Perspectivas metodológicas del análisis del discurso aplicadas al estudio de los sistemas de salud

Introducción: El análisis del discurso es un abordaje alternativo de investigación de sistemas de salud. Objetivo: Describir la producción científica que investiga los sistemas de salud utilizando el análisis del discurso como perspectiva teórico-metodológica. Métodos: Revisión sistemática exploratoria de literatura, que incluyó la búsqueda de textos en inglés y español en cinco bases de datos (SciELO, MEDLINE, PubMed, EBSCO y ScienceDirect). Se utilizaron los descriptores "sistema OR salud" AND "análisis OR discurso" y sus traducciones al inglés. Se incluyeron artículos originales con metodología cualitativa, revisiones sistemáticas exploratorias de la literatura, ensayos y tesis doctorales, cuya metodología o tema de revisión fuese expresamente descrita como análisis de discurso de sistemas de salud, de sus funciones o estructura organizativa, publicados en el periodo entre enero de 1994 a diciembre de 2019; se excluyeron textos con metodología cuantitativa, estudios mixtos y metaanálisis. Resultados: Se incluyó un total de 27 textos en la revisión, se describió en cuatro categorías la forma como el análisis del discurso puede ser utilizado en el estudio de los sistemas de salud: el concepto del proceso salud enfermedad, la autonomía del sujeto, los discursos de gestión y los sistemas de salud como política pública. Discusión: Los sistemas de salud son campos para el ejercicio de las relaciones de poder que construyen sujetos, configuran la autonomía del sujeto y determinan las intervenciones del proceso salud-enfermedad. Conclusiones: Esta revisión identificó que el discurso es utilizado como dispositivo de poder que configura sujetos y la forma como se interviene el proceso salud-enfermedad.

Introduction: An alternative approach to health systems research is discourse analysis. Objective: To describe the scientific production that investigates health systems using discourse analysis as a theoretical-methodological perspective. Methodology: Systematic review. The search was conducted in five databases (SciELO, MEDLINE, PubMed, EBSCO and Science Direct), in both Spanish and English. The descriptors used were "sistema OR salud" AND "análisis OR discurso", and their English equivalents. Qualitative studies, scoping reviews, essays and PhD theses, published between January 1994 and December 2019, were included; in all cases their subject was described clearly as discourse analysis of health systems, their functions or organizative structure. Results: A total of 27 texts were included in the revision; four categories describe how discourse analysis can be used in the study of health systems as well, the concept of the health-disease process, subject autonomy, management discourses, and health systems as public policy. Discussion: Health systems are fields for the exercise of power relations that construct subjects, configure the autonomy of the subject, and determine the interventions of the health-disease process. Conclusions: This review identifies that discourse is used as a device of power that configures subjects and the way in which the health-disease process is intervened.

From nightingale to now: Transforming global collaboration in pandemics

@#This article aims to investigate the transformative potential of a global pandemic treaty, focusing on the critical role of Filipino nurses in addressing global health challenges and promoting equitable healthcare systems. Inspired by Florence Nightingale's legacy, the article outlines ten steps for transformative international collaboration. It highlights the critical need for improved global cooperation in response to the projected shortage of health workers by 2030. It advocates for a treaty prioritizing healthcare worker protection, equitable resource distribution, and nursing migration solutions. Nurses' valuable insights and perspectives must be considered by actively involving them in treaty development and implementation. The study employs an informed presentation methodology, connecting Nightingale's inspirational words to today's global health challenges, such as the COVID- 19 pandemic. Key findings highlight the treaty's transformative potential in governance, early warning systems, preparedness and response, research and development, capacity building, ethical considerations, financing, the One Health approach, and climate change. The treaty can strengthen healthcare systems, protect public health, and create a resilient and equitable future in global health by empowering nurses and fostering international collaboration.

Internet de las cosas en el ámbito de la atención médica: tendencias y desafíos / Internet of Things in the Field of Health Care: Trends and Challenges

La internet de las cosas ha mantenido un crecimiento continuo en los últimos años. Las potencialidades de uso que muestra en diferentes campos han sido ampliamente documentadas. Su utilización efectiva en el campo de la salud puede traer consigo mejoras en la eficiencia de los tratamientos médicos, prevenir situaciones de riesgo, ayudar a elevar la calidad del servicio y proporcionar soporte a la toma de decisiones. La presente revisión profundiza en aspectos medulares de su utilización con el objetivo de explorar las principales tendencias y desafíos relacionados con la creciente utilización de la internet de las cosas en la salud, prestando mayor atención a los aspectos relacionados con las arquitecturas utilizadas para el despliegue de sistemas de internet de las cosas en ese ámbito, el manejo de la seguridad de estos sistemas y las herramientas para el apoyo a la toma de decisiones empleadas. Mediante el análisis documental se logra mostrar las principales características de estos sistemas, así como su arquitectura, herramientas utilizadas para la gestión de los datos capturados y mecanismos de seguridad. La utilización de la internet de las cosas en el campo de la salud tiene gran impacto, mejorando la vida de millones de personas en todo el mundo y brindando grandes oportunidades para el desarrollo de sistemas inteligentes de salud(AU)

The internet of things has maintained continuous growth in recent years. The potentialities of use that it shows in different fields have been widely documented. Its effective use in the field of health can bring improvements in the efficiency of medical treatments, prevention of risky situations, help raising the quality of service and provide support for decision-making. The present review explores into core aspects of its use in order to analyze trends, challenges and strengths. Document analysis was used to show the main characteristics of these systems, as well as their architecture, tools used for the management of the captured data and security mechanisms. The use of the internet of things in the health field has a great impact, improving the lives of millions of people around the world and providing great opportunities for the development of intelligent health systems(AU)

