Sulamis Dain

Adequação do processo de assistência pré-natal entre as usuárias do Sistema Único de Saúde em Juiz de Fora-MG

PURPOSE: to evaluate the adequacy of the prenatal care process offered to users of the Unified Health Care System (SUS) in Juiz de Fora-MG and to compare the municipal services. METHODS: a transversal study with auditing was carried out on the records of 370 pregnant women, selected by systematic sampling among women who carried their pregnancies to term and gave birth using SUS services in the first semester of 2002, with prenatal care given in Juiz de Fora. For statistical analysis the c2 test was used to compare the municipal services (level of significance: 5%). The evaluation followed a three-tiered complementary sequence, using: the utilization of prenatal care (Kessner index: beginning and frequency of care) at level 1; the utilization of prenatal care and basic laboratory tests, according to the Humanization Program of Prenatal Care and Birth (ABO-Rh, hemoglobin/hematocrit, VDRL, glycemia and urinalysis), at level 2; and the utilization of prenatal care, the basic laboratory tests and the obligatory clinical-obstetric procedures during a prenatal visit (assessment of blood pressure, weight, edema, uterine fundal height, gestational age, fetal heart rate and fetal presentation), at level 3. RESULTS: the observed adequacy of the process was only 26.7% (level 1), 1.9% (level 2) and 1.1% (level 3). We also observed a prenatal coverage of 99.04%, an average of 6.4 visits per pregnant woman, and an average gestational age of 17.4 weeks at the time of the first prenatal visit. There were no significant differences between the municipal services. CONCLUSIONS: prenatal care offered to SUS users in Juiz de Fora should be reviewed from a qualitative standpoint, and periodic evaluations as necessary instruments of improvement are recommendable. Managers and professionals should undertake actions aimed at increasing compliance with norms/routines of the program - principally the request/recording of basic complementary tests - and which guarantee increased utilization of prenatal care.

Genetic services and testing in Brazil

The Federative Republic of Brazil is a country of continental dimensions, whose territory covers more than 8.5 million km2 and borders all the countries of South America except for Chile and Ecuador. After more than three centuries as a colony of Portugal, it became an independent monarchy in 1822 and a federal republic in 1889. It was under a 20-year long military dictatorship on the second half of last century, and today, after six presidential elections, the country has emerged as a consolidated democracy and as a political and economic leader in the region. The Brazilian economy also acquired a strong position in the global economy in recent years (IBGE 2010; United Nations 2010). It is defined as an upper middle-income country, but inequality remains significant, according to Human Development Report (UNDP 2009). Brazil is distinguished by an admirable national unity, based mainly in the Portuguese language, which is spoken in all regions, and by a magnificent biodiversity and natural resources. The agriculture is large and well-developed, while mining, manufacturing, and service sectors are having a significant growth. Notwithstanding, the country still faces economical, political, and social problems, whose paramount example is the highly unequal income distribution (IBGE 2010; United Nations 2010). In the past decades, with health improvement of the population in general, due to more effective sanitation and better control of infectious and nutritional diseases, it can be stated that Brazil has been living an epidemiological transition. Taking such statement into consideration, birth defects and genetic diseases are increasingly assuming a more important role in morbidity and mortality, especially in large centers and reference hospitals (Horovitz et al. 2005). This paper presents the background data on basic demographic statistics, health indicators and health expenditure, and information on the genetic services and genetic testing available in the country.

Os vários mundos do financiamento da Saúde no Brasil: uma tentativa de integração

O artigo aborda o dilema subjacente ao financiamento da Saude, entre a visao de longo prazo proposta pela Seguridade Social em 1988, e a visao de curto prazo, centrada nos sucessivos ajustes fiscais, que vem frustrando a expansao de recursos da Saude no Brasil. No contexto da regulamentacao da Emenda Constitucional 29, da renovacao da CMPF e da DRU, e de uma proxima reforma tributaria, sao tratados aspectos do sistema tributario, das contribuicoes sociais, dos subsidios, incentivos e renuncia de arrecadacao. Considera tambem aspectos politico-institucionais das relacoes intergovernamentais e das relacoes entre o setor publico e o setor privado, presentes ao financiamento da Saude. O trabalho torna evidente a existencia de espaco para ampliar o patamar de financiamento do SUS, de modo a superar os vazios sanitarios, bem como as desigualdades de oferta de servicos no territorio. Sugere tambem a revisao das relacoes financeiras intergovernamentais e entre o setor publico e o setor privado. Finalmente, apresenta aspectos virtuosos do gasto publico e dos instrumentos de financiamento do setor para o desenvolvimento economico e tecnologico do Brasil.

