Precarização do trabalho odontológico na saúde suplementar: uma análise bioética / Precarisation of dentistry in private healthcare: bioethical analysis

Resumo O presente trabalho evidenciou o processo de trabalho do cirurgião-dentista (CD) no setor de saúde suplementar a partir da visão do profissional, sob a luz da Bioética de Intervenção. Foi realizado um estudo observacional-seccional do tipo inquérito circunscrito à região do Distrito Federal. Os dados foram coletados por meio de 108 questionários respondidos por CDs credenciados à duas modalidades de operadora: autogestão e odontologia de grupo, com a finalidade de conhecer a percepção e o grau de satisfação profissional diante do mercado de trabalho odontológico. A insatisfação maior por parte dos profissionais foi relacionada à remuneração dos trabalhos odontológicos pelas operadoras. Para a operadora de autogestão 1, 38,1% dos profissionais responderam que a remuneração era satisfatória, enquanto para a de autogestão 2 e odontologia de grupo, houve 100% de insatisfação. Outro dado encontrado foi que a operadora de odontologia de grupo restringiu os tratamentos selecionados aos pacientes de forma expressiva. Conclui-se que existe a perda de autonomia profissional, desvalorização dos ressarcimentos e precarização do trabalho odontológico na saúde suplementar, demonstrando conflitos éticos nessa relação de trabalho.

Abstract The present study highlighted the labour process of the dental surgeon (DS) in the private healthcare sector from the healthcare professional's perspective based on intervention bioethics. An observational, cross-sectional survey study was performed within the Federal District (Distrito Federal) region. Data were collected from 108 questionnaires completed by DSs affiliated with two types of private health insurers, self-insurance and group insurance, to assess job perception and the degree of job satisfaction in the dentistry market. The main source of dissatisfaction for healthcare professionals was related to the pay for dental procedures by insurers. For self-insurer 1, 38.1% healthcare professionals replied that the pay was satisfactory, whereas in self-insurance 2 and in the group insurance, 100% of healthcare professionals were dissatisfied. Another finding was that the group insurer considerably restricted elective treatments. In conclusion, loss of professional autonomy, depreciation of insurance claims and precarisation of dentistry occurs in the private healthcare sector, thus demonstrating the ethical conflicts in this relationship.

Medical perception of stroke care conditions in Brazil / Percepção médica sobre as condições para atendimento do AVC no Brasil

ABSTRACT Stroke is currently the second leading cause of death in Brazil. Neurologists' reports on the absence of adequate resources for stroke care are frequent; however, there are no objective data on this perception. Objective To assess the perception of neurologists of stroke care conditions in Brazil. Methods Neurologists from all over Brazil were surveyed by means of an anonymous questionnaire about the main shortcomings in stroke care, focusing particularly on physical structure and infrastructure (diagnostic methods, patient transport, availability of beds, multi-professional team). Results The main shortcomings are indicated: the worst conditions, among all items surveyed, were found in the public sector. In the private sector, conditions were better. Conclusions Care conditions are worse in the public sector with regard to both infrastructure and human resources. Future public health policies for the prevention and treatment of stroke should be formulated, taking into consideration neurologists' perceptions.

RESUMO O acidente vascular cerebral é atualmente a segunda causa de morte no Brasil. São frequentes os relatos de médicos neurologistas sobre a ausência de recursos adequados para o atendimento do AVC, no entanto, não existem dados objetivos sobre essa percepção. Objetivo Analisar a percepção de médicos neurologistas sobre as condições para o atendimento de AVC no Brasil. Métodos Neste estudo foi realizada pesquisa por questionário anônimo com médicos neurologistas de todo o Brasil, perguntando-se as principais deficiências para o atendimento, com foco na estrutura física, infraestrutura (métodos diagnósticos, transporte do doente, disponibilidade de leitos, equipe multiprofissional). Resultados As principais deficiências são apontadas; no setor público notou-se as piores condições, em todos os itens pesquisados. No setor privado, as condições são melhores. Conclusões As condições de atendimento são piores no setor público, tanto de infraestrutura quanto de recursos humanos. Futuras políticas de saúde pública para prevenção e tratamento do AVC deveriam ser elaboradas levando em consideração a percepção do neurologista.