Challenges in dementia care: comparing key issues from Brazil and the United Kingdom / Desafios no cuidado a pessoas com demência: comparando questões-chave entre Brasil e Reino Unido

ABSTRACT. The United Kingdom-Brazil Dementia Workshop took place in July 2019 in the city of Belo Horizonte, MG, Brazil, with an interdisciplinary group of health and care professionals from the United Kingdom and from Brazil to address challenges in diagnosis, public perception and care of dementia. The aim of this article is to present the results identified in relation to challenges in the care of dementia, including recommendations that could potentially guide local and State/Municipal authorities and care services for people with dementia in the future. Four key issues were prioritised to identify challenges and generate possible solutions in Brazil and the United Kingdom: I) limitations of current health systems; II) continuous and long-term support for family carers (pre-diagnosis, mourning); III) support for people with advanced dementia and end-of-life care; IV) support for people with young-onset dementia. In both countries, carers feel left without post-diagnostic support; information on the progression of dementia is lacking and some people do not even have a specific diagnosis; encouraging and providing training for carers best manage some of the symptoms is imperative; preparation for end of life care and support carers after the death of their loved ones remains highly needed; strengthening services and qualification of health professionals, also creating protocols to guide dementia-related services represent a common challenge to overcome. The authors outline recommendations according to the issues identified to assist future formulation of adequate policies and services for people with dementia and carers.

RESUMO. O United Kingdom-Brazil Dementia Workshop aconteceu em julho de 2019 na cidade de Belo Horizonte, Minas Gerais, Brasil, com a presença de grupo interdisciplinar de profissionais de saúde e assistência do Reino Unido e Brasil, para abordar desafios no diagnóstico, percepção pública e cuidado à pessoa com demência. O objetivo do presente artigo foi apresentar os resultados encontrados em relação aos desafios no tratamento da demência, incluindo recomendações que possam potencialmente orientar autoridades locais e estaduais/municipais e serviços de atenção à pessoa com demência. Quatro questões-chave foram priorizadas para identificar desafios e gerar possíveis soluções no Brasil e no Reino Unido: I) limitações atuais dos sistemas de saúde; II) suporte contínuo e de longo prazo para cuidadores familiares (pré-diagnóstico, luto); III) apoio a pessoas com demência avançada e cuidados no fim de vida; IV) apoio a pessoas com demência precoce. Em ambos os países, cuidadores se percebem sem apoio pós-diagnóstico; faltam informações sobre a progressão da demência e algumas pessoas sequer têm diagnóstico específico; encorajar e providenciar treino para cuidadores melhor lidarem com sintomas é imperativo; preparação para cuidados no fim da vida e apoio aos cuidadores após morte de familiares permanecem necessários; fortalecer os serviços e qualificação de profissionais de saúde, além de elaborar protocolos para guiar serviços relacionados à demência, é desafio comum a ser superado. Os autores apresentam recomendações quanto às questões identificadas para auxiliar na futura formulação de políticas públicas e serviços para pessoas com demência e cuidadores.

Resisting privatization and marketization of health care: People's Health Movement's experiences from India, Philippines and Europe / Resistindo à privatização e à comercialização dos cuidados de saúde: experiências do Movimento pela Saúde dos Povos na Índia, nas Filipinas e na Europa

ABSTRACT For the last three decades, healthcare systems have been under pressure to adapt to a neoliberal world and incorporate market principles. The introduction of market-based instruments, increasing competition among health care providers, introducing publicly -funded private sector provisioning of healthcare through health insurance financing systems to replace public provisioning of health care, promoting individual responsibility for health and finally, the introduction of market relations through privatization, deregulation and decentralization of health care have been some common elements seen globally. These reforms, undertaken under the guise of increasing efficiency and quality through competition and choice, have in fact harmed the physical, emotional and mental health of communities around the world and also contributed to a significant rise in inequities in health and healthcare access. They have weakened the public healthcare systems of countries and led to commercialization of healthcare. This article presents three case studies of resistance, to the commercialization of health care, by the People's Health Movement (PHM) and associated networks. It aims to contribute to the understanding of the way neoliberal reforms, including those imposed under structural adjustment programmes and some promoted under the Universal Health Coverage (UHC) paradigm, have impacted country-level health systems and access of people to health care, and bring out lessons from the resistance against these reforms.

RESUMO Durante as últimas três décadas, os sistemas de saúde têm estado sob pressão para se adaptarem a um mundo neoliberal e incorporarem princípios de mercado. A introdução de instrumentos de mercado, o aumento da concorrência entre os prestadores de cuidados de saúde, a introdução de prestação de cuidados de saúde do sector privado com financiamento público através de sistemas de financiamento de seguros de saúde para substituir o fornecimento público de cuidados de saúde, a promoção da responsabilidade individual pela saúde e, finalmente, a introdução de relações de mercado através da privatização, desregulamentação e descentralização dos cuidados de saúde têm sido alguns elementos comuns vistos a nível global. Estas reformas, empreendidas sob o pretexto de aumentar a eficiência e a qualidade através da concorrência e da escolha, prejudicaram de facto a saúde física, emocional e mental das comunidades em todo o mundo e também contribuíram para um aumento significativo das desigualdades na saúde e no acesso aos cuidados de saúde. Elas enfraqueceram os sistemas públicos de saúde dos países e levaram à comercialização dos cuidados de saúde. Este artigo apresenta três estudos de caso de resistência à comercialização dos cuidados de saúde, pelo Movimento pela Saúde dos Povos (MSP) e redes associadas. Visa contribuir para a compreensão da forma como as reformas neoliberais, incluindo as impostas pelos programas de ajustamento estrutural e algumas promovidas no âmbito do paradigma da Cobertura Universal da Saúde (CUS), tiveram impacto nos sistemas de saúde dos países e no acesso das pessoas aos cuidados de saúde, e tirar lições da resistência contra estas reformas.

