Leituras sobre o sanitarismo desenvolvimentista e interpretações para a reforma sanitária brasileira e a saúde coletiva / Readings about developmentalist health and interpretations for the Brazilian health reform and public health

Resumo Na literatura do campo da saúde coletiva há uma construção que sustenta a associação entre o movimento pela reforma sanitária dos anos 1970 e o que se denominou sanitarismo desenvolvimentista. A partir dos discursos de dois sanitaristas do período desenvolvimentista - Mário Magalhães da Silveira e Carlos Gentile de Mello -, buscou-se reconhecer como se deu a construção desse lugar de "precursor" da reforma sanitária. Foi feita a análise das interfaces entre a saúde coletiva, o pensamento desenvolvimentista, a estratégia de construção do "sanitarista desenvolvimentista" e a reforma sanitária. Sem negar o papel precursor daqueles sanitaristas, argumenta-se que a construção do Sistema Único de Saúde não é uma mera continuidade do pensamento desenvolvimentista.

Abstract In the Brazilian public health literature, an association has been drawn between the 1970s health reform movement and what has been called developmentalist health. By investigating the discourse of two sanitarians from the developmentalist period - Mario Magalhães da Silveira and Carlos Gentile de Mello - we seek to unpick how their status of "precursors" of the health reform was constructed, analyzing the interfaces between public health, developmentalist thinking, the strategy for the construction of the developmentalist health and the health reform. Without refuting the pioneering nature of the sanitarians' ideas, we argue that the Brazilian Unified Health System, Sistema Único de Saúde, was created not simply in continuation of developmentalist thinking.

De Alma-Ata a Astana: o percurso dos Cuidados de Saúde Primários em Portugal, 1978-2018 e a génese da Medicina Familiar / From Alma-Ata to Astana: the path of Primary Health Care in Portugal, 1978-2018 and the genesis of Family Medicine

Resumo Ao longo século XX, as profundas alterações que ocorreram na Medicina apenas podem ser completamente esclarecidas se forem observadas numa perspectiva histórica, pois elas sempre ocorreram em resposta a influências externas, umas científicas e tecnológicas, outras de ordem social. A moderna Medicina Familiar é uma das muitas disciplinas novas que se desenvolveram durante o curso da história da Medicina e aqui debatemos de forma crítica, os últimos 40 anos dos cuidados primários em saúde em Portugal, começando em 1971, mesmo antes da Declaração de Alma-Ata (1978). Ao longo do percurso, em 2005, surge a Reforma dos Cuidados Primários em Saúde em Portugal e as novas unidades de saúde familiar, que até setembro de 2019 atendiam cerca de 94% dos cidadãos portugueses, ou seja, mais de nove milhões e meio de pessoas. No final dessa trajetória, de forma solidária e voluntária, esta Reforma serviu de inspiração para outra, no Brasil, na cidade do Rio de Janeiro, em 2009. Por fim, apresentamos os desafios apontados na Declaração de Astana de 2018, dentre elas, a questão da força de trabalho nos cuidados de saúde primários, como fator essencial para o desempenho e a sustentabilidade dos sistemas de saúde.

Abstract Throughout the twentieth century, the profound changes that have taken place in Medicine can only be wholly explained if observed from a historical perspective, for they have always occurred in response to external influences, some scientific and technological, others of a social nature. Modern Family Medicine is one of the many new disciplines that have developed during medical history, and we critically discuss the last 40 years of primary health care in Portugal, which started in 1971, long before the Alma-Ata Declaration (1978). Along the way, in 2005, the Primary Health Care Reform emerges in Portugal, along with the new family health facilities, which until September 2019, attended about 94 % of Portuguese citizens, i.e., 9,5 million people. At the end of this course, in solidarity and voluntarily, this Reform inspired another one in Brazil, in Rio de Janeiro, in 2009. Finally, we present the challenges pointed out in the 2018 Astana Declaration, among them, the issue of the workforce in primary health care as an essential factor for the performance and sustainability of health systems.

