O impacto financeiro na saúde pública contra ist's em específico hiv no município de Ji-Paraná: análise de dados (2019 a 2022) / The financial impact on public health against ist's in specific hiv in the municipality of Ji-Paraná: data analysis (2019 to 2022) / Impacto financiero en la salud pública contra el vih en el municipio de Ji-Paraná: análisis de datos (2019 a 2022)

O investimento financeiro desempenha um papel fundamental no combate ao HIV, sendo essencial no financiamento de programas de prevenção, como campanhas de conscientização pública, distribuição de preservativos, testagem, tratamento e pesquisas. Sem investimento adequado, as taxas de infecção podem aumentar e as pessoas que vivem com HIV podem não ter acesso aos tratamentos e serviços de que precisam. Este estudo tem como objetivo analisar sobre o aumento de investimento na área da vigilância epidemiológica relativa ao combate a Infecções Sexualmente Transmissíveis (IST's) com um olhar para o vírus da imunodeficiência humana HIV, no município de Ji- Paraná no período de 2019 a 2022. Adotou-se como metodologia uma pesquisa elaborada de forma quantitativa, de caráter exploratório, por meio de uma análise de dados dos registros públicos epidemiológicos e também dos investimentos no fundo municipal de saúde publicados no portal de transparência do município de Ji-Paraná. O seguinte estudo possibilitou a análise dos investimentos realizados no fundo municipal de saúde para a realização de ações voltadas para o controle, diagnósticos e tratamento da Human Immuno Deficiency Virus (HIV) que teve influência direta na diminuição dos casos registrados pelo portal do Sistema de Informações de Agravos de Notificação (SINAN) no período de 2019 a 2020. Conclui-se que o investimento em saúde pública para o combate ao HIV/AIDS é fundamental e pode ser um grande desafio financeiro para os municípios, especialmente em tempos de crise econômica e escassez de recursos, a alocação de recursos adequados para programas de prevenção, tratamento, cuidados de saúde, serviços de apoio, pesquisa e monitoramento pode ajudar a reduzir a incidência de novos casos de HIV e garantir que as pessoas que vivem com HIV recebam o suporte necessário para gerenciar sua condição.

Financial investment plays a fundamental role in the fight against HIV, being essential in financing prevention programs, such as public awareness campaigns, condom distribution, testing, treatment, and research. Without adequate investment, infection rates can increase and people living with HIV may not have access to the trea- tments and services they need. This study aims to analyze the increase in investment in the area of epidemiological surveillance related to the fight against Sexually Transmitted Infections (STIs) with a focus on the Human Immunodeficiency Virus (HIV) in the mu- nicipality of Ji-Paraná from 2019 to 2022. A quantitative exploratory research methodo- logy was adopted, through an analysis of data from public epidemiological records and also investments in the municipal health fund published on the transparency portal of the municipality of Ji-Paraná. This study enabled the analysis of investments made in the municipal health fund for actions aimed at the control, diagnosis, and treatment of the Human Immuno Deficiency Virus (HIV), which had a direct influence on the decrease in cases recorded by the Notification of Aggravations Information System (SINAN) portal from 2019 to 2020. It is concluded that public health investment for the fight against HIV/AIDS is essential and can be a significant financial challenge for municipalities, especially in times of economic crisis and resource scarcity. Adequate allocation of re- sources for prevention programs, treatment, healthcare, support services, research, and monitoring can help reduce the incidence of new HIV cases and ensure that people living with HIV receive the necessary support to manage their condition. KEYWORDS: AIDS/HIV; Public Health; Financing.

La inversión financiera juega un papel fundamental en la lucha contra el VIH, siendo esencial para el financiamiento de programas de prevención, como campañas de concientización pública, distribución de preservativos, pruebas, tratamiento e investi- gaciones. Sin una inversión adecuada, las tasas de infección pueden aumentar y las per- sonas que viven con VIH pueden no tener acceso a los tratamientos y servicios que nece- sitan. Este estudio tiene como objetivo analizar el aumento de la inversión en el área de la vigilancia epidemiológica en relación a la lucha contra las Infecciones de Transmisión Sexual (ITS), con un enfoque en el virus de la inmunodeficiencia humana VIH, en el municipio de Ji-Paraná en el período de 2019 a 2022. Se adoptó como metodología una investigación elaborada de forma cuantitativa, de carácter exploratorio, a través de un análisis de datos de registros públicos epidemiológicos y también de las inversiones en el fondo municipal de salud publicadas en el portal de transparencia del municipio de Ji- Paraná. Este estudio permitió el análisis de las inversiones realizadas en el fondo munici- pal de salud para llevar a cabo acciones enfocadas en el control, diagnóstico y tratamiento del Virus de Inmunodeficiencia Humana (VIH), lo que tuvo una influencia directa en la disminución de los casos registrados por el portal del Sistema de Información de Agravios de Notificación (SINAN) en el período de 2019 a 2020. Se concluye que la inversión en salud pública para la lucha contra el VIH/SIDA es fundamental y puede ser un gran de- safío financiero para los municipios, especialmente en tiempos de crisis económica y es- casez de recursos, la asignación de recursos adecuados para programas de prevención, tratamiento, cuidado de la salud, servicios de apoyo, investigación y monitoreo puede ayudar a reducir la incidencia de nuevos casos de VIH y garantizar que las personas que viven con VIH reciban el apoyo necesario para manejar su condición.

Continuum de desmontes da saúde pública na crise do covid-19: o neofascismo de Bolsonaro / Continuum of public health dismantling during the covid-19 crisis: Bolsonaro's neofascism

Resumo Neste artigo, aprofunda-se a discussão crítica às políticas adotadas pelo governo Bolsonaro em relação à saúde pública, particularmente no que tange ao financiamento em geral, ao enfrentamento da pandemia e ao primeiro ano de implantação do novo modelo de "financiamento" para a Atenção Primária à Saúde (APS). A análise evidencia o acirramento da legitimidade restrita do regime político, assumida por políticas ultraneoliberais e pelo neofascismo do governo Bolsonaro. Estas formas de dominação - política e econômica - engendram uma conjuntura interna que visa remodelar a acumulação de capital na saúde pública via APS por meio de mecanismos "operacionais" burocráticos sutis de desconstrução da universidade do "financiamento". Na primeira parte, discute-se a abrangência da crise tripla do capital - sanitária, econômica e ecológica - e sua relação orgânica com o Estado no capitalismo dependente brasileiro, abrindo espaço para o crescimento da restrição do regime político endossado pela ascensão do neofascismo. Na segunda parte, aborda-se a escalada do desfinanciamento do Sistema Único de Saúde (SUS) em plena crise de covid-19 e os efeitos da implementação do modelo de financiamento da APS, evidenciando a continuidade do processo de valorização de um "SUS operacional" em detrimento do seu princípio de universalidade como dimensão neofascista do governo Bolsonaro.

Abstract This article deepens the critical discussion about the policies of the Bolsonaro government regarding public health, particularly regarding the general financing, the confrontation of the pandemic, and the first year of implementation of the new financing model for Primary Health Care (PHC). The analysis evidences the aggravation of the restrict legitimacy of the political regime, assumed by ultra-neoliberal policies and by the neofascism of the Bolsonaro government. These forms of domination - political and economic - produce an internal conjuncture that seeks to remodel the capital accumulation in public health by PHC by subtle bureaucratic "operational" mechanisms of deconstruction of financing universality. In the first part, the coverage of the triple crisis of the capital - sanitary, economic and ecological - and its organic relationship to the State in the Brazilian dependent capitalism is discussed, opening space to the increase of the restriction of the political regime endorsed by the ascension of the neofascism. In the second part, the increase of the de-financing of the Unified Health System (SUS) right in the middle of the covid-19 crisis and the effects of the implementation of the financing model of the PHC, evidencing the continuity of the process of valuing an "operational SUS" in detriment of its universality principle as a neofascist dimension of Bolsonaro's government.

Evolução da estrutura e resultados da Atenção Primária à Saúde no Brasil entre 2008 e 2019 / Evolution of the structure and results of Primary Health Care in Brazil between 2008 and 2019

Resumo Descreve a evolução da estrutura e resultados da Atenção Primária à Saúde (APS) no Brasil, entre 2008 e 2019. Foram calculadas a mediana de variáveis como: despesa per capita em APS por habitante coberto, cobertura da APS e as taxas de mortalidade e internações por condições sensíveis à atenção primária (CSAP) de 5.565 municípios brasileiros estratificados segundo porte populacional e quintil do Índice Brasileiro de Privação (IBP) e analisada a tendência mediana no período. Houve aumento de 12% na mediana da despesa em APS. A cobertura da APS expandiu, sendo que 3.168 municípios apresentaram 100% de cobertura em 2019, contra 2.632 em 2008. A mediana das taxas de mortalidade e internações por CSAP aumentou 0,2% e diminuiu 44,9% respectivamente. A despesa em APS foi menor nos municípios com maior privação socioeconômica. Quanto maior o porte populacional e melhores as condições socioeconômicas dos municípios, menor a cobertura da APS. Quanto maior a privação socioeconômica dos municípios, maiores foram as medianas das taxas de mortalidade por CSAP. Este estudo demonstrou que a evolução da APS foi heterogênea e está associada tanto ao porte populacional como às condições socioeconômicas dos municípios.

Abstract This paper describes the structure and results of Primary Health Care (PHC) in Brazil between 2008 and 2019. The medians of the following variables were calculated: PHC spending per inhabitant covered, PHC coverage, and rates of mortality and hospitalizations due to primary care sensitive conditions (PCSC), in 5,565 Brazilian municipalities stratified according to population size and quintile of the Brazilian Deprivation Index (IBP), and the median trend in the period was analyzed. There was a 12% increase in median PHC spending. PHC coverage expanded, with 3,168 municipalities presenting 100% coverage in 2019, compared to 2,632 in 2008. The median rates of PCSC mortality and hospitalizations increased 0.2% and decreased 44.9%, respectively. PHC spending was lower in municipalities with greater socioeconomic deprivation. The bigger the population and the better the socioeconomic conditions were in the municipalities, the lower the PHC coverage. The greater the socioeconomic deprivation was in the municipalities, the higher the median PCSC mortality rates. This study showed that the evolution of PHC was heterogeneous and is associated both with the population size and with the socioeconomic conditions of the municipalities.

Financiamiento en investigación en salud: obteniendo financiamiento. Consejos útiles para aumentar las chances de éxito. Parte 2 / Health research funding: obtaining grants. Tips to improve the success rate. Part 2

Esta es la segunda parte de un artículo sobre la búsqueda de financiamiento para un proyecto de investigación. Todo proyecto de investigación requiere una fuente de financiamiento para poder ser llevado adelante. La búsqueda de fondos es una tarea que lleva tiempo y esfuerzo con una baja tasa de éxito. Compartimos algunos consejos que podrían ayudar a aumentar esa tasa de éxito en relación con: 1) cómo reconocer la necesidad de búsqueda de una fuente de financiamiento externo, 2) de dónde provienen los fondos, 3) qué gastos se pueden financiar habitualmente con los fondos y 4) cómo mejorar la escritura y la presentación a una convocatoria. (AU)

This is the second part of our series on searching funds for a research plan. Every research proposal requires a source of funding to be carried out. Looking for funds is a time and effort consuming task with a low success rate. We share some tips that may help to improve that success rate related to (1) how to recognize the need of an external funding source, (2) where the funds are coming from, (3) what costs can be funded and (4) how to improve a proposal writing and submission. (AU)

Análise do financiamento federal do Sistema Único de Saúde para o enfrentamento da Covid-19 / Analysis of the federal funding of the Unified Health System to fight the COVID-19

RESUMO O objetivo deste artigo é o de analisar o financiamento federal do Sistema Único de Saúde (SUS) para o enfrentamento da pandemia da Covid-19 em 2020 e durante o primeiro quadrimestre de 2021 - períodos caracterizados como da primeira e da segunda ondas. Realizou-se pesquisa documental com levantamento de dados disponíveis em sítios eletrônicos oficiais. A pandemia se instalou no Brasil em fevereiro de 2020, no contexto do subfinanciamento crônico do SUS, que se aprofundou com o estrangulamento de dotações verificado a partir da Emenda Constitucional 95/2016, que definiu o teto das despesas primárias e o congelamento do piso federal do SUS até 2036, no mesmo valor do piso de 2017. Essa medida constitucional viabilizou o aprofundamento da política de austeridade fiscal pela via da redução das despesas primárias e da dívida pública em relação ao Produto Interno Bruto. Tais objetivos condicionaram também o financiamento federal para o combate à pandemia da Covid-19 em 2020 e 2021, cuja execução orçamentária e financeira pode ser caracterizada como reativa e retardatária. Essa forma de execução comprometeu o atendimento das necessidades de saúde da população, além de prejudicar a gestão do SUS nas esferas de governo subnacionais.

ABSTRACT The purpose of this article is to analyze the federal funding of the Unified Health System (SUS) to fight the COVID-19 pandemic in 2020 and during the first four months of 2021 - periods characterized as the first and second waves. Documentary research was carried out, with data available on official websites. The pandemic took hold in Brazil in February 2020, in the context of the chronic underfunding of SUS, which deepened with the strangulation of appropriations verified from the Constitutional Amendment 95/2016, which defined the ceiling on primary expenditure and the freezing of the federal floor of SUS until 2036, at the same value as the 2017 floor. This constitutional measure made it possible to deepen the fiscal austerity policy by reducing primary expenditure and public debt in relation to the Gross Domestic Product. These goals also conditioned federal funding to combat the COVID-19 pandemic in 2020 and 2021, whose budget and financial execution can be characterized as reactive and delayed. This form of execution compromised meeting the health needs of the population, in addition to harming the management of SUS in subnational government spheres.

Financiamiento del sistema de salud colombiano: Tendencias y desafíos / Financing of the Colombian health system: Trends and challenges

RESUMEN El financiamiento es una función fundamental que contribuye al propósito que tienen los sistemas de salud de mejorar el estado de salud de la población. Esta función se concreta en la recaudación de fondos, su mancomunación y asignación, y en ella se diferencian las fuentes y los usos de los recursos, especialmente en cuanto al carácter público o privado y a la forma como se cubren los costos de los servicios de salud. En este artículo se presenta una mirada de largo plazo sobre el financiamiento de la salud en Colombia, identificando los antecedentes y la evolución a partir de la reforma de 1993. Se identifican cuatro momentos en esta evolución: I. incremento significativo de recursos, al momento de expedir las Leyes 60 y 100 de 1993; II. contención fiscal, en el marco de la crisis de 1998 y 1999; III. mayor esfuerzo fiscal, especialmente a partir de 2010, y IV. sustitución de fuentes, de cotizaciones a impuestos generales, que se inició en 2012. Se evidencia un desarrollo importante de la función de financiamiento, con un fortalecimiento a partir de la Administradora de los Recursos del Sistema (ADRES), la reducción en la dependencia de las cotizaciones, el proceso de igualación per cápita entre regímenes de aseguramiento, y un mayor aporte de impuestos generales para buscar el equilibrio del sistema. Todo ello implica mantener el predominio público y garantizar la protección financiera en salud.

ABSTRACT Financing is a fundamental function that contributes to the purpose of health systems to improve the health status of the population. This function takes the form of fundraising, pooling and allocation, and it differentiates the sources and uses of resources, especially in terms of their public or private nature and the way in which health costs are covered. This article presents a long-term view of health financing in Colombia, identifying the background and evolution since the 1993 reform. Four moments in this evolution are identified: I. significant increase in resources, at the time of issuing Laws 60 and 100 of 1993; II. fiscal containment, in the context of the 1998 and 1999 crisis; IV. greater fiscal effort, especially since 2010, and V. substitution of sources, from contributions to general taxes, which began in 2012. An important development of the financing function is evident, with a strengthening of the System's Resources Administrator (ADRES), a reduction in the dependence on contributions, the process of equalization of the capita among insurance regimes, and a greater contribution of general taxes to seek the balance of the system, all of which implies maintaining public predominance and guaranteeing financial protection in health.

Cost of hospitalization of pediatric covid-19 patients in a tertiary pediatric hospital in the Philippines

BACKGROUND@#Out of pocket expenses still comprises a major share in health financing. A reactive approach in COVID-19 treatment may be problematic for the patient’s finances. National health insurance systems like PHIC have COVID-related care benefits, but whether these offer sufficient coverage is unknown.@*OBJECTIVES@#This study aims to describe the hospitalization costs incurred by pediatric COVID-19 patients admitted at a Filipino tertiary pediatric hospital, to determine the major cost drivers of hospitalization, and to determine how various payment methods provide coverage in paying for hospitalizations costs.@*METHODS@#Financial statements of pediatric COVID-19 patients were reviewed, from which costs were categorized. Deductions were also compared with total hospitalization to determine adequacy of various financial assistance programs.@*RESULTS@#Fifty-six charts and financial statements were reviewed for a 9-month period. Majority of the patients are of the 1-month to 6-year-old group (39.3%), of critical severity (66.1%), and with comorbidities (76.8%). Aggregated hospitalization costs of all COVID-19 patients amounted to PHP 9.5 million; medical costs accounted for the majority of the hospital costs at 35.40%. Mean total hospitalization cost per patient was determined to be PHP 170,170 and mean daily cost was PHP 16,870. PHIC COVID-19 packages may provide deducted as much as 90.56% of the overall costs, but only 28.6% of patients were able to avail of this privilege. Out-of-pocket expenditure remains at 33% of the total hospitalization cost.@*CONCLUSION@#COVID-19 hospitalization in this institution mainly consists of the 1-month to 6 years old, and the costs in the average can reach up approximately PHP 170,000, as basic medical fees drive the majority of the costs. Patients with no known comorbids tend to have higher costs of care but more data is needed to elaborate on the trend. Availing PHIC packages can greatly ameliorate the financial burden of hospitalization. However, checks in timely and accurate filing of claims should be in place to assure those that can avail this assistance are rightfully supported.@*RECOMMENDATIONS@#A larger patient base with equal representation of patient categories is recommended in order to determine more comprehensive cost patterns and make significant associations.

A resiliência das grandes cidades brasileiras e a pandemia da Covid-19 / The resilience of large Brazilian cities and the COVID-19 pandemic

RESUMO O objetivo do artigo foi descrever a resiliência do gasto governamental com Ações e Serviços Públicos de Saúde (ASPS) no Brasil durante a pandemia da Covid-19 em 2020. Demonstra-se que o desenvolvimento do setor público de saúde contemporâneo foi baseado no federalismo cooperativo. Nesse contexto, a participação municipal no financiamento foi consolidada em torno do pacto da vinculação orçamentária entre os níveis da federação (governo central, estados e municípios). Com base nos indicadores do Sistema de Informação sobre Orçamento Público de Saúde (Siops)/DataSUS/Ministério da Saúde, descrevem-se o Índice de Vinculação Orçamentária e a resiliência da amostra de 87 municípios com elevada disponibilidade orçamentária. Expõe-se que o governo central retirou o apoio à expansão das despesas com ASPS, estabilizando a alocação de seus recursos por meio do veto à vinculação orçamentária. A mudança de orientação federal transferiu o ônus da expansão do financiamento aos governos municipais e estaduais nas últimas décadas. Conclui-se que a estabilização das despesas federais foi compensada pelo crescimento da vinculação do orçamento municipal com as ASPS. Durante o primeiro ciclo da pandemia da Covid-19, a vinculação orçamentária foi crucial para a expansão do financiamento das ASPS na maioria dos municípios da amostra, possibilitando a condição resiliente.

ABSTRACT This paper aimed to describe the resilience of the Federal Government's fund of Public Health Actions and Services (ASPS) in Brazil during the 2020 COVID-19 pandemic. It shows that the development of the contemporary public health sector was based on cooperative federalism. In this context, municipal participation in financing was consolidated around the constitutional agreement of budget binding between the levels of the Brazilian federation (Central Government, states, and municipalities). The Budget Binding Index (BBI) and the resilience of the sample of 87 municipalities with a high budget are described from the Public Health Budget Information System (SIOPS) indicators, available at DataSUS/Ministry of Health. The paper shows that the central government withdrew its support for increased ASPS expenditure in the last decade, stabilizing the allocation of its resources through the veto on budget binding. The change in federal orientation shifted the burden of expanding financing to municipal and state governments. The paper concludes that the increase in municipal expenditures offset the stabilization of federal expenditures. Budget binding was crucial to the resilience of ASPS funding in most municipalities in the sample during the first cycle of the COVID-19 pandemic.

The MalaysianDRG Casemix System: Financial Implications of Inaccurate Clinical Documentation and Coding Error

@#Introduction: A casemix system measures costs of health service provision that is crucial in the planning and hospital budgeting. The MalaysianDRG casemix system has been implemented since 2010, yet many health professionals were unaware of its importance. To highlight this problem, we estimated the miscalculation of costs in providing treatment, that occurred due to inaccurate clinical documentation and coding error in the MalaysianDRG casemix system. Methods: Using a cross-sectional study design, 226 coded case notes from two healthcare institutions in Malaysia were selected and re-coded. If a difference between codes was observed, the new code would be chosen as the final code. The cases were then re-grouped using the MalaysianDRG casemix system. The cost per case derived from the new and original codes was compared. Then, the outcomes were verified by a casemix expert from the Ministry of Health. Results: Results indicated 61.9% inaccurate clinical documentation and 25.2% coding error. The difference in costs of treatment provision, due to inaccurate clinical documentation was RM227,657 and RM 68,216 for coding error. Using paired t-test analysis, differences between mean (SD) cost per case of the original vs. new codes due to inaccurate clinical documentation [RM10,208.19(12273) vs. RM11,244.53(13785.27), p<0.05], and coding error [RM10,208.19(12273.04) vs. RM11,215.52(13798.03) p<0.05] were statistically significant. These results raised important questions regarding costly financial implications arising from inaccurate clinical documentation and coding error in the MalaysianDRG casemix system. Conclusion: To achieve the full benefit of the MalaysianDRG casemix system, the quality and accuracy of its data must first be established.

Mudanças no financiamento da Atenção Primária à Saúde no Sistema de Saúde Brasileiro: avanço ou retrocesso? / Primary health care financing changes in the Brazilian Health System: advance ou setback?

Resumo Em 2019, o governo brasileiro lançou uma nova política para a Atenção Primária à Saúde (APS) no Sistema Único de Saúde (SUS). Chamada de "Previne Brasil", a política modificou o financiamento da APS para municípios. No lugar de habitantes e de equipes de Estratégia Saúde da Família (ESF), as transferências intergovernamentais passaram a ser calculadas a partir do número de pessoas cadastradas em serviços de APS e de resultados alcançados sobre um grupo selecionado de indicadores. As mudanças terão um conjunto de impactos para o SUS e para a saúde da população que precisaram ser identificados e monitorados. Neste artigo, discute-se os possíveis efeitos da nova política a partir de uma breve análise de contexto sobre tendências globais de financiamento de sistemas de saúde e de remuneração por serviços de saúde, bem como dos avanços, desafios e ameaças à APS e ao SUS. Com base na análise realizada, entende-se que a nova política parece ter objetivo restritivo, que deve limitar a universalidade, aumentar as distorções no financiamento e induzir a focalização de ações da APS no SUS, contribuindo para a reversão de conquistas históricas na redução das desigualdades na saúde no Brasil.

Abstract In 2019, the Brazilian government launched a new Primary Health Care (PHC) policy for the Unified Health System (SUS). Called "PrevineBrasil", the policy changed the PHC funding for municipalities. Instead of inhabitants and Family Health Strategy (ESF) teams, intergovernmental transfers are calculated from the number of people registered in PHC services and the results achieved in a selected group of indicators. The changes will have a set of impacts for the SUS and the health of the population, which must be observed and monitored. In this paper, possible effects of the new policy are discussed from a brief context analysis of global trends in health systems financing and health services' remuneration models, as well as on the advances, challenges, and threats to PHC and the SUS. Based on the analysis, the new policy seems to have a restrictive purpose, which should limit universality, increase distortions in financing and induce the focus of PHC actions on the SUS, contributing to the reversal of historic achievements in reducing health inequalities in Brazil.

Retrocesso da reforma psiquiátrica: o desmonte da política nacional de saúde mental brasileira de 2016 a 2019 / Regress of the psychiatric reform: the dismantling of the national Brazilian mental health policy from 2016 to 2019 / Retroceso de la reforma psiquiátrica: el desmantelamiento de la política nacional de salud mental brasileña de 2016 a 2019

Resumo O artigo analisa os retrocessos na Política Nacional de Saúde Mental no período de 2016-2019, com base em estudo das normativas emanadas pelo governo federal e documentos de caráter público, e no estudo dos dados do Ministério da Saúde relativos à rede de saúde mental do Sistema Único de Saúde. Foram avaliados todos os documentos normativos que compõem um conjunto de 'reorientações' da Política, além daqueles que a afetam diretamente, incluindo posicionamentos contrários emitidos por instâncias dos poderes executivo, legislativo e judiciário. A análise indica os primeiros efeitos destas mudanças na Rede de Atenção Psicossocial, como o incentivo à internação psiquiátrica e ao financiamento de comunidades terapêuticas, ações fundamentadas em uma abordagem proibicionista das questões relacionadas ao uso de álcool e outras drogas. A análise dos dados de gestão permite afirmar que há tendência de estagnação do ritmo de implantação de serviços de base comunitária. Este estudo pretende contribuir para uma melhor compreensão sobre os fundamentos e a direção estratégica das mudanças, que implicam retrocesso nas diretrizes da Reforma Psiquiátrica, pretendendo ampliar o debate sobre as formas de resistência ao desmonte da Política Nacional de Saúde Mental.

Abstract The article analyzes the setbacks in the National Mental Health Policy in the period between 2016 and 2019, based on a study of the norms issued by the federal government and documents of a public nature, and on the study of data from the Brazilian Ministry of Health regarding the mental health network of the Unified Health System. All normative documents that make up a set of 'reorientations' of the Policy were evaluated, in addition to those that directly affect it, including opposing positions issued by the executive, legislative and judicial branches. The analysis indicates the first effects of these changes in the Psychosocial Care Network, such as encouraging psychiatric hospitalization and financing for therapeutic communities, actions based on a prohibitionist approach to issues related to the use of alcohol and other drugs. The analysis of the management data allows to affirm that there is a tendency of stagnation in the pace of implantation of community-based services. This study aims to contribute to a better understanding of the fundamentals and the strategic direction of the changes, which imply a setback in the Psychiatric Reform guidelines, aiming to broaden the debate on the forms of resistance to the dismantling of the National Mental Health Policy.

Resumen El artículo analiza el retrocesso de la Política Nacional de Salud Mental en el período 2016-2019, basado en un estudio de las normas emitidas por el gobierno federal y documentos públicos, y en el estudio de datos del Ministerio de Salud brasileño relacionados con la red de salud mental del Sistema de Salud Unificado. Se evaluaron todos los documentos normativos que conforman un conjunto de 'reorientaciones' de la Política, además de los que la afectan directamente, incluidas las posiciones opuestas emitidas por instancias de los poderes ejecutivo, legislativo y judicial. El análisis indica los primeros efectos de estos cambios en la Red de Atención Psicosocial, tales como el incentivo a la hospitalización psiquiátrica y la financiación de comunidades terapéuticas, acciones basadas en un enfoque prohibicionista a cuestiones relacionadas con el uso de alcohol y otras drogas. El análisis de los datos de gestión permite afirmar que existe una tendencia al estancamiento en el ritmo de implantación de los servicios basados en la comunidad. Este estudio tiene como objetivo contribuir a una mejor comprensión de los fundamentos y la dirección estratégica de los cambios, lo que implica un retroceso en las directrices de la Reforma Psiquiátrica, con el objetivo de ampliar el debate sobre las formas de resistencia al desmantelamiento de la Política Nacional de Salud Mental.

O futuro do SUS: impactos das reformas neoliberais na saúde pública - austeridade versus universalidade / The future of the SUS: impacts of neoliberal reforms on public health - austerity versus universality

RESUMO O ensaio analisa os efeitos da política de austeridade sobre o Sistema Único de Saúde (SUS). Dados orçamentários e fiscais indicam que o Novo Regime Fiscal (NRF), criado pela Emenda Constitucional nº 95/2016 (EC 95), transformou o subfinanciamento crônico da saúde em desfinanciamento do SUS. Ademais, o NRF altera as relações entre as dimensões fiscal e social, uma vez que a despesa passa a ser avaliada a partir da pressão que exerce sobre o teto. Particularmente, o sistema de saúde universal se torna um excesso em relação ao limite estabelecido pela EC 95, pois os direitos sociais passam a aparecer como objeto de ajuste à fronteira fiscal, a partir da qual o gasto é tomado como irregular. Será mostrado que tais mudanças já implicam redução do orçamento disponível de saúde.

ABSTRACT The essay analyzes the effects of the austerity policy on the Unified Health System (SUS). Budgetary and fiscal data indicate that the New Tax Regime (NTR), created by Constitutional Amendment nº 95/2016 (CA 95), has transformed chronic underfunding into reduction of the health budget. In addition, the NTR alters the relations between the fiscal and social dimensions, since the expense is now evaluated from the pressure exerted on the cap. Particularly, the universal health care system becomes an excess in relation to the limit established by CA 95, since social rights begin to appear as an object of adjustment to the fiscal frontier, from which the expense is taken as irregular. The article shows that such changes already imply reduction of the available health budget.

Gastos empobrecedores de salud: un desafío para la cobertura universal de salud en el Paraguay / Impoverishing health expenditure: a challenge for universal health coverage in Paraguay

El gasto de bolsillo es la principal fuente de financiamiento del sistema de salud en Paraguay. Es necesario revertir esta situación para que la Cobertura Universal de Salud sea efectiva en 2030, un logro que forma parte de los Objetivos de Desarrollo Sostenible. El objetivo de este estudio fue determinar la incidencia del Gasto Empobrecedor en Salud en los hogares paraguayos. Tomó en cuenta aquellos hogares cuyos gastos de bolsillo causaron una caída por debajo de la línea de pobreza, así como los hogares que profundizaron su pobreza a causa de estos gastos de salud. Como material y método, el estudio analizó la Encuesta Permanente de Hogares 2014; tomó la definición de los gastos de bolsillo de la Organización Mundial de la Salud y la definición oficial de pobreza monetaria del país de la Dirección General de Estadísticas, Encuestas y Censos de la STP. El resultado es que 23,387 hogares fueron empujados por debajo de la línea de pobreza debido a gastos de bolsillo en caso de enfermedad. Esto representó el 1,8% de los hogares no pobres y el 1,4% del total de hogares. Además, el 61.9% de los hogares que ya se encontraban en situación de pobreza la empeoraron debido a los gastos de bolsillo en salud. La conclusión es que los hogares paraguayos están expuestos a gastos de salud excesivos y que se requieren políticas específicas para protegerlos. Las estrategias para combatir la pobreza pueden ser más efectivas cuando se consideran los gastos de salud en caso de una enfermedad o accidente.

Out-of-pocket spending is the main financing of the health system in Paraguay. Reversing this situation is necessary for the Universal Health Coverage to be effective in 2030, an achievement that is part of the Sustainable Development Goals. The objective of this study was to determine the incidence of Impoverishment health expenditure in Paraguayan households. I take into account those households whose out-of-pocket expenses caused a fall below the poverty line, as well as households that deepened their poverty as a cause of these health expenditures. As a material and method, the study analyzed the Permanent Household Survey 2014; took the definition of the outof- pocket expenses of the World Health Organization and the official definition of monetary poverty of the country of the General Directorate of Statistics, Surveys and Census of the STP. The result is that 23,387 households were pushed below the poverty line due to out-of-pocket expenses in case of illness. This represented 1.8% of non-poor households and 1.4% of total households. In addition, 61.9% of households already in poverty worsened their poverty due to out-of-pocket health expenditures. The conclusion is that Paraguayan households are exposed to excessive health expenditures and that specific policies are required to protect the population in the area. Strategies to combat poverty can be more effective when considering health expenditures in case of the event of an illness or accident.

Gasto catastrófico y cobertura universal de salud: Análisis en el Sistema Nacional de Salud del Paraguay / Catastrophic health expenditure and universal health coverage: Analysis in the National Health System of Paraguay

Introducción: La cobertura universal de salud es una meta de salud de los Objetivos del Desarrollo Sostenible de las NNUU para el 2030. Un componente de la cobertura en salud es la protección financiera para recibir atención médica ante una enfermedad. Y, un indicador de la protección financiera es la incidencia de Gastos Catastróficos por motivos de salud. Objetivo: El objetivo de este trabajo es describir la evolución del Gasto Catastrófico de salud de los hogares paraguayos entre el 2000 y el 2015. Materiales y Métodos: El material utilizado fue la Encuesta Permanente de Hogares de la DGEEC. El Gasto Catastrófico fue definido como aquellos gastos de bolsillo ≥ al 30% de la capacidad de pago de los hogares. Resultados: Los resultados indican que, durante ese periodo, la proporción de hogares afectados por gastos catastróficos varió entre 2,8% y 4,33%, siendo la mediana 4,10%. Los más afectados fueron los hogares rurales y los pobres. La proporción de hogares afectados presentó una tendencia al descenso, sobre todo para hogares urbanos y no pobres. Conclusión: La conclusión es que los hogares paraguayos están expuestos a gastos catastróficos por motivos de salud. La ocurrencia es mayor según las referidas características socioeconómicas. El desempeño actual del sistema nacional de salud no será suficiente para alcanzar la cobertura universal con protección financiera para todos. Por tanto, es necesario implementar nuevas políticas para la población más expuesta.

Introduction: Universal health coverage is a health goal of the UN Sustainable Development Goals by 2030. One component of health coverage is the financial protection to receive medical care for a disease. And, an indicator of financial protection is the incidence of Catastrophic Expenditures for health reasons. The objective of this paper is to describe the evolution of the Catastrophic Health Expenditure of Paraguayan households between 2000 and 2015. Materials and Methods: The material used was the Permanent Household Survey of the DGEEC. Catastrophic Expenditure was defined as those out-of-pocket expenses ≥ 30% of the household's payment capacity. Results: The results indicate that during this period, the proportion of households affected by catastrophic expenses ranged between 2.8% and 4.33%, with the median being 4.10%. Rural households and the poor were the most affected. The proportion of affected households showed a downward trend, especially for urban and non-poor households. Conclusion: In conclusion, Paraguayan households are exposed to catastrophic expenses for health reasons. The occurrence is greater according to the referred socioeconomic characteristics. The current performance of the national health system will not be enough to achieve universal coverage with financial protection for all. Therefore, it is necessary to implement new policies for the most exposed population.

Universal health coverage in India: Newer innovations and the role of public health

The realization of Universal Health Coverage requires adequate healthcare financing and human resources to provide financial protection to the economically disadvantaged population by covering their medicine, diagnostics, and service costs. Conventionally, inadequate public healthcare financing and the lack of skilled human resources are considered as the major barriers towards achieving UHC in India. To strengthen the Indian healthcare system, there has been significant increase budgetary allocation towards healthcare, a national health protection scheme targeting low-income households, upgrading of primary health-care and expansion of the health work-force. Nevertheless, an evolving paradigm for improving holistic health, sanitation, nutrition, gender equity, drug accessibility and affordability, innovative initiatives in national health programs for reduction of maternal deaths, tuberculosis and HIV burden and the utilization of information technology in healthcare provision of the underserved and the marginalized is gaining rapid acceleration. These represent a genuine innovation towards fulfillment of UHC goals for India.

Willingness to Pay for Outpatient Services User Fees: Malaysian Community Perspective / Jurnal Sains Kesihatan Malaysia

@#Health care services are not often accessible and available for all people in one country due to multiple reasons such asthe geographical barrier, affordability, etc. The aim of this study was to analyse willingness to pay (WTP) for healthcareservices user fees among Malaysian population and determine its’ influencing factors. Structured interviews wereconducted involving 774 households in 4 states represents Peninsular Malaysia. Validated questionnaires with openended, followed by bidding games were applied to elicit maximum amount of WTP. The study was analysed descriptivelyand with multivariate regression method to adjust for potential confounding factors. More than half of respondents WTPmore than current fee for the government clinic outpatient registration fee with mean MYR3.76 (SD2.71). Majority ofrespondents not WTP more than usual for private clinic simple outpatient treatment charges with the mean MYR38.76(SD5.45). Factors that were found to have significant associations with WTP for both government and private clinic wereincome and having health insurance. Community willing to pay for healthcare services user fees and charges but atcertain amount. The healthcare services user fees and charges can be increased up to community WTP level to avoidfrom catastrophic expenditure.

Analysis of the financing policy of integrating NCMS and URBMI:Based on the perspective of equity / 中国卫生政策研究

Objectives:This paper intends to analyze the financing policies of integrating NCMS and URBMI in terms of equity. Methods:Data on the financing of NCMS and URBMI from 2008 to 2015 were collected from the China health statistics yearbook (2009—2012) the China health and Family Planning Statistics yearbook(2013—2016),the National Handbook of NCMS Information(2008—2015),the China human resources and social security statistics year-book (2009—2016),and the China social security yearbook(2009—2015)."Ability to pay"approach was introduced to measure the inequity in health financing of medical insurance for urban and rural residents. The proportion of indi-vidual contributions as to NCMS and URBMI as a percentage of the per capita disposable income was used as an actual indicator to analyze the equity in health financing between rural and urban residents. Results:The URBMI had a finan-cing mechanism that was similar to that used by NCMS in that public finance accounted for more than three quarters of the pooling funds,and the individual contribution accounts for less than? of the per capita contribution amount. The scale of financing for NCMS was less than 5% of the per capita net income of rural residents and less than 2% of the per capita disposable income of urban residents for URBMI. Individual contributions to the NCMS and URBMI funds were less than 1% of their disposable and net incomes. The disparities in health financing between urban and rural resi-dents in China was not improved as expected with the introduction of NCMS and URBMI. Conclusions:The proportion of individual contributions to the URBMI and NCMS funds were small in terms of contributors'incomes. The equal financing per capita for URBMI and NCMS masks the inequality of urban and rural residents in the financing of medical insurance.

La estrategia integral de salud: un enfoque necesario / Health comprehensive strategy: a necessary approach

En la cobertura universal de salud se destaca la importancia del financiamiento en los sistemas de salud y de los recursos de la población para acceder a los servicios sanitarios, donde también influyen otros aspectos, como la falta de voluntad política, de conocimiento, organización y preparación de las autoridades y los directivos de los diferentes sectores y niveles, para lograr una atención que se corresponda con los determinantes sociales de la salud. A pesar de que se definen los problemas exógenos que afectan a la salud de la población y que influyen en los sistemas de salud, como el medio ambiente, los desastres naturales, entre otros; no se precisa cómo estos sistemas deben interactuar de forma más activa con los fenómenos que los originan y los factores que intervienen, por lo que en este artículo se realizan algunas propuestas a tales efectos.

In the health universal covering, the importance of financing the health systems and the population's resources stands out to make the health services disposable, where there is also the influence of other aspects such as the lack of political will, knowledge, organization and training of authorities and heads of the different sectors and levels, to achieve a care in correspondence with the health social determinants. Although exogenous problems which affect the population's health and that influence in the health systems, as environment, natural disasters, among others are defined, is not stated how these systems should interact in a more active way with the phenomena that originate them and the factors that intervene, so that some proposals to such effects are described in this work

Progress and Challenges of China's Health Financing System / 中国卫生经济

Objective:To analyze the progress and challenges of China's health financing system,and raise some policy suggestions.Methods:Making qualitatively and quantitatively analysis of health financing level and structure,the mode of health inputs and the functions of funding agencies.Results:The development of the Chinese health financing system has made progress in certain aspects since 2009 when the new phase of Chinese health system reform was initiated.The total volume of health financing has been increasing yearly;the structure of health financing has been optimized;financing pattern has been clarified;the financial security level has been improved;input mechanism has been refined;the function of finaucing institutions has been adjusted accordingly.However,there are still some challenges,including lack of top-down design of health financing,high residents' out-of-pocket expenses,inadequate equity,lack of accompanying design fit for the need and demand of the poorest and the richest.Conclusion:It is suggested to improve the financing and management mode,raise the financing level of health insurance and optimize the efficiency of health funds,so as to further promote the construction of health financing system..

The historical experience of health financing in typical developed countries and its implications to China: A comparative study perspective / 中国卫生政策研究

Objectives: The purpose of this study is to summarize the historical experience of health financing in typical developed countries, in order to provide reference for China's health financing over the next 15 years.Methods: This paper uses hierarchical cluster analysis to determine the historical stage of typical developed countries similar to China in economic and social development from 2015 to 2030.Literature review is used to analyze the historical data and reform measures of health financing in typical developed countries during the similar stage.Results: The study found that the historical stage of typical developed countries that is similar to China in 2015-2030 is between the mid-or late-1970s and the beginning of the 21st century.During this period, the experience of health financing in typical developed countries mainly focused on controlling expenditures and costs, improving the health financing policy, strengthening the security system, etc.Conclusions: The similar stage research approach introduced in this paper provides a new idea and perspective to use the international experience for reference.Drawing lessons from the experience of health financing in typical developed countries combined with the Chinese context, this paper suggests the government should develop and improve diversified health financing channels, integrate and improve the health security system, and control the rapid escalation of health expenditure.