Luiza Sterman Heimann

Desigualdades no acesso e utilização dos serviços de saúde na Região Metropolitana de São Paulo

This paper presents case study findings in five municipalities in the Sao Paulo Metropolitan Region. Inequalities in access to health care services and their utilization were described through advanced tabulation data from the 1998 SEADE Life Conditions Survey. The variables analyzed were: owning or not owning private health care insurance, income and age brackets. The health care service attributes studied were: health care services coverage by a health insurance plan, health services demands and average waiting time to receive health care. Compared with other studies, using the 1998 IBGE PNAD, the results allowed us to confirm interregional imbalances which can only be detected in shorter special scale studies: the municipalities. Despite showing the high private health insurances coverage the Sao Paulo Metropolitan Region has a great inner heterogeneity. The inequalities in private health care insurance, access, waiting time, and type of insurance coverage were observed through income quintiles and age classes analyses. Findings suggest that an expansion of the States regulation capacity is necessary in order to empower the Brazilian Health Care System principles of universality and equity to be qualified to offer Brazilians the right to access health care services.

Sistema de saúde universal e território: desafios de uma política regional para a Amazônia Legal

This article presents the results of a study on Federal health policy in the Brazilian Legal Amazon (BLA) from 2003 to 2005, aimed at backing the development of regional health policies. The region has peculiar dynamics, an extensive border area, and adverse social indicators. The methodology included documental and financial analysis, participatory observation, interviews with heads of various Federal Ministries and State and Municipal health secretaries from the BLA; characterization of geographic situations in the BLA; and field studies in 15 municipalities. Institutional consolidation of health policy proved to be low in the Amazon during the study period, due to structural, institutional, and political difficulties. The identification of six geographic situations was useful for systematizing land use differences with repercussions on health, and which should be considered when implementing public policies. There is a certain gap between Federal actions and territorial dynamics, expressed as a mismatch between the current policy and its recognition by local administrators. In addition to establishing a regional policy for the Amazon, there is an evident need for differentiated policies within the region.

Governança e regulação na saúde: desafios para a gestão na Região Metropolitana de São Paulo, Brasil

Este artigo discute a relacao publico/privado no Sistema Unico de Saude (SUS) da perspectiva do gestor municipal, a partir de pesquisa cujo objetivo foi identificar estrategias e mecanismos de governanca na relacao publico/privado do setor saude na busca da equidade na Regiao Metropolitana de Sao Paulo, Brasil. Governanca e ferramenta analitica. O problema e a regulacao do sistema de saude. O material para analise foi obtido por meio de entrevistas com secretarios municipais e estaduais de saude, conselheiros e tecnicos do SUS. Assim, foi possivel agregar os resultados em: (a) mecanismos e instrumentos de regulacao; (b) espacos de poder; e (c) posicao do ator SUS sobre a relacao publico/privado. Ha mecanismos e instrumentos de regulacao utilizados nos municipios para servicos estatais. Para o setor complementar e suplementar a acao regulatoria, neste nivel de gestao, praticamente inexiste. Os espacos de poder institucionais sao inumeros e reconhecidos como lugares para encaminhamento de demandas mais do que foruns de pactuacao. Apesar dos avancos, a governanca se apresentou como de tipo formalista. O debate da regulacao na relacao publico/privado mostrou-se necessario para avancos na gestao do sistema.

Diferenciais intermunicipais de condições de vida e saúde: construção de um indicador composto

OBJETIVO: Descrever um indice para reconhecimento das desigualdades de condicoes de vida e saude e sua relacao com o planejamento em saude. METODOS: Foram selecionadas variaveis e indicadores que refletissem os processos demograficos, economicos, ambientais e de educacao, bem como oferta e producao de servicos de saude. Esses indicadores foram utilizados no escalonamento adimensional dos indicadores e agrupamento dos 5.507 municipios brasileiros. As fontes de dados foram o censo de 2000 e os sistemas de informacoes do Ministerio da Saude. Para analise dos dados foram aplicados os testes z-score e cluster analysis. Com base nesses testes foram definidos quatro grupos de municipios segundo condicoes de vida. RESULTADOS: Existe uma polarizacao entre o grupo de melhores condicoes de vida e saude (grupo 1) e o de piores condicoes (grupo 4). O grupo 1 e caracterizado pelos municipios de maior porte populacional e no grupo 4 estao principalmente os menores municipios. Quanto a macrorregiao do Pais, os municipios do grupo 1 concentram-se no Sul e Sudeste e no grupo 4 estao os municipios do Nordeste. CONCLUSOES: Por incorporar dimensoes da realidade como habitacao, meio ambiente e saude, o indice de condicoes de vida e saude permitiu identificar municipios mais vulneraveis, embasando a definicao de prioridades, criterios para financiamento e repasse de recursos de forma mais equitativa.OBJECTIVE To describe an index to identify inequities in living conditions and health and its relationship with health planning. METHODS Variables and indicators that would reflect demographic, economic, environment and education processes as well as supply and production of health services were applied for nondimensional scaling and clustering of 5,507 Brazilian municipalities. Data sources were the 2000 Census and the Brazilian Ministry of Health information systems. Z-score test statistic and cluster analysis were performed allowing to defining 4 groups of municipalities by living conditions. RESULTS There was seen a polarization between the group with the best living conditions and health (Group 1) and the group with the worst living conditions (Group 4). Group 1 consisted of municipalities with larger populations while Group 4 comprised mainly the smallest municipalities. As for Brazilian macroregions, municipalities in Group 1 are clustered in the south and southeast and those in Group 4 are in the Northeast. CONCLUSIONS The living conditions and health index comprises reality dimensions such as housing, environment and health which allows to identifying the most vulnerable municipalities and can provide input for setting priorities, and developing criteria for more equitable financing and resource allocation.