Resisting privatization and marketization of health care: Peoples Health Movements experiences from India, Philippines and Europe / Resistindo à privatização e à comercialização dos cuidados de saúde: experiências do Movimento pela Saúde dos Povos na Índia, nas Filipinas e na Europa

ABSTRACT For the last three decades, healthcare systems have been under pressure to adapt to a neoliberal world and incorporate market principles. The introduction of market-based instruments, increasing competition among health care providers, introducing publicly -funded private sector provisioning of healthcare through health insurance financing systems to replace public provisioning of health care, promoting individual responsibility for health and finally, the introduction of market relations through privatization, deregulation and decentralization of health care have been some common elements seen globally. These reforms, undertaken under the guise of increasing efficiency and quality through competition and choice, have in fact harmed the physical, emotional and mental health of communities around the world and also contributed to a significant rise in inequities in health and healthcare access. They have weakened the public healthcare systems of countries and led to commercialization of healthcare. This article presents three case studies of resistance, to the commercialization of health care, by the People's Health Movement (PHM) and associated networks. It aims to contribute to the understanding of the way neoliberal reforms, including those imposed under structural adjustment programmes and some promoted under the Universal Health Coverage (UHC) paradigm, have impacted country-level health systems and access of people to health care, and bring out lessons from the resistance against these reforms.

RESUMO Durante as últimas três décadas, os sistemas de saúde têm estado sob pressão para se adaptarem a um mundo neoliberal e incorporarem princípios de mercado. A introdução de instrumentos de mercado, o aumento da concorrência entre os prestadores de cuidados de saúde, a introdução de prestação de cuidados de saúde do sector privado com financiamento público através de sistemas de financiamento de seguros de saúde para substituir o fornecimento público de cuidados de saúde, a promoção da responsabilidade individual pela saúde e, finalmente, a introdução de relações de mercado através da privatização, desregulamentação e descentralização dos cuidados de saúde têm sido alguns elementos comuns vistos a nível global. Estas reformas, empreendidas sob o pretexto de aumentar a eficiência e a qualidade através da concorrência e da escolha, prejudicaram de facto a saúde física, emocional e mental das comunidades em todo o mundo e também contribuíram para um aumento significativo das desigualdades na saúde e no acesso aos cuidados de saúde. Elas enfraqueceram os sistemas públicos de saúde dos países e levaram à comercialização dos cuidados de saúde. Este artigo apresenta três estudos de caso de resistência à comercialização dos cuidados de saúde, pelo Movimento pela Saúde dos Povos (MSP) e redes associadas. Visa contribuir para a compreensão da forma como as reformas neoliberais, incluindo as impostas pelos programas de ajustamento estrutural e algumas promovidas no âmbito do paradigma da Cobertura Universal da Saúde (CUS), tiveram impacto nos sistemas de saúde dos países e no acesso das pessoas aos cuidados de saúde, e tirar lições da resistência contra estas reformas.

O Itinerário Terapêutico no Brasil: revisão sistemática e metassíntese a partir das concepções negativa e positiva de saúde / The Therapeutic Itinerary in Brazil: systematic review and meta-synthesis from the health negative and positive conceptions of health

RESUMO A compreensão de como as pessoas procuram ajuda para resolver suas demandas ou problemas de saúde tem sido cada vez mais o foco de pesquisas. Objetiva-se analisar a produção científica nacional que aborda os Itinerários Terapêuticos (IT) a partir das concepções negativa e positiva de saúde. Foram pesquisados estudos na Biblioteca Virtual em Saúde, no período de 2008 a 2019. O metaestudo teve como objetivo interpretar e resumir os resultados. Foram identificados 224 estudos, e 50 foram selecionados. O principal núcleo de interesse na abordagem teórica considerou a doença/problema como disparador para a busca de terapêutica. Observa-se o predomínio de estudos com alto rigor metodológico e que usaram entrevistas e análise de conteúdo para produção de dados. Os resultados dos estudos revelam os sentidos que os sujeitos atribuem ao processo saúde-doença-cuidado. Entre as redes de apoio aos IT, destacam-se a família e os serviços de saúde. A resolutividade do sistema formal e a integralidade do cuidado também foram analisadas. Conclui-se que a ampliação de referenciais de análise e as perspectivas teóricas nos estudos sobre IT, a exemplo da concepção positiva de saúde, podem contribuir para a efetividade da integralidade e a eficácia simbólica no cuidado em saúde.

ABSTRACT The understanding of how people look for help to solve their demands or health problems has increasingly been the focus of researches. The objective is to analyze national scientific production that addresses the Therapeutic Itineraries (TI) in Brazil from the negative and positive conceptions of health. Studies from the period between 2008 and 2019 were investigated on the Virtual Library in Health. The meta-study had the objective of interpreting and summarizing the results. 224 studies were identified, and 50 were selected. The main core of interest in the theoretical approach deemed the disease/problem as the trigger to the quest for treatment. It was noticed the dominance of studies with high methodological accuracy that used interviews and content analysis for data production. The results of the studies indicate the meaning that the subjects attach to the health-disease-care process. Among the IT support networks, the family and the healthcare services are emphasized. The formal system resolvability and care comprehensiveness were also analyzed. It is concluded that the expansion of analytical frameworks and theoretical perspectives on IT studies, such as the positive conception of health, can contribute to the effectiveness of comprehensiveness and symbolic effectiveness in health care.

