Profesionales médicos cubanos para la atención primaria de salud: el caso de Portugal / Cuban health personnel for primary health care: the Portugal case

RESUMEN Objetivo Analizar el proceso de contratación de médicos cubanos por parte del Gobierno de Portugal y comprender la percepción de los profesionales cubanos sobre el ejercicio de la profesión en el exterior. Métodos Se realizó un estudio de caso cualitativo-descriptivo-analítico, con triangulación de datos a partir de la recolección de información de múltiples fuentes de evidencia. Se entrevistó a un total de 16 informantes clave, se analizaron documentos y se realizó observación directa. Resultados Los resultados más evidentes muestran que se estableció una cooperación para hacer frente a la escasez crónica de médicos en atención primaria; la elección de médicos de nacionalidad cubana tiene una dimensión política. Se llevó a cabo un acuerdo entre las partes para permitir el registro de médicos cubanos en la Orden de Médicos de Portugal. Conclusiones Hubo un resultado positivo en la contratación de médicos cubanos por parte de Portugal, ya que aumentó el número de usuarios con acceso a los servicios y también se tuvo una brecha de tiempo para que el gobierno tomara algunas medidas para mitigar el problema de la escasez de médicos.

ABSTRACT Objective To analyze the process of recruitment of Cuban doctors by the government of Portugal and to understand the perception of these Cubans about the exercise of their professions abroad. Methods A qualitative-descriptive-analytical case study was carried out, with data triangulation, based on the collection of information from multiple sources of evidence. Sixteen key informants were interviewed, documents were analyzed, and direct observation was carried out. Results The most evident results demonstrate that the cooperation was established to address the chronic shortage of doctors in primary care; the choice of Cuban doctors had a political dimension. An arrangement was made to enable the registration of Cuban doctors in the Portuguese Medical Association. Conclusions There was a positive outcome in the recruitment of Cuban doctors by Portugal since it increased the number of patients with access to services, and allowed a time gap for the government to take some measures in order to mitigate the problem of shortage of doctors.

¿Cómo evolucionó la distribución de médicas y médicos especialistas en Argentina?: un análisis demográfico de la profesión médica al 2020 / How did the distribution of doctors and medical specialists evolve in Argentina?: a demographic analysis of the medical profession to 2020

Las políticas sobre trabajadores/as de salud deben garantizar su distribución adecuada. En Argentina dicha distribución es desigual, sobre todo en especialistas en atención primaria de la salud (APS). El objetivo de este trabajo fue describir la distribución de médicos/as, especialistas lineales y en APS en Argentina, durante el año 2020, teniendo en cuenta la situación económica y sanitaria de cada jurisdicción. Se trata de un trabajo descriptivo y analítico, que utilizó fuentes de datos primarias y secundarias. Se correlacionó la tasa de mortalidad infantil y el producto bruto per cápita de cada jurisdicción ordenándolas de mejores a peores indicadores. La tasa de médicos fue 3,88 médicos/as cada 1000 habitantes, 72% concentrándose en 4 jurisdicciones (Ciudad Autónoma de Buenos Aires, Provincia de Buenos Aires, Córdoba y Santa Fe). El 53% son especialistas y el 27,6% lo son en APS. CABA tuvo una tasa de 16,5 médicos/as por mil; Santiago del Estero y Formosa alcanzaron valores de 1,8 y 1,9 médicas/os por mil habitantes respectivamente. Con respecto a 2014, se observó disminución de especialistas en APS (-14,8%), registrándose las mayores pérdidas en Santiago del Estero, Formosa y Catamarca (-84,5%; -70,1% y -87,3%). La situación nacional sobre la distribución de médicos/as en Argentina desde 1954 a la actualidad fue empeorando en detrimento de las provincias con mayores necesidades. La baja adherencia al sistema de residencias a especialidades de APS pronostica un empeoramiento de la situación de no haber cambios estructurales. Será necesario un fortalecimiento del rol rector del estado en el abordaje de esta problemática (AU)

Policies on health workers must guarantee their adequate distribution. In Argentina, this distribution is unequal, particularly among primary care specialists (PHC).The objective of this article is to describe the distribution of physicians, PHC and non-PHC specialists in Argentina in 2020, considering the economic and health situation of each jurisdiction.We conducted a descriptive cross-sectional study with an analytical stage using primary and secondary data sources. The jurisdictions were classified according to the correlation between infant mortality rate and gross product per capita.The rate of physicians in Argentina in 2020 was 3.88 physicians per 1,000 inhabitants. 72% are concentrated in 4 jurisdictions (City of Buenos Aires, Province of Buenos Aires, Córdoba and Santa Fe). 53% are specialists and 27.6% are PHC specialists. The City of Buenos Aires has a rate of 16.5 physicians per thousand; and Santiago del Estero and Formosa reach values of 1.8 and 1.9 physicians per thousand inhabitants, respectively.There was a decrease in PHC specialists (-14.8%), with major losses recorded in Santiago del Estero, Formosa and Catamarca (-84.5%; -70.1% and -87.3%, respectively).The distribution of physicians in Argentina from 1954 to the present has worsened to the detriment of the provinces with the greatest needs. The lack of adheren-ce to the specialty of PHC predicts a worsening of the situation if there are no structural changes. It is necessary to strengthen the leading role of the state in addressing this problem (AU)