Atenção primária em saúde: um estudo multidimensional sobre os desafios e potencialidades na Região Metropolitana de São Paulo (SP, Brasil)

This paper presents some results of a case study in the Metropolitan Region of Sao Paulo (SP, Brazil) as part of a multicentric study conducted in Argentina, Brazil, Paraguay and Uruguay. The aim is to evaluate Primary Health Care (PHC) as a strategy to achieve integrated and universal healthcare systems. The methodological approach was based on five analytical dimensions: stewardship capability; financing; provision; comprehensiveness and intersectoral approach. The techniques included literature review, document analysis and interviews with key informants: policy makers; managers, experts, users and professionals. The results were organized in response to the challenges and possibilities of PHC as a structural system according to the five dimensions. The following emerged from the interviews: different interpretations on the concept and role of PHC and a consensus as the gateway to the system; weaknesses in funding; challenges in health workforce administration and the need for new legal-institutional design for regional management. The potential aspects were: broader coverage/universality, PHC as the basis for the organization of the system; connection with the territory and understanding specific population needs.

Regionalization of health in Brazil: an analytical perspective

Este artigo visa a contribuir com o debate sobre a politica de regionalizacao do SUS e a constituicao das regioes de saude no Brasil. Compreende-las pressupoe reconhecer a dicotomia entre saude coletiva e saude individual - que marca a historia da saude publica brasileira - e identificar as diferentes racionalidades que conduzem esse processo. Tais racionalidades permitem nao apenas considerar o legado da municipalizacao no atual processo de regionalizacao, como tambem estabelecer nexos entre dois campos do conhecimento fundamentais para o debate, a epidemiologia e a geografia. A epidemiologia clinica, ao privilegiar a saude individual, fundamenta um modelo assistencial que prioriza a otimizacao de recursos. O reconhecimento da saude no seu conceito ampliado, na epidemiologia social, fundamenta um modelo de atencao voltado para os determinantes sociais. Com a geografia, podem-se formular regioes funcionais, baseadas na teoria de Christaller, ou regioes lablachianas, que reconhecem a estrutura social loco/regional, possibilitando a intervencao nos determinantes ou condicionantes da maneira de adoecer e morrer das populacoes.

Equidad en la salud: evaluación de políticas públicas en Belo Horizonte, Minas Gerais, Brasil, 1993-1997

This article evaluates government measures to reduce inequity in the health sector in Belo Horizonte from 1993 to 1997. Our hypothesis is that a municipal administration committed to equity can reduce disparities in health with the support of the Unified National Health System (SUS). The methodology used an urban quality of life index in Belo Horizonte to detect social inequalities in living conditions, as well as differences between the component indices in the infant mortality rate. Other municipal measures were assessed according to the investment resulting from the implementation of a participatory local budget and open planning process. The urban quality of life index appeared to be an appropriate measure for orienting municipal administration. The infant mortality rate proved to be a good indicator for measuring inequality in health. There was a reduction in IMR and mortality reducing gaps in the districts studied. We observed greater investment of physical and financial resources in the districts with the lowest urban quality of life index, and it can thus be stated that the municipal administration reduced the prevailing inequalities.

Differences in living conditions and health between cities: construction of a composite indicator

OBJETIVO: Descrever um indice para reconhecimento das desigualdades de condicoes de vida e saude e sua relacao com o planejamento em saude. METODOS: Foram selecionadas variaveis e indicadores que refletissem os processos demograficos, economicos, ambientais e de educacao, bem como oferta e producao de servicos de saude. Esses indicadores foram utilizados no escalonamento adimensional dos indicadores e agrupamento dos 5.507 municipios brasileiros. As fontes de dados foram o censo de 2000 e os sistemas de informacoes do Ministerio da Saude. Para analise dos dados foram aplicados os testes z-score e cluster analysis. Com base nesses testes foram definidos quatro grupos de municipios segundo condicoes de vida. RESULTADOS: Existe uma polarizacao entre o grupo de melhores condicoes de vida e saude (grupo 1) e o de piores condicoes (grupo 4). O grupo 1 e caracterizado pelos municipios de maior porte populacional e no grupo 4 estao principalmente os menores municipios. Quanto a macrorregiao do Pais, os municipios do grupo 1 concentram-se no Sul e Sudeste e no grupo 4 estao os municipios do Nordeste. CONCLUSOES: Por incorporar dimensoes da realidade como habitacao, meio ambiente e saude, o indice de condicoes de vida e saude permitiu identificar municipios mais vulneraveis, embasando a definicao de prioridades, criterios para financiamento e repasse de recursos de forma mais equitativa.OBJECTIVE To describe an index to identify inequities in living conditions and health and its relationship with health planning. METHODS Variables and indicators that would reflect demographic, economic, environment and education processes as well as supply and production of health services were applied for nondimensional scaling and clustering of 5,507 Brazilian municipalities. Data sources were the 2000 Census and the Brazilian Ministry of Health information systems. Z-score test statistic and cluster analysis were performed allowing to defining 4 groups of municipalities by living conditions. RESULTS There was seen a polarization between the group with the best living conditions and health (Group 1) and the group with the worst living conditions (Group 4). Group 1 consisted of municipalities with larger populations while Group 4 comprised mainly the smallest municipalities. As for Brazilian macroregions, municipalities in Group 1 are clustered in the south and southeast and those in Group 4 are in the Northeast. CONCLUSIONS The living conditions and health index comprises reality dimensions such as housing, environment and health which allows to identifying the most vulnerable municipalities and can provide input for setting priorities, and developing criteria for more equitable financing and resource allocation.