El reconocimiento del sistema indígena de salud. Implicaciones de la cobertura de salud gubernamental en México / Recognizing the Indigenous Healthcare System. Implications of Government Healthcare Coverage in Mexico / O reconhecimento do sistema indígena de saúde. Implicações da cobertura de saúde governamental no México

Resumen El presente artículo tiene como objetivo analizar la situación que se presenta en la atención a la salud de los pueblos indígenas de México, considerando aspectos sociales y teóricos, así como las implicaciones a nivel bioético. Los pueblos indígenas tienen los peores indicadores de salud, por lo que el gobierno se ha planteado como meta construir instituciones médicas que brinden servicio a estos grupos sociales. Sin embargo, no se ha considerado que las culturas indígenas tienen sistemas médicos distintos, lo cual probabiliza una baja frecuencia de utilización, abandonos y poca adherencia terapéutica; además, se soslaya la preservación del conocimiento tradicional indígena, específicamente, de su medicina. La falta de reconocimiento de las diferencias en las realidades sociales del equipo de salud respecto de los pacientes indígenas es un problema bioético, ya que los programas gubernamentales no han considerado las diferencias culturales. Aunque la inequidad social favorece la falta de justicia en este ámbito, se propone enfocar los análisis a la interacción lingüística equipo médico-paciente indígena, considerando la importancia de promover un discurso que permita la comprensión del sistema médico del otro, más que uno que muestre valoraciones negativas. Esta posición podría aportar conocimiento y soluciones en Bioética.

Abstract This article aims to analyze the situation of healthcare of indigenous peoples in Mexico, considering social and theoretical aspects and bioethical implications. Indigenous peoples have the worst health indicators, so the government has set the goal of building medical institutions that provide services to these social groups. However, it has not considered that indigenous cultures have different medical systems, which entails low frequency of use, desertion and poor adherence to therapy. In addition, the preservation of indigenous traditional knowledge, specifically their medicine, is ignored. The health team's failure to recognize differences in social realities with respect to indigenous patients is a bioethical problem since government programs have not contemplated cultural diversity. Although social inequality favors injustice in this area, we propose to focus analyses on the medical team-indigenous patient linguistic interaction because of the significance of promoting a discourse to understand the other's medical system, rather than one that reflects negative opinions. This stand could provide knowledge and solutions to bioethics.

Resumo Este artigo tem como objetivo analisar a situação que se apresenta na atenção de saúde dos povos indígenas do México, considerando aspectos sociais e teóricos, bem como as implicações no âmbito bioético. Os povos indígenas têm os piores indicadores de saúde, razão pela qual o governo propôs como meta construir instituições médicas que ofereçam serviço a esses grupos sociais. Contudo, não foi considerado que as culturas indígenas têm sistemas médicos diferentes, o que justificaria uma baixa frequência de sua utilização, abandonos e pouca adesão terapêutica; além disso, ignora-se a preservação do conhecimento tradicional indígena, em específico de sua medicina. A falta de reconhecimento das diferenças nas realidades sociais da equipe de saúde a respeito dos pacientes indígenas é um problema bioético, já que os programas governamentais não consideram as diferenças culturais. Embora a inequidade social favoreça a falta de justiça nesse contexto, propõe-se focar as análises na interação linguística equipe médica-paciente indígena, considerando a importância de promover um discurso que permita a compreensão do sistema médico do outro, mais do que um que mostra avaliações negativas. Essa posição poderia contribuir com conhecimento e soluções em bioética.

Envejecimiento demográfico en Cuba y los desafíos que presenta para el Estado / Challenges facing the Cuban State arising from demographic aging

El envejecimiento demográfico en Cuba, visualizado desde hace más de dos décadas, es indudablemente una conquista de las políticas de salud pública y del desarrollo social del país. Aunque el Estado instituyó un sistema de atención encaminado a garantizar a sus personas mayores condiciones favorables para su envejecimiento, el logro social de una mayor longevidad establece nuevos retos en materia de políticas sociales, infraestructuras y servicios de atención e inclusión social hacia el colectivo de los mayores. La población cubana se caracteriza por el decrecimiento y altos índices de esperanza de vida, que incrementan la proporción de personas de 60 y más años, aspecto que introduce un nuevo escenario gerontológico. El presente artículo se propone analizar algunos desafíos hacia el Estado cubano para la conformación de políticas que posibiliten la continuidad del logro social de una mayor longevidad en correspondencia con las condiciones coherentes con el modelo de desarrollo que el país refrenda.

Demographic aging in Cuba, which has been occurring for over two decades, is undoubtedly an achievement of the country's public health policies and social development. Although the State instituted a system of care aimed at guaranteeing elderly people favorable conditions for aging, the social achievement of greater longevity creates new challenges for social policy, infrastructure, healthcare systems and social inclusion. The Cuban population is diminishing and at the same time, life expectancy is increasing. These two conditions increase the proportion of people aged 60 and over, thus introducing a new scenario of an aging population. The present article analyzes some of the challenges that the Cuban State must face when developing policies that address and preserve the social achievement of a greater longevity, together with the conditions inherent in the development model that the country endorses.

