Ligia Maria Vieira-da-Silva

Acessibilidade aos serviços de saúde em um município do Estado da Bahia, Brasil, em gestão plena do sistema

In order to analyze the implementation of measures targeting accessibility to primary health care in a municipality (county) in the State of Bahia, Brazil, a single case study was performed with two levels of analysis: system and services organization. The data were obtained from semi-structured interviews, observation of routine care, and document analysis. Of the four health units analyzed, three showed intermediate-level implementation of measures targeting accessibility. The Family Health Units showed better performance, due to measures for patient reception and referral to specialized services, but they revealed problems with scheduling of appointments. Despite having defined primary care as the portal of entry into the system and the implementation of a help desk for setting appointments with specialists, there are persistent organizational barriers in the municipality. A specific policy is recommended to improve accessibility, aimed at organization of the services supply in order to change the health care model.

Eqüidade em saúde: uma análise crítica de conceitos

A equidade em saude tem sido estudada principalmente a partir de uma perspectiva epidemiologica e pouca atencao tem sido dada as questoes conceituais. Em grande parte dos estudos revisados, a equidade tem sido utilizada como sinonimo de igualdade, e seu oposto, a iniquidade, como sinonimo de desigualdade. As tentativas de melhor precisar seus significados tem sido, em boa parte, descritivas, com lacunas no que diz respeito a discussao das relacoes entre equidade em saude, justica e o processo de determinacao social da saude-doenca. Neste ensaio, pretendemos analisar criticamente a serie significante diversidade, diferenca, desigualdade, iniquidade, distincao no que concerne a producao da saude-doenca-cuidado em grupos sociais e suas possibilidades de articulacao a uma teoria social da saude. Nesse percurso, estaremos apoiados, por um lado, no conceito de Perelman de equidade e em alguns dos argumentos de Heller sobre a justica e, por outro lado, na sociologia das praticas de Bourdieu, com o objetivo de melhor desenvolver esses conceitos, procurando discutir implicacoes para a formulacao de politicas publicas no campo da saude.

A efetividade do dentifrício fluoretado no controle da cárie dental: uma meta-análise

OBJETIVO: Realizar uma meta-analise sobre a efetividade da escovacao com dentifricio fluoretado na reducao da carie dental para calcular o efeito das diferentes hipoteses testadas. METODOS: Foram revisados artigos publicados sobre a efetividade da educacao em saude oral no periodo compreendido entre 1980 e 1998, indexados nas bases de dados Medline e Lilacs. Para avaliacao da qualidade dos artigos, foram utilizados os criterios de rigor metodologico de Kay & Locker apos serem submetidos a um comite de experts formado por pesquisadores I-A do CNPq. Dos 43 artigos identificados, 22 (51,2%) atingiram os criterios de rigor metodologico propostos. O calculo do tamanho do efeito da intervencao de cada estudo foi feito a partir das diferencas de resultados entre os grupos de teste e controle. O efeito global foi calculado para cada agrupamento de estudos segundo as hipoteses testadas. RESULTADOS: O aumento da concentracao do fluor parece estar associado com o aumento do efeito (reducao global = -0,17 IC 95% -0,22/-0,12). O maior percentual de reducao de carie foi verificado na comparacao entre dentifricios fluoretados e aqueles sem fluor (reducao global = -0,29 IC 95% -0,34/-0,24). A adicao de anti-microbianos (reducao global = -0,03 IC 95% -0,07/+0,02), diferencas nos sistemas abrasivos (reducao global = -0,02 IC 95% -0,09/+0,04) e diferencas nos principios ativos nao aumentam a efetividade dos mesmos (reducao global = -0,04 IC 95% -0,10/+0,01). CONCLUSOES: As maiores reducoes de carie foram encontradas nos estudos com escovacao supervisionada. A sintese confirmou a importância da escovacao com dentifricio fluoretado no controle da carie dental. Contudo, aponta para uma enfase nos aspectos medicamentosos relacionados ao controle da doenca, em detrimento de acoes educativas especificas. A heterogeneidade de resultados indica que sejam considerados os contextos de implantacao das praticas preventivas no processo de sua avaliacao.

