Política Nacional de Atenção Básica de 2017: análise da composição das equipes e cobertura nacional da Saúde da Família / National Primary Care Policy 2017: analysis of teams composition and national coverage of Family Health

Resumo A Estratégia Saúde da Família é a principal forma de organização do sistema de saúde brasileiro. Contudo, a terceira edição da Política Nacional de Atenção Básica (PNAB) passou a reconhecer financeiramente outros tipos de equipes. Para analisar os efeitos da PNAB de 2017 na composição das equipes, foi realizado um estudo de série temporal de 2007 a 2019 utilizando dados do Cadastro Nacional de Estabelecimentos de Saúde (CNES) de postos de trabalho e de equipes e a cobertura nacional da Saúde da Família. Observou-se a concentração de médicos nas regiões Sudeste e Nordeste e oscilação dessa categoria profissional ante os acontecimentos do Programa Mais Médicos. Houve acréscimo de 5% de enfermeiros e redução de 0,3% dos ACS no país. A despeito da autorização e financiamento para implantação de equipes de "Atenção Básica" (eAB), elas correspondem a menos de 1% do total de equipes. Vale ressaltar que a modalidade preferencial dos gestores municipais se mantem pela Equipes de Saúde da Família, correspondendo a 75% do total de equipes e em crescimento. Apesar dos questionamentos e expectativas gerados pela PNAB de 2017 no contexto da Atenção Primária à Saúde, conclui-se que, em relação às equipes e suas composições, não houve mudança significativa após dois anos de sua vigência.

Abstract The Family Health Strategy is the main form of organization of the Brazilian health system. However, the third edition of the National Primary Health Care Policy (PNAB) recognized other types of teams financially. A time series study was conducted from 2007 to 2019 using data from the National Register of Health Facilities (CNES) of jobs, teams and national coverage of Family Health to analyze the effects of the 2017 National Primary Health Care Policy (PNAB) on team composition. We observed the concentration of doctors in the Southeast and Northeast and variation of this professional category before the events of the "Mais Médicos" (More Doctors) Program. The number of nurses increased 5% and Community Health Workers (ACS) dropped 0.3% in the country. Despite the authorization and funding for the implementation of "Primary Care" teams (eAB), they correspond to less than 1% of the total teams. It is noteworthy that the municipal managers' preferred mode is the traditional Family Health Teams, equivalent to 75% of the total and growing. While the questionings and expectations generated by the 2017 PNAB in the context of Primary Health Care, we can conclude that, regarding the teams and their compositions, no significant change was identified two years into its coming into force.

Medicina familiar en el Perú: camino a la consolidación como disciplina científica / Family medicine in Peru: consolidating the discipline

La medicina familiar en el Perú tuvo sus orígenes en el año 1989, fecha en que se creó el residentado médico para esta especialidad; a partir de entonces ha tenido etapas de auge y otras de retroceso, en la actualidad existen más de 250 médicos familiares egresados, se ofrecen entre 70 y 90 plazas de residentado en forma anual, no habiendo aun inserción de la medicina familiar en el pregrado de las facultades de medicina. La inserción de los médicos familiares en el sistema de salud ha sido más lenta y complicada de lo esperado, el Perú tiene un sistema mixto de salud con múltiples aseguradores y prestadores y con un 30 por ciento de la población sin cobertura; o sea no cuentan con un real cumplimiento de características de sistemas basados en atención primaria como primer contacto y acceso, longitudinalidad, integralidad y coordinación. Se espera a futuro consolidar la especialidad mejorando los escenarios de formación y desarrollando un sistema sanitario único.

Family medicine in Peru had its origins in 1989, when the first family medicine residency was created; thereafter has had stages of improving and decline, there are currently more than 250 family physician graduated, between 70 and 90 seats of residency in annually, not having even insert family medicine in undergraduate medical schools. The inclusion of family physicians in the health system has been torpid, Peru has a mixed health system with multiple insurers and providers and 30 percent of the population without coverage, no real compliance characteristics of systems based on attention primary and first contact and access, longitudinality, comprehensiveness and coordination. It is expected to strengthen the specialty improve future training scenarios and developing a united health system.