Coordenação da assistência à tuberculose: registro de dados e a implementação de um sistema informatizado / Coordinated care for tuberculosis: data registration and implementation of a computerized system

Resumo O objetivo deste artigo é analisar fontes de registro da tuberculose (TB) antes e após a implantação do Sistema Informatizado para Registro da Assistência à TB em Ribeirão Preto (SP). Estudo epidemiológico descritivo-analítico, do tipo intervenção. Os dados foram coletados em fontes secundárias, a partir de um formulário estruturado, e analisados através de teste Qui-quadrado ou Exato de Fisher com nível de significância de 5%. Identificou-se associação entre o período anterior da implantação do sistema com o arquivamento da Ficha do Tratamento Diretamente Observado no prontuário e o registro de orientação de retorno às consultas pela equipe de enfermagem. O posterior esteve associado com o aumento do registro do contato telefônico e endereço do doente de TB, data de término do tratamento, situação de encerramento, resultado da baciloscopia de escarro para controle mensal, teste anti-HIV, consultas mensais e solicitação de exames realizados pelo médico, atendimento com assistente social, condições de vida do doente, controle de comunicantes, incentivos sociais e uso de álcool e drogas. A implantação do sistema possibilitou a melhora no registro de algumas variáveis, ainda que outras fontes de registro tenham permanecido que não fossem o próprio sistema.

Abstract Objective to analyze sources of data for tuberculosis (TB) before and after the implementation of the Computerized System to Record Care for TB in Ribeirão Preto - SP. Method Intervention, descriptive-analytical epidemiological study. Data was collected from secondary sources using a structured form, and analyzed using Chi-squared or Fisher’s Exact Test, with a significance level of 5%. Results We found an association between the period before implementation of the system and placing the Directly Observed Treatment Card in the file, and registration of instructions for the return visit by the nursing team. The latter was associated with an increase in registered data regarding TB patient telephone number, address, end of treatment date, status at closing, sputum smear results for monthly control, HIV test, monthly checkups, tests ordered by physician, social worker visits, patient living conditions, contact control, social incentives and the use of drugs and alcohol. Conclusion Implementing the system improved the registration of a number of variables, despite the fact that other sources of data other than the system continue to exist.

Profesionalidad médica en el capitalismo tardío: percepciones de estudiantes de medicina de la Universidad de Chile / Medical professionalism in late capitalism: perceptions of the medical students at Universidad de Chile

Introducción. La profesionalidad médica está en crisis por la transición desde el libre ejercicio a ser empleados de corporaciones que manejan todo lo relacionado con salud con criterios correspondientes al modelo socioeconómico imperante, permeando la conceptualización y prácticas del ejercicio profesional. Objetivos. Describir cómo los estudiantes de medicina perciben su profesionalidad, identificando factores contextuales que la modulan e implicaciones sobre su vida profesional y personal. Diseño. Investigación cualitativa enmarcada en un estudio del aporte del internado rural a la formación médica. Participantes. Estudiantes del último año de la carrera de medicina. Lugar. Facultad de Medicina, Universidad de Chile. Intervenciones. Se realizaron quince entrevistas semiestructuradas a estudiantes del último año de la carrera en medicina, aplicando análisis narrativo de contenidos e interpretación de significados. Principales medidas de resultados. Percepción de su profesionalidad. Resultados. Existió fuerte tensión entre los valores y principios del ejercicio de la profesión médica y los condicionantes institucionales y contextuales de su práctica. Los entrevistados asumieron responsablemente la búsqueda de soluciones para los motivos de consulta de sus pacientes, desarrollando estrategias individuales orientadas a vencer las limitaciones del sistema y manejar la frustración experimentada. Conclusiones. Conocer cómo los futuros médicos viven e intentan sobrellevar las contradicciones entre su profesionalidad y la realidad laboral evidencia la necesidad de modificar la formación médica. Se propone que lo colectivo se convierta en sustrato y mecanismo de este cambio.

Introduction: Medical professionalism is facing a crisis due to the transition from liberal practice to becoming employees of corporations that manage health related issues with criteria corresponding to the prevailing socioeconomic model which also influences medical concepts and practices. Objectives/: To describe how medical students perceive their professionalism; to identify influencing contextual factors and to portray their implications in student's lives and professional performance. Design: Qualitative research framed in a study regarding the contribution of the rural internship to the medical undergraduate program. Participants: Last year students of medical school. Setting. Faculty of Medicine, Universidad de Chile. Interventions. Fifteen semi-structured interviews were performed to students in their last year at medical school. Narrative analysis followed by interpretation of its meaning was applied to the resulting information. Main outcome measures: Perception of professionalism. Results: Strong tension exists between professionalism's core principles and values and institutional and contextual factors shaping current medical practice. Interviewees take their duty to respond to patient's demands and needs with high sense of responsibility, developing individual strategies to overcome system's limitations and cope with arising frustrations. Conclusions: Evidence on how medical students perceive and try to cope with these contradictions poses the need for a profound transformation of medical education. Focusing on the collective is proposed as a conceptual base as well as a key mechanism for this change.

Innovation on classification of healthcare systems / 中国卫生政策研究

This article addresses the issue of the classification of healthcare systems, with the intent to take a step further than the previously analysed models of healthcare organisation. As concerns the financing of healthcare services, the standard tripartite classification ( according to which healthcare systems are divided into three groups:voluntary insurance, social health insurance and universal coverage) is enriched with two additionaltypes: compul-sory national health insurance and residual programs. With respect to the provision of services and the relationship between insurers and providers, it is important to distinguish between vertically integrated and separated systems. What differentiates this analysis from the majority of previous studies is its underlying logic. Assuming that all sys-tems are hybrid,the article proposes to put aside the classic logic for classifying healthcare systems ( according to which individual countries are pigeonholed into different classes depending on the prevailing system) in favour of the identikit logic. The concept of segmentation ( of healthcare services or population) proves to be remarkably use-ful to this purpose.

Structural Factors of the Middle East Respiratory Syndrome Coronavirus Outbreak as a Public Health Crisis in Korea and Future Response Strategies / 예방의학회지

The recent Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak has originated from a failure in the national quarantine system in the Republic of Korea as most basic role of protecting the safety and lives of its citizens. Furthermore, a number of the Korean healthcare system's weaknesses seem to have been completely exposed. The MERS-CoV outbreak can be considered a typical public health crisis in that the public was not only greatly terrorized by the actual fear of the disease, but also experienced a great impact to their daily lives, all in a short period of time. Preparedness for and an appropriate response to a public health crisis require comprehensive systematic public healthcare measures to address risks comprehensively with an all-hazards approach. Consequently, discussion regarding establishment of post-MERS-CoV improvement measures must focus on the total reform of the national quarantine system and strengthening of the public health infrastructure. In addition, the Korea Centers for Disease Control and Prevention must implement specific strategies of action including taking on the role of "control tower" in a public health emergency, training of Field Epidemic Intelligence Service officers, establishment of collaborative governance between central and local governments for infection prevention and control, strengthening the roles and capabilities of community-based public hospitals, and development of nationwide crisis communication methods.

Epidemiological Profile of Leprosy in the Brazilian state of Piauí between 2003 and 2008 / Perfil epidemiológico da hanseníase no estado do Piauí, período de 2003 a 2008

BACKGROUND: Leprosy is a chronic infectious disease caused by Mycobacterium leprae. It is considered a major public health issue in developing countries. OBJECTIVES: To evaluate the clinical and epidemiological profile of leprosy patients between 2003 and 2008 in the state of Piauí, to analyze detection and prevalence rates in the general population and in the population of children under 15 years of age, and to evaluate the predominant clinical forms. METHODS: Data were obtained from the notifiable diseases database of the State Health Department, Piauí, Brazil. Medical records are retrieved from patients' charts using a specific questionnaire and the collected data is then entered into the database system. RESULTS: Of the 12,238 cases of leprosy reported in this period, 85% represented new cases. The mean overall annual detection rate was 54 cases/100,000 habitants. The rate for children under 15 years of age was 15.3 cases/100,000 habitants. Overall, 52.18% of the patients were male; 64.66% were between 20 and 59 years of age; and 53.53% had the paucibacillary form of leprosy. Nevertheless, in 88.82% of cases of the paucibacillary form of the disease, more than five lesions were present, while in 10.55% of cases of the multibacillary form of the disease, no lesions were present. Over 20% of patients had some degree of disability. CONCLUSION: These indicators point to a high circulation of bacilli in the community and highlight the extreme difficulty experienced by the primary healthcare network in organizing itself in order to ensure that patients with this complex disease receive an accurate and early diagnosis.

FUNDAMENTOS: A hanseníase é uma doença infecciosa crônica, causada pelo Mycobacterium leprae, sendo considerada um grande problema de saúde pública nos países em desenvolvimento. OBJETIVOS: Objetivou-se estudar o perfil clinicoepidemiológico dos pacientes com hanseníase no período de 2003 a 2008, no estado do Piauí, verificar suas taxas de detecção e de prevalência na população geral e em menores de 15 anos e avaliar as formas clínicas predominantes. MÉTODOS: Os dados foram obtidos a partir da base do Sistema de Informação de Agravos de Notificação da Secretaria de Saúde do estado do Piauí, sendo as informações procedentes dos prontuários médicos, organizadas em um questionário específico. RESULTADOS: Do total de 12.238 casos de hanseníase notificados no período em questão, 85% eram casos novos (taxa de detecção geral anual média de 54 casos/100.000 habitantes e em menores de 15 anos de 15,3/100.000 habitantes); 52,18 % eram homens, 64,66 % dos pacientes encontravam-se na faixa etária de 20 a 59 anos e 53,53 % apresentavam a forma paucibacilar. No entanto, 88,82% das formas paucibacilares apresentavam mais de cinco lesões e 10,55 % das formas multibacilares não tinham qualquer lesão. Mais de 20% dos pacientes tinham algum grau de incapacidade. CONCLUSÃO: Conclui-se que estes indicadores apontam para uma elevada circulação do bacilo na comunidade e a grande dificuldade que a rede básica apresenta de se organizar de forma a diagnosticar correta e precocemente os casos desta complexa doença.

Pain Management in Cancer Patients Who Are Registered in Public Health Centers

PURPOSE: This study was designed to describe outcomes of pain management, to identify pain intensity, pain management and barriers to pain management, and to test correlation among the variables in cancer patients who are registered in public health centers. METHODS: By using a descriptive survey design, 3 instruments were used to collect data: the Numeric Rating Scale for pain, the Barriers Questionnaire-Korean version, and a one-item self-report tool about patient satisfaction. A sample of 190 patients with cancer was recruited from a public health center. RESULTS: The mean rating for pain during the past 24 hr was mild and the mean score of barriers to pain management was 3.20. Patients were satisfied with pain management but they also had concerns it. A negative correlation was found among pain severity, pain relief and satisfaction of pain management. However, there was not significant correlation between the patient-related barriers to pain management and other variables. CONCLUSION: These results suggest that the intervention for cancer patients should focus not only on patient-related barriers to pain management, but also address health-care system related barriers.