Atuação do enfermeiro na reconfiguração do cuidado paliativo em uma unidade de referência nacional (2004) / Nursing performance in the reconfiguration of palliative care in a national reference unit (2004)

No Brasil, o século XX, alcançou políticas públicas voltadas para a oncologia, que influenciaram diretamente na organização e estrutura do Instituto Nacional de Câncer (INCA) e na assistência ao paciente em cuidados paliativos. Esse cenário contribuiu diretamente para o desenvolvimento de iniciativas voltadas à reconfiguração da assistência desses cuidados no Hospital do Câncer IV (HCIV). Esta pesquisa tem como objeto de estudo: reconfiguração do cuidado paliativo do enfermeiro em uma unidade de referência nacional, com vistas a obter a acreditação hospitalar. Os objetivos: descrever as circunstâncias que ensejaram a reconfiguração do cuidado paliativo oncológico do enfermeiro no HCIV; analisar as estratégias empreendidas pelo enfermeiro para reconfigurar o cuidado paliativo oncológico frente ao processo de acreditação hospitalar no HCIV; e discutir os primeiros efeitos simbólicos da reconfiguração do cuidado paliativo oncológico do enfermeiro no HCIV, visando o processo de acreditação hospitalar. Metodologia: trata-se de um estudo histórico-social, de abordagem qualitativa, na perspectiva da História do Tempo Presente, cujo cenário foi o Hospital de Câncer IV (HCIV). As fontes históricas foram: diretas (escritas: relatório, manuais, folderes, entre outros; e depoimentos orais temáticos com sete participantes) e as indiretas (artigos científicos e livros sobre o tema). Os resultados evidenciaram que, para se reconfigurar o cuidado de enfermagem em uma unidade de referência nacional para cuidados paliativos em pacientes oncológicos, iniciou-se, em 2004, um grande investimento institucional, empreendido pela unidade e pelos enfermeiros, tais como a implantação do novo modelo de gestão, centrado em eixos específicos de trabalho, entre eles a acreditação hospitalar. Além disso, foram criados a Divisão de Enfermagem, o regimento interno da unidade, o Núcleo de Assistência de Enfermagem e o ambulatório de curativos tumorais e ostomizados, bem como ocorreu o desenvolvimento do Fórum do 5.o Sinal Vital. Também foram consolidadas a educação continuada e a humanização em âmbito institucional por meio do Projeto de Humanização, vinculado à Política Nacional de Humanização (PNH). Concluiu-se que os enfermeiros, apoiados por uma aliança pactuada com a direção da instituição, contribuíram para que a unidade atendesse aos critérios e objetivos determinados. Destarte, se destacaram, empreenderam eficazes estratégias e alcançaram significativos avanços no cuidado de enfermagem a pacientes oncológicos em estágio avançado, à medida que participavam desse investimento, se transformavam em porta-vozes legítimos de um discurso autorizado no campo da enfermagem oncológica no Brasil.

In Brazil, the 20th century was an increase in public policies focused on oncology, which directly influenced the organization and structure of the National Cancer Institute (INCA) and patient care in palliative care. This scenario has directly contributed to the development of initiatives aimed at the reconfiguration of health services in Cancer Hospital IV (HCIV). The research has as object of study the reconfiguration of the palliative care nursing support in a national unit of reference, in order to establish the hospital accreditation program. Objectives: to describe the circumstances that led to the reconfiguration of the palliative care nursing support in HCIV; to analyze the strategies undertaken by nurses to reconfigure oncologic palliative care in the HCIV accreditation program and to discuss the first symbolic effects that the process produced among the participating nurses professionals. Methods: This is a historical-social study with a qualitative approach from the perspective of the History of Present Time, whose scenario was Cancer Hospital IV (HCIV). The historical sources were direct as reports, manuals, folders and thematic oral statements with 7 participants and indirect sources as scientific articles and books. The results showed that in order to reconfigure nursing care in a national referral unit in palliative care for cancer patients, a major institutional investment was initiated in 2004, conducted by the council and nurses to implement a new management model, centred in specific working areas, seeking for a hospital accreditation. In addition, the Nursing Management Services, the unit's internal regiment, the Nursing Station and tumour and ostomy dressing outpatient clinic were created and the 5th Vital Sign Forum was held. Continued education and institutional humanization were also consolidated through the Humanization Project linked to the National Humanization Policy (PNH). It was concluded that the nurses, supported by an alliance with the institution's management, contributed to achieving the determined objectives that the unit pursued. In addition, they have held a prominent position, undertook effective strategies and achieved significant advances in nursing care for advanced cancer patients. As they participated in this investment, they became legitimate spokespersons for an authorized discourse in the field of oncology nursing in Brazil.