Medicina familiar y comunitaria y salud de la familia en Brasil: una estrategia para ofrecer atención primaria de salud para todos / Family and community medicine and family health in Brazil: a strategy to provide primary health care for all

Las políticas que generaron los diseños de los sistemas de salud en Brasil han tenido una alta participación de la sociedad civil. Es el caso de la Estrategia de Salud Familiar, basada en los principios básicos del Sistema Único de Salud de Brasil (SUS): universalidad, integración y equidad, en un contexto de descentralización y control social de la gestión. En esta revisión se dan a conocer los hitos del SUS y su misión institucional, profundizando en lo que se entiende por salud familiar, describiendo como la medicina familiar y comunitaria y la salud de la familia han sido una estrategia para ofrecer atención primaria de salud para todos.

Health policies that spawned the design of the health systems in Brazil were undertaken with strong civil society participation. This is the case of the Family Health Strategy, based on the basic principles of the Brazilian Single Health System (SUS): universality, equity and integration, in the context of decentralization and social control of health administration. This review focuses on the SUS milestones and its institutional mission, delving into what is meant by family health and describing how family medicine and community and family health have been a strategy to provide primary health care for all.

Modelo de salud familiar en Chile y mayor resolutividad de la atención primaria de salud: ¿contradictorios o complementarios / Family health model in Chile and greater resoluteness of primary health care: contradictory or complementary

Desde 1978 y por medio de la Declaración de Alma Ata, se describe que la atención primaria de salud (APS) debe entenderse como parte integrante del sistema completo de asistencia sanitaria y del espíritu de justicia social del desarrollo. Se ha demostrado en el tiempo que esta estrategia puede adaptarse a una amplia variedad de contextos políticos, sociales, culturales y económicos. Luego de 25 años la Organización Panamericana de la Salud (OPS) sugirió la revisión y adopción de una estrategia renovada para la APS, que incluyera desafíos epidemiológicos, nuevos conocimientos e instrumentos de mejores prácticas y su contribución en la efectividad de la atención primaria, además del reconocimiento de que la APS es una estrategia para fortalecer la capacidad de la sociedad y reducir las inequidades en salud. En el presente análisis se describe la realidad de Chile, considerando los valores, principios y elementos esenciales en un sistema de salud basado en la atención primaria y las reformas necesarias para reorientar los sistemas sanitarios hacia la salud.

Since 1978 and in accordance with the Alma Ata Declaration, primary care is described as an integral part of the healthcare system and fundamental to achieve social justice together with development. Time has validated this approach, which can be applied to a broad variety of political, social, cultural, and economic realities. After 25 years, the Pan-American Health Organization (PAHO) suggested revising and adopting a renewed strategy for primary care, so as to include epidemiological challenges, new knowledge and better instruments, with the purpose of enhancing effectiveness of primary care and also as a way of acknowledging that it is a strategy that strengthens a society’s capacity to reduce health inequities. This analysis describes the Chilean reality, taking into account values, principles and essential elements of a healthcare system based on primary care. It also looks at the reforms that are needed in order to redirect health systems towards health outcomes.

Evolución de la oferta de médicos. Chile 1993-2008 / Evolution of the availability of physicians in Chile

There is a significant increase in the physician availability in Chile in the last 15 years, due to the immigration of foreign physicians, but mainly due to the increasing number of graduates from private universities with medical schools. In the last four years, the number of physicians increased from 25.542 to 29.996 and the number of graduates, from 918 to 1.136. These figures show a nearly exponential growth. The number of physicians/number of beneficiaries' ratio increased from 1/630 to 1/569 in the last four years, due to the greater increase in the number of physicians than in the number of inhabitants. The future will show a similar trend in this ratio. The specialist/general practitioner ratio remains practically the same, as the number of physicians/beneficiaries ratio in the public system. The oversupply of physicians should alert authorities about the inconvenience in creating new medical schools and a careful plan of relationship between the offer and demand of medical services.

Un programa para recuperar y mejorar el aporte de los médicos en la atención primaria de salud / A programme for the recovery and improvement of physicians’ contribution to primary health care

Antecedentes: Chile reconoce la importancia de la atención primaria de salud (APS) y ha hecho progresos en su implementación. Sin embargo, persiste el problema de la falta de motivación de los egresados de las Escuelas de Medicina por participar en la APS y permanecer ahí. Un factor es la limitación que significa estar en el ámbito municipal, en comparación con el cauce amplio del sistema hospitalario y las posibilidades de especialización. Consecuencias: en la APS hay un déficit cuantitativo de médicos, una alta rotación de ellos y una baja resolutividad. Resulta un exceso de consultas en servicios de urgencia y un problema de insatisfacción de la población. Un camino de solución: desde el año 2007, el Ministerio de Salud, en conjunto con la Universidad de Chile, ha puesto en marcha el Programa de Especialistas Básicos para la APS urbana, que se basa en experiencias nacionales anteriores. Se describe este programa con sus ventajas y reducido costo. La experiencia inicial es alentadora.