Stroke and Myocardial Infarction: Effects of the "Hiperdia" and "Mais Médicos" Programs on the Hospitalizations Trends in Brazil

Abstract Background Stroke and acute myocardial infarction (AMI) are cardiovascular diseases commonly characterized by the development of atheromatous plaques associated with major complications and high mortality rates. Objective To identify an epidemiological trend in hospitalizations due to stroke and AMI and to analyze the relationship between health programs applied in Primary Health Care, gender and the Federative Unit. Methods Ecological study with a time series design between 1998 and 2018, collecting data from all federal units in Brazil stratified by, gender and place of residence. There were analyzed Hospitalization Authorizations (AIH) for stroke and MI, consulting the Hospital Admissions System (SIH) of the Informatics Department of the National Health Service with p <0.05. Results From 1998 to 2018, the rate of hospitalization for AMI increased in Brazil approximately 42.58 events per 100 thousand inhabitants annually (p<0.001), while hospitalizations for stroke declined 32.17 cases (p=0.03). This pattern was observed in both sexes in AMI and stroke. There is also evidence of the effect of the Hiperdia (p<0.001) and Mais Médicos (p=0.001) program in reducing stroke and Hiperdia cases in mitigating the evolution of AMI cases (p = 0.0001). Conclusion Although these diseases remain as an important cause of death, stroke hospitalization has reduced significantly in the period evaluated. National programs as the Hiperdia and Mais Médicos showed an impact in the acute cases of strokes and AMI.

Recrutamento e retenção de médicos para a Atenção Básica: permanentes desafios para o Brasil / Recruitment and retention of physicians for Primary Health Care: permanent challenges for Brazil

O objetivo deste estudo é analisar as evidências científicas e documentais sobre as estratégias relacionadas ao recrutamento e à retenção de médicos para Atenção Básica (AB) e implementadas pelo Programa Mais Médicos. Trata-se de uma revisão integrativa que incluiu documentos oficiais sobre o PMM e artigos sobre recrutamento e retenção de médicos na AB. As estratégias encontradas na literatura foram formação médica, incentivos aos médicos, características intrínsecas ao médico e à localidade, investimento em infraestrutura e recrutamento de médicos intercambistas. O PMM contemplou todas essas categorias, porém não contemplou todas as subcategorias encontradas na literatura, como presença de equipe interprofissional. Portanto, as medidas implementadas a partir do Programa encontram-se em consonância com as estratégias mais apontadas na literatura atual sobre recrutamento e retenção de médicos na AB.

The aim of this study is to analyze the scientific and documentary evidence on the strategies related to the recruitment and retention of doctors for Primary Care (AB) and those implemented by the Mais Médicos Program. It is an integrative review that included official documents on the PMM and articles on recruiting and retaining doctors in AB. The strategies found in the literature were medical training, incentives for doctors, characteristics intrinsic to the doctor and the location, investment in infrastructure and recruitment of exchange students. The PMM covered all of these categories, but did not include all the subcategories found in the literature, such as the presence of an interprofessional team. Therefore, the measures implemented from the Program are in line with the most pointed strategies in the current literature on the recruitment and retention of doctors in AB.

Accessibility of Prenatal Care Can Affect Inequitable Health Outcomes of Pregnant Women Living in Obstetric Care Underserved Areas: a Nationwide Population-Based Study

BACKGROUND: As of 2011, among 250 administrative districts in Korea, 54 districts did not have obstetrics and gynecology clinics or hospitals providing prenatal care and delivery services. The Korean government designated 38 regions among 54 districts as “Obstetric Care Underserved Areas (OCUA).” However, little is known there are any differences in pregnancy, prenatal care, and outcomes of women dwelling in OCUA compared to women in other areas. The purposes of this study were to compare the pregnancy related indicators (PRIs) and adequacy of prenatal care between OCUA region and non-OCUA region. METHODS: Using National Health Insurance database in Korea from January 1, 2012 to December 31, 2014, we constructed the whole dataset of women who terminated pregnancy including delivery and abortion. We assessed incidence rate of 17 PRIs and adequacy of prenatal care. All indicators were compared between OCUA group and non-OCUA group. RESULTS: The women dwelling in OCUA regions were more likely to get abortion (4.6% in OCUA vs. 3.6% in non-OCUA) and receive inadequate prenatal care (7.2% vs. 4.4%). Regarding abortion rate, there were significant regional differences in abortion rate. The highest abortion rate was 10.3% and the lowest region was 1.2%. Among 38 OCUA regions, 29 regions' abortion rates were higher than the national average of abortion rate (3.56%) and there were 10 regions in which abortion rates were higher than 7.0%. In addition, some PRIs such as acute pyelonephritis and transfusion in obstetric hemorrhage were more worse in OCUA regions compared to non-OCUA regions. CONCLUSION: PRIs are different according to the regions where women are living. The Korean government should make an effort reducing these gaps of obstetric cares between OCUA and non-OCUA.

The More Doctors Program in remote areas: the experience of the Special Supervision Group in Pará, Brazil / O Programa Mais Médicos em áreas remotas: a experiência do Grupo Especial de Supervisão no Pará, Brasil / El Programa Más Médicos en áreas remotas: la experiencia del Grupo Especial de Supervisión en el estado de Pará, Brasil

The More Doctors Program encompasses an academic supervision carried out by supervisory institutions that have signed an agreement with the Ministry of Education (MEC). Academic supervision is part of the educational offers and implies periodic and regular visits to participant doctors. However, due to the difficulties of some institutions in the North region to fulfill their responsibilities under the Project More Doctors for Brazil, MEC created the Special Supervision Group (GES), which has been operating since 2014 in that region. This article records the GES experience in the state of Pará from January 2015 to May 2017. Its main contribution is to enable the provision of care for the population that inhabits a vast region where there is shortage of doctors, as the supervision of the professionals is mandatory and if it did not occur, the Program would not be allowed in Pará.(AU)

O Programa Mais Médicos (PMM) abrange, no eixo provimento, a supervisão acadêmica, realizada por instituições supervisoras (IS) que firmaram termo de adesão com o Ministério da Educação (MEC). A supervisão é parte das ofertas educacionais e implica visita periódica e regular aos médicos participantes do PMM. Entretanto, devido às dificuldades de algumas IS da região Norte cumprirem o que lhes cabe no âmbito do Projeto Mais Médicos para o Brasil (PMMB), o MEC criou o Grupo Especial de Supervisão (GES), que atua desde 2014 nessa região. Este artigo registra a experiência do GES no estado do Pará no período de janeiro de 2015 a maio de 2017. Sua principal contribuição é possibilitar o atendimento à população habitante de uma região vasta e com notória escassez de médicos, uma vez que a supervisão dos profissionais é obrigatória e, caso ausente, inviabilizaria o programa no Pará.(AU)

El Programa Más Médicos (PMM) abarca la supervisión académica realizada por las Instituciones Supervisoras (IS) que hayan firmado documento de adhesión con el Ministerio de la Educación (MEC). La supervisión académica es parte de las ofertas educativas e implica una visita periódica y regular a los médicos del PMM. Sin embargo, debido a las dificultades de algunas IS de la región Norte para cumplir sus responsabilidades en el ámbito del PMMB, el MEC creó el Grupo Especial de Supervisión (GES), que actúa desde 2014 en la región. Este artículo registra la experiencia del GES en el estado de Pará en el período de enero de 2015 a mayo de 2017. Su contribución es hacer posible la asistencia a una población que habita una vasta región con notable escasez de médicos, una vez que la supervisión de los profesionales es obligatoria y si no la hubiera inviabilizaría el Programa en el Estado de Pará.(AU)

Fatores que influenciaram o processo de formulação de políticas de recursos humanos em saúde no Brasil e em Portugal: estudo de caso múltiplo / Factores que influenciaron el proceso de formulación de políticas de recursos humanos en salud en Brasil y Portugal: estudio de caso múltiple / Factors that influence human resources for health policy formulation: a multiple case study in Brazil and Portugal

O estudo objetiva analisar o processo em que as políticas de recursos humanos em saúde (RHS), que visam melhorar a distribuição geográfica dos médicos, são (ou não) informadas por evidência científica no Brasil e em Portugal. Foi realizado um estudo de caso-múltiplo sobre o processo de decisão das políticas de RHS no Brasil e em Portugal. Para compor os estudos de caso, as políticas escolhidas foram o Programa Mais Médicos (PMM) e a estratégia de contratação de médicos estrangeiros por acordos bilaterais para o trabalho no Serviço Nacional de Saúde (SNS) português. Foram entrevistados 27 atores-chave no processo de formulação das políticas em análise nos seguintes tópicos: fatores que influenciaram a formulação, atores que eram esperados ganhar ou perder, evidências científicas e os dados disponíveis utilizados para a formulação, entre outros. Os fatores mais evidentes identificados nas entrevistas como sendo influenciadores do PMM foram: Instituições; Fatores Externos (eleições presidenciais); Interesses de grupos (por exemplo, associações de profissionais médicos), governos (brasileiro e cubano), organização internacional e sociedade civil; e Ideias (evidência científica). Os fatores mais listados em Portugal foram: Instituições e Interesses dos governos (português e envolvidos nos acordos bilaterais), sociedade civil e grupos (associações de profissionais médicos). Ao contrário do que se verificou no estudo de caso do Brasil, em que reconhecidamente a evidência teve um papel importante na formulação da política em análise, em Portugal a evidência científica não foi identificada como contributo para a formulação da intervenção em estudo.(AU)

El estudio tiene por objetivo analizar el proceso en el que las políticas de recursos humanos en salud (RHS), que tienen como fin la mejora de la distribución geográfica de los médicos, son (o no) informadas por evidencias científicas en Brasil y en Portugal. Se trata de un estudio de caso-múltiple sobre el proceso de decisión de las políticas de RHS en Brasil y en Portugal. Para configurar los estudios de caso, las políticas elegidas fueron el Programa Más Médicos (PMM) y la estrategia de contratación de médicos extranjeros mediante acuerdos bilaterales para el trabajo en el Servicio Nacional de Salud (SNS) portugués. Se entrevistaron a 27 actores-clave en el proceso de formulación de las políticas en el análisis en los siguientes asuntos: factores que influenciaron la formulación, actores que se esperaba ganar o perder, evidencias científicas y datos disponibles utilizados para la formulación, entre otros. Los factores más evidentes, identificados en las entrevistas como de influencia en el PMM, fueron: instituciones; factores externos (elecciones presidenciales); intereses de grupos (por ejemplo, asociaciones de profesionales médicos), gobiernos (brasileño y cubano), organización internacional y sociedad civil; e ideas (evidencia científica). Los factores más registrados en Portugal fueron: instituciones e intereses de los gobiernos (como el portugués y los involucrados en los acuerdos bilaterales), sociedad civil y grupos (asociaciones de profesionales médicos). Al contrario de lo que se verificó en el estudio de caso de Brasil, donde se reconoció que la evidencia tuvo un papel importante en la formulación de la política en análisis, en Portugal la evidencia científica no fue identificada como una contribución para la formulación de la intervención en estudio.(AU)

