A ação coletiva e a cooperação no Sistema Único de Saúde / Collective action and cooperation in the Unified Health System

Resumo Embora o princípio de regionalização dos serviços de saúde conste em documentos oficiais e norteie a organização atual do Sistema Único de Saúde, esse processo depende em certa medida da ação coletiva e da cooperação entre os entes federados. Consideram-se a ação coletiva e a cooperação como elementos de políticas federativas e como comportamento social. Nesta perspectiva, buscou-se analisar como a ação coletiva e a cooperação são abordadas nos documentos oficiais de regulamentação e organização das políticas de saúde que tratam da regionalização. Trata-se de uma análise documental de 16 normas oficiais, publicadas entre 1988 e 2018, e discussão do tema, apoiado sobretudo nos referenciais de coletividade e institucionalidade política. Para a análise dos documentos oficiais, utilizou-se a técnica de análise do conteúdo. Os resultados apontam que a ação coletiva e a cooperação são abordadas em documentos oficiais, especialmente pelos vocábulos "solidariedade" e "cogestão", e que as políticas de regionalização possuem caráter altamente normativo. Sua implementação dependerá de mecanismos de coordenação, coerção e recompensa, além de aspectos relacionados à gestão dos serviços, como equilíbrio entre os interesses coletivos e individuais, e a construção de identidades sociais entre gestores com vistas à cogestão.

Abstract Although the principle of regionalization of health services is contained in official documents and guides the current organization of the Unified Health System, this process depends to a certain extent on collective action and cooperation between federated entities. Collective action and cooperation are considered elements of federal policies and social behavior. In this perspective, we sought to analyze how collective action and cooperation are addressed in the official documents of regulation and organization of health policies that deal with regionalization. It is a documentary analysis of 16 official norms, published between 1988 and 2018, and discussion of the theme, supported mainly by the collective and political institutional frameworks. For the analysis of official documents, the technique of content analysis was used. The results show that collective action and cooperation are addressed in official documents, especially by the words "solidarity" and "co-management", and that regionalization policies have a highly normative character. Its implementation will depend on coordination, coercion, and reward mechanisms, as well as aspects related to the management of services, such as balance between collective and individual interests, and the construction of social identities between managers with a view to co-management.

La administración en salud, componente de desarrollo de la salud pública / Health management as a component of the development of the public health care

La salud pública como esfuerzo organizado de la sociedad y el estado por la salud, bienestar y la calidad de vida trasciende a los servicios de salud, razón por lo cual se hacen más complejos los procesos de conducción. Por lo tanto, se requiere dirigir con fundamentos científicos, con claridad de que la gerencia en salud o administración en salud es ciencia, además de técnica y arte y sumado al nivel de integración externa del sector de la salud con otros sectores es necesario considerar a la Intersectorialidad, componente político y tecnológico de la gerencia imprescindible para dar respuesta de solución a la determinación social de la salud. El interpretar la importancia de la conducción de los sistemas de salud no ha sido fácil en el transitar de la historia, incluso se ha considerado a veces que la insostenibilidad de buenos sistemas de salud, o la imposibilidad de otros para alcanzar resultados de excelencia ha sido solo por carecer del dinero suficiente. La pregunta básica debiera estar orientada a explicarnos, qué estamos haciendo con el que tenemos pues no se trata de producir salud al precio que sea; lo que se requiere es hacer la mayor y mejor salud posible con los recursos que están a nuestra disposición. Esa correspondencia del saber hacer con los recursos disponibles requiere del dominio de la administración en salud. Para que los sistemas de salud sean en realidad una inversión y no un gasto, es necesario resolver numerosos problemas de estrategias, organización, procesos, competencias profesionales, toma de decisiones, descentralización, capacidad de cambio y liderazgo, sin los cuales seguiremos apareciendo como los grandes gastadores y esa no es la idea. La razón de ser de la gerencia en salud es lograr crecer en calidad y oportunidad de hacer más y mejor salud empleando la menor cantidad de recursos posibles, para lo cual se dispone de los instrumentos y las tecnologías de cómo hacerlo. A los que trabajamos el campo de la administración de la salud, nos corresponde lograr que esto se entienda y se haga. La Administración o Gerencia de la Salud Pública, requiere de un sostenido fortalecimiento y la necesidad de fomentar la conciencia de su importancia. Esto constituye, en estos tiempos, una prioridad no solo en la formación y preparación de los directivos sino sobre todo en la generalización de una cultura gerencial que influya en la concepción y operación de las estrategias, de las estructuras, de los modelos y del modo cómo el servicio es organizado, prestado y asegurado, siempre pensando en la mejor salud con el uso más racional de los recursos. Si no se parte de esta concepción, cualquier sistema por muy bueno que sea, corre el riesgo de perder sostenibilidad(AU)