Implantação da estratégia DOTS no controle da Tuberculose na Paraíba: entre o compromisso político e o envolvimento das equipes do programa saúde da família (1999-2004) / Implementation of the DOTS strategy in the control of TB in Paraiba: between the political commitment and the involvement of the teams of the family health program (1999-2004)

Foi analisada a implantação da estratégia Tratamento Diretamente Observado de Curta Duração (DOTS) no controle da tuberculose, sob a ótica dos coordenadores do Programa de Controle da Tuberculose (PCT), nos seis municípios prioritários da Paraíba. Foram realizadas entrevistas semiestruturadas com sete coordenadores de PCT. Fortalezas do DOTS: cinco municípios alcançaram a taxa de cura de 90 por cento. Entre as debilidades identificou-se, na dimensão política, a descontinuidade do cargo de coordenador de PCT, o despreparo da equipe local, a precariedade da estrutura técnico-administrativa e a insuficiência da rede laboratorial; na dimensão operacional ainda é baixa a incorporação da busca de sintomáticos respiratórios pelas Equipes de Saúde da Família. Ocorreram mudanças de cunho epidemiológico, operacional e político. a implantação e garantia da sustentabilidade do DOTS no Estado dependem do modo da organização dos serviços de saúde e o compromisso político do gestor no apoio a estratégia.

The scope of this paper is to analyze the implementation of the Directly Observed Treatment Short-Course (DOTS) strategy in the control of tuberculosis, from the standpoint of the coordinators of the Tuberculosis Control Program (TCP) in six priority municipalities in the state of Paraíba, Brazil. Semi-structured interviews were conducted with seven TCP coordinators. Five municipalities proved to be DOTS success points achieving a 90 percent cure rate. Among the DOTS weak points in the political dimension, the following aspects were identified: lack of continuity of the TCP coordinator position; lack of preparedness of the local team; precarious technical-administration structure and insufficiency of the laboratory network. In the operational dimension, the search for respiratory symptoms by the Family Health Teams is still low. Changes of an epidemiological, operational and political nature have been incorporated, though the implementation and guarantee of the sustainability of DOTS in the State depends on the way the health services are organized and on the manager's political commitment to support the strategy.

Nuevo profesionalismo, educación médica y sistemas de salud / New professionalism, medical education and healthcare systems

El propósito de este artículo es discutir de qué modo el denominado "nuevo profesionalismo" puede ayudar a que la educación de los médicos se haga teniendo en cuenta los efectos de la globalización tanto sobre la situación de salud como sobre las necesidades de profesionales sanitarios, con particular énfasis en los países de la Unión Europea los cuales están inmersos en un profundo proceso de reforma de sus enseñanzas universitarias. Para ello, en primer lugar se presentan los conceptos básicos del "nuevo profesionalismo" y de las estrategias fundamentales de la educación médica actual que trata de formar médicos capaces de afrontar los retos éticos, científicos y profesionales que se plantean a comienzos del presente siglo. A continuación, se insiste en la interdependencia de las reformas del pregrado, del posgrado y de la formación continuada. Se plantean luego los retos y dificultades que han de afrontarse a la hora de cambiar las distintas etapas de la educación médica. Y se concluye que, pese a lo reciente de las reformas de la educación médica, a su gran complejidad, y a la todavía escasa disponibilidad de evaluaciones contrastadas sobre sus resultados, existen fuertes sinergias entre los principios y valores del "nuevo profesionalismo" y los objetivos de las reformas.

The scope of this paper is to discuss how so-called "new professionalism" can help in how the education of physicians is conducted, by taking into account the effects of globalization both on the situation of health and on the needs of health professionals with particular emphasis on European Union countries, which are engaged in a profound process of reform in university education. To achieve this, first we present the basic concepts of "new professionalism" and the key strategies of current medical education, which is to train physicians capable of dealing with ethical, scientific and professional challenges that are arising at the beginning of this century. The interdependence of reforms in the undergraduate, graduate and ongoing training areas is then emphasized. The challenges and difficulties to be faced when switching to different stages of medical education are then outlined. It was concluded that, notwithstanding recent reforms in medical education, their great complexity and the still limited availability of contrasting assessments of their results, there are strong synergies between the principles and values of the "new professionalism" and the objectives of the reforms.

Saúde e territorialização na perspectiva do desenvolvimento / Health and territorialization from the perpective of development

A relação entre saúde e desenvolvimento é complexa e remete ao campo da economia política, dado que envolve diferentes interesses sociais, políticos e econômicos. No caso brasileiro, esta associação é particularmente relevante no que diz respeito à dimensão territorial, tendo em vista o papel central dos serviços de saúde para organização da rede urbana e delimitação de escalas e limites territoriais. No campo teórico-conceitual, o artigo explora vertentes analíticas das relações entre saúde e desenvolvimento, bem como entre a saúde e a questão territorial. A seguir, analisa a trajetória da política de descentralização e regionalização do Sistema Único de Saúde (SUS) e dos investimentos federais, que constituem a base de sua evolução espacial. A partir da revisão conceitual e dos dados empíricos, procuram-se estabelecer os nexos teóricos e político-institucionais entre saúde e desenvolvimento, buscando subsidiar a discussão dos desafios para uma nova inserção da saúde no modelo de desenvolvimento brasileiro, historicamente marcado por desigualdades econômicas e sociais com forte expressão territorial.

