Guía de acercamiento y negociación / Approach and negotiation guide

El presente documento, es una actualización del que se elaborara en el 2016. Bajo la premisa aportada por el Convenio 169, en el artículo 25 que establece que: "Los servicios de salud…deberán planearse y administrarse en cooperación con los pueblos interesados y tener en cuenta sus condiciones económicas, geográficas, sociales y culturales, así como sus métodos de prevención, prácticas curativas y medicamentos tradicionales." Por ello, el modelo presentado, establece que "toda acción que se planifica desde fuera de la comunidad, altera su camino normal y se constituyen en intervenciones que reconfigura su cultura, formas de vida y cosmopercepción. Es necesario reconsiderar que las comunidades saben vivir y desarrollarse desde sus realidades, y que las intervenciones constituirán acciones para apoyar sus procesos históricos, incluyendo las de salud. Y agrega que: "debe tomar en cuenta las condiciones económicas, geográficas sociales y culturales de los pueblos; este párrafo justifica plenamente del porqué la planeación y administración de los servicios deben darse en conjunto; por cuanto ellos son los que conocen sus propias necesidades, sus realidades, su cultura, su organización local y todo lo referente a la comunidad."

Brigadas de salud en cardiología pediátrica: del triaje médico al triaje social / Pediatric cardiology health brigades: from medical triage to social triage

RESUMEN Este artículo explora aspectos socioculturales de un programa de brigadas de cardiología pediátrica para la atención de menores de poblaciones de escasos recursos que habitan en regiones periféricas de Colombia. Problematizamos las brigadas como estrategia humanitaria para cerrar las brechas de inequidad en el acceso a la atención en salud, y como contexto particular para el encuentro médico, la experiencia de la cardiopatía y la definición de las trayectorias de cuidado. A partir de la observación etnográfica de brigadas y de entrevistas a familias asistentes y personal de salud, realizadas durante el año 2016 en cinco ciudades diferentes, indagamos en las dinámicas que configuran el encuentro médico y cuestionamos los mecanismos (médicos y sociales) mediante los cuales se evalúa y decide qué familias pueden acceder a atención médica especializada en Bogotá. Se concluye que las brigadas, al ser iniciativas que continúan anclándose en el humanitarismo, en lugar de contribuir a la transformación de las condiciones que generan inequidades en salud acaban reproduciéndolas y exacerbándolas en la medida que seleccionan las vidas con prioridad para ser salvadas.

ABSTRACT This article explores the sociocultural aspects of a program of pediatric cardiology health brigades that provides care to children from low-income populations in peripheral regions of Colombia. We analyzed the brigades as a humanitarian strategy to close the gaps of inequity in access to health care, and as a particular context of the medical encounter, the experience of heart disease and the definition of care trajectories. Based on ethnographic observation of brigades and interviews with families receiving care and with health personnel, carried out in 2016 in five different cities, we looked at the dynamics that shape the medical encounter and questioned the mechanisms (medical and social) through which it is evaluated and decided which families can access care in Bogota. We conclude that the brigades, as initiatives that continue to be anchored in humanitarism instead of contributing to the transformation of the conditions that generate health inequities, reproduce and exacerbate such inequities by selecting which lives receive priority to be saved.

Aporte del uso de herramientas básicas de Telemedicina en la atención de niños y adolescentes con Artritis idiopática juvenil, en el Hospital de Puerto Montt. Chile / Contribution of the use of basic telemedicine tools to the care of children and adolescents with juvenile idiopathic arthritis at the Puerto Montt Hospital, Chile

Resumen: Niños y adolescentes con enfermedades reumatológicas, requieren atención especializada e integral, sin embargo, reumatólogos e inmunólogos pediátricos se concentran en hospitales con tecnología específica, costosa y moderna. Como algunos pacientes con Artritis idiopática juvenil (AIJ) vive en áreas rurales, lejanas y de accesibilidad limitada, el uso de Telemedicina (TM) puede optimizar el diagnóstico, seguimiento y pronóstico. Objetivo: Mostrar 10 años de experiencia de un modelo de atención mixta: presencial y a distancia, usando TM básica; el impacto institucional, ventajas, des ventajas y aceptación reportados por padres y pacientes. Pacientes y Método: Estudio exploratorio, descriptivo, retrospectivo con componente cualitativo. Previa autorización de comité ético-científico del Servicio de salud del Reloncaví y la aplicación de consentimiento/asentimiento informado, se efectuó revisión de historias clínicas y se aplicó encuesta cualitativa a padres y niños mayores de 14 años con AIJ, atendidos entre 2005-2015 en el policlínico de reumatología infantil Hospital Puerto Montt. Resultados: Participaron 27/35 pacientes con AIJ atendidos por pediatra capacitado, aseso rado a distancia (1.000 km) por inmunólogo. 8/35 pacientes no contestaron por opción o cambio de domicilio. 70 % de padres y pacientes aceptaron el modelo de atención y 4% preferirían atención esporádica solo por especialista para diagnóstico y seguimiento. El número de pacientes trasladados anualmente disminuyó de 10 a 1. Las ventajas del modelo de atención superaron las desventajas per cibidas por padres y pacientes con AIJ. Conclusión: El uso de herramientas de TM en AIJ disminuyó los traslados, mejoró el seguimiento y fue considerado ventajoso por los padres y pacientes.