¿Es suficiente el recurso humano nutricionista en el sistema hospitalario público en Chile?: Una deuda pendiente / Adequacy of nutritionist (dietician) resources in Chilean public hospitals

Background: Human resource deficit is an important management problem in Chilean public hospitals. Aim: To analyze the adequacy of Nutritionist (Dietician) resources in public hospitals. Material and Methods: A questionnaire about Nutritionist resources was sent to head Nutritionists of all public Chilean hospitals, asking about the number of Nutritionists per service, number of hospital beds and number of daily rations served. Results were analyzed based on the Technical Guideline about Nutritional and Feeding Services of public hospitals issued by the Chilean Ministry of Health in 2005. Results: According to the guideline, there should be 1,396 nutritionists working in public hospitals and the results of the survey showed that there were only 603 professionals with a 57% deficit. Conclusions: There is a huge gap between the amount of Nutritionists (Dieticians) required and those effectively working in public hospitals.

Alternativas de gerência de unidades públicas de saúde / Alternatives of management of public health units

Alternativas de Gerência de Unidades Públicas de Saúde apresenta os modelos de gerência da Administração Pública Brasileira, a Lei n. 13.019/2014 e um levantamento feito nos estados sobre os modelos de gerência de unidades públicas de saúde.

Creation of Public Health Cadre in Karnataka State, India.

Background: Public Health is the science and art of promoting Health, preventing diseases and prolonging life through organized efforts of Society. The Government of Karnataka constituted a committee to revive the Public health system in state of Karnataka to provide recommendations for creation of Public health ca-dre. Objectives: To provide recommendations for creation of efficient public health system through creation of public health cadre. Methods: We reviewed several documents for studying the history and current struc-ture of the department regarding creation of public health cadre/department. We conducted 35 brainstorm-ing sessions involving in-depth discussions. We also conducted field visits and administered a pre-designed format for collecting the feedbacks from the officials of different levels. Results: The reviewed documents had a common finding of implementing public health cadre. Our analysis of current human resources in health department indicates that there is shortfall of qualified public health professionals in the department to opt and continue in public health cadre. Among the existing staff, 51% of the respondents wanted to up-date their skills through continued professional education. Our results from the study demonstrated to create a Public health directorate and public health cadre in Karnataka state. Conclusions: We recommend that there can be three levels in Public Health Cadre namely, Taluk level officers, District level officers and State level officers. We recommend time bound promotions of medical officers in accordance with published and updated common seniority list, which is the basis for all service matters.

Competencias esenciales en salud pública: un marco regional para las Américas / Core competencies in public health: a regional framework for the Americas

Se describe la respuesta a un llamado de la Organización Panamericana de la Salud, realizado en 2010, para conformar el Marco Regional de Competencias Esenciales en Salud Pública, con el propósito de apoyar a los Estados de las Américas en sus esfuerzos por fortalecer las capacidades de sus sistemas de salud pública, en tanto estrategia para el desempeño óptimo de las Funciones Esenciales de Salud Pública. El proceso metodológico de dicha respuesta se dividió en cuatro fases. En la primera se convocó a un equipo de expertos que definieron la metodología a seguir durante un taller en el Instituto Nacional de Salud Pública de México en 2010. La segunda fase fue la constitución de grupos de trabajo, utilizando dos criterios: experiencia y composición multidisciplinaria, lo cual derivó en un equipo regional con 225 integrantes de 12 países. Estos equipos elaboraron una propuesta inicial de 88 competencias. En la tercera fase se realizó una validación cruzada de las competencias, cuyo número se redujo a 64. Durante la cuarta fase, que incluyó dos talleres en marzo (Medellín, Colombia) y junio (Lima, Perú) de 2011, las discusiones se centraron en analizar la correspondencia de los resultados con la metodología.