A historical perspective on malaria control in Brazil

Malaria has always been an important public health problem in Brazil. The early history of Brazilian malaria and its control was powered by colonisation by Europeans and the forced relocation of Africans as slaves. Internal migration brought malaria to many regions in Brazil where, given suitableAnopheles mosquito vectors, it thrived. Almost from the start, officials recognised the problem malaria presented to economic development, but early control efforts were hampered by still developing public health control and ignorance of the underlying biology and ecology of malaria. Multiple regional and national malaria control efforts have been attempted with varying success. At present, the Amazon Basin accounts for 99% of Brazil’s reported malaria cases with regional increases in incidence often associated with large scale public works or migration. Here, we provide an exhaustive summary of primary literature in English, Spanish and Portuguese regarding Brazilian malaria control. Our goal was not to interpret the history of Brazilian malaria control from a particular political or theoretical perspective, but rather to provide a straightforward, chronological narrative of the events that have transpired in Brazil over the past 200 years and identify common themes.

Políticas de salud a la mujer en Brasil, 1974-2004 / Políticas de saúde para a mulher no Brasil, 1974-2004 / Women’s health policies in Brazil, 1974-2004

Estudio bibliográfico con el propósito de establecer los principales marcos de la trayectoria evolutiva del contexto en que surgen los programas y políticas de salud pública dirigidas para la mujer en Brasil, en el período de 1974-2004, y discutir sus implicaciones como propuestas gubernamentales con los movimientos políticos y sociales. Se verificó que el Estado, en ese período, posibilitó tres transformaciones: la formulación del Programa Nacional de Salud Materno-Infantil en 1974; los Programas de Salud dirigidos para la Asistencia Integral a la Salud de la Mujer y a Salud del Niño en 1984, y la determinación de una Política de Asistencia Integral a la Salud de la Mujer en 2004. Se contempla en esta política y en el plan del discurso oficial la perspectiva de la integralidad de las acciones de salud, el enfoque de género y de la humanización de la asistencia a la populación femenina.

Estudo bibliográfico com o propósito de estabelecer os principais marcos da trajetória evolutiva do contexto em que surgem os programas e políticas de saúde pública dirigidas para a mulher no Brasil, no período de 1974-2004, e discutir as suas implicações como propostas governamentais com os movimentos políticos y sociais. Verificou-se que o Estado, nesse período, possibilitou três transformações: a formulação do Programa Nacional de Saúde Materno-Infantil em 1974; os Programas de Saúde dirigidos para a Assistência Integral à Saúde da Mulher e à Saúde da Criança em 1984, e a determinação de uma Política de Assistência Integral à Saúde da Mulher em 2004. Contempla-se nesta política e no plano do discurso oficial a perspectiva da integralidade das ações de saúde, o enfoque de gênero e da humanização da assistência à população feminina.

This bibliographic study was designed to identify key milestones in the trajectory of an evolving context in which women’s public health programs and policies emerged in Brazil from 1974-2004 and to discuss their implications as government policy proposals with respect to political and social movements. It was ascertained that, in this period, the State made three changes possible: formulation of the National Maternal and Infant Health Program in 1974, the health programs directed to Comprehensive Women’s and Children’s Health Care in 1984, and introduction of a Comprehensive Women’s Health Care Policy in 2004. The perspective embodied in this policy and related official discourse provides for comprehensive health actions, a gender focus, and humanization of care for women.