Diferencias intermunicipales de condiciones de vida y salud: construcción de un indicador compuesto

OBJETIVO: Descrever um indice para reconhecimento das desigualdades de condicoes de vida e saude e sua relacao com o planejamento em saude. METODOS: Foram selecionadas variaveis e indicadores que refletissem os processos demograficos, economicos, ambientais e de educacao, bem como oferta e producao de servicos de saude. Esses indicadores foram utilizados no escalonamento adimensional dos indicadores e agrupamento dos 5.507 municipios brasileiros. As fontes de dados foram o censo de 2000 e os sistemas de informacoes do Ministerio da Saude. Para analise dos dados foram aplicados os testes z-score e cluster analysis. Com base nesses testes foram definidos quatro grupos de municipios segundo condicoes de vida. RESULTADOS: Existe uma polarizacao entre o grupo de melhores condicoes de vida e saude (grupo 1) e o de piores condicoes (grupo 4). O grupo 1 e caracterizado pelos municipios de maior porte populacional e no grupo 4 estao principalmente os menores municipios. Quanto a macrorregiao do Pais, os municipios do grupo 1 concentram-se no Sul e Sudeste e no grupo 4 estao os municipios do Nordeste. CONCLUSOES: Por incorporar dimensoes da realidade como habitacao, meio ambiente e saude, o indice de condicoes de vida e saude permitiu identificar municipios mais vulneraveis, embasando a definicao de prioridades, criterios para financiamento e repasse de recursos de forma mais equitativa.OBJECTIVE To describe an index to identify inequities in living conditions and health and its relationship with health planning. METHODS Variables and indicators that would reflect demographic, economic, environment and education processes as well as supply and production of health services were applied for nondimensional scaling and clustering of 5,507 Brazilian municipalities. Data sources were the 2000 Census and the Brazilian Ministry of Health information systems. Z-score test statistic and cluster analysis were performed allowing to defining 4 groups of municipalities by living conditions. RESULTS There was seen a polarization between the group with the best living conditions and health (Group 1) and the group with the worst living conditions (Group 4). Group 1 consisted of municipalities with larger populations while Group 4 comprised mainly the smallest municipalities. As for Brazilian macroregions, municipalities in Group 1 are clustered in the south and southeast and those in Group 4 are in the Northeast. CONCLUSIONS The living conditions and health index comprises reality dimensions such as housing, environment and health which allows to identifying the most vulnerable municipalities and can provide input for setting priorities, and developing criteria for more equitable financing and resource allocation.

Mortalidade em Municípios do Estado de São Paulo e indicadores sócio-econômicos: uma análise de agrupamento

o trabalho discute a analise de dados de mortalidade em municipios do Estado de Sao Paulo agrupados segundo indicadores de natureza socio-economica como instrumento de investigacao epidemiologica no campo do planejamento e gestao de servicos de saude. Foram extraidos de bancos de dados do IBGE e da Fundacao SEADE, 15 indicadores de natureza socio-economica de todos os 49 municipios com mais de 100 mil habitantes do Estado de Sao Paulo. Para o reconhecimento de grupos homogeneos de municipios aplicouse a tecnica de analise de agrupamento (Cluster Analysis), identificando 7 grupos. Examinouse a seguir a capacidade discriminatoria que as condicoes de saude teriam para os grupos identificados, atraves da tecnica de analise discriminante, usando o agrupamento identificado como variavel dependente e os coeficientes de mortalidade por causa especifica como variaveis independentes, ou preditoras de grupo. Essa tecnica apontou uma concorda.ncia entre valores observados e preditos de 83,67%. Analisando-se as diferencas estatisticamente significantes atraves da analise de varia.ncia, foi possivel classificar qualitativamente os 7 grupos de municipios. Esse exercicio demostra a potencialidade da aplicacao de tecnicas de analise mu/tivariada no reconhecimento da complexa realidade social e sanitaria que solicita um projeto de intervencao.