Governança regional do sistema de saúde no Brasil: configurações de atores e papel das Comissões Intergovernamentais / Regional governance of the health system in Brazil: configurations of actors and the role of the Interagency Commissions

Resumo O foco da análise é o papel exercido pelas Comissões Intergestores Regionais, considerando a diversidade de atores que influenciam a política de saúde em contextos regionais específicos. A pesquisa envolveu a realização de cinco estudos de caso em cada uma das macrorregiões brasileiras, com aplicação de 128 questionários a gestores, prestadores e representantes da sociedade civil, entre agosto de 2015 e agosto de 2016. Adotou-se a perspectiva comparada, considerando três eixos de análise: configurações de atores (governamentais e não governamentais; públicos e privados) nas decisões e conflitos regionais, dinâmica de funcionamento e atuação, e contribuições das comissões para a política e a organização do sistema de saúde. Verificou-se a diversidade de atores com alto grau de influência nas regiões e a função das Comissões Intergestores Regionais na coordenação das políticas e na resolução de conflitos. Estas favorecem a negociação intergovernamental e a organização do Sistema Único de Saúde frente à estrutura federativa brasileira. Contudo, possuem atuação limitada como espaço de governança regional da saúde, sendo incapazes de incorporar as diversas configurações de atores públicos e privados com poder e influência sobre as decisões de saúde.

Abstract The analytical focus is on the role of the Regional Interagency Commissions (CIR), considering the diversity of actors that influence health policy in specific regional contexts. The research involved conducting five case studies in each of the Brazilian macroregions, with the application of 128 questionnaires to public managers, service providers and civil society representatives, between August 2015 and August 2016. The comparative perspective was adopted, by considering three analytical approaches: the configuration of actors (governmental and non-governmental; public and private) on regional decisions and conflicts, operation dynamics and contributions of commissions to health system policy and organization. The results showed the diversity of actors with a high degree of influence in the regions and the role of the Regional Interagency Commissions in policy coordination and conflict resolution. The commissions favor interagency negotiation and the organization of the Unified Health System vis-à-vis the Brazilian federative structure. However, they have limited scope as a space for regional health governance and are unable to incorporate the different configurations of public and private actors with power and influence over health decisions.

A governança e a relação público-privado no cotidiano das práticas em municípios de pequeno porte / Health governance and the public-private relationship in small municipalities

Resumo No contexto institucional do sistema de saúde ressalta-se que a relação entre os setores público e privado ocorre, sobretudo, para a execução de serviços de saúde de média complexidade, principalmente nos municípios de pequeno porte (MPP). Assim, este artigo objetiva analisar a relação entre gestores públicos e prestadores privados no processo de governança regional, quanto aos fatores envolvidos na contratualização e nos mecanismos de gestão e planejamento das ações de média complexidade. Trata-se de um estudo de caso de natureza qualitativa, realizado em uma região de saúde do Paraná por meio de entrevistas com gestores públicos e privados, realizadas no período de dezembro de 2016 a fevereiro de 2017, e análise documental de instrumentos de gestão e tabelas de contratos firmados entre os mesmos. Os resultados apontam interdependência na relação de gestores públicos e prestadores privados; assimetrias de poder; interesses e benefícios, a depender da tipificação de contrato entre o município com o prestador; destacando-se vantagens e práticas clientelistas. O incipiente processo de planejamento e de medidas regulatórias pelos municípios da região e Estado demonstram a necessidade de investir em ações que favoreçam a governança, a capacidade regulatória de governos locais e o controle social nesta região.

Abstract Within the institutional healthcare system, the public and private sectors come into relationship mainly in the context of the execution of medium-complexity health services, especially in small municipalities (SMs). The aim of this study is to analyse the relationship between public managers and private providers in the regional governance process with regard to the factors involved in the contracting process and management and planning mechanisms of medium-complexity actions. This is a qualitative case study conducted in a health region of the state of Paraná via interviews with public and private managers performed from December 2016 to February 2017. Documental analysis of management tools and price schedules in contracts between public and private managers was also performed. The results indicated interdependence in the relationship between public managers and private providers, power asymmetries, interests, and benefits, depending on the type of contract between the municipality and the provider and, of particular note, advantages and clientelistic practices. The incipient planning process and regulatory measures of the municipalities in the region and state indicate the need to invest in actions that favour governance, the regulatory capacity of local governments, and social scrutiny in this region.

Implantação de salas de apoio à amamentação em empresas públicas e privadas: potencialidades e dificuldades / Despliegue de habitaciones lactancia de apoyo en empresas públicas y privadas: capacidades y dificultades / Establishment of lactaton rooms in public and private companies: potentialities and difficulties

RESUMO Objetivo Conhecer a visão de gestores de empresas públicas e privadas acerca das salas de apoio à amamentação, com vistas à sua implantação. Método Pesquisa qualitativa, exploratória descritiva, realizada em 2015, da qual participaram 20 gestores da Grande Florianópolis. Para a coleta de dados, foram utilizadas entrevistas semiestruturadas/projetivas e, para a análise, a Análise de Conteúdo, associada aos recursos do software Atlas.ti. Resultados Emergiram duas categorias, a saber, dificuldades e facilidades na implantação de sala de apoio à amamentação, com predomínio de aspectos dificultadores, especialmente financeiros, envolvidos na disponibilização de espaço físico. Dialeticamente, também houve reconhecimento do baixo custo envolvido, o que facilitaria sua implantação. Conclusões Aspectos financeiros, culturais e políticos dificultam a implantação de salas de apoio à amamentação, mas há o reconhecimento da importância da medida. Para o sucesso da amamentação, a implantação de salas de apoio é importante, porém, não suficiente, sendo necessárias múltiplas ações e, principalmente, uma atuação mais efetiva da enfermagem e dos demais profissionais de saúde.