The Change of the Health Insurance Policy and Social Welfare Discourse in 1970s / 의사학

This study is to analyze the change of the health insurance policy in the 1970s in relation to social welfare discourse. The public health care in Korea was in very poor condition around the first amendment of the National Health Insurance Act in 1970. Furthermore, due to the introduction of new medical technology, increasing number of big hospitals participating in the medical market, inflation, and other factors, medical expenses skyrocketed and made it hard for ordinary people to enjoy medical services. Accordingly, the social solution to the problem of medical expenses which an individual found hard to deal with became of demand. And as the way to the solution, it was inevitable to consider the introduction of health insurance as social insurance. In this condition, Park regime began to stress the social development from the 1960s. It was to aim to settle various social problems triggered by the rapid industrialization in the 1960s through social development as well as economic development. As the social development was emphasized, the matter of social welfare appeared of importance and led to the first amendment of the National Health Insurance Act in 1970. However, it was impossible for Korean government to enforce a nationwide health insurance. The key issue was how to fund it. Park regime was reluctant to use government fund; it was also hard to burden private companies. Even while the health insurance policy was not determined yet for this reason, the social demand for health insurance became large and large. In particular, in the midst of the first "Oil Shock" which gave a big blow to people's living condition from the late 1973, some reported issues in relation to health service, such as hospitals' rejection of the poor, became a big problem. Coupled with the social demand for a health insurance system, the changes occurred within the medical community was also important. Most of all, hospitals was facing the decrease of the effectiveness of their medical facilities. Therefore, they began to see health insurance as a means of developing potential demand for medical service. In addition, the business world, which already expanded their own corporate welfare for employees from the early 1970s, sharing the idea that it was impossible to keep the issue of public health insurance unsolved, showed an enthusiastic attitude. These factors finally enabled Park regime to adopt the public health insurance system. Likewise, it is critical to understand the establishment of the public health insurance system in Korea through pursuing the process to it. What matters is the discoursive changes as well as the changes in social condition around the establishment, not merely the policy changes per se. Then most people, including decision makers in Park regime, thought of social welfare as a privilege developed countries. Thus, in the 1970s when unbalanced industrialization brought about widening gap between social classes, the employment of a social welfare policy could be recognized as a symbol of an escape from backwardness. In fact, with the introduction of the national health insurance in the 1970s, Park regime could fortify the material fundamental of a social welfare discourse which would be mobilized to strengthen the dichotomous discourse of developedness and backwardness and to dump the social crisis caused by Park regime's industrialization drive on the next generation.

Fórum: o desafio SUS: 20 anos do Sistema Único de Saúde. Introdução / Forum: twenty years of experience and the challenge with the Unified National Health System. Introduction

Esta introdução apresenta o Fórum sobre os 20 anos do Sistema Único de Saúde (SUS), constituído por três artigos e um posfácio. O primeiro texto faz um balanço da implantação do SUS, considerando as diretrizes constitucionais na área da saúde. Situa o contexto e as principais questões que nortearam a criação do SUS e propõe uma renovada articulação das políticas setoriais com um projeto mais amplo para a sociedade. O segundo analisa a dinâmica do SUS; os avanços no acesso e na integralidade da atenção; e os desafios para a concretização de seus objetivos, em face de fatores externos ao sistema, implicando a necessidade de maior politização das análises sobre o tema. O terceiro artigo aborda processos sociais e políticos que se desenvolveram entre 1988 e 2008. Centra a análise na trajetória de duas instâncias colegiadas do SUS de nível federal: o Conselho Nacional de Saúde e a Comissão Intergestores Tripartite. Em que pese a complexidade apontada pelas autoras e os importantes obstáculos identificados, as reflexões revelam que o SUS foi uma exitosa política social, contribuindo, ao mesmo tempo, para a consolidação da democracia no país.

This Introduction presents the Forum on the 20 years of experience with the Unified National Health System (SUS), consisting of 3 articles and a postscript. The first article provides a historical overview of the implementation of the SUS, in light of the Constitutional provisions pertaining to health. It discusses the context and main issues underlying the creation of the SUS in Brazil and proposes a renewed linkage between health sector policies and an expanded project for Brazilian society. The second article analyzes the SUS' dynamics; strides in access to and comprehensiveness of care; and challenges for the achievement of its objectives, in light of factors that are external to the system, involving the need for greater politicization of analyses on the issue. The third article approaches social and political processes that developed from 1988 to 2008. It mainly analyzes the history of two collegiate bodies under the SUS at the Federal level: the National Health Council and the Tripartite Inter-Managers' Commission. Despite the complexity identified by the authors and the important obstacles they identify, the reflections indicate that the SUS has been a successful social policy, besides contributing to the consolidation of democracy in Brazil.