The response is described to the 2010 call from the Pan American Health Organization to develop a Regional Framework on Core Competencies in Public Health, with a view to supporting the efforts of the countries in the Americas to build public health systems capacity as a strategy for optimal performance of the Essential Public Health Functions. The methodological process for the response was divided into four phases. In the first, a team of experts was convened who defined the methodology to be used during a workshop at the National Institute of Public Health of Mexico in 2010. The second phase involved formation of the working groups, using two criteria: experience and multidisciplinary membership, which resulted in a regional team with 225 members from 12 countries. This team prepared an initial proposal with 88 competencies. In the third phase, the competencies were cross-validated and their number reduced to 64. During the fourth phase, which included two workshops, in March 2011 (Medellín, Colombia) and June 2011 (Lima, Peru), discussions centered on analyzing the association between the results and the methodology.

Diagnóstico de la capacidad para el ejercicio de las funciones esenciales de salud pública en países de Mesoamérica, los estados mexicanos de Chiapas y Quintana Roo y la República Dominicana / Diagnosis of capacity to perform essential public health functions in the Central American countries, the Dominican Republic, and the Mexican states of Chiapas and Quintana Roo

OBJETIVO: Caracterizar la capacidad para el desempeño de las funciones esenciales de la salud pública (FESP) de las instituciones públicas y privadas en países de Mesoamérica, los estados mexicanos de Chiapas y Quintana Roo y la República Dominicana. MÉTODOS: Se aplicó una encuesta en línea a 83 organizaciones de Belice, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Panamá, la República Dominicana y los estados mexicanos de Chiapas y Quintana Roo sobre la capacidad de cumplir cada una de las 11 FESP. Los resultados se validaron en un taller con representantes de los ministerios de salud de los siete países y los dos estados mexicanos participantes. RESULTADOS: La mayor capacidad para el desempeño se identificó en la FESP 1 (monitoreo, evaluación y análisis del estado de salud de la población), la FESP 2.1.1 (vigilancia, investigación y control de riesgos y amenazas a la salud pública para enfermedades infecciosas) y la FESP 5 (desarrollo de políticas y planificación en salud). La mayor debilidad se encontró en la FESP 2.1.2 (vigilancia, investigación y monitoreo de las enfermedades no infecciosas). Las asimetrías en el desempeño de las FESP al interior de cada país indican debilidades en las funciones de los laboratorios y de la investigación en salud pública. CONCLUSIONES: Se requiere mejorar el desempeño estratégico en la mayor parte de las FESP en los países y territorios analizados y reforzar la infraestructura, el equipamiento y los recursos humanos, tanto a nivel estratégico como táctico. Se debe aplicar un enfoque regional para aprovechar la capacidad diferencial con vistas al fortalecimiento y el apoyo técnico cooperativo.

OBJECTIVE: Characterize the capacity of public and private institutions in the Central American countries, the Dominican Republic, and the Mexican states of Chiapas and Quintana Roo to perform essential public health functions (EPHFs). METHODS: An online survey of 83 organizations in Belize, Costa Rica, the Dominican Republic, El Salvador, Guatemala, Honduras, Nicaragua, Panama, and the Mexican states of Chiapas and Quintana Roo was conducted to learn about their capacity to perform each of the 11 EPHFs. The results were validated in a workshop with representatives of the ministries of health from the seven countries and the two participating Mexican states. RESULTS: High levels of performance capacity were found most often for EPHF 1 (monitoring, evaluation, and analysis of health status of the population), EPHF 2.1.1 (surveillance, research, and control of risks and threats to public health from infectious diseases), and EPHF 5 (policy development and health planning). The greatest weakness was found in EPHF 2.1.2 (surveillance, research, and monitoring of noninfectious diseases). Asymmetries in EPHF performance within each country mainly revealed weaknesses in the laboratory and public health research functions. CONCLUSIONS: In the countries and territories analyzed, there is a need to improve strategic performance in most of the EPHFs, as well as to strengthen infrastructure, upgrade equipment, and further develop human resources at both the strategic and the tactical levels. A regional approach should be used to take advantage of the different levels of capacity, with a view to greater strengthening and enhanced technical support and cooperation.