The relationship between health and development is complex and lies in the field of political economy, given that it involves different social, political, and economic interests. In the Brazilian case, this association is particularly relevant in terms of the territorial dimension, in light of the central role of healthcare services in the organization of the urban network and the demarcation of territorial schedules and limits. In the theoretical-conceptual field, this study explores analytical areas that approach the relations between health and development, as well as between health and the territorial issue; and analyzes the history of the decentralization and regionalization policy in the Unified National Health System (SUS) and Federal investments that constitute the basis for its spatial evolution. Based on this conceptual review and empirical data, the study attempts to establish theoretical and political-institutional connections between health and development. The aim is thus to support the discussion on challenges facing a new role for health in the Brazilian development model, historically marked by economic and social inequalities with strong territorial overtones.

Comparación de ranking del Ministerio de Salud (Minsal) e impacto financiero de las 40 primeras patologías Auge-GES vigentes en Chile / Comparing the Minsal ranking with the financial impact of the first 40 Auge-GES pathologies in Chile

El presente artículo compara el ranking Minsal de 40 patologías Auge-GES con el determinado por impacto financiero. Se elaboró una base de datos homogénea, se estandarizaron datos y se aplicaron correlaciones Pearson y Spearman. Se concluye que el criterio de impacto financiero cambia efectivamente las prioridades y modifica la congruencia social de la política de Estado.

Reforma y gobernanza en salud: el atractivo del gerenciamiento en la acción pública / Governance and health: the rise of the managerialism in public sector reform

El artículo propone un examen de diferentes proyectos de reforma de los sistemas de salud de Canadá y de algunas provincias canadienses. Indica ciertas tendencias en la renovación de la gobernanza. El análisis se apoya sobre la hipótesis de que una reforma es per se un ejercicio de renovación de la concepción y de las prácticas de gobernanza. Al buscar renovar la gobernanza, los reformadores esperan encontrar instrumentos suficientes y eficaces para alcanzar los objetivos anunciados en sus reformas. El artículo muestra que la concepción y las modalidades operativas de la gobernanza se transforma a través del tiempo y que ellas muestran ciertas tensiones inherentes al proceso de transformación y legitimación del sistema público de salud. La primera parte discute las relaciones entre reforma y cambio. La segunda describe la noción de gobernanza implícita en el análisis. La tercera parte traza la evolución de la concepción de gobernanza, mediante el análisis de contenido de diferentes informes para propuestas de reformas Se analizan las ideologías y los principios organizadores del núcleo de los proyectos reformistas, para dar cuenta de las nuevas tendencia en materia de gobernanza reveladas por las reformas. Se identifican cinco ideologías: la ideología democrática, la ideología de la "salud poblacional", la ideología privatizadora o de negocios, la ideología gerencial y la ideología de la equidad y del humanismo. Ello permite una discusión sobre el alcance de la perspectiva gerencial de la gobernanza que parece dominar los actuales proyectos de reforma.

The article examines various healthcare systems reform projects in Canada and some Canadian provinces and reveals some tendencies in governance renewal. The analisis is based on the hypothesis that reform is an exercise aiming at the renewal of governance conception and practices. In renewing governance, reform leaders hope to use adequate and effective levers to attain announced reform objectives. The article shows that the conceptions and operational modalities of governance have changed over time and that they reveal tensions inherent to the transformation and legitimation process of public healthcare systems. The first section discusses the relationships between reform and change. The second section defines the conception of gouvernance used for the analisis. Based on a content analisis of the various reform reports, the third section reveals the evolution of the conception of governance in healthcare systems in Canada. In order to expose the new tendencies, ideologies and operational principles at the heart of the reform projects are analysed. Five ideologies are identified: the democratic ideology, the "population health" ideology, the business ideology, the managerial ideology and the ideology of equity and humanism. This leads to a discussion on the dominant influence of the managerial ideology in the current reform projects.

L’article propose un examen de différents projets de réforme des systèmes de santé au Canada et dans certaines provinces canadiennes. Il révèle certaines tendances dans le renouvellement de la gouvernance. L’analyse s’appuie sur l’hypothèse qu’une réforme est en soit un exercice de renouvellement de la conception et des pratiques de gouvernance. En cherchant à renouveler la gouvernance, les réformateurs espèrent se donner des leviers suffisants et efficaces pour atteindre les objectifs annoncés des réformes. L’article montre que les conceptions et les modalités opératoires de la gouvernance se sont transformées à travers le temps et qu’elles révèlent certaines tensions inhérentes au processus de transformation et de légitimation des systèmes publics de santé. Une première section discute des rapports entre réforme et changement. Une deuxième section décrit la conception de la gouvernance à la base de l’analyse. La troisième section retrace au moyen d’une analyse du contenu de différents rapports proposant des réformes, l’évolution de la conception de la gouvernance. Pour rendre compte des nouvelles tendances en matière de gouvernance révélées par les réformes, les idéologies et les principes organisateurs qui sont au coeur des projets réformistes sont analysés. Cinq idéologies peuvent être dégagées: l’idéologie démocratique, l’idéologie « santé des populations », l’idéologie affairiste, l’idéologie managériale et l’idéologie de l’équité et de l’humanisme. Ceci permet une discussion sur la portée d’une approche dite managériale de la gouvernance qui semble dominer les projets de réforme actuels.