This study aims to analyze whether the process by which policies for human resources for health that aim to improve the geographic distribution of physicians have been informed by scientific evidence in Brazil and Portugal. This was a multiple case study on a decision-making process for human resources for health in Brazil and Portugal. The respective case studies were based on Brazil's More Doctors Program (Programa Mais Médicos - PMM) and Portugal's strategy of hiring foreign physicians through bilateral agreements, to work in the country's National Health Service (SNS). We interviewed 27 key actors in the policy-making process on the following topics: factors that influenced the policy decisions, actors that were expected to win or lose from the policy, and the scientific evidence and available data used in the policy-making, among others. The most evident factors appearing in the interviews as having influenced the PMM were: institutions; external factors (Presidential elections); group interests (e.g. physicians' professional associations), governments (Brazil and Cuba), international organizations, and civil society; and ideas (scientific evidence). The most frequently cited factors in Portugal were: institutions and interests of government (from Portugal and the countries involved in the bilateral agreements), civil society, and groups (physicians' professional associations). Contrary to the case study in Brazil, where the evidence was reported to having played an important role in the policy decisions, in Portugal, scientific evidence was not identified as contributing to the specific policy process.(AU)

Distancia al centro de atención en salud y mortalidad durante los primeros años de vida: revisión sistemática y metaanálisis / Distance from healthcare facilities and early life mortality: a systematic review and meta-analysis / Distância ao centro de atendimento em saúde e mortalidade durante os primeiros anos de vida: revisão sistemática e meta-análise

Resumen Objetivo: actualizar las revisiones sistemáticas sobre el efecto de la distancia a los centros de atención en salud, en la mortalidad de menores de 5 años, con artículos publicados hasta mayo de 2015. Metodología: revisión sistemática con metaanálisis según recomendaciones de PRISMA. Se estimó un modelo de efectos aleatorios y se realizaron análisis de sesgo y de heterogeneidad de las estimaciones. Resultados: residir a más de 5 km del centro de atención de salud se asocia con un mayor riesgo de muerte en los periodos perinatal OR 2,76 (IC95% 1,80- 4,23), neonatal OR 1,62 (IC95% 1,33-1,96), infantil OR 1,31 (IC95% 1,16- 1,48), durante la niñez OR 1,57 (IC95% 1,29-1,92) y en todos los grupos de edad OR 1,63 (IC95% 1,41-1,88). Conclusión: se resalta la importancia de considerar una distribución geográfica de los centros de atención en salud, que permita a los menores residentes en áreas remotas menores riesgos de muerte, particularmente durante el primer mes de vida.

Abstract Objective: to update the systematic reviews of the literature discussing the effect of the distance from healthcare facilities on the mortality of children under five years of age using academic papers up to May, 2015. Methodology: a systematic review of the literature and a meta-analysis conducted in accordance with the PRISMA guidelines. A random effect model was estimated and bias and heterogeneity analyses were conducted on the estimates. Results: residing farther than 5 km away from the closest healthcare facility is associated with a greater risk of death during the following periods: perinatal OR 2.76 (CI95% 1.80 - 4.23), neonatal OR 1.62 (CI95% 1.33 - 1.96), infancy OR 1.31 (CI95% 1.16 - 1.48) childhood OR 1.57 (CI95% 1.29 - 1.92) and all age groups OR 1.63 (IC95% 1.41 - 1.88). Conclusión: the authors highlight the importance of considering a geographical distribution of healthcare facilities which reduces death risk among children residing in remote areas, particularly during the first month of life.

Resumo Objetivo: atualizar as revisões sistemáticas sobre o efeito da distância aos centros de atendimento em saúde, na mortalidade de menores de 5 anos, com artigos publicados até maio de 2015. Metodologia: revisão sistemática com meta-análise segundo recomendações de PRIMA. Estimou-se um modelo de efeitos aleatórios e se realizaram análises de distorção e de heterogeneidade das estimações. Resultados: morar a mais de 5 km do posto de atendimento de saúde está associado com um maior risco de morte nos períodos perinatal OR 2,76 (IC95% 1,80 - 4,23), neonatal OR 1,62 (IC95% 1,33-1,96), infantil OR 1,31 (IC95% 1,16-1,48), durante a infância OR 1,57 (IC95% 1,29-1,92) e em todos os grupos etários OR 1,63 (IC95% 1,41-1,88). Conclusão: Salienta-se a importância de considerar uma distribuição geográfica dos postos de atendimento em saúde, permitindo às crianças moradoras em áreas distantes, menores riscos de morte, particularmente durante o primeiro mês de vida.