Abstract: Children and adolescents with rheumatologic diseases require specialized and comprehensive care, but pediatric rheumatologists and immunologists are concentrated in hospitals with specific, high-cost and modern technology. Considering that some patients with juvenile idiopathic arthritis (JIA) live in rural, remote and limited accessibility areas, the use of Telemedicine (TM) can optimize diag nosis, follow-up and prognosis. Objective: Reporting 10 years of experience of a mixed care model: face-to-face and distance, using basic TM; the institutional impact, advantages, disadvantages and acceptance informed by parents and patients. Patients and Method: Exploratory, descriptive, and re trospective study with qualitative component. After the authorization of a scientific-ethics committee of the Reloncaví Health Service and the application of informed consent, a review of medical records was carried out and a qualitative survey was applied to parents and children over 14 years of age with JIA, seen between 2005-2015 in the pediatric ambulatory rheumatology polyclinic of Puerto Montt Hospital. Results: The were 27/35 participating patients with JIA attended by a trained pediatrician and assisted by distance (1,000 km) by an immunologist. The 8/35 patients did not answer by choice or change of address. The 70% of parents and patients accepted the model of care and 4% would pre fer sporadic care only by specialists for diagnosis and follow-up. The number of patients transferred annually decreased from 10 to 1. The advantages of the care model outweighed the disadvantages perceived by parents and JIA patients. Conclusion: The use of TM tools in JIA decreased transfers, improved follow-up and were considered advantageous by patients and their parents.

Referral system in rural Iran: improvement proposals / O sistema de encaminhamento de pacientes na zona rural do Irã: propostas para melhorias / Sistema de derivación sanitario en zonas rurales de Irán: propuestas de mejora

Because of insufficient communication between primary health care providers and specialists, which leads to inefficiencies and ineffectiveness in rural population health outcomes, to implement a well-functioning referral system is one of the most important tasks for some countries. Using purposive and snowballing sampling methods, we included health experts, policy-makers, family physicians, clinical specialists, and experts from health insurance organizations in this study according to pre-determined criteria. We recorded all interviews, transcribed and analyzed their content using qualitative methods. We extracted 1,522 individual codes initially. We also collected supplementary data through document review. From reviews and summarizations, four main themes, ten subthemes, and 24 issues emerged from the data. The solutions developed were: care system reform, education system reform, payment system reform, and improves in culture-building and public education. Given the executive experience, the full familiarity, the occupational and geographical diversity of participants, the solutions proposed in this study could positively affect the implementation and improvement of the referral system in Iran. The suggested solutions are complementary to each other and have less interchangeability.

Devido à comunicação insuficiente entre os profissionais de saúde na atenção primária e os especialistas, levando a ineficiências e ineficácias nos desfechos de saúde na população rural, a implementação de um sistema funcional de referência e contra-referência é uma das tarefas mais importantes para alguns países. Com o uso de métodos propositais e de "bola de neve", o estudo incluiu especialistas em saúde pública, gestores, especialistas clínicos e representantes de planos de saúde, de acordo com critérios predeterminados. Gravamos e transcrevemos todas as entrevistas, e depois analisamos o conteúdo através de métodos qualitativos. Inicialmente extraímos 1.522 códigos individuais. Também coletamos dados complementares através da revisão de documentos. A partir das revisões e resumos, emergiram dados sobre quatro temas principais, dez subtemas e 24 questões. Foram desenvolvidas as seguintes soluções: reforma do sistema de atenção, reforma do sistema de ensino, reforma do sistema de remuneração e melhorias na construção de cultura e no ensino público. Em função da experiência executiva, a familiaridade plena e a diversidade ocupacional e geográfica dos participantes, as soluções propostas pelo estudo poderiam impactar positivamente a implementação e melhoria do sistema de encaminhamento de pacientes no Irã. As soluções propostas se complementam e são menos intercambiáveis.