Distribuição espacial da mortalidade por tuberculose em Salvador, Bahia, Brasil

Com o objetivo de descrever a distribuicao espacial da mortalidade por tuberculose em Salvador nos anos de 1991, 1994 e 1997, foi realizado um estudo ecologico, descritivo, tendo como unidade de analise o Distrito Sanitario (DS). Foram calculados os coeficientes padronizados de mortalidade por tuberculose e a mortalidade proporcional por tuberculose, em relacao ao conjunto das doencas infecciosas e parasitarias, utilizando-se as declaracoes de obitos como fonte de dados. O DS com os maiores coeficientes padronizados foi o Suburbio Ferroviario, com taxas de 15,7, 10,6 e 10,6/100 mil habitantes, em 1991, 1994 e 1997, respectivamente. Em 1997, foram observadas as menores taxas padronizadas. A mortalidade proporcional por tuberculose em Salvador, nos anos de 1991, 1994 e 1997, representou 20,7%, 18,2 % e 16,9%, respectivamente, do total das mortes por doencas infecciosas e parasitarias. A faixa etaria de maior risco, nos anos estudados, foi aquela acima de 65 anos. Os autores discutem as possibilidades de utilizacao dos resultados deste estudo para a implementacao de politicas locais de saude equânimes e desenvolvimento de operacoes de vigilância da saude, tendo em vista a identificacao de DS com maior risco de obito e as faixas etarias mais acometidas.

The genesis of collective health in Brazil

During the 1970s in Brazil a social space directed towards health problems on the population level, called collective health, was created and institutionalised. To what extent did this Brazilian invention correspond to a specific socio-historical practice? The works published on this topic have considered social medicine as a homogeneous phenomenon without empirically studying the specificities of national experiences. To bridge this gap, a historical study on the genesis of collective health in Brazil was carried out based on Bourdieus field theory. The interaction between the paths of the founders and the conditions of historical possibilities were researched through documentary and bibliographical sources, as well as through in-depth interviews of the founders. This social space originated from a meeting of agents with different social backgrounds but who interconnected, creating a structure that was independent of each agent considered individually. One of the components of this establishment was the joining of theoretical production and the implementation of health reforms that resulted in the organisation of a universal health system. This study attempts to show how the international political situation and the contradictions of the national crisis created a universe of possibilities, allowing for the genesis of this sui generis space in Brazil.

As práticas preventivas no controle da cárie dental: uma síntese de pesquisas

A literature review was conducted on the effectiveness of measures to prevent dental caries. Articles published in scientific journals from 1980 to 1998 and indexed in MEDLINE were selected. Some 210 articles were found and their abstracts classified according to intervention strategies, type of research design, and observed effects. The most frequent preventive measures were the use of fluoride toothpaste (20.5%), fluoride mouthwash (17.2%), and occlusal sealants (18,1%). The main target population was schoolchildren 6-12 years old (53.8%) and teenagers (15.7%). Western Europe produced 58.7% of the articles on this subject, followed by United States (22.7%), Eastern Europe, Asia, Canada, and Latin America. No relationship was identified between program results (effective as opposed to ineffective studies) and the type of preventive practice and research design, indicating that other issues need to be investigated, such as the context of organizational implementation (where, how, and by whom prevention is implemented). Education in oral hygiene as a basic tool and key component in specific preventive action has received little research attention.Foi realizada uma revisao sistematica de trabalhos de pesquisa sobre a efetividade das acoes preventivas no controle da carie dental, publicados no MEDLINE no periodo compreendido entre 1980 e 1998. Foram localizados 210 artigos, sendo que seus resumos foram analisados segundo as estrategias de intervencao, os tipos de desenho de pesquisa utilizados e os efeitos. As praticas preventivas mais avaliadas foram os dentifricios com fluor (20,5%), os bochechos com fluor (17,2%) e os selantes oclusais (18,1%). Houve uma predominância de estudos em individuos na idade escolar entre 6 e 12 anos (53,8%). Observou-se um maior numero de trabalhos oriundos da Europa Ocidental (58,6%), seguidos dos Estados Unidos (20,4%). Nao foram encontradas relacoes entre o resultado (estudos efetivos e nao efetivos) e o tipo de estrategia avaliada, por um lado, e o tipo de desenho do estudo utilizado, por outro. Esse fato revela que outras explicacoes para a diversidade dos resultados devem ser buscadas, principalmente no que diz respeito ao contexto de implantacao dos programas (onde, como e quem os implementa). A educacao em saude oral esta sendo pouco descrita ou considerada nos estudos de intervencao isolados.