A reforma sanitária brasileira após 20 anos do SUS: reflexões / Reflections on Brazilian National Health Reform after 20 years of experience with the Unified National Health System

Este artigo apresenta algumas reflexões sobre os desafios que esses 20 anos de implantação do Sistema Único de Saúde (SUS) e das diretrizes constitucionais na área da saúde significam para a reflexão acadêmica e para os gestores da área da saúde. Traz como se apresentavam as principais questões naquela época e como elas são tratadas hoje. Termina com a indagação sobre a necessidade de se voltar a articular os projetos setoriais a um projeto maior sobre a sociedade, sob pena de se transformar as propostas originais para a saúde em meras propostas de caráter gerencial.

This article provides some reflections on the challenges that have arisen during 20 of experience with the implementation of Brazil's Unified National Health System and the significance of Constitutional provisions related to health for both academic research and health sector managers. The article discusses the main issues during these 20 years and how they are currently managed, and concludes by inquiring into the need for reconnecting health sector projects to a broader project for Brazilian society, without which the original proposals for health run the risk of becoming merely managerial ones.

"O Brasil não é só doença": o programa de saúde pública de Juscelino Kubitschek / "Brazil isn't only disease": Juscelino Kubitschek's public health program

Analisa o programa de saúde do candidato à Presidência da República Juscelino Kubitschek e seu diálogo com interpretações que identificavam o Brasil como 'país doente' a ser recuperado pela medicina. Os contextos nacional e internacional são marcados pela ideia de desenvolvimento e pelo otimismo sanitário do pós-Segunda Guerra Mundial. Aborda o modo como Kubitschek elaborou, no contexto de seu projeto de desenvolvimento, os temas da centralidade das endemias rurais e do abandono do trabalhador rural, caros ao movimento sanitarista da década de 1910, e indica a articulação de saúde e desenvolvimento nesse programa setorial, bem como a introdução de agendas sanitárias emergentes.

Analyzes the public health program that Juscelino Kubitschek presented while running for president and its dialogue with interpretations that identified Brazil as an ailing country that should be recovered through public medicine. The proposals and goals contained in Kubitschek's healthcare program, as released during his 1955 campaign, serve as the main sources for this analysis. They also were key to establishing this dialogue, which was both prompted and shaped by a national and international context characterized by the post-war idea of development and public health optimism. Within the context of his development project, the article looks at how Kubitschek elaborated the themes of the centrality of rural endemic disease and the abandonment of the rural worker, both dear to the sanitary movement in the 1910s. It also underscores how Kubitschek the candidate endeavored to link health and development within this arena of government policy.

Evolução histórica dos programas de prevenção e controle da dengue no Brasil / The historical evolution of dengue prevention and control programs in Brazil

An epidemiological analysis of the forms and distribution of Dengue fever in Brazil and worldwide was carried out. The National Program of Dengue Control (NPDC) was evaluated based on the data available at "Diagdengue" an official computerized information system allowing to follow-up the implantation and impact of the Program. A factorial analysis was performed by means of a set of indicators contributing to variability. The indicator scores were added and the cities demanding for prior attention of the NPCD were classified for the construction of an index, which is presented three-monthly for every state, with intervals distributed between 0 and 9. The implantation of the NCPD is irregular. Cities with bad implantation are predominating in the north and northeast of the country. In the second analysis, socio-economic variables of the selected cities were added. For the association tests these cities were classified into two groups: "Bad" and "Good/Very Good", based on the association of the index of building infestation informed in the FAD (Yellow Fever and Dengue) database and the constructed index. Associations were verified based on variance analysis, trend test and trend estimate. It was observed that cities with low rates of illiteracy, efficient garbage collection and high ratio of sanitary installations are correlated with a good classification of the city according to Diagdengue.