RESUMEN Objetivo Conocer la visión de los gestores de la empresa pública y privada sobre las habitaciones de apoyo a la lactancia, con vistas a su puesta en práctica. Método La investigación fue cualitativa, exploratoria y descriptiva. Participaron 20 gerentes en Florianópolis en 2015. Para la recolección de datos se utilizaron entrevistas semiestructuradas/proyectiva y para análisis, Análisis de Contenido asociado a los recursos del software Atlas.ti. Resultados Surgieron dos categorías, las dificultades y las facilidades en la implantación de sala de apoyo a la lactancia, donde predominan los aspectos que obstaculizan, especialmente los financieros, involucrados en el espacio físico. Dialécticamente, también hubo reconocimiento del bajo costo involucrado, lo que facilitaría su aplicación. Conclusión Los aspectos financieros, culturales y políticos dificultan la implantación de salas de lactancia materna,es importsnte implantar salas de apoyo, sin embargo, no es suficiente, requiere múltiples acciones y, sobre todo, un funcionamiento más eficaz de la enfermería y otros profesionales de la salud.

ABSTRACT Objective To know how managers of public and private companies view lactation support rooms and their implantation. Method This is study is based on qualitative, exploratory, and descriptive research. Twenty managers from Greater Florianópolis participated in the research, in 2015. Data were collected by means of semi-structured/projective interviews, and subjected to content analysis associated with Atlas.ti software. Results Data analysis led to the following two categories: difficulties and facilities of establishing a lactation room, with a predominance of financial difficulties and the lack of physical space. Dialectically, the subjects also recognised the low cost involved, which facilitates establishment. Conclusion Financial, cultural, and political aspects make it difficult to set up lactation rooms, but the importance of this measure was acknowledged. Although the success of breastfeeding partly depends on these support rooms, it also requires multiple actions, especially the effective participation of nurses and other health workers.

Application of preventive medicine resources in the health insurance system / Aplicação de recursos em medicina preventiva no sistema de saúde complementar

ABSTRACT Objective To identify the financial resources and investments provided for preventive medicine programs by health insurance companies of all kinds. Methods Data were collected from 30 large health insurance companies, with over 100 thousand individuals recorded, and registered at the Agência Nacional de Saúde Suplementar. Results It was possible to identify the percentage of participants of the programs in relation to the total number of beneficiaries of the health insurance companies, the prevention and promotion actions held in preventive medicine programs, the inclusion criteria for the programs, as well as the evaluation of human resources and organizational structure of the preventive medicine programs. Conclusion Most of the respondents (46.7%) invested more than US$ 50,000.00 in preventive medicine program, while 26.7% invested more than US$ 500,000.00. The remaining, about 20%, invested less than US$ 50,000.00, and 3.3% did not report the value applied.

RESUMO Objetivo Identificar os recursos financeiros e os investimentos disponibilizados para os programas de medicina preventiva em operadoras de saúde suplementar de todos os tipos. Métodos Foram levantados dados referentes a 30 operadoras de saúde registradas na Agência Nacional de Saúde Suplementar, de grande porte, com registro acima de 100 mil vidas. Resultados Foi possível identificar o porcentual de participantes dos programas em relação ao número total de beneficiários da operadora, as ações de prevenção e promoção realizadas nos programas de medicina preventiva, os critérios de inclusão nos programas, bem como a avaliação dos recursos humanos e da estrutura organizacional dos programas de medicina preventiva pesquisadas. Conclusão A maior parte dos pesquisados (46,7%) investiu mais de US$ 50,000.00 no programa de medicina preventiva, enquanto 26,7% investiram mais de US$ 500,000.00. Os restantes, cerca de 20%, investiram menos de US$ 50,000.00 e 3,3% não informaram o valor aplicado.