Background: Chile recognizes the importance of Primary Health Care (PHC) and advances have been accomplished in this field. Nevertheless there is a lack of interest of medical graduates in entering PHC activities and staying there. One reason for this is the restriction resulting from full time work within the municipal administration of the PHC clinics, in comparison with the mainstream of the hospital system, with its possibilities for specialization. Consequences: in PHC there is a quantitative deficit and a revolving door of doctors and clinical effectiveness is low. This results in an excessive utilization of emergency departments and in a degree of insatisfaction among the population. A scheme for improvement: Starting in 2007, the Ministry of Health, jointly with the University of Chile is implementing the “Programme of Basic Specialists for Urban PHC”, which is based on previous national experience. The Programme is here described, with an analysis of its cost and advantages. The results so far are encouraging.

Incorporación de médicos especialistas a la atención primaria ¿una paradoja nacional? / Incorporation ofspecialists to primary health care to increase its efficieney

In the last decade, the number of general practitioners has decreased in Chile and there is a lack ofinterest among new doctors to work in Primary Care. The low number ofpositions for primary care physicians in the national publie and community health services are one cause, among others, for this decrease. On top, there is a lack of incentives and continuous training in community health services. This situation lead to reinforce primary care with internists, gynecologist, surgeons and psychiatrists in training. During their residence, part of the working journey of these trainees will be carried out in general medical outpatients clinics. This solution has been criticized by university authorities. The other solution is to incorpórate certified basic specialists in teams of three to five, in outpatient clinics of communities with high number of beneficiarles. This initiative is supported by the great number of specialists available in Chile, but is hampered by the lack of working positions and financing. It would increase the problem solving capacity at the primary level, decreasing the number of specialist derivations, that collapse secondary levels of health care.

Médicos en el nivel primario del sistema público de atención de salud de Chile: tendencia, distribución geográfica y normas / Physicians at the primary care level of the public health care system of Chile: trend, geographical distribution and standards

Se actualizan los datos sobre dotación de horas médicas en la Atención Primaria del sistema Público de Atención de Salud. Para el año 2007 se presenta la distribución según área geográfica y tipo de establecimiento. Se examina la tendencia de la dotación entre los años 2002 y 2007. Se calculan las atenciones proporcionadas en promedio por cada hora médica y las atenciones anuales promedio por beneficiario del sistema Público. El nivel de la dotación va en aumento pero es todavía inferior, en la mayoría de las regiones, al de la norma aceptada por el Ministerio de Salud. Las atenciones proporcionadas por el Sistema Público están también por debajo de lo observado en los países industrializados. Se discute la relación entre las metas de concentración de atenciones, el rendimiento de la hora médica y la necesidad de recursos médicos para la APS. Junto con la necesidad de contar con información actualizada y confiable acerca de la situación prevalente, se acentúa la importancia del modelo de atención integral consagrado en la política nacional de salud, como condicionante principal para acordar normas de cantidad y de médicos por población, normas de utilización de dicho tiempo, y normas de calidad. A la vez, estas características deben condicionar la formación y carrera de los médicos.

We update the existing information on the medical staffing of Primary Health Care in the Public Health Care System of Chile. The distribution of physicians among geographical areas and types of facilities in the year 2007 is presented. The trend of the doctor to beneficiary population ratio for the period 2002-2007 is examined. We estimate the average number of visits per physician-hour and the average number of visits per beneficiary. The level of staffing is increasing but, in most regions, is still below the norm accepted by the Ministry of Health. Over all, the medical PHC services provided by the Public System are below the level attained in the industrialized nations. We discuss the links between doctor visit targets, the productivity of PHC doctors and the requirement of physician hours. There is a need for up to date and reliable information on the prevailing situation (which this paper attempts to provide); but consideration of the health care model proposed in the national health policy is also essential for setting standards of PHC physicians to population ratio, as well as norms for the utilization of their time and for quality standards. In turn, these characteristics should form the basis for the education and the career of doctors.