Debido a la insuficiente comunicación entre los responsables de la atención primaria y los especialistas, se producen ineficiencias y falta de eficacia en las condiciones de salud de la población rural iraní. Por ello, implementar un buen sistema de derivación sanitario es una de las tareas más importantes para algunos países. Usando un método de muestreo intencional y de bola de nieve, incluimos a expertos en salud, formuladores de políticas, médicos de familia, especialistas clínicos, y expertos del ámbito de las empresas de seguros de salud en este estudio, de acuerdo con criterios predeterminados. Grabamos todas las entrevistas, transcribimos y analizamos su contenido usando métodos cualitativos. En un principio se seleccionaron 1.522 códigos individuales. También obtuvimos datos complementarios a través de la revisión de documentación. Fruto de las revisiones y puestas en común, se obtuvieron 4 temas principales, 10 subtemas y 24 cuestiones que afloraron de estos datos. Las soluciones desarrolladas fueron: reforma del sistema de atención, reforma del sistema educativo, reforma del sistema de pago, y mejoras en la educación cultural y pública. Dada la experiencia ejecutiva, la gran sinceridad en las respuestas, la diversidad ocupacional y geográfica de los participantes, las soluciones propuestas en este estudio pueden afectar positivamente la implementación y mejora del sistema de derivación sanitario en Irán. Las soluciones sugeridas son complementarias entre ellas, aunque poseen una menor intercambiabilidad entre sí.

Acercamiento y negociación comunitaria: modelo incluyente en salud [MIS] / Community approach and negotiation: inclusive model in health [MIS]

Bajo la premisa aportada por el Convenio 169, en el artículo 25 que establece que: "Los servicios de salud…deberán planearse y administrarse en cooperación con los pueblos interesados y tener en cuenta sus condiciones económicas, geográficas, sociales y culturales, así como sus métodos de prevención, prácticas curativas y medicamentos tradicionales." Por ello, el modelo presentado, establece que "toda acción que se planifica desde fuera de la comunidad, altera su camino normal y se constituyen en intervenciones que reconfigura su cultura, formas de vida y cosmopercepción. Es necesario reconsiderar que las comunidades saben vivir y desarrollarse desde sus realidades, y que las intervenciones constituirán acciones para apoyar sus procesos históricos, incluyendo las de salud. Y agrega que: "debe tomar en cuenta las condiciones económicas, geográficas sociales y culturales de los pueblos; este párrafo justifica plenamente del porqué la planeación y administración de los servicios deben darse en conjunto; por cuanto ellos son los que conocen sus propias necesidades, sus realidades, su cultura, su organización local y todo lo referente a la comunidad."

Perspectives of the Community and PHC Doctors from Three Southern States in India on Community Preference for Health Services Provided by Rural Medical Practitioners.

Research question: Study to determine the reasons why community members continue to access healthcare through Rural Medical Practitioners (RMPs). Objective : To find out the impression of stakeholders i.e. community leaders, PHC doctors and members of community on the need of RMPs cater to the health needs of the communities. Study design : Cross sectional study. Setting : Remote and rural villages in Andhra Pradesh, Tamilnadu and Kerala. Participants : 322 persons who include 59 RMPs, 81 village heads, 55 PHC doctors and 127 patients.

Health care inequities in north India: Role of public sector in universalizing health care.

Background & objectives: Income inequality is associated with poor health. Inequities exist in service utilization and financing for health care. Health care costs push high number of households into poverty in India. We undertook this study to ascertain inequities in health status, service utilization and out-of-pocket (OOP) health expenditures in two States in north India namely, Haryana and Punjab, and Union Territory of Chandigarh. Methods: Data from National Sample Survey 60th Round on Morbidity and Health Care were analyzed by mean consumption expenditure quintiles. Indicators were devised to document inequities in the dimensions of horizontal and vertical inequity; and redistribution of public subsidy. Concentration index (CI), and equity ratio in conjunction with concentration curve were computed to measure inequity. Results: Reporting of morbidity and hospitalization rate had a pro-rich distribution in all three States indicating poor utilization of health services by low income households. Nearly 57 and 60 per cent households from poorest income quintile in Haryana and Punjab, respectively faced catastrophic OOP hospitalization expenditure at 10 per cent threshold. Lower prevalence of catastrophic expenditure was recorded in higher income groups. Public sector also incurred high costs for hospitalization in selected three States. Medicines constituted 19 to 47 per cent of hospitalization expenditure and 59 to 86 per cent OPD expenditure borne OOP by households in public sector. Public sector hospitalizations had a pro-poor distribution in Haryana, Punjab and Chandigarh. Interpretation & conclusions: Our analysis indicates that public sector health service utilization needs to be improved. OOP health care expenditures at public sector institutions should to be curtailed to improve utilization of poorer segments of population. Greater availability of medicines in public sector and regulation of their prices provide a unique opportunity to reduce public sector OOP expenditure.

Incentivos para atraer y retener personal de salud de zonas rurales del Perú: un estudio cualitativo / Incentives to attract and retain the health workforce in rural areas of Peru: a qualitative study

El objetivo fue identificar incentivos de atracción y retención en zonas rurales y distantes de Ayacucho, Perú. Fueron realizadas entrevistas en profundidad con 80 médicos, enfermeras, obstetras y técnicos (20 por grupