Myriam Ruiz-Rodríguez

Experiencia de implementación de un modelo de Atención Primaria

Objetivo Identificar las dificultades y los factores dinamizadores en la implementacion de un modelo de atencion primaria en Santander en la ultima decada. Metodos Estudio cualitativo con un enfoque de pluralismo y la triangulacion de fuentes y actores, con analisis de critica del limite y de los valores de los juicios (Boundary critique). Resultados Segun las categorias emergentes derivadas de la apropiacion de los atributos del modelo se encuentran problematicas tanto en aspectos filosofico-conceptuales como en la gestion operativa. No se desarrollo en la practica el modelo planteado discursivamente en el diseno. La estrategia de APS es selectiva liderada desde el nivel departamental, centrada en acciones de predominio rural realizadas por auxiliares de enfermeria y orientado al cumplimiento de metas de Salud Publica en el primer nivel de atencion. Conclusiones Se identifican dificultades tanto en el nivel nacional, departamental y municipal, que pueden ser aprovechados en otros contextos de orden nacional e internacional. Las limitantes mas destacadas son de tipo estructural y determinadas por un sistema de salud de mercado de aseguramiento que opera con una logica contractual de segmentacion institucional y fragmentacion operativa. Se sugieren como elementos operativos esenciales para enfrentar las problematica y fomentar la puesta en practica de un modelo integral de APS en el pais: gestion del talento humano centrado en competencias en APS, gestion local adecuada y estudios sistematicos de evaluacion.

Determinants of Performance of Health Systems Concerning Maternal and Child Health: A Global Approach

Aims To assess the association of social determinants on the performance of health systems around the world. Methods A transnational ecological study was conducted with an observation level focused on the country. In order to research on the strength of the association between the annual maternal and child mortality in 154 countries and social determinants: corruption, democratization, income inequality and cultural fragmentation, we used a mixed linear regression model for repeated measures with random intercepts and a conglomerate-based geographical analysis, between 2000 and 2010. Results Health determinants with a significant association on child mortality(<1year): higher access to water (βa Quartile 4(Q4) vs Quartile 1(Q1) = -6,14; 95%CI: -11,63 to -0,73), sanitation systems, (Q4 vs Q1 = -25,58; 95%CI: -31,91 to -19,25), % measles vaccination coverage (Q4 vs Q1 = -7.35; 95%CI: -10,18 to -4,52), % of births attended by a healthcare professional (Q4 vs Q1 = -7,91; 95%CI: -11,36 to -4,52) and a % of the total health expenditure (Q3 vs Q1 = -2,85; 95%CI: -4,93 to -0,7). Ethnic fragmentation (Q4 vs Q1 = 9,93; 95%CI: -0.03 to 19.89) had a marginal effect. For child mortality<5 years, an association was found for these variables and democratization (not free vs free = 11,23; 95%CI: -0,82 to 23,29), out-of-pocket expenditure (Q1 vs Q4 = 17,71; 95%CI: 5,86 to 29,56). For MMR (Maternal mortality ratio), % of access to water for all the quartiles, % of access to sanitation systems, (Q3 vs Q1 = -171,15; 95%CI: -281,29 to -61), birth attention by a healthcare professional (Q4 vs Q1 = -231,23; 95%CI: -349,32 to -113,15), and having corrupt government (Q3 vs Q1 = 83,05; 95%CI: 33,10 to 133). Conclusions Improving access to water and sanitation systems, decreasing corruption in the health sector must become priorities in health systems. The ethno-linguistic cultural fragmentation and the detriment of democracy turn out to be two factors related to health results.

Beneficios de combinar métodos para analizar causas de muertes maternas, Bucaramanga, Colombia

OBJECTIVE: Define critical points of change in the maternal care process, guide decision-making in this area, and support the strengthening of service delivery policies, with a view to achieving the Millennium Development Goal of improving maternal health. METHODS: Retrospective descriptive study of a series of cases of maternal deaths recorded in Bucaramanga between 2004 and 2009. The study examined epidemiologic reporting cards, clinical histories, field visits, and the records of analysis committees. The road to survival (analysis of delays) and detection of critical links in care were used as the methods of analysis. The information obtained was triangulated. RESULTS: The 10 maternal deaths occurred in an urban area, and the women had received medical care from professionals at a health facility. The four types of delays-in recognizing the problem, in the timeliness of decisions and actions, in care/the logistics of referral, and in the quality of care-occurred with similar frequency in the 10 cases studied. The critical links in the prevention of maternal deaths were those related to deficiencies in the vertical and horizontal integration of the care process and the quality of care. CONCLUSIONS: Combining analysis methods made it possible to identify the deficiencies in care most related to maternal deaths. However, their use should be accompanied by other methods that make it possible to identify determinants that go beyond the context of service delivery. One documented lesson learned is the importance of the continuity and monitoring of interventions as a success factor in reducing maternal mortality.

Access to medicines among internally displaced and non-displaced people in urban areas in Colombia

This study analyzes access to medicines among displaced and non-displaced populations in urban areas in Bucaramanga, Colombia. A household survey was carried out to study access to medicines for self-reported and medically diagnosed health conditions. Multiple Poisson regression with robust variance was used to determine factors associated with access to medicines. Two thousand and sixty individuals from 514 families participated. Only 29.1% (95%CI: 22.04-37.08) of the individuals in the sample with prescriptions and 44.3% (95%CI: 40.42-48.25) with self-reported needs for pharmacotherapy were taking medicines. Greater access was associated with the perceived severity of the illness, higher income, having a health center nearby and not perceiving barriers in accessing services. Social security affiliation and being displaced were not related. Social security coverage alone does not have an effect on access to medicines because it does not include essential medicines that correspond to the health needs of this population. Resolving administrative and geographical barriers is likely to improve access to medicines.