Perfil y número de médicos generales que requiere el país / The profile and number of primary care physicians required in Chile

Medical schools curricular planning aim to obtain a physician trained to work as general practitioner and the Chilean health reform, considers ambulatory primary care as the main axis of health care. However there is still a low interest among physicians to work in primary health care, where there are problems related to a low level of clinical resolution, clinical and administrative management deficiencies and a low level of leadership in health promotion. The causes of these deficiencies stem from university training, government policies and the great attraction that exerts the technological and specialized model of secondary and tertiary health care. We analyze the ideal profe that the general practitioner should have in our health care system and the possible solutions to primary health care problems. We also emphasize the need to coordinate the professional resource needs with university training, to reduce the existing gaps between medical training and professional practice.

Disponibilidad de médicos en Chile al año 2004 / Availability of physicians in Chile at the year 2004

Background: The number of physicians available in a given country, their efficiency, quality and specialization is of utmost epidemiological importance. Aim: To evaluate the availability of physicians in Chile. Material and methods: The information about the number of physicians in Chile up to the year 2004, was obtained from the Ministry of Health, national universities and the register of immigrant physicians since 1950. Results: The total number of physicians licensed to practice was 25,542, of whom 2,700 are immigrants. The physician/inhabitant ratio increased from 1/921 in 1998 to 1/612 in 2004. The greater impact in the increment of available physicians was given by the immigration of professionals and by the increase in the number of physicians graduated from national universities, mainly from the new private universities. Forty two percent of physicians work at public services and 61 percent of these are certified specialists. The regional distribution of general practitioners and basic specialists is adequate. Along the country, the mean physician/beneficiary ratio is 8.45/10,000, the specialist/beneficiary ratio is 4.9/10,000 and the general practitioner/beneficiary ratio is 2.3/10,000. Conclusions: The national information of available physicians, especially in the private sector, should be improved. Immigration of physicians should be regulated, maintaining validation examinations and a National Medical Test to assess medical proficiency should be instituted.

Magnitud y características de la consulta externa atendida por médico generalista en centros sanitarios periféricos / Ambulatory care by general practitioners

Se aborda la problemática de la relación entre médicos generalistas y especialistas y su disociación con las frecuecias de las patologías susceptibles de ser resueltas en el Primer Nivel de atención (80 a 93,5 por ciento). El objetivo formulado para esta primera etapa del estudio consiste en establecer la magnitud y las características de la consulta atendida por médico generalista a nivel de centros de salud situados en la periferia de la ciudad de La Plata (Argentina). El volumen más importante de consultas se ubicó dentro de las causadas por morbilidad. La demanda predominante responde a patologías propias de las condiciones de vida, con amplio predominio de infecciones respiratorias, seguidas por las gastrointestinales. Por otro lado, los controles se hallan predominantemente referidos al binomio materno-infantil, observándose una reducida carga de exámenes de salud, propios del adulto. La concentración de consultas resulta sumamente reducida como consecuencia del modelo prestacional vigente, el que carece de capacidad de retención. Los controles representan algo más del 20 por ciento de la demanda, con una concentración un poco más alta. El predominio de la demanda femenina es notorio, pero deben ser contempladas las causas obstétricas a fin de establecer el alcance genuino de esta preponderancia

Control de la trichuriasis en una zona rural de Cuba / Trichuriasis control in a rural zone of Cuba

Durante el año 1988 en el territorio del II Frente Oriental en Santiago de Cuba y como parte del Plan Turquino de desarrollo socioeconómico, iniciaron su labor 50 médicos de familia, se construyeron viviendas y un acueducto que beneficiaron a más del 50 por ciento de la población. Paralelamente a esto se desarrolló un estudio de prevalencia de helmintos intestinales. Los que resultaron positivos se les administró quimioterapia selectiva en dosis única de mebenzadol (400 mg).La reducción parasitaria que se produjo a partir de estos beneficios fue evaluada dos años después. Al azar se crearon 4 grupos de estudio: grupo I integrado por 730 personas que recibieron quimioterapia, los beneficios del saneamiento y la atención de cuatro médicos de familia, el grupo II con 400 personas sólo recibió el beneficio del médico de familia (4 médicos para esta población), el grupo III con 306 personas recibió quimioterapia solamente y el grupo IV con 300 personas como grupo control. Al evaluar el comportamiento de estos grupos se observa una disminución de la prevalencia de Trichuris trichiura de 40 por ciento a 4,4 por ciento en el grupo I, el grupo II de 31 por ciento a 29 por ciento y para el grupo III de 35 por ciento a 14 por ciento , en cambio para el grupo IV se registra un aumento de 35 a 51 por ciento . Se recomienda el control integral para la reducción de la trichuriasis principal parasitosis en Cuba y el Caribe.