O uso de contratos de gestão e incentivos profissionais no setor público de saúde / The use of management contracts and professional incentives in the public health sector

A gestão por resultados constitui um dos pilares da reforma na gestão pública, inclusive na área da saúde, tendo como principais inovações: a institucionalização de contratos de gestão e a utilização de incentivos profissionais. O objetivo deste artigo de revisão de literatura é apresentar e discutir a utilidade e aplicabilidade de contratos de gestão e incentivos profissionais na gestão por resultados no setor público de saúde. A gestão por resultados só será possível quando existir corresponsabilidade e compromisso mútuo entre os trabalhadores e o nível diretivo. Por isso, as metas preestabelecidas devem ser pactuadas entre todos os atores envolvidos e avaliadas de forma periódica para que os incentivos profissionais sejam garantidos. Para efetivamente aumentar a responsabilização sobre os resultados desejados é preciso aprimorar os mecanismos de controle e monitoramento, definir de forma mais precisa indicadores e seus padrões no campo da assistência e da gestão, capacitar as partes envolvidas na elaboração do plano e aperfeiçoar o uso de incentivos profissionais.

Results-based management is a cornerstone of reform in public administration, including the health field, and has become the basis for other innovations such as the institutionalization of management contracts and the use of professional incentives. This review article aims to introduce and discuss the use of such management contracts in the public health sector. Management by results has developed means and tools that highlight the importance of shared responsibility and mutual commitment between workers and management-level directors. Thus, preset goals are negotiated among all the stakeholders and are evaluated periodically in order to grant professional incentives. It is necessary to improve the mechanisms for control and observation, to more precisely determine the healthcare and management indicators and their patterns, to train stakeholders in designing the plan, and to improve the use of professional incentives in order to effectively increase accountability vis-à-vis the desired results.

Orientações para as secretarias executivas dos Conselhos de Saúde / Orientations for the executive secretariat of the Health Councils

A Lei nº 8.142/90 instituiu os Conselhos de Saúde, como atividades estratégicas de caráter permanente e deliberativo, para atuar na formulação das políticas de saúde nas esferas municipais, estaduais e federal. Os Conselhos representam hoje um importante espaço para a efetivação do Controle Social dando voz à sociedade que participa do planejamento, monitora e avalia as ações dos gestores. Para contribuir na atuação técnico-administrativa dos Conselhos são instituídas as Secretarias Executivas. O presente Manual tem como objetivo informar e auxiliar na realização das atividades rotineiras exercidas pelas Secretarias Executivas dos Conselhos de Saúde. Para isso, será apresentada a forma como a Secretária-Executiva do Conselho Nacional de Saúde desenvolve seu fluxo de trabalho. Os exemplos demonstrados podem ser utilizados nos municípios e estados, levando-se em consideração a realidade local. A elaboração deste documento foi aprovada na 220ª Reunião Ordinária do Conselho Nacional de Saúde em abril de 2011 e, também é fruto de um encaminhamento definido durante o Encontro das Secretarias Executivas de Conselhos de Saúde, realizado no dia 1º de junho de 2011, em Brasília. No Manual para Secretarias Executivas de Conselhos de Saúde estão disponíveis as competências e atribuições da área responsável pelas questões administrativas dos Conselhos, a organização, estrutura e os procedimentos rotineiros para melhor condução dos trabalhos da Secretaria Executiva. Além disso, traz as orientações e modelos para elaboração dos mais variados documentos comumente utilizados nos Conselhos. Assim sendo, espera-se que este Manual possa efetivamente orientar os secretários e secretárias-executivas em suas trajetórias, favorecendo-os na obtenção dos resultados almejados.

