Maria Angelica Borges dos Santos

As segmentações da oferta de serviços de saúde no Brasil: arranjos institucionais, credores, pagadores e provedores

A partir de revisao bibliografica e dados do Datasus, IBGE e agencias internacionais, sao discutidas segmentacoes e especializacoes na oferta de servicos de saude no Brasil. A leitura institucionalista do caso brasileiro destaca transformacoes que vem sofrendo o SUS, com enfase em relacoes publico-privadas e no papel e estrategias dos varios atores para formatar o sistema de saude segundo seus interesses e suas conviccoes. Os constrangimentos ao desenvolvimento das politicas sociais gerados pelo ajuste macroeconomico e consensos entre atores politicos de maior peso contribuem para a tendencia atual de especializacao do setor publico em tecnologias de cuidados de baixo custo e complexidade, enquanto o setor privado mais dinâmico passa a priorizar os segmentos de atencao de media e alta complexidade mais bem remunerados pela tabela SUS e mais valorizados por compradores de planos de saude privados. Um fortalecimento da presenca de conselhos de saude e de atores ainda pouco representados na arena politica poderia contribuir para uma maior atencao aos impactos potenciais desse padrao de especializacoes.

O Sistema Único de Saúde como desdobramento das políticas de saúde do século XX

Based on non-systematic search of bibliography and of national and international databases and research reports on Brazilian healthcare, this paper reviews health policies and the healthcare service market in Brazil along the 20th century, in an attempt to track the origins and structuring of the Brazilian public health system (Sistema Unico de Saude). Using a historical neoinstitutionalism framework, we discuss institutional arenas and specific relationships between payers, providers and creditors relevant to the various shapes assumed by health policies and the health system in Brazil. Institutional arrangements derived from interactions between successive political actors seem to have had a role both on present patterns of healthcare service supply and on restrictions and challenges faced by SUS.

A organização do abastecimento do hospital público a partir da cadeia produtiva: uma abordagem logística para a área de saúde

Despite their importance for hospital operations, discussions of healthcare organization logistics and supply and materials management are notably lacking in Brazilian literature. This paper describes a methodology for organizing the supply of medical materials in public hospitals, based on an action-research approach. Interventions were based on the assumption that a significant portion of problems in Brazils National Health System (SUS) facilities derive from the fact that their clinical and administrative departments do not see themselves as belonging to the same production chain - neither the hospital nor the supply department is aware of what the other produces. The development of the methodology and its main steps are presented and discussed, against a background of recent literature and total quality and supply chain management concepts.

O processo de construção de mapas de risco em um hospital público

The paper presents a discussion about the experience of building a risk map by workers in a public hospital, in Rio de Janeiro city, resting on concepts of occupational health surveillance, total quality and biosafety. It goes from the first step to persuade the workers and managers, to identify the potential sources of risk in the work environment, the elaboration of the map, until the discussion about the preventive measures and the presentation of the results by the workers at a scientific meeting in the hospital. The elaboration of the risk map acted as a learning opportunity to socialize concepts in the work health area, to integrate workers, to systematize the work process and to discuss work organization, having practical consequences which have furthered changes in the working environment.

Systematic Review With Meta-Analyses and Critical Appraisal of Clinical Prediction Rules for Pulmonary Tuberculosis in Hospitals

OBJECTIVE To systematically review studies evaluating clinical prediction rules (CPRs) for adult inpatients suspected to have pulmonary tuberculosis. DESIGN Systematic review with meta-analyses. SETTING Hospitals. Patients Inpatients at least 15 years of age admitted to acute care. METHODS A search was conducted in 5 indexed electronic databases with no language or year of publication restrictions. We performed a meta-analysis for those CPRs with at least 2 validation studies. Results were reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses. RESULTS Of the 461 abstracts selected, 36 articles were fully analyzed and 11 articles were included, yielding 8 CPRs derived in 4 countries. Broad validation studies were identified for 2 CPRs. The most frequent clinical predictors were fever and weight loss. All CPRs included chest imaging signs. Most CPRs were derived in countries with a low prevalence of pulmonary tuberculosis and included homeless, immigrants, and those who reacted to the purified protein derivative test. Both of the CPRs derived in countries with a high prevalence of pulmonary tuberculosis strongly relied on chest radiograph predictors. Accuracy of the different CPRs was high (area under receiver operating characteristic curve, 0.79-0.91). Meta-analysis of 4 validation studies for Wisniveskys CPR indicates optimistic pooled results: sensitivity, 94.1% (95% CI, 89.7%-96.7%); negative likelihood ratio, 0.22 (95% CI, 0.12-0.40). CONCLUSION On the basis of a critical appraisal of the 2 best validated CPRs, the presence of weight loss and/or fever in inpatients warrants obtaining a chest radiograph, regardless of the presence of productive cough. If the chest radiograph is abnormal, the patient should be placed in isolation until more specific test results are available. Validation in different settings is required to maximize external generalization of existing CPRs.

