and proceeds to discuss the implications for universal care. The authors examine recent health system reforms in Spain, Germany, and the United Kingdom. Health systems are described using a matrix to compare state intervention in financing, regulation, organization, and services delivery. The reforms’ impacts on universal care are examined in three dimensions: breadth of population coverage, depth of the services package, and height of coverage by public financing. Models of health protection, institutionality, stakeholder constellations, and differing positions in the European economy are factors that condition the repercussions of restrictive policies that have undermined universality to different degrees in the three dimensions specified above and have extended policies for regulated competition as well as commercialization in health care systems.

Contribuições da análise comparada para um marco abrangente na avaliação de sistemas orientados pela atenção primária na América Latina

OBJETIVOS: demonstrar que o estudo da integracao e da coordenacao do cuidado traz elementos importantes para a avaliacao de sistemas orientados por uma politica de atencao primaria de saude (APS). METODOS: estudo descritivo das formas e fatores que facilitam ou dificultam a integracao da APS, a partir da analise comparada de reformas realizadas na America Latina, atraves de revisao sistematica e analise de documentos. RESULTADOS: tres modalidades de integracao foram identificadas: atencao primaria seletiva no interior de programas materno-infantis, APS como porta de entrada e eixo estruturante de um sistema publico e experiencias municipais em sistemas baseados em seguros. Um modelo explicativo da problematica da fragmentacao e desenvolvido, mostrando a necessidade de articular a analise dos niveis macro, meso e microssocial para uma visao abrangente do desempenho dos servicos. CONCLUSOES: ha persistencia de segmentacao com fragmentacao dos servicos, mesmo nos casos de sistemas de base universal. O modelo proposto articula essas duas categorias, contribuindo na selecao de indicadores para avaliacao de sistemas publicos orientados por essa politica.