Coletânea de normas para o controle social no Sistema Único de Saúde - 3ª edição / Norms collection for the social control in the unified health system

Passados 23 anos da criação do Sistema Único de Saúde (SUS) pela Constituição Federal, mudanças na legislação foram necessárias para garantir o fortalecimento e a implementação plena do sistema. Prova dessas transformações, apresentamos a terceira edição da Coletânea de Normas para o Controle Social no Sistema Único de Saúde. A publicação do Conselho Nacional de Saúde (CNS) é destinada a todos os conselheiros de saúde do País que passam a ter em mãos uma ferramenta de rápida busca a essas normas. A Coletânea acrescenta, por exemplo, o Decreto de nº 5.839, de 11 de julho de 2006, que trata da organização, as atribuições e o processo eleitoral do Conselho Nacional de Saúde (CNS) e dá outras providências. E contempla igualmente as alterações que sofreram a Lei Orgânica da Saúde (Lei nº 8.080/90) que passa a contar agora com mais um capítulo que fala sobre a assistência terapêutica e a incorporação de tecnologia em saúde no âmbito do SUS; e a Lei nº 8.429 que altera dois artigos da Lei de Improbidade Administrativa. Outra importante inclusão na Coletânea de Normas para o Controle Social no Sistema Único de Saúde foi o Decreto nº 7.508, de 28 de junho de 2011. O referido decreto regulamenta a Lei nº 8.080, de 19 de setembro de 1990, para dispor sobre a organização do Sistema Único de Saúde (SUS), o planejamento da saúde, a assistência à saúde e a articulação interfederativa. Além das normas citadas, a publicação traz ainda os dispositivos constitucionais que determinam as diretrizes do SUS (Art. 6.º e Art. 196 a Art. 200 da CF) e a Emenda Constitucional 29/2000 que trata da destinação mínima de recursos provenientes das três esferas de gestão para o financiamento das ações e dos serviços de saúde. A regulamentação da Emenda Constitucional nº 29 (EC 29) representa hoje uma das principais lutas do CNS. A legislação brasileira que regulariza a saúde não se finda com essa publicação. As leis acompanham as mudanças sociais e econômicas da sociedade para, assim, procurar seu constante aprimoramento. O objetivo do CNS é disponibilizar aos conselheiros de saúde um documento de consulta prática para servir de suporte ao trabalho que eles realizam na busca por uma saúde pública cada vez mais eficiente, fortalecendo, assim também, o Controle Social.

Imagem-objetivo para a descentralização da vigilância sanitária em nível municipal / A framework for health surveillance decentralization

A descentralização das ações de vigilância sanitária não dispõe de critérios e padrões consensuais para sua avaliação. Objetivando formular e validar uma imagem-objetivo da vigilância sanitária municipal que corresponda à definição de um sistema municipal de vigilância sanitária adequado às necessidades da população, elaborou-se um modelo lógico do qual derivou uma matriz que contém dimensões e critérios para avaliar a gestão e as práticas. A matriz foi submetida a um grupo de especialistas, para validação, mediante conferência de consenso. Dos 54 critérios propostos, 59,3 por cento foram consensuais e 53 (98 por cento) importantes, o que correspondeu a validação da matriz. Considerando a provisoriedade de consensos assim obtidos, o instrumento produzido poderá ser modificado e adaptado. As autoras discutem o potencial da estratégia avaliativa aqui adotada que permite diversas possibilidades de redefinição de critérios e de renovação do consenso.

No consensus has been reached concerning the definition of criteria and standards for evaluating the decentralization of actions by municipal health surveillance systems. With the aim of developing and validating an objective image for municipal health surveillance that would correspond to an appropriate system for the population's health care needs, a logical framework was elaborated, from which a matrix containing dimensions and criteria for management and practices was obtained. The framework was submitted to an expert group for validation at a consensus conference. Of the 54 criteria, there was consensus for 59.3 percent, while 53 items (98 percent) were considered important, thus validating the matrix. In view of the provisory nature of the consensuses, the resulting instrument, which can be used either in its entirety or in part, enables modification and adaptation. The authors discuss the potential of the evaluation strategy adopted here, which allows various possibilities for redefining the criteria and renewing the consensus.

Case detection rate targets under DOTS: the Indian experience.

The DOTS programme in India has been recognized as the fastest growing programme in the world. It currently covers more than 1 billion people (90% of the population). In spite of this rapid expansion, the programme has consistently achieved the global target of 85% cure rates. However, improvement in case detection rates has been slow, and the global target of 70% has been achieved only in the last few quarters. Public-private partnerships were initiated at the national and local level with the non-health public sector, corporate sector and non-governmental organizations, private practitioners and medical colleges. The partnerships have significantly contributed to the case detection rates in the country, especially the medical colleges, which have contributed up to 5%-15%. Some areas achieved case detection rates well above 70%. There is a need to forge new initiatives, strengthen existing partnerships and make special efforts to access the poorer, vulnerable and hard-to-reach sections of society more effectively. This would not only increase the numbers of cases but also serve the overarching objective of equity. Disaggregated targets should be set, with much higher ones for selected areas, sectors and institutions.