Preferências para o trabalho na atenção primária por estudantes de medicina em Minas Gerais, Brasil: evidências de um experimento de preferência declarada / Preferences for work in primary care among medical students in Minas Gerais State, Brazil: evidence from a discrete choice experiment / Preferencias para el trabajo en la atención primaria por parte de estudiantes de medicina en Minas Gerais, Brasil: evidencias de un experimento de preferencia declarada

Este artigo tem por objetivo apresentar os resultados da aplicação de um experimento de preferência declarada (DCE - discrete choice experiment) realizado em 2012 com 277 estudantes do último ano dos cursos de medicina do Estado de Minas Gerais, Brasil. O experimento permitiu investigar as preferências dos estudantes sobre o trabalho futuro como médicos na atenção primária à saúde, com base em de cenários de emprego hipotéticos que visavam aferir a probabilidade de deslocamento para áreas com escassez de médicos. A aplicação do DCE envolveu (i) uma etapa qualitativa para definição dos atributos e seus respectivos níveis que comporiam os cenários de emprego, (ii) uma etapa de construção e aplicação do instrumento e (iii) uma etapa de análise com a aplicação de logit multinomial de probabilidade condicional para estimativa dos pesos de cada atributo e construção de cenários de probabilidade de escolha. Os resultados apontaram que o atributo do emprego que mais impactou a escolha dos respondentes foi o de localização do trabalho, seguido por condições de trabalho, remuneração, acesso à residência médica, tipo de vínculo e carga de trabalho. Constatou-se que os entrevistados de faculdades privadas, com maior renda familiar e do sexo feminino, em geral, têm maior resistência para deslocar-se para as regiões urbanas inseguras e áreas remotas do interior. Os cenários de emprego que se mostraram mais plausíveis em termos de intervenção pública foram aqueles que combinavam os salários de valores intermediários, boas condições de trabalho e obtenção de 10 a 20 pontos adicionais nos exames de residência médica.

This article presents the results of a discrete choice experiment (DCE) conducted in 2012 with 277 final-year medical students from Minas Gerais State, Brazil. The experiment tested students' preferences concerning future work as physicians in primary health care, based on hypothetical job scenarios aimed at measuring the likelihood of placement in areas with a shortage of doctors. Application of DCE involved (i) a qualitative stage to define the attributes and their respective levels to comprise the job scenarios, (ii) construction and application of the instrument, and (iii) analysis with application of multinomial logit with conditional probability to estimate the weight of attributes and to construct scenarios for choice probability. The results indicate that the job attribute that most impacted students' choice was location, followed by job conditions, pay, access to medical residency, type of employment relationship, and workload. Students from private medical schools, with higher family income, and females were generally more likely to resist job assignments in unsafe urban areas and remote areas of the countryside. The job scenarios that proved most plausible in terms of public intervention were those that combined middle-level wages, good working conditions, and 10 to 20 bonus points on medical residency exams.

This article presents the results of a discrete choice experiment (DCE) conducted in 2012 with 277 final-year medical students from Minas Gerais State, Brazil. The experiment tested students' preferences concerning future work as physicians in primary health care, based on hypothetical job scenarios aimed at measuring the likelihood of placement in areas with a shortage of doctors. Application of DCE involved (i) a qualitative stage to define the attributes and their respective levels to comprise the job scenarios, (ii) construction and application of the instrument, and (iii) analysis with application of multinomial logit with conditional probability to estimate the weight of attributes and to construct scenarios for choice probability. The results indicate that the job attribute that most impacted students' choice was location, followed by job conditions, pay, access to medical residency, type of employment relationship, and workload. Students from private medical schools, with higher family income, and females were generally more likely to resist job assignments in unsafe urban areas and remote areas of the countryside. The job scenarios that proved most plausible in terms of public intervention were those that combined middle-level wages, good working conditions, and 10 to 20 bonus points on medical residency exams.

Surgery in Brazilian Health Care: funding and physician distribution / Cirurgia no Sistema Brasileiro de Saúde: financiamento e distribuição de médicos

ABSTRACT Objective: to analyze demographic Brazilian medical data from the national public healthcare system (SUS), which provides free universal health coverage for the entire population, and discuss the problems revealed, with particular focus on surgical care. Methods: data was obtained from public healthcare databases including the Medical Demography, the Brazilian Federal Council of Medicine, the Brazilian Institute of Geography and Statistics, and the National Database of Healthcare Establishments. Density and distribution of the medical workforce and healthcare facilities were calculated, and the geographic regions were analyzed using the public private inequality index. Results: Brazil has an average of two physicians for every 1,000 inhabitants, who are unequally distributed throughout the country. There are 22,276 board certified general surgeons in Brazil (11.49 for every 100,000 people). The country currently has 257 medical schools, with 25,159 vacancies for medical students each year, with only around 13,500 vacancies for residency. The public private inequality index is 3.90 for the country, and ranges from 1.63 in the Rio de Janeiro up to 12.06 in Bahia. Conclusions: A significant part of the local population still faces many difficulties in accessing surgical care, particularly in the north and northeast of the country, where there are fewer hospitals and surgeons. Physicians and surgeons are particularly scarce in the public health system nationwide, and better incentives are needed to ensure an equal public and private workforce.

RESUMO Objetivo: analisar dados demográficos do Sistema Único de Saúde (SUS) brasileiro, que promove cobertura de saúde universal a toda população, e discutir os problemas revelados, com particular ênfase nos cuidados cirúrgicos. Métodos: os dados foram obtidos a partir dos bancos de dados de saúde pública da Demografia Médica, do Conselho Federal de Medicina, do Instituto Brasileiro de Geografia e Estatística e do Cadastro Nacional dos Estabelecimentos de Saúde. A densidade e a distribuição do trabalho médico e dos estabelecimentos de saúde foram avaliadas, e as regiões geográficas foram analisadas usando o índice de desigualdade público-privado (IDPP). Resultados: o Brasil tem, em média, dois médicos por 1000 habitantes, que são desigualmente distribuídos no país. Tem 22.276 cirurgiões gerais certificados (11,49 por 100.000 habitantes). Existem no país 257 escolas de medicina, com 25.159 vagas por ano, e apenas cerca de 13.500 vagas de residência médica. O índice de desigualdade público-privado é de 3,90 para o país e varia de 1,63 no Rio de Janeiro até 12,06 na Bahia. Conclusão: uma parte significativa da população brasileira ainda encontra muitas dificuldades no acesso ao tratamento cirúrgico, particularmente na região norte e nordeste do país. Médicos e, particularmente, cirurgiões são escassos no sistema público de saúde e incentivos devem ser criados para assegurar uma força médica igual no setor público e no setor privado em todas as regiões do país.

Accesibilidad geográfica al cuidado obstétrico y neonatal y su efecto en la mortalidad neonatal temprana en Colombia 2012-2014 / Geographical Accessibility to Obstetric and Neonatal Care and its Effect on Early Neonatal Mortality in Colombia, 2012-2014

Introduction: The distribution of health resources influences early neonatal mortality, granting access to obstetric care which is a major public health problem. However, the geographical dimension of this influence has not been studied in Colombia. Objective: To describe the geographical accessibility to obstetric and neonatal care beds and its association with early neonatal mortality in Colombia and its municipalities. Method: An ecological study at municipal level was carried out. Ordinary least squares (OLS) regression and a geographically weighted regression (GWR) were used to explore statistical and spatial associations. Results: The municipalities in Colombia with Higher mortality tend to have lower geographical accessibility to obstetric and neonatal beds after controlling the fertility and economic characteristics of these municipalities. This association is significant only in municipalities of the west coast. The strength of this association decreases in inner municipalities. Discussion: The centralization of obstetric and neonatal beds in major municipalities around the central region leaves municipalities with high risk of mortality underserved. The decentralization of obstetric and neonatal healthcare resources is a mandatory issue in order to reduce geographical disparities in mortality and to improve neonatal survival, and a healthy beginning of life...(AU)

Introducción: La distribución de los recursos de salud influencia la mortalidad neonatal temprana, garantizar el acceso atención obstétrica es un problema de salud pública. Sin embargo, la dimensión geográfica de esta influencia no ha sido estudiada en Colombia. Objetivo: Describir la accesibilidad geográfica a camas obstétricas y neonatales y su asociación con la mortalidad neonatal temprana en Colombia por municipios. Método: Se realizó un estudio ecológico a nivel municipal. Se recurrió a regresión por mínimos cuadrados y a regresión geográficamente ponderada para explorar las asociaciones estadísticas y espaciales. Resultados: Municipios con mayores tasas de mortalidad tienden a mostrar menor accesibilidad geográfica a camas obstétricas y neonatales, después de controlar las características municipales, económicas y de fecundidad. Esta asociación solo es significativa en municipios de la costa oeste. La fuerza de la asociación disminuye en municipios del interior. Discusión: Centralizar las camas obstétricas y neonatales en ciudades principales de la región central deja desatendidos a los municipios con mayor mortalidad. La descentralización de recursos de cuidado obstétrico y neonatal es un asunto obligatorio para reducir desigualdades geográficas en mortalidad, aumentar la supervivencia neonatal y lograr un inicio de vida saludable...(AU)

Introdução: A distribuição dos recursos da saúde tem influência na mortalidade precoce do neonatal, garantir o acesso aos cuidados obstétricos é um problema da saúde pública. A pesar de que, a dimensão geográfica desta influência não foi estudada na Colômbia. Objetivo: Descrever a acessibilidade geográfica aos leitos obstétricos e neonatos e, a sua associação com a mortalidade neonatal precoce na Colômbia, nos municípios. Método: O estudo ecológico foi realizado nos municípios. A regressão de mínimos quadrados e a regressão geograficamente ponderada foram utilizadas para explorar as associações estatísticas e espaciais. Resultados: Os municípios com taxas de mortalidade mais elevadas tendem a mostrar menor acessibilidade geográfica aos leitos obstétricos e neonatos após o controle das características municipais, econômicas e da fertilidade. Esta associação é apenas significativa nos municípios do litoral oeste. A força da associação diminui nos municípios do interior. Discussão: A centralização de camas obstétricas e neonatas nas principais cidades da região central, deixa os municípios não atendidos com a maior taxa de mortalidade. A descentralização dos recursos dos cuidados obstétricos e neonatos é uma questão obrigatória para reduzir as desigualdades geográficas na mortalidade, aumentar a sobrevivência neonatal e alcançar um bom início de vida saudável...(AU)

University of Tsukuba's Short-Stay, Regional Health Care, Clinical Clerkship Program in Medically Underserved Areas / 医学教育

Since 2009, a five-day, regional health care, clinical clerkship in medically underserved areas has been available to all fifth-year medical students at the University of Tsukuba. In the program, students listen to and observe health problems in non-clinical settings, wherever these problems actually exist. Students can experience health care lectures and health examinations. They can also experience a clinical work environment. The short stay helps students to understand the living environment of the area they observe. It is also effective for students to consider health problems from the perspective of the local inhabitants. This program aims to directly convey the interest and importance of community medicine, and to contribute to the supply of physicians in these areas. A longitudinal study is needed to evaluate the effect of the program.