Detection of Zika Virus in April 2013 Patient Samples, Rio de Janeiro, Brazil

We tested 210 dengue virus‒negative samples collected from febrile patients during a dengue virus type 4 outbreak in Rio de Janeiro in April 2013 and found 3 samples positive for Zika virus. Our findings support previously published entomological data suggesting Zika virus was introduced into Brazil during October 2012–May 2013.

Precisão e confiabilidade de um teste imuno-cromatográfico rápido NS1 para diagnóstico DENV-1 no ponto de atendimento e no laboratório

Background Rapid immunochromatographic tests (ICT) for dengue non-structural protein 1 (NS1) have shown good performance for diagnosing acute-phase dengue in serum in laboratory settings, but rarely have been assessed in whole blood and at point of care (POC). This study compare the accuracy and inter- and intra-observer reliability of the NS1 Bioeasy™ ICT in whole blood at POC versus serum in the laboratory, during a DENV-1 epidemic. Methods Cross-sectional study involving 144 adults spontaneously demanding care in an emergency department within 4 days of onset of acute febrile illness. Accuracy of NS1 Bioeasy™ ICT was compared in whole blood and serum, both at 15 and 30 min, blinded to the reference RT-PCR or NS1 ELISA. Non-dengue patients were also tested for Zika virus with RT-PCR. Reliability of whole blood and serum readings by the same or different observers was measured by simple kappa (95% CI). Results At 15 min, sensitivity (Sn) of NS1 Bioeasy™ ICT in whole blood/POC was 76.7% (95% CI: 68.0–84.1) and specificity (Sp) was 87.0% (95% CI: 66.4–97.2). Sn in serum/laboratory was 82% (95% CI: 74.1–88.6) and Sp 100% (95% CI: 85.8–100). Positive likelihood ratio was 5.9 (95% CI: 2.0–17.0) for whole blood/POC and 19.8 (95% CI: 2.9–135.1) for serum/laboratory. Reliability of matched readings of whole blood/POC and serum/laboratory by the same observer (k = 0.83, 95% CI: 0.74–0.93) or different observers (k = 0.81, 95% CI: 0.72–0.92) was almost perfect, with higher discordant levels in the absence of dengue. Results did not differ statistically at 5%. Conclusions NS1 Bioeasy™ ICT in DENV-1 epidemics is a potentially confirmatory test. Invalid results at 15 min should be reread at 30 min. To optimize impact of implementing ICT in the management of false-negatives it should be incorporated into an algorithm according to setting and available specimen. Trial registration UTN U1111-1145-9451.

Autonomy for financial management in public and private healthcare facilities in Brazil

Autonomia financeira e um diferencial positivo na gestao publica, sendo referida na Pesquisa de Assistencia Medico-Sanitaria (2009) por 3,9% dos 52.055 estabelecimentos publicos de saude. Foi mais frequente em estabelecimentos publicos com internacao (17,8% do total), da administracao estadual (26,3%) e da Regiao Sul (6,6%) e, em geral, era parcial (apenas para algumas areas, como despesas emergenciais, material de consumo e permanentes, servicos de terceiros e pessoal). Quanto a natureza juridica, 83,7% dos 2.011 estabelecimentos publicos que referiram alguma autonomia sao da administracao direta. A atribuicao de autonomia financeira a estabelecimentos publicos de saude parece ser definicao politica local, que nao se prende necessariamente a mudancas de natureza juridica. Ainda assim, confirmou-se um espectro crescente de maior autonomia segundo natureza juridica, em que estabelecimentos da administracao direta da saude sao os menos autonomos e as sociedades empresariais as mais autonomas; 85,8% dos 45.394 estabelecimentos privados tinham alguma autonomia financeira.Autonomy in financial management is an advantage in public administration. A 2009 National Healthcare Facility Survey showed that 3.9% of Brazils 52,055 public healthcare facilities had some degree of financial autonomy. Such autonomy was more common in inpatient facilities (17.8%), those managed by State governments (26.3%), and in Southern Brazil (6.6%). Autonomy was mainly partial (for resources in specific areas, relating to small outlays, consumables and capital goods, and outsourced services or personnel). 74.3% of 2,264 public facilities with any financial autonomy were under direct government administration. Financial autonomy in public healthcare facilities appears to be linked to local political decisions and not necessarily to the facilitys specific legal and administrative status. However, legal status displays distinct scopes of autonomy - those under direct government administration tend to be less autonomous, and those under private businesses more autonomous; 85.8% of the 45,394 private healthcare facilities reported that they were financially autonomous.

