Paulo Roberto do Nascimento

A gestão semiplena e a participação popular na administração da saúde

The introduction of the Unified Health System (SUS) by the Brazilian government has helped enhance community participation. A survey in 12 municipalities in different States of the country focused on the decentralization process implemented by the Federal government (Basic Operational Ruling NOB01/93). Based on the rulings implementation, community participation has improved in the municipalities, the number of local health councils has increased, and more local people have become involved in the process. Another important aspect of the new health policy has been the direct influence of the local health councils in managing the system. Local health councils have thus been an efficient channel for community involvement. This paper discusses how the population has been represented in such councils in the wake of the decentralization process. The authors ask, what is the relationship between social democracy and political democracy, and what kind of state reform should be carried out?

Integralidade da atenção às doenças cardiovasculares e diabetes mellitus: o papel da regionalização do Sistema Único de Saúde no estado de São Paulo

Objective: To analyze the indicators for adult healthcare structures, processes and results relating to diabetes mellitus and arterial hypertension, in the light of the regionalization of the National Health System (SUS) in the State of Sao Paulo. Methods: Analyses were performed for five healthcare regions. Structure indicators (human development index, hospital index, intensive care unit bed index, outpatient index, human resources index and management type), process indicators (coverage of the family health program (FHP) strategy, coverage of basic and specialized consultations, inflow/ outflow index and management effort) and result indicators (% early death due to stroke, acute myocardial infarction, heart failure and diabetes complications) were analyzed. Results: Mogi das Cruzes region presented the highest mortality rates for the four events assessed and the highest proportion of early deaths. Sao Jose do Rio Preto region had the lowest proportion of early deaths, among the health regions studied. This may be related to greater adequacy of healthcare provision, larger FHP coverage and greater basic and specialized consultation coverage, along with the presence of initiatives for strengthening the formal mechanisms for regional agreement-making. Final Considerations: The comprehensiveness of healthcare for diabetes mellitus and arterial hypertension seems to depend on achieving a design that is technically appropriate for putting service referencing and adequate management and care practices into effect.OBJETIVO: Analisar indicadores de estrutura, processo e de resultados da atencao a saude do adulto, especificamente de Diabetes Mellitus (DM) e Hipertensao Arterial (HA), a luz da regionalizacao do Sistema Unico de Saude no estado de Sao Paulo. METODOS: As analises foram realizadas para cinco Regionais de Saude. Foram analisados os indicadores de estrutura (Indice de Desenvolvimento Humano, indices de hospitais, de leitos de UTI, de ambulatorios, de recursos humanos e tipo de gestao), de processo (cobertura de Estrategia Saude da Familia [ESF], cobertura de consultas basicas e especializadas, indice de invasao/evasao e esforco gestor) e de resultado (% de mortalidade precoce por Acidente Vascular Cerebral, Infarto Agudo do Miocardio, Insuficiencia Cardiaca e por complicacoes de DM). RESULTADOS: A Regional de Mogi das Cruzes apresentou os valores mais elevados das taxas de mortalidade para os quatro eventos estudados e tambem quanto a proporcao de mortalidade precoce. Em relacao a este ultimo indicador, a Regional de Rio Preto apresentou o menor valor entre as Regionais de Saude estudadas, o que poderia estar relacionado com a adequacao da oferta de servicos, maior cobertura da ESF e de consultas basicas e especializadas, alem de iniciativas para o fortalecimento de mecanismos formais de pactuacao regional. CONSIDERACOES FINAIS: A integralidade da atencao nesta linha de cuidado parece depender de um desenho tecnicamente adequado para a efetividade do referenciamento dos servicos e de praticas adequadas de gestao e de cuidado.

Prevalência da dor lombar no Brasil: uma revisão sistemática

O artigo descreve a qualidade metodologica dos estudos publicados sobre prevalencia de dor lombar realizados no Brasil. Dezoito estudos foram considerados elegiveis apos pesquisas nas seguintes bases de dados: LILACS, PubMed, Embase, CINAHL, SPORTDiscus e SciELO. Alto risco de vies foi encontrado nos criterios de validade externa relacionados com a amostragem, e vies de nao-resposta. Considerando os criterios de validade interna, a principal fonte de vies estava relacionada com a falta de uma definicao de caso aceitavel, bem como a utilizacao de instrumentos que nao apresentavam construto de confiabilidade e a validade provados. Nenhum estudo representativo com valores de prevalencia da dor lombar no Brasil foi encontrado. Os trabalhos publicados incluidos nesta revisao apresentaram um alto risco de vies que afetam os dados de prevalencia. Futuros estudos com desenho metodologico adequado sao necessarios, a fim de apresentar o real impacto da dor lombar no Brasil e permitir comparacoes.The article describes the methodological quality of published studies on prevalence of low back pain in Brazil. Eighteen studies were considered eligible after searches in the following electronic databases: LILACS, PubMed, Embase, CINAHL, SPORTDiscus and SciELO. A high source of bias was observed in the criteria for external validity related to sampling, in addition to non-response bias. Considering the criteria for internal validity, the main sources of bias were the lack of an acceptable definition of low back pain and the use of instruments that lacked proven reliability and validity. No representative study was found that provides a generalizable prevalence of low back pain in Brazil. The published studies included in this review showed a high risk of bias that affects the prevalence data. Future studies with appropriate methodological design are necessary to verify the real impact of low back pain in Brazil and allow comparisons.