¿Salud Pública o Privada? Los factores más importantes al evaluar el sistema de salud en Chile / Evaluation of public and private health care systems

Background: There is a great degree of dissatisfaction with the Chilean health care system. Aim: To investigate which are the most relevant perceived factors when the health care system is evaluated. Material and Methods: Analysis of a survey about the Chilean health care system carried out during 2011, 2012 and 2013, involving 2,801 respondents. Results: The response capacity of emergency systems was the main factor considered for the evaluation of public and private health care systems. Respondents who were affiliated to private insurance systems also took into consideration the quality of medical infrastructure. Conclusions: There are different factors considered when public or private health care systems are evaluated.

[ importance and role of volunteers in achieving sustainable development with emphasis on Red Crescent society of Iran: [Opportunities and Threats]]

Nowadays, sustainable and effective development has an important position in counties' micro and macro planning which includes several parts such as personal development, culture and social system, government, economic system infrastructure, and environment. However, this process is recommended by governments and governmental organizations to use the ability of non-governmental organizations, members, volunteers, legal persons and their role in achieving sustainable development. Therefore, development of organizations and NGOs has increased in many countries in the past years. In Iran, government assigned responsibilities for private sectors in recent years. This paper aimed to study the position of volunteers, the value of their social and economic activities, and the role of volunteers in achieving sustainable development at international level and Red Crescent society, the largest NGO, is investigated as one of the responsible organization for organizing volunteer activities. In this paper, the methods of achieving sustainable development were studied using library documents and information from networks by voluntary participation and the author' experience in the field of volunteers management nationally and internationally. Nowadays, with spreading of economic and social problems in the world, international organizations especially UN has tended to promote volunteering culture. And they are trying to use volunteers in order to minimize economic pressure to needy and vulnerable groups [Importance of volunteers' role in the world]; increasing of social crises in the world has shown decline of civilized western world from religious and valuable concepts. So with valuable and humanitarian concepts and values and voluntary activities, it is trying to find and get together a kind of common culture in people's relationships regardless of their color, race, language and religion [communicating of people around the world with each other through volunteering concept]; regarding civil society and developing of democracy by volunteers in various communities and attention of governments, politicians and decision-makers in societies are other important issues in volunteers participation [Attention of governments and politicians to volunteering concept]; and the responsible international organizations are trying to increase participation of the private sectors and organizations in voluntary activities and utilize fully of their ability in order to help the needy and affected people. Accordingly, major donors and sponsors of volunteer programs are private companies, entrepreneurs, banks, financial institutions, and local businesses [active participation of private sectors and volunteers in volunteers' activities]. Undoubtedly, promotion of volunteering culture in the world and ubiquity participation of volunteers without any financial and material expectation can leave behind a significant effect on all society aspects based on human nature especially in social and economic dimensions. However, it seems that volunteers in community and promotion of volunteering culture can revive human values in different countries in addition to facilitate the access of effective development for them. Therefore, volunteers' sense of responsibility can revive values and personal beliefs in the community and also leads to people growth

La investigación clínica en residencias de medicina interna de la Argentina: Facilitadores y barreras / Clinical research in internal medicine residencies in Argentina: Supporters and detractors

En el proceso de formación de los residentes de medicina interna, distintas organizaciones académicas y gubernamentales han recomendado incluir competencias específicas en investigación clínica. El estado actual de la investigación en este contexto no ha sido todavía relevado en nuestro país. El objetivo de este trabajo fue describir las actividades de investigación en las residencias de medicina interna como indicador de la adquisición de dichas competencias e identificar los facilitadores y barreras para la misma. Se realizó un estudio de corte transversal, se analizaron múltiples niveles para considerar las residencias como conglomerados. Se incluyeron 382 residentes de 24 residencias. Predominaron las mujeres, la mediana de edad fue 29 años. El 71% de los residentes informaron actividades de investigación. La mitad de ellos habían participado como autores de trabajos en congresos, solo el 9% había publicado su experiencia. Los factores predictores de desarrollar tareas de investigación fueron pertenecer a una residencia numerosa, OR 16.99 (IC 95%, 2.096-137.87), pertenecer al tercer año de residencia, OR 9.95 (IC 95%, 2.84-34.82), y haber realizado un curso de investigación, OR 2.78 (IC 95%, 1.10-7.04). Las variables que disminuyen la probabilidad de realizar investigación fueron la localización en el Gran Buenos Aires o Capital Federal, OR 0.25 (IC 95%, 0.0072-0.91), ser mujer, OR 0.34 (IC 95 0.14-0.79) y la carga asistencial, OR 0.97 (IC 95%, 0.95-0.99). Conocer los factores que influyen en la investigación contribuye a mejorar la formación de los residentes de medicina interna.

Several academic and government organizations have strongly recommended the inclusion of specific competences in clinical research. So far, the current state of research within this framework has not been modified in our country. The main goal of this study was to provide a thorough description of the research activities in medical residencies, which could be used as an indicator of the acquisition of such competences and to identify the supporters and detractors to achieve them. A cross section study was carried out and several levels were analyzed in order to consider residencies as a cluster; 382 residents from 24 different residencies were included. The study showed a preponderance of women. The average age was 29 years old. A 71% of the residents asserted doing research. Half of those residents have stated being authors of papers presented in congresses; only 9% have published their experience. Factors which predict the development of research assignments were: to belong to a large residency, OR 16.99 (IC 95%, 2.096-137.87), being in the 3rd year of the residency, OR 9.95 (IC 95%, 2.84- 34.82), completion of a research course, OR 2.78 (IC 95%, 1.10-7.04). Variables which reduce the chance to do research: location in Buenos Aires, OR 0.25 (IC 95%, 0.0072-0.91), being a woman, OR 0.34 (IC 95%, 0.14-0.79) and patients assistance workload, OR 0.97 (IC 95%, 0.95-0.99). We believe that the identification of factors which influence the possibility of doing research will lead to a improvement in the training of medical residents.

Entidades empresariais e a política nacional de saúde: da cultura de crise à cultura da colaboração / Business entities and national health policy: the cultural crisis of the culture of collaboration

Esta tese enfoca as entidades de representação dos empresários da saúde na primeira década de 2000, com destaque para a atuação da Confederação Nacional de Saúde,Hospitais, Estabelecimentos e Serviços (CNSa), buscando compreender valores e ideias presentes nas suas agendas e suas interfaces com a política nacional de saúde. Propõe-se situar a atuação das entidades empresariais no movimento de luta política empreendidopelo movimento sanitário nos anos 1970-1980, e de reacomodação de forças políticas e rearranjo das relações entre Estado e sociedade nos anos 1990-2010, levando em consideração as redefinições das bases sociais e legais do Estado brasileiro. Conclui-se que tais entidades empresariais vêm atuando no direcionamento da política nacional de saúde nas últimas duas décadas, buscando ampliar sua organização política e deslocar posições de confronto na arena da saúde para posições de colaboração. As noções de qualidade, eficiência e relação custo-benefício na assistência à saúde vão se tornandovariáveis fundamentais na competição pelos recursos públicos e pela administração da assistência à saúde, graças ao trabalho de difusão de valores e ideias relacionados à capacidade de gestão privada como parâmetro a ser seguido pelos serviços de saúde, sejam eles privados, públicos ou geridos mediante parcerias público-privadas.

Metodología de adaptación de una guía clínica para el manejo de pacientes adultos con neumonía adquirida en la comunidad en una red de salud privada / The adaptation methodology of a guideline for the management of adults with community-acquired pneumonia

Background: Clinical practice guidelines (CPG) are widely used as tools for improving quality of health care. Guidelines developed elsewhere, can be adapted using a valid and systematic process. Aim: To describe the methodology used in the process of adaptation of a guideline for the management of adults with community-acquired pneumonia (CAP) in a private health care organization. Material and Methods: We used the ADAPTE framework involving three main phases. At the set-up phase a guideline adaptation group integrated by medical specialists from different disciplines, a methodologist and a nurse coordinator was formed. At the adaptation phase, the specific clinical questions to be addressed by the guidelines were identified. Results: Twenty five guidelines were initially retrieved. After their assessment, the number was reduced to only three. Recommendations from these guidelines were 'mapped' and focused searches were carried out where 'evidence gaps' were identified. An initial draft was written and revised by the adaptation group. At the finalization phase, the external review of the guideline was carried out and a process for the regular review and update of the adapted guideline was defined. Conclusions: We developed a guideline for the management of adults with CAP, adapted to the local context of our health care system, using guidelines developed elsewhere. This guideline creation method can be an efficient means of saving professional resources.

Sistema de salud de El Salvador / The health system of El Salvador

En este artículo se describen las condiciones de salud de la población salvadoreña y, con mayor detalle, el sistema de salud de El Salvador, incluyendo su estructura y cobertura, sus fuentes de financiamiento, los recursos físicos, materiales y humanos con los que cuenta, las actividades de rectoría que desarrolla el Ministerio de Salud Pública y Asistencia Social, y la participación de los usuarios de los servicios de salud en la evaluación del sistema. Asimismo se discuten las más recientes innovaciones implantadas por el sistema salvadoreño de salud, dentro de las que destacan la aprobación de la Ley de Creación del Sistema Nacional de Salud que busca ampliar la cobertura, disminuir las desigualdades y mejorar la coordinación de las instituciones públicas de salud.

This paper describes the health conditions in El Salvador and the main característics of the Salvadoran health system, including its structure and coverage, its financial sources, the physical, material and human resources available, the stewardship functions developed by the Ministry of Public Health, and the participation of health care users in the evaluation of the system. It also discusses the most recent policy innovations including the approval of the Law for the Creation of the National Health System, which intends to expand coverage, reduce health inequalities and improve the coordination of public health institutions.

Sistema de salud de Argentina / The health system of Argentina

En este artículo se describe el sistema de salud de Argentina, que está compuesto por tres sectores: público, de seguridad social y privado. El sector público está integrado por los ministerios nacional y provincial, y la red de hospitales y centros de salud públicos que prestan atención gratuita a toda persona que lo demande, fundamentalmente a personas sin seguridad social y sin capacidad de pago. Se financia con recursos fiscales y recibe pagos ocasionales de parte del sistema de seguridad social cuando atiende a sus afiliados. El sector del seguro social obligatorio está organizado en torno a las Obras Sociales (OS), que aseguran y prestan servicios a los trabajadores y sus familias. La mayoría de las OS operan a través de contratos con prestadores privados y se financian con contribuciones de los trabajadores y patronales. El sector privado está conformado por profesionales de la salud y establecimientos que atienden a demandantes individuales, a los beneficiarios de las OS y de los seguros privados. Este sector también incluye entidades de seguro voluntario llamadas Empresas de Medicina Prepaga que se financian sobre todo con primas que pagan las familias y/o las empresas. En este trabajo también se describen las innovaciones recientes en el sistema de salud, incluyendo el Programa Remediar.

This paper describes the health system of Argentina.This system has three sectors: public, social security and private.The public sector includes the national and provincial ministries as well as the network of public hospitals and primary health care units which provide care to the poor and uninsured population. This sector is financed with taxes and payments made by social security beneficiaries that use public health care facilities. The social security sector or Obras Sociales (OS) covers all workers of the formal economy and their families. Most OS operate through contracts with private providers and are financed with payroll contributions of employers and employees. Finally, the private sector includes all those private providers offering services to individuals, OS beneficiaries and all those with private health insurance.This sector also includes private insurance agencies called Prepaid Medicine Enterprises, financed mostly through premiums paid by families and/or employers.This paper also discusses some of the recent innovations implemented in Argentina, including the program Remediar.

Sistema de salud de Bolivia / The health system of Bolivia

En este trabajo se describen las características generales del sistema de salud de Bolivia: su organización y cobertura; sus fuentes de financiamiento y gasto en salud; los recursos físicos, materiales y humanos de los que dispone; las actividades de rectoría que desarrolla, y el nivel que ha alcanzado la investigación en salud. También se discuten las innovaciones más recientes que se han llevado a cabo en los últimos años, incluyendo el Seguro Universal Materno Infantil, el Programa de Extensión de Cobertura a Áreas Rurales, el Modelo de Salud Familiar, Comunitaria e Intercultural y el programa de subsidios monetarios Juana Azurduy, dirigido a fortalecer la atención prenatal y del parto.

This paper describes the Bolivian health system, including its structure and organization, its financing sources, its health expenditure, its physical, material and humans resources, its stewardship activities and the its health research institutions. It also discusses the most recent policy innovations developed in Bolivia: the Maternal and Child Universal Insurance, the Program for the Extension of Coverage to Rural Areas, the Family, Community and Inter-Cultural Health Model and the cash-transfer program Juana Azurduy intended to strengthen maternal and child care.

Sistema de salud de Brasil / The health system of Brazil

En este trabajo se describe el sistema de salud de Brasil, que está compuesto por un sector público que cubre alrededor de 75 por ciento de la población y un creciente sector privado que ofrece atención a la salud al restante 25 por ciento de los brasileños. El sector público está constituido por el Sistema Único de Salud (SUS) y su financiamiento proviene de impuestos generales y contribuciones sociales recaudadas por los tres niveles de gobierno (federal, estatal y municipal). El SUS presta servicios de manera descentralizada a través de sus redes de clínicas, hospitales y otro tipo de instalaciones, y a través de contratos con establecimientos privados. El SUS es además responsable de la coordinación del sector público. El sector privado está conformado por un sistema de esquemas de aseguramiento conocido como Salud Suplementaria financiado con recursos de las empresas y/o las familias: la medicina de grupo (empresas y familias), las cooperativas médicas, los llamados Planes Autoadministrados (empresas) y los planes de seguros de salud individuales. También existen consultorios, hospitales, clínicas y laboratorios privados que funcionan sobre la base de pagos de bolsillo, que utilizan sobre todo la población de mayores ingresos. En este trabajo se analizan los recursos con los que cuenta el sistema, las actividades de rectoría que se desarrollan y las innovaciones más recientemente implantadas, incluyendo el Programa de Salud de la Familia y el Programa Más Salud.

This paper describes the Brazilian health system, which includes a public sector covering almost 75 percent of the population and an expanding private sector offering health services to the rest of the population. The public sector is organized around the Sistema Único de Saúde (SUS) and it is financed with general taxes and social contributions collected by the three levels of government (federal, state and municipal). SUS provides health care through a decentralized network of clinics, hospitals and other establishments, as well as through contracts with private providers. SUS is also responsible for the coordination of the public sector. The private sector includes a system of insurance schemes known as Supplementary Health which is financed by employers and/or households: group medicine (companies and households), medical cooperatives, the so called Self-Administered Plans (companies) and individual insurance plans.The private sector also includes clinics, hospitals and laboratories offering services on out-of-pocket basis mostly used by the high-income population. This paper also describes the resources of the system, the stewardship activities developed by the Ministry of Health and other actors, and the most recent policy innovations implemented in Brazil, including the programs saúde da Familia and Mais Saúde.

Sistema de salud de Chile / The health system of Chile

En este trabajo se describe el sistema de salud de Chile, incluyendo su estructura, financiamiento, beneficiarios y recursos físicos, materiales y humanos de los que dispone. Este sistema está compuesto por dos sectores, público y privado. El sector público está formado por todos los organismos que constituyen el Sistema Nacional de Servicios de Salud y cubre aproximadamente a 70 por ciento de la población, incluyendo a los pobres del campo y las ciudades, la clase media baja y los jubilados, así como los profesionales y técnicos. El sector privado cubre aproximadamente a 17.5 por ciento de la población perteneciente a los grupos sociales de mayores ingresos. Un pequeño sector de la población, perteneciente a la clase alta, realiza pagos directos de bolsillo a proveedores privados de servicios de atención a la salud. Alrededor de 10 por ciento de la población está cubierta por otras agencias públicas, fundamentalmente los Servicios de Salud de las Fuerzas Armadas. Recientemente el sistema se reformó creando el Régimen General de Garantías en Salud, que establece un Sistema Universal con Garantías Explícitas que se tradujo, en 2005, en el Plan de Acceso Universal con Garantías Explícitas (AUGE), que garantiza el acceso oportuno a servicios de calidad para 56 problemas de salud, incluyendo cáncer en niños, cáncer de mama, trastornos isquémicos del corazón, VIH/SIDA y diabetes.

This paper describes the Chilean health system, including its structure, financing, beneficiaries, and its physical, material and human resources. This system has two sectors, public and private. The public sector comprises all the organisms that constitute the National System of Health Services, which covers 70 percent of the population, including the rural and urban poor, the low middle-class, the retired, and the self-employed professionals and technicians.The private sector covers 17.5 percent of the population, mostly the upper middle-class and the high-income population. A small proportion of the population uses private health services and pays for them out-of-pocket. Around l0 percent of the population is covered by other public agencies, basically the Health Services for the Armed Forces. The system was recently reformed with the establishment of a Universal System of Explicit Entitlements, which operates through a Universal Plan of Explicit Entitlements (AUGE), which guarantees timely access to treatment for 56 health problems, including cancer in children, breast cancer, ischaemic heart disease, HIV/AIDS and diabetes.

Sistema de salud de Colombia / The health system of Colombia

En este trabajo se presenta una breve descripción de las condiciones de salud de Colombia y una descripción detallada del sistema colombiano de salud. Esta última incluye una descripción de su estructura y cobertura, sus fuentes de financiamiento, el gasto en salud, los recursos con los que cuenta, quién vigila y evalúa al sector salud y qué herramientas de participación tienen los usuarios. Dentro de las innovaciones más recientes del sistema se incluyen las modificaciones al Plan Obligatorio de Salud y a los montos de la unidad de pago por capitación, la integración vertical entre empresas promotoras de salud y las instituciones prestadoras de servicios, así como el establecimiento de nuevas fuentes de recursos para lograr la universalidad e igualar los planes de beneficios entre los distintos regímenes.

This document briefly describes the health conditions of the Colombian population and, in more detail, the characteristics of the Colombian health system. The description of the system includes its structure and coverage; financing sources; expenditure in health; physical material and human resources available; monitoring and evaluation procedures; and mechanisms through which the population participates in the evaluation of the system. Salient among the most recent innovations implemented in the Colombian health system are the modification of the Compulsory Health Plan and the capitation payment unit, the vertical integration of the health promotion enterprises and the institutions in charge of the provision of services and the mobilization of additional resources to meet the objectives of universal coverage and the homologation of health benefits among health regimes.

Sistema de salud de Costa Rica / The health system of Costa Rica

En este trabajo se describe el sistema de salud de Costa Rica, que presta servicios de salud, agua y saneamiento. El componente de servicios de salud incluye un sector público y uno privado. El sector público está dominado por la Caja Costarricense de Seguro Social (CCSS), institución autónoma encargada del financiamiento, compra y prestación de la mayoría de los servicios personales. La CCSS se financia con contribuciones de los afiliados, los empleadores y el Estado, y administra tres regímenes: el seguro de enfermedad y maternidad, el seguro de invalidez, vejez y muerte, y el régimen no contributivo. La CCSS presta servicios en sus propias instalaciones o contrata prestadores del sector privado con los que establece contratos denominados "compromisos de gestión". El sector privado comprende una amplia red de prestadores que ofrecen servicios ambulatorios y de especialidad con fines lucrativos. Estos servicios se financian sobre todo con pagos de bolsillo, pero también con primas de seguros privados. El Ministerio de Salud es el rector del sistema y como tal cumple con funciones de dirección política, regulación sanitaria, direccionamiento de la investigación y desarrollo tecnológico. Dentro de las innovaciones relativamente recientes que se han implantado en Costa Rica destacan la implantación de los equipos básicos de atención integral de salud (EBAIS), la desconcentración de los hospitales y clínicas públicos, la introducción de los acuerdos de gestión y la creación de las Juntas de Salud.

This paper describes the Costa Rican health system which provides health, water and sanitation services. The health component of the system includes a public and a private sector. The public sector is dominated by the Caja Costarricense de Seguro Social (CCSS), an autonomous institution in charge of financing, purchasing and delivering most of the personal health services in Costa Rica. CCSS is financed with contributions of the affiliates, employers and the state, and manages three regimes: maternity and illness insurance, disability, old age and death insurance, and a non-contributive regime. CCSS provides services in its own facilities but also contracts with private providers. The private sector includes a broad set of services offering ambulatory and hospital care. These services are financed mostly out-of-pocket, but also with private insurance premiums. The Ministry of Health is the steward of the system, in charge of strategic planning, sanitary regulation, and research and technology development. Among the recent policy innovations we can mention the establishment of the basic teams for comprehensive health care (EBAIS), the de-concentration of hospitals and public clinics, the introduction of management agreements and the creation of the Health Boards.

Sistema de salud de Ecuador / The health system of Ecuador

En este trabajo se describen las condiciones de salud en Ecuador y, con mayor detalle, las características del sistema ecuatoriano de salud, incluyendo su estructura y cobertura, sus fuentes de financiamiento, los recursos físicos, materiales y humanos de los que dispone, las tareas de rectoría que desarrolla el Ministerio de Salud Pública, la generación de información en salud, las tareas de investigación, y la participación de los ciudadanos en la operación y evaluación del sistema. También se discuten las innovaciones más recientes que se han implantado en el sistema ecuatoriano de salud dentro de las que destaca la incorporación de un capítulo específico sobre salud a la nueva Constitución que reconoce a la protección de la salud como un derecho humano y la construcción de la Red Pública Integral de Salud.

This paper describes the health conditions in Ecuador and, in more detail, the characteristics of the Ecuadorian health system, including its structure and coverage, its financial sources, the physical, material and human resources available, and the stewardship activities developed by the Ministry of Public Health. It also describes the structure and content of its health information system, and the participation of citizens in the operation and evaluation of the health system. The paper ends with a discussion of the most recent policy innovations implemented in the Ecuadorian system, including the incorporation of a chapter on health into the new Constitution which recognizes the protection of health as a human right, and the construction of the Comprehensive Public Health Network.

Sistema de salud de Guatemala / The health system of Guatemala

En este trabajo se describen las condiciones de salud y el sistema de salud de Guatemala, incluyendo su estructura y cobertura, sus fuentes de financiamiento, las actividades de rectoría que en él se desarrollan, así como las tareas de generación de información en salud e investigación. También se discuten los esfuerzos por ampliar la cobertura de servicios básicos, sobre todo a las comunidades rurales pobres. Destacan dentro de las innovaciones recientes del sistema guatemalteco de salud el Programa de Extensión de Cobertura de Servicios Básicos y el Programa de Accesibilidad de Medicamentos, así como los acuerdos del Ministerio de Salud con organizaciones de la sociedad civil para prestar servicios básicos en comunidades rurales.

This paper describes the health conditions in Guatemala and, in more detail, the characteristics of the Guatemalan health system, including its structure en coverage, its financial sources, the stewardship functions developed by the Ministry of Health, as well as the generation of health information and the development of research activities. It also discusses the recent efforts to extend coverage of essential health services, mostly to poor rural areas.The most recent innovations also discussed in this paper include the Program for the Expansion of Coverage of Essential Services, the Program to Expand Access to Essential Drugs and the agreements between the Ministry of Health and several non-governmental organizations to provide essential services in rural settings.