Autonomia financeira em estabelecimentos publicos e privados de saude no Brasil

Autonomia financeira e um diferencial positivo na gestao publica, sendo referida na Pesquisa de Assistencia Medico-Sanitaria (2009) por 3,9% dos 52.055 estabelecimentos publicos de saude. Foi mais frequente em estabelecimentos publicos com internacao (17,8% do total), da administracao estadual (26,3%) e da Regiao Sul (6,6%) e, em geral, era parcial (apenas para algumas areas, como despesas emergenciais, material de consumo e permanentes, servicos de terceiros e pessoal). Quanto a natureza juridica, 83,7% dos 2.011 estabelecimentos publicos que referiram alguma autonomia sao da administracao direta. A atribuicao de autonomia financeira a estabelecimentos publicos de saude parece ser definicao politica local, que nao se prende necessariamente a mudancas de natureza juridica. Ainda assim, confirmou-se um espectro crescente de maior autonomia segundo natureza juridica, em que estabelecimentos da administracao direta da saude sao os menos autonomos e as sociedades empresariais as mais autonomas; 85,8% dos 45.394 estabelecimentos privados tinham alguma autonomia financeira.Autonomy in financial management is an advantage in public administration. A 2009 National Healthcare Facility Survey showed that 3.9% of Brazils 52,055 public healthcare facilities had some degree of financial autonomy. Such autonomy was more common in inpatient facilities (17.8%), those managed by State governments (26.3%), and in Southern Brazil (6.6%). Autonomy was mainly partial (for resources in specific areas, relating to small outlays, consumables and capital goods, and outsourced services or personnel). 74.3% of 2,264 public facilities with any financial autonomy were under direct government administration. Financial autonomy in public healthcare facilities appears to be linked to local political decisions and not necessarily to the facilitys specific legal and administrative status. However, legal status displays distinct scopes of autonomy - those under direct government administration tend to be less autonomous, and those under private businesses more autonomous; 85.8% of the 45,394 private healthcare facilities reported that they were financially autonomous.

Performance indicators and decision making for outsourcing public health laboratory services

OBJETIVO: Elaborar indicadores de desempenho e terceirizacao em rede de laboratorios clinicos, baseados em sistemas de informacoes e registros administrativos publicos. METODOS: A rede tinha 33 laboratorios com equipamentos automatizados, mas sem informatizacao, 90 postos de coleta e 983 funcionarios, no municipio de Rio de Janeiro, RJ. As informacoes foram obtidas de registros administrativos do Sistema de Informacoes de Orcamentos Publicos para a Saude e do Sistema de Informacoes Ambulatoriais e Hospitalares do Sistema Unico de Saude. Os indicadores (producao, produtividade, utilizacao e custos) foram elaborados com dados colhidos como rotina de 2006 a 2008. As variacoes da producao, custos e precos unitarios dos testes no periodo foram analisadas por indices de Laspeyres e de Paasche, especificos para medir a atividade dos laboratorios, e pelo Indice de Precos ao Consumidor Amplo do Instituto Brasileiro de Geografia e Estatistica. RESULTADOS: A producao foi de 10.359.111 testes em 2008 (aumento de 10,6% em relacao a 2006) e a relacao testes/funcionario cresceu 8,6%. As despesas com insumos, salarios e prestador conveniado aumentaram, respectivamente 2,3%, 45,4% e 18,3%. Os testes laboratoriais por consulta e internacao cresceram 10% e 20%. Os custos diretos totalizaram R