Accessibility to primary healthcare in the capital city of a northeastern state of Brazil: an evaluation of the results of a programme

Background Organisational barriers to primary healthcare are still relevant in developing countries. Although descriptive reports of some experiences focusing on improving accessibility have been published, few studies have evaluated specific interventions aimed at overcoming the organisational obstacles. Objective To evaluate the results of a project designed to improve accessibility to healthcare services in Salvador, Bahia, Brazil. Methodology An evaluative, cross-sectional, ex post facto study that included a control group was carried out in a random sample of 710 users of 25 healthcare units of the primary municipal healthcare network. The association between the project implementation degree and outcome variables was measured by prevalence ratios (PR) and statistical inference was based on Taylor series 95% CIs. Results Better access to primary healthcare was found in units in which the intervention had been implemented than in those in which it had not been implemented, particularly with respect to reducing avoidable queues, the waiting time for scheduling a consultation (PR=0.23; 95% CI 0.15 to 0.34); the time of arrival in the queue (PR=0.16; 95% CI 0.09 to 0.31) and the introduction of a system for scheduling appointments by telephone (PR=0.76; 95% CI 0.70 to 0.83). Conclusion Owing to the simplicity of the programme and the impact it achieved, it may be reproduced in other underdeveloped countries to improve access to healthcare services. In addition, some of the instruments may be used in routine programme evaluation.

Imagem-objetivo para a descentralização da vigilância sanitária em nível municipal

No consensus has been reached concerning the definition of criteria and standards for evaluating the decentralization of actions by municipal health surveillance systems. With the aim of developing and validating an objective image for municipal health surveillance that would correspond to an appropriate system for the populations health care needs, a logical framework was elaborated, from which a matrix containing dimensions and criteria for management and practices was obtained. The framework was submitted to an expert group for validation at a consensus conference. Of the 54 criteria, there was consensus for 59.3%, while 53 items (98%) were considered important, thus validating the matrix. In view of the provisory nature of the consensuses, the resulting instrument, which can be used either in its entirety or in part, enables modification and adaptation. The authors discuss the potential of the evaluation strategy adopted here, which allows various possibilities for redefining the criteria and renewing the consensus.

Trends in hospitalizations for respiratory diseases in Salvador, Bahia State, Brazil, 1998-2009

Respiratory diseases are the leading cause of hospitalizations in Brazil (excluding hospital admissions related to childbirth, pregnancy, and postpartum). To analyze the trend and seasonality of hospitalizations for respiratory diseases in Salvador, Bahia State, Brazil, 1998-2009, a time trend study was performed using simple linear regression. Hospitalization rates for all respiratory diseases and specifically for asthma, chronic obstructive pulmonary disease (COPD), and pneumonia were calculated by year and age group. Hospitalizations for all respiratory diseases decreased by 45.6% (β = -2.2; p < 0.001); those due to asthma showed the largest decline (annual average 1.2/10,000), pneumonia showed the largest reduction until 2002, subsequently tending to stabilize, and COPD remained unchanged. The under-5-year age group showed the largest decline in hospitalizations for all respiratory diseases. There was no seasonality in hospitalizations for COPD. There was a reduction in the burden of hospitalizations due to respiratory diseases in Salvador, mainly due to the drop in asthma and pneumonia in children < 5 years. However, the city still has hospitalization rates for respiratory diseases that are higher than in other large Brazilian cities.

Avaliação da cobertura da atenção básica à saúde em Salvador, Bahia, Brasil (2000 a 2007)

In order to test a method for evaluating coverage of primary healthcare services in Salvador, Bahia State, Brazil (2000-2007), a study of spatial and temporal clusters was performed, with the city and its 12 health districts as the analytical units. The real and potential coverage rates were estimated for various primary care procedures. Estimation of coverage rates used both the Ministry of Health guideline and a second standard aimed at establishing an approximation to the populations health needs. The data were obtained from the Outpatient Information System of the Unified National Health System (SIA-SUS). Low coverage rates were observed, despite a slight increase in real coverage for medical consultations (7.8%) and basic nursing care (66.7%). Meanwhile, dental consultations showed a 40% reduction. The study discussed the possibilities for using the methodology to monitor coverage and its limitations given the deficiencies in the information systems.