An evaluation of the Medical Pool Placement and Utilization Program (MedPool PUP) of the Philippine Department of Health

OBJECTIVE: This study evaluates the effectiveness of the Medical Pool Placement and Utilization Program (MedPool PUP) of the Philippine Department of Health whose purpose is to augment the medical resource requirements of public hospitals.  METHOD: Mix method was used to gather data through a questionnaire survey sent by fax, email or postal mail. Beneficiary hospitals were selected and key informant interviews done to both the executive officers and the deployed medical pool physicians to further gain insights on the results of the survey.  RESULTS: A total of 75 public hospitals were beneficiaries of the MedPool PUP covering all hospital categories- Level 1, Level 2, Level 3 and Level 4 hospitals. Fifty-one hospitals responded to the survey. Justifications for requesting deployment include: a) need for additional physicians (43%), b) need for a medical specialist of a given clinical specialty (23%), c) need for accredited specialists to maintain a residency training accreditation (23%), d) need for substitute doctors while their regular doctors undergo training (8%) and e) need for a trainer of a specific medical specialty (2%). Almost all deployed doctors have finished a residency training program belonging to a medical specialty. Although the work descriptions covering the deployment of the MedPool doctors are focused on providing medical care to the patients, the contributions to the achievements of the hospitals s by the MedPool doctors go beyond these. They are also involved in medical training of other doctors, many are also given additional assignments in clinical administration and researches. Some also get involved in outreach services. Many exceptional contributions to the hospitals were given by the deployed doctors. In 12 out of 16 (75%) hospitals visited, the doctors deployed were able to introduce new clinical services such as heart surgery, ophthalmology, renal transplant, hepato-biliary surgery, automation of clinical laboratory procedures, among others. This is the primary basis for this study to conclude that the MedPool PUP is effective. CONCLUSION: The effectiveness of the MedPool PUP has been shown to go beyond augmenting the medical staffs of public hospitals in providing services. The doctors it deployed have contributed significantly in improving the clinical services by introducing new specialty services and enhancing existing ones. It is recommended that MedPool PUP be continued and strengthened to fill the needs of public hospitals based on a system of priorities. 

The collapse of infrastructure for childbirth: causes and consequences

Despite low childbirth rate in Korea, the number of women with high-risk pregnancies is steadily increasing, mostly due to increased maternal age, multiple pregnancies, and obesity. In fact, one out of five Korean women is above 35 years old at childbirth. It is well known that high risk pregnancy is closely related with increased maternal mortality, either by direct or indirect causes. Despite such problems, however, Korea's health care infrastructure for childbirth has deteriorated, leaving approximately 20% of the geographic area of the country medically underserved with regard to optimal maternity care. Such a collapse has been caused by the decrease in the number of maternity hospitals and their financial difficulties due to medical fee reimbursement for childbirth being too low. The problem is aggravated by a lack of obstetricians who can provide skilled attendance at childbirth. In addition, extensive legal pressure has dissuaded talented medical students from pursuing obstetrics and gynecology, thereby resulting in aging and severe gender imbalance in such professions. The direct consequence of the collapse in infrastructure for childbirth is an increased maternal mortality ratio, especially in underserved areas. Moreover, increased maternal death caused by postpartum bleeding reflects an obvious sign of danger in the maternal health care system. Furthermore, the number of tertiary hospitals that can provide optimal care to high risk pregnant women has decreased to two-thirds of what it once was, and the training of competent obstetricians for the mothers of the future continues to be a difficulty.

Program for obstetric care supporting underserved areas in Korea: outcome and evaluation standards

In 2011, the government of South Korea established a support program for obstetric care for underserved geographical areas to address the serious problem of the low birth rate. The birth rate of some underserved areas has since been increasing, and several indexes of mother and child health have since improved. However, various problems have also been noted in the evaluation of the policy for this support program. The birth rate of some rural areas remains low, and the inadequacy of professional health care providers has not been resolved. The medical fee for delivery should be rationalized, and countermeasures for medical litigation should be established. Furthermore, better communication between local residents and healthcare providers are necessary to improve maternal and child health. For effective long-term provision of obstetric care through this support program for underserved areas, new outcome and evaluation standards are necessary. Critical requirements for launching an initial support program and outcomes including the birth rate and indices of maternal and child health should be itemized and assessed. Support for health care providers requires expansion including support personnel, the establishment of a transfer system, and measures to address legal problems. A multifaceted approach including regular maternal education and an information network system for local residents is necessary. Future support programs should include total care for maternal and child health, so cooperation of the government offices and health care centers is essential. At the same time, new standards of evaluation of obstetric care support programs for underserved areas need to be established for appropriate evaluation of comprehensive family health.