Indian public health standards (IPHS) for community health centres.

The health care system in India has expanded considerably over the last few decades but the quality of the services is not up to the mark due to various reasons. Hence standards are being introduced in order to improve the quality of services. A task group under the chairmanship of Director General of Health Services, Government of India was constituted to recommend the standards to be called as Indian Public Health Standards. IPHS are a set of standards envisaged to improve the quality of health care delivery in the country under the National Rural Health Mission.

A deficient public health system as a contributing cause of Severe Acute Respiratory Syndrome (SARS) epidemic in mainland China.

SARS (Severe Acute Respiratory Syndrome) is a newly emerging infectious disease which spread over 32 countries and areas, infected more than 8,000 people and causing more than 900 deaths from November 2002 to August 2003. More than 90% of the SARS cases and death were reported from China. Nevertheless, we still know little about this disease, particularly in etiology. SARS, as an emergency of Public Health System (PHS), alarmed health workers throughout the world proving there is still the potential for an epidemic of an emerging infection both in developed and developing areas. Many reports indicated that the insufficiency of the PHS of China was one of the critical factors contributing to the outbreak of SARS. In this study, we attempt to demonstrate some of the categories of PHS that contributed to the SARS epidemic. Two of the categories studied were the living environment and health resources. In the living environment area, the population and population density were examined. Health resources include the medical facilities, health workers, and per capita public health expenditures. An understanding of these areas is important to prevent future epidemic.

Desafíos para el Caribe a 10 años de la Conferencia Internacional sobre la Población y el Desarrollo de El Cairo, Egipto / Challenges facing Caribbean countries 10 years after the International Conference on Population and Development in Cairo, Egypt

At the International Conference on Population and Development (ICPD) that was held in Cairo, Egypt, in 1994, participants acknowledged that population, economic growth, and sustainable development are concepts that are closely linked, and important strides were made in terms of increased recognition of sexual and reproductive rights. The Programme of Action ratified at that Conference was adopted as a platform for designing national and international policies in the areas of population and development for a period of twenty years. However, in Latin America and the Caribbean all types of obstacles-financial, institutional, and human-still stand in the way of attaining the goals of the Programme of Action, and some governments have established measures that undermine their people's exercise of sexual and reproductive rights. The Caribbean Subregional Meeting to Assess the Implementation of the Programme of Action of the International Conference on Population and Development 10 Years after its Adoption was held in Port of Spain, Trinidad and Tobago, in November of 2003. At the meeting, which was attended by representatives from 20 Caribbean countries and territories, a call was made for more rational use of available resources and for mobilization of additional funds for developing and implementing population and development programs and policies in the Caribbean. The meeting also saw the approval of the Caribbean Declaration, which lays out the challenges that should serve as the roadmap for taking actions to consolidate the progress achieved so far and come closer to attaining the goals established by the ICPD. In the Declaration, the countries and territories of the Caribbean asserted their commitment to continue legislative reforms at the national level while seeking to enforce these reforms in an effort to ensure implementation of the ICPD's Programme of Action and of the Caribbean Plan of Action for Population and Development that was adopted in 1996 by the Economic Community for Latin America and the Caribbean.

Desigualdades en la provisión de asistencia médica en el sector público de salud en Chile / Inequalities in public health care provision in Chile

From 1997 to 1999, the Chilean Ministry of Health conducted studies on the health care networks in each of the country's 13 regions in order to help plan regional health sector development and define investment projects. Health insurance coverage displayed major geographic, age, and gender variations. Out-patient and in-patient medical care in the public sector showed substantial geographic variations. According to patient discharge records from national referral hospitals, only some 20 of total health care capability is used to treat 60 of the Chilean population living in regions outside the Greater Metropolitan area. Analysis of primary care funding shows that municipalities allocating the highest per capita funds are not the ones with the greatest health care needs. New reform proposals must address the issue of complementarity between the public and private health sectors and strengthen the Ministry of Health's leadership role in order for the health system to improve its overall response to the population's health care needs.