A sustentabilidade econômico-financeira no Proesf em municípios do Amapá, Maranhão, Pará e Tocantins

Nos estudos de linha de base do Projeto de Expansao do Programa Saude da Familia (Proesf), o artigo trata do tema do financiamento do Programa de Saude da Familia (PSF) na otica de sua sustentabilidade financeira. Aspectos relativos a construcao de medidas e indicadores de sustentabilidade sao abordados a partir da experiencia recente de diferenciacao da politica de incentivos financeiros do SUS aos municipios de mais de 100 mil habitantes no Brasil atraves do Proesf. A sugestao de inclusao destes indicadores apenas permite definir a coerencia a longo prazo das acoes planejadas do ponto de vista de financiamento. O tema, entretanto, nao esgota a necessidade de revisao critica dos criterios hoje utilizados pela politica de incentivos do PSF e de sua diferenciacao entre municipios, que nao se deriva exclusivamente do porte municipal. As diferencas de situacoes municipais quanto a sustentabilidade, apontadas no estudo, chamam a atencao para os limites e limitacoes da aplicacao de politicas homogeneas para situacoes desiguais, com consequencias previsiveis sobre a manutencao e agravamento da iniquidade.

Construção do Sistema Brasileiro de Vigilância Sanitária: argumentos para debate

This paper analyzes the Brazilian Sanitary Surveillance System as an arrangement aimed at regulating and reducing health risks associated with consumption of products, use of health services and the environment. Historical, political and tax aspects were considered and their development compared with the National Health Surveillance System, which has received strong international cooperation. The comparison was based on the trajectory of their national systems and related federal agencies, as well as on criteria adopted for decentralization. The central category of analysis is federative coordination and was based on the framework of federalism and intergovernmental relations. The institutional context of health and sanitary surveillance presents strong political competition, instability in the project and probable reduction of the ability of federal coordination after the Pact for Health. The National Sanitary Surveillance System due to its nature of public good and high externality in its field of action requires federal coordination for increasing the regional and local cooperation, also because of the structural heterogeneity of Brazilian municipalities.

Análise de custo-efetividade em relação às terapias renais substitutivas: como pensar estudos em relação a essas intervenções no Brasil?

This study aims to contribute to the discussion on the possibility of applying health economics assessment, specifically the cost-effectiveness technique, to renal replacement therapies for end-stage renal failure. A review was conducted on the interventions and their alternative courses from the perspective of the various methodological proposals in the literature, considering the availability of data and information in Brazil to back this type of research.

Avaliação em Saúde e Avaliação Econômica em Saúde: introdução ao debate sobre seus pontos de interseção

The study aims to infer the existence of a continuum between Health Assessment and Economic Assessment in Health, by highlighting points of intersection of these forms of appraisal. To achieve this, a review of the theoretical foundations, methods and approaches of both forms of assessment was conducted. It was based on the theoretical model of health evaluation as reported by Hartz et al and economic assessment in health approaches reported by Brouwer et al. It was seen that there is a continuum between the theoretical model of evaluative research and the extrawelfarist approach for economic assessment in health, and between the normative theoretical model for health assessment and the welfarist approaches for economic assessment in health. However, in practice the assessment is still conducted using the normative theoretical model and with a welfarist approach.

A Audiência Pública da Saúde: questões para a judicialização e para a gestão de saúde no Brasil

Judicialization has been in use on several countries as a term to define various phenomena according to their intensity and historicity. Recently, the Judiciary Power has addressed health issues in Brazil, a form of “policy judicialization”. The term, however, lacks the precise definitions that would enable a deeper analysis of this phenomenon’s range in Brazil. The last years have seen a significant increase on judicial actions aimed at guaranteeing health rights. Among its consequences, this led to a quick assimilation by health administrators of the term “health judicialization”. Many health related judicial actions have arrived at the highest level of Brazil’s Legal System. This has led the Supreme Court to create a Public Hearing to address civil society’s issues regarding health rights, where fifty people were heard. This research analyses the rhetoric observed on these speakers’ main arguments to understand their opinion regarding the judicialization phenomenon, and the main consequences to health administration.

Os impasses do financiamento fiscal do SUS

This comment is inspired in the article written by Luciana Dias de Lima regarding the relationships between fiscal federalism and the process of decentralization of the Single Health System. It highlights and expands issues regarding the transformations that have taken place in the intergovernmental relationships and the changes in public institutionality that marked the period the author analyzed. The comment calls the readers attention to the potential deconstruction of the federative relationships of the Single Health System described and analyzed in the text proposed for, if the Executives new tax reform, which is currently proceduring, is approved.

O processo de regionalização da saúde sob a ótica da teoria dos custos de transação

This study analyzes the incidence of transaction costs in the regionalization process of health policies in the Brazilian federal system. In this work, regionalized health actions contracted and agreed between federal agencies have assumed a transactional nature. A conceptual theoretical essay of reflective nature was prepared with the purpose of questioning and proposing new approaches to improve the health regionalization process. The main considerations suggest that institutional management tools proposed by the standards and regulations of the Unified Health System have a low potential to reduce transaction costs, especially due to hardships in reconciling common goals among the entities, environment surrounded by uncertainty, asymmetries and incomplete information, bounded rationality and conflict of interest. However, regionalization can reduce the incidence of social and/or operational costs, through improved access to health and the construction of more efficient governance models.