Referenciamento regional em saúde: estudo comparado de cinco casos no Estado de São Paulo, Brasil

OBJETIVO: avaliar praticas gestoras de referenciamento regional no Estado de Sao Paulo, identificando as principais dificuldades encontradas nos processos de pactuacao com vistas a integralidade da atencao. Metodologia; foram selecionadas 5 Regioes (Campinas- CPN, Piracicaba-PRC, Mogi das Cruzes-MC, Sao Jose do Rio Preto-SJRP e Sao Jose dos Campos-SJC) nas quais foram analisados: indicadores de 4 linhas de cuidado (Hipertensao Arterial-HA e Diabetes Mellitus-DM, Saude Mental, Bucal e da Mulher); os instrumentos de referenciamento operantes e a percepcao dos gestores regionais e municipais sobre este processo. RESULTADOS: o desempenho dos gestores no tocante ao alcance da universalidade e integralidade da atencao foi analisado atraves de 11 indicadores, resultando em um escore com variacao de 0 a 5. A classificacao das regioes foi: SJRP (4,55); CPN (2,91); SJC (2,27); PRC (2,27) e MC (1,91). A analise das entrevistas com gestores revelou que os mecanismos formais de referenciamento sao insuficientes, bem como os instrumentos para o seu acompanhamento; nas regioes metropolitanas parece haver maior dificuldade para pactuacao das referencias; o fortalecimento dos espacos de negociacao entre os gestores foi apontado como um fator facilitador do processo.

Low back pain prevalence in Brazil: a systematic review

O artigo descreve a qualidade metodologica dos estudos publicados sobre prevalencia de dor lombar realizados no Brasil. Dezoito estudos foram considerados elegiveis apos pesquisas nas seguintes bases de dados: LILACS, PubMed, Embase, CINAHL, SPORTDiscus e SciELO. Alto risco de vies foi encontrado nos criterios de validade externa relacionados com a amostragem, e vies de nao-resposta. Considerando os criterios de validade interna, a principal fonte de vies estava relacionada com a falta de uma definicao de caso aceitavel, bem como a utilizacao de instrumentos que nao apresentavam construto de confiabilidade e a validade provados. Nenhum estudo representativo com valores de prevalencia da dor lombar no Brasil foi encontrado. Os trabalhos publicados incluidos nesta revisao apresentaram um alto risco de vies que afetam os dados de prevalencia. Futuros estudos com desenho metodologico adequado sao necessarios, a fim de apresentar o real impacto da dor lombar no Brasil e permitir comparacoes.The article describes the methodological quality of published studies on prevalence of low back pain in Brazil. Eighteen studies were considered eligible after searches in the following electronic databases: LILACS, PubMed, Embase, CINAHL, SPORTDiscus and SciELO. A high source of bias was observed in the criteria for external validity related to sampling, in addition to non-response bias. Considering the criteria for internal validity, the main sources of bias were the lack of an acceptable definition of low back pain and the use of instruments that lacked proven reliability and validity. No representative study was found that provides a generalizable prevalence of low back pain in Brazil. The published studies included in this review showed a high risk of bias that affects the prevalence data. Future studies with appropriate methodological design are necessary to verify the real impact of low back pain in Brazil and allow comparisons.

Monitoring Millennium Development Goals in Brazilian municipalities: challenges to be met in facing up to iniquities

The Healthy Cities and Agenda 21 programs improve living and health conditions and affect social and economic determinants of health. The Millennium Development Goals (MDG) indicators can be used to assess the impact of social agendas. A data search was carried out for the period 1997 to 2006 to obtain 48 indicators proposed by the United Nations and a further 74 proposed by the technical group for the MDGin Brazil. There is a scarcity of studies concerned with assessing the MDG at the municipal level. Data from Brazilian health information systems are not always consistent or accurate for municipalities. The lack of availability and reliable data led to the substitution of some indicators. The information systems did not always provide annual data; national household surveys could not be disaggregated at the municipal level and there were also modifications on conceptual definitions over time. As a result, the project created an alternative list with 29 indicators. MDG monitoring at the local community can be important to measure the performance of actions toward improvements in quality of life and social iniquities.

Práticas democráticas participativas na construção de agendas sociais de desenvolvimento em municípios do sudeste brasileiro

This article present the results of a study which focused on local processes for implementing social agendas Agenda 21 and Healthy Cities in the southeast region of Brazil. It looks at the relations between efforts and their effects on social health determinants, especially those which may be understood by considering the relationship between social actors and the system. Six case studies were carried out to analyze the social experience of implementing their respective agendas. Data was collected through Individual and collective interviews, survey documentation and direct observation of experiences. They were analyzed according to previously defined research topics. Results show that values such as participation, collective construction of policies, sustainability and empowerment become part of the ideology and experience of those directly involved. Furthermore, values also positively impact on actions PARTICIPATORY DEMOCRATIC PRACTICES IN THE CONSTRUCTION OF SOCIAL DEVELOPMENT AGENDAS IN MUNICIPALITIES IN THE SOUTHEAST OF BRAZIL MARCIA FARIA WESTPHAL, JUAN CARLOS ANEIROS FERNANDEZ, PAULO ROBERTO NASCIMENTO, FABIOLA ZIONI, LUCIA MARCIA ANDRÉ, ROSILDA MENDES, GRACE PEIXOTO NORONHA, RAFAEL DA SILVEIRA MOREIRA which have been adopted, promoting health and quality of life of citizens living in theseEste artigo apresenta os resultados e a analise de um estudo que focalizou os processos locais de implantacao das agendas sociais - Cidades Saudaveis e Agenda 21 - em municipios da regiao Sudeste do Brasil, relacionando o esforco realizado e seus efeitos sobre os determinantes sociais de saude, especialmente os que podem ser apreendidos considerando-se a relacao entre atores sociais e sistema. Realizaram-se estudos de caso em seis municipios para analise da experiencia social de implementacao da respectiva agenda. Entrevistas individuais e coletivas, levantamento de documentacao e observacao direta produziram os dados que foram analisados em funcao de temas de pesquisa previamente definidos. Resultados demonstram que valores como participacao, construcao coletiva de politicas, sustentabilidade e empoderamento, passam a integrar o ideario e a experiencia dos atores diretamente envolvidos, alem de interferirem ao ponto de acoes positivas serem adotadas e implementadas, para promover a saude e a qualidade de vida dos cidadaos que vivem nestes locais.

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.

La prevalencia de dolor lumbar en Brasil: una revisión sistemática

O artigo descreve a qualidade metodologica dos estudos publicados sobre prevalencia de dor lombar realizados no Brasil. Dezoito estudos foram considerados elegiveis apos pesquisas nas seguintes bases de dados: LILACS, PubMed, Embase, CINAHL, SPORTDiscus e SciELO. Alto risco de vies foi encontrado nos criterios de validade externa relacionados com a amostragem, e vies de nao-resposta. Considerando os criterios de validade interna, a principal fonte de vies estava relacionada com a falta de uma definicao de caso aceitavel, bem como a utilizacao de instrumentos que nao apresentavam construto de confiabilidade e a validade provados. Nenhum estudo representativo com valores de prevalencia da dor lombar no Brasil foi encontrado. Os trabalhos publicados incluidos nesta revisao apresentaram um alto risco de vies que afetam os dados de prevalencia. Futuros estudos com desenho metodologico adequado sao necessarios, a fim de apresentar o real impacto da dor lombar no Brasil e permitir comparacoes.The article describes the methodological quality of published studies on prevalence of low back pain in Brazil. Eighteen studies were considered eligible after searches in the following electronic databases: LILACS, PubMed, Embase, CINAHL, SPORTDiscus and SciELO. A high source of bias was observed in the criteria for external validity related to sampling, in addition to non-response bias. Considering the criteria for internal validity, the main sources of bias were the lack of an acceptable definition of low back pain and the use of instruments that lacked proven reliability and validity. No representative study was found that provides a generalizable prevalence of low back pain in Brazil. The published studies included in this review showed a high risk of bias that affects the prevalence data. Future studies with appropriate methodological design are necessary to verify the real impact of low back pain in Brazil and allow comparisons.

Metropolitan Environmental Health: Asymmetrical Knowledge and Management in São Paulo, Brazil

Metropolitan areas have been seen as empty political arenas even though there is a renewed interest in discussing the need for their integrated management. In this context environmental and health issues have come into the spotlight, as political and administrative fragmentation does not assist in dealing with the spread of different pollutants which do not adhere to administrative, or even natural boundaries. This paper aims to explore the Sao Paulo Metropolitan Region (SPMR), Brazil, encompassing 39 municipalities, taking into account an unequal distribution of knowledge and administrative efforts in addressing environmental health issues. The study was conducted by using secondary indicators provided by public institutions and by undertaking a bibliographical review. Sao Paulo municipality, as the capital city, concentrates demands for environmental services as well as the need for pollution dispersion, both of which cross municipal boundaries. There is greater concentration of knowledge about the Sao Paulo municipality, for example the main research effort towards understanding the health impacts of air pollution focuses on its spatial limits. It also centralizes public policies to control atmospheric emissions but these cannot solve the larger, regional problem. In relation to public water supply there is a clear distinction between municipalities that have a greater demand for water and those that produce it, since the latter often present inferior economic and social conditions. This situation reveals extremely asymmetrical relations within the metropolitan space and points to the need to use strategic indicators to induce actions involving health, environment and other public administrative sectors.