Luiz Odorico Monteiro de Andrade

Health-system reform and universal health coverage in Latin America

Starting in the late 1980s, many Latin American countries began social sector reforms to alleviate poverty, reduce socioeconomic inequalities, improve health outcomes, and provide financial risk protection. In particular, starting in the 1990s, reforms aimed at strengthening health systems to reduce inequalities in health access and outcomes focused on expansion of universal health coverage, especially for poor citizens. In Latin America, health-system reforms have produced a distinct approach to universal health coverage, underpinned by the principles of equity, solidarity, and collective action to overcome social inequalities. In most of the countries studied, government financing enabled the introduction of supply-side interventions to expand insurance coverage for uninsured citizens--with defined and enlarged benefits packages--and to scale up delivery of health services. Countries such as Brazil and Cuba introduced tax-financed universal health systems. These changes were combined with demand-side interventions aimed at alleviating poverty (targeting many social determinants of health) and improving access of the most disadvantaged populations. Hence, the distinguishing features of health-system strengthening for universal health coverage and lessons from the Latin American experience are relevant for countries advancing universal health coverage.

Social determinants of health, universal health coverage, and sustainable development: case studies from Latin American countries

Many intrinsically related determinants of health and disease exist, including social and economic status, education, employment, housing, and physical and environmental exposures. These factors interact to cumulatively affect health and disease burden of individuals and populations, and to establish health inequities and disparities across and within countries. Biomedical models of health care decrease adverse consequences of disease, but are not enough to effectively improve individual and population health and advance health equity. Social determinants of health are especially important in Latin American countries, which are characterised by adverse colonial legacies, tremendous social injustice, huge socioeconomic disparities, and wide health inequities. Poverty and inequality worsened substantially in the 1980s, 1990s, and early 2000s in these countries. Many Latin American countries have introduced public policies that integrate health, social, and economic actions, and have sought to develop health systems that incorporate multisectoral interventions when introducing universal health coverage to improve health and its upstream determinants. We present case studies from four Latin American countries to show the design and implementation of health programmes underpinned by intersectoral action and social participation that have reached national scale to effectively address social determinants of health, improve health outcomes, and reduce health inequities. Investment in managerial and political capacity, strong political and managerial commitment, and state programmes, not just time-limited government actions, have been crucial in underpinning the success of these policies.

Treatment of bancroftian filariasis in Recife, Brazil: a two-year comparative study of the efficacy of single treatments with ivermectin or diethylcarbamazine

The effectiveness of single oral doses of ivermectin (200 or 400 micrograms/kg) and diethylcarbamazine (DEC, 6 mg/kg), preceded 4 d earlier by either placebo or very small doses of these drugs, was compared, over a 2-year period, in a double-blind trial in 67 microfilaraemic Brazilian men with bancroftian filariasis. Regimens containing ivermectin alone decreased the number of microfilariae significantly faster and more effectively for the first month after treatment than regimens containing DEC alone, but the latter were significantly more effective throughout the second year after treatment (1.7-8.2% of pretreatment levels with DEC vs. 12.6-30.8% with ivermectin during that period); the higher ivermectin dose showed a tendency towards more effectiveness than the lower dose. Most effective was the combination of ivermectin (20 micrograms/kg) followed 4 d later by DEC (6 mg/kg), with reduction of microfilaraemia to 2.4% of pretreatment levels at 2 years. Adverse reactions were well tolerated with all regimens, the reactions being significantly more generalized (i.e., fever) following ivermectin and localized (i.e., scrotal inflammatory nodules around dying adult worms) following DEC. Further trials of single-dose combination therapy vs. single high doses of ivermectin or DEC should determine the ideal regimen for treatment and control of bancroftian filariasis.

Comparative efficacy of three different diethylcarbamazine regimens in lymphatic filariasis.

To assess the efficacy of diethylcarbamazine (DEC) in clearing Wuchereria bancrofti microfilariae (mf) from the circulation, we conducted a single blind hospital-based therapeutic trial of 3 DEC regimens. All patients were assessed by filtration of 1 mL of venous blood taken before and 1, 3, 6 and 12 months after DEC administration. The efficacy of a 12 d course of 6 mg/kg DEC once daily was identical to that of a similar course with 2 mg/kg given 3 times daily, indicating that split-dose treatment does not improve mf clearance over single daily drug administration. Microfilarial densities in patients treated only once with 6 mg/kg DEC remained significantly higher at 1, 3, and 6 months after treatment. However, all 3 treatment regimens proved equally effective in controlling microfilaraemia after 12 months, when 41, 42 and 40% of patients in the 3 treatment groups were amicrofilaraemic. These results suggest that a single DEC dose of 6 mg/kg administered annually or biannually may be a suitable regimen to control bancroftian filariasis in Recife, Brazil.

Human toxocariasis: frequency of anti-Toxocara antibodies in children and adolescents from an outpatient clinic for lymphatic filariasis in Recife, Northeast Brazil

In a transversal study on a sample of 386 children and adolescents from an outpatient clinic for filariasis in Recife, Northeast Brazil, the frequency of anti-Toxocara antibodies and its relation to age, gender, number of peripheral eosinophils, Wuchereria bancrofti microfilariae and intestinal helminths was determined. The total anti-Toxocara IgG antibody frequency was 39.4%, by ELISA technique. The difference in frequency between males (40.1%) and females (37.6%) was not statistically significant. The 6 to 10-year-old subset presented the highest frequency of anti-Toxocara antibodies (60%), and within this age group there was a statistically significant male bias. There was also a significant association between the number of eosinophils and the presence of anti-Toxocara antibodies. Intestinal parasite frequency was 52.1%, but no association was found between this data and the presence of anti-Toxocara antibodies. In the present sample, 42.2% of the patients were Wuchereria bancrofti carriers, however, again this was not associated with the presence of anti-Toxocara antibodies. In conclusion, anti-Toxocara antibodies were highly prevalent in this sample. The present data show that there is no cross correlation between anti-Toxocara IgG antibody and the presence of intestinal helminths and filariasis.

Redes interfederativas de saúde: um desafio para o SUS nos seus vinte anos

The present paper deals with the construction of health interfederal networks, composed by each federate organization that together will manage nationwide the Unified Health System in a shared and coordinated way. It also ranks the necessary conceptual elements to the network construction and adequate operation like local management boards, interfederal board of trustees and administrative organizational contracts.

Avaliacao do teste de imunofluorescencia indireta para diagnostico da filariose bancroftiana usando a microfilaria de W. bancrofti como antigeno em Recife - PE, Brasil

Analisou-se o teste de imunofluorescencia indireta com microfilarias de W. bancrofti tratadas pela papaina, como antigeno, amplamente utilizado em Recife para o imunodiagnostico da filariose linfatica. Foram testados soros de 50 pacientes portadores das diversas formas clinicas da doenca, incluindo microfilaremia assintomatica, eosinofilia pulmonar tropical, elefantiase de membros inferiores, linfagite aguda e quiluria. Para o grupo controle, foram selecionados 50 individuos vivendo pelo menos ha 5 anos em area endemica, sem nenhuma evidencia clinica e/ou laboratorial da doenca, constituindo os chamados endemicos normais. A sensibilidade e especificidade do teste, segundo diferentes pontos de corte, mostraram a impossibilidade de diferenciacao entre o grupo controle e o grupo sabidamente infectado. Tambem nao foi possivel estabelecer correlacao entre os titulos encontrados e as diferentes formas clinicas. Foi considerada a existencia de reacoes cruzadas relacionadas a helmintiases intestinais, porem nenhuma relacao direta foi encontrada.

Integração de instituições de ensino superior com sistemas municipais de saúde à luz de uma tipologia da colaboração interprofissional

O objetivo deste estudo foi investigar o processo de colaboracao interprofissional entre os diretores, docentes de instituicoes de ensino superior (IES), gestores dos Sistemas Municipais de Saude e profissionais da Estrategia de Saude da Familia de duas cidades estrategicas para expansao do ensino superior em saude no Ceara. Tratou-se de estudo analitico de casos multiplos. Foram utilizadas pesquisa documental e entrevistas semi-estruturadas com 75 gestores e profissionais da saude, diretores e docentes de IES. O corpus de dados foi submetido a analise tematica ancorada em uma Tipologia da Colaboracao Interprofissional. Os resultados evidenciam que, em Sobral, a colaboracao entre os atores mencionados encontra-se em desenvolvimento, enquanto em Juazeiro do Norte esta incipiente. Os elementos facilitadores foram a clareza dos beneficios da integracao para a qualidade da atencao e a formacao profissional, a institucionalizacao e a gestao participativa do processo.

Educação e saúde em uma região em situação de vulnerabilidade social: avanços e desafios para as políticas públicas

Este estudo se propos a compreender a evolucao temporal da educacao e sua influencia na saude da populacao do Grande Bom Jardim (GBJ), Fortaleza, estado do Ceara, Brasil, territorio marcado pela vulnerabilidade social. Baseou-se na abordagem qualitativa, com utilizacao de grupo focal e entrevista semiestruturada, aplicados a 45 participantes. Realizou-se analise de conteudo, o que possibilitou a categorizacao dos dados a partir da tecnica de analise tematica. Os resultados mostraram repercussao positiva na saude do morador, decorrente da implementacao de politicas sociais que reduziram o analfabetismo e propiciaram o avanco no acesso a escola, que possui papel fundamental na criacao de ambientes saudaveis, na perspectiva da promocao da saude. Entretanto, ainda ha grande demanda pela educacao de qualidade como veiculo mediador de desenvolvimento do potencial humano.