Why Women Living in an Obstetric Care Underserved Area Do Not Utilize Their Local Hospital Supported by Korean Government for Childbirth

PURPOSE: This study aimed to understand why mothers do not utilize the prenatal care and delivery services at their local hospital supported by the government program, the Supporting Program for Obstetric Care Underserved Area (SPOU). METHODS: We conducted a focus group interview by recruiting four mothers who delivered in the hospital in their community (a rural underserved obstetric care area) and another four mothers who delivered in the hospital outside of the community. RESULTS: From the finding, the mothers were not satisfied with the quality of services that the community hospital provided, in terms of professionalism of the obstetric care team, and the outdated medical device and facilities. Also, the mothers believed that the hospital in the metropolitan city is better for their health as well as that of their babies. The mothers who delivered in the outside community hospital considered geographical closeness less than they did the quality of obstetric care. The mothers who delivered in the community hospital gave the reason why they chose the hospital, which was convenience and emergency preparedness due to its geographical closeness. However, they were not satisfied with the quality of services provided by the community hospital like the other mothers who delivered in the hospital outside of the community. CONCLUSIONS: Therefore, in order to successfully deliver the SPOU program, the Korean government should make an effort in increasing the quality of maternity service provided in the community hospital and improving the physical factors of a community hospital such as outdated medical equipment and facilities.

Entendendo a necessidade de médicos no interior da Amazônia - Brasil / Understanding the need for doctors in innerstate Amazon - Brazil

Um dos dilemas atuais do setor saúde no mundo é a má distribuição de médicos entre áreas rurais e urbanas, e entre capitais e interior. No Brasil, a Região Norte é a que possui a menor quantidade de médicos por habitantes. O objetivo deste estudo foi analisar os indicadores de distribuição de médicos na Região Norte, com especial atenção para as disparidades entre capitais e interior. Trata-se de um estudo ecológico, cujas fontes consultadas foram os bancos de dados ou documentos oficiais do IBGE, CFM e ANS. O principal indicador utilizado foi a relação de médicos por mil habitantes. A Região Norte possui um médico por mil habitantes. O conjunto de capitais possui 2,5, variando de 1,4 em Macapá a 3,4 em Belém. O interior da Amazônia possui 0,4, variando de 0,2 no Amazonas a 1,1 no Tocantins. O acesso a médicos nas capitais chega a ser mais de dez vezes superior no Amazonas e no Pará em relação ao interior. O local que mais necessita de médicos no Brasil é o interior da Amazônia.

One of the current dilemmas inhealthcare worldwideis the unequal distribution of doctors between rural and urban areas, and capital cities and smaller towns. The north of Brazil is the region with lowest number of doctors per capita. The aim of this study is to analyze the indicators of physician distribution in the north of Brazil, focusing especially on disparities between capital cities and smaller towns. This ecological study draws on official statistics and documents of Brazilian institutions.Themain indicator used was the ratio of doctors per one thousand inhabitants. The nothern region has one doctor per one thousand inhabitants. The number in the set of capital cities was 2.5, ranging from 1.4 in Macapa to 3.4 in Belem. In innerstateregions of the Amazonthe figure was 0.4, ranging from 0.2 in Amazonas to 1.1 in Tocantins. Access to doctors in the capital cities of Amazonas and Paráis more than ten times greater than outside the capitals. This is the region of Brazil that is most in need of doctors.

A 10-year analysis of metastatic prostate cancer as an initial presentation in an underserved population

Objective To analyze patients from an underserved area who presented initially with metastatic prostate cancer in order to identify patients in our population who would suffer greatly if PSA screening was eliminated. Materials and Methods A prospectively maintained androgen deprivation therapy database from an inner city municipal hospital was queried to identify patients who presented with metastatic prostate cancer. We identified 129 individuals from 1999 to 2009 eligible for study. Those who underwent previous treatment for prostate cancer were excluded. We examined metastatic distribution and analyzed survival using Kaplan Meier probability curves. Results The median age of presentation was 68 with a median Gleason sum of 8 per prostate biopsy. Thirty-two patients presented with hydronephrosis with a median creatinine of 1.79, two of whom required emergent dialysis. Of those patients who underwent radiographic imaging at presentation, 35.5% (33/93) had lymphadenopathy suspicious for metastasis, 16.1% (15/93) had masses suspicious for visceral metastases. Of the patients who underwent a bone scan 93% (118/127) had positive findings with 7.9% (10/127) exhibiting signs of cord compression. The 2 and 5- year cancer specific survival was 92.1% and 65.6%, respectively. Conclusions In this study we have highlighted a group of men in an underserved community who presented with aggressive and morbid PCa despite widespread acceptance of PSA screening. .

An Early Stage Evaluation of the Supporting Program for Obstetric Care Underserved Areas in Korea

"The Supporting Program for Obstetric Care Underserved Areas (SPOU)" provides financial aids to rural community (or district) hospitals to reopen prenatal care and delivery services for regions without obstetrics and gynecology clinics or hospitals. The purpose of this study was to evaluate the early stage effect of the SPOU program. The proportion of the number of birth through SPOU was calculated by each region. Also survey was conducted to investigate the extent of overall satisfaction, elements of dissatisfaction, and suggestions for improvement of the program; 209 subjects participated from 7 to 12 December, 2012. Overall, 20% of pregnant women in Youngdong (71 cases) and Gangjin (106 cases) used their community (or district) hospitals through the SPOU whereas Yecheon (23 cases) was 8%; their satisfaction rates were high. Short distance and easy accessibility was the main reason among women choosing community (or district) hospital whereas the reasons of not selecting the community (or district) hospital were favor of the outside hospital's facility, system, and trust in the medical staffs. The SPOU seems to be currently effective at an early stage. However, to successfully implement this program, the government should make continuous efforts to recruit highly qualified medical staffs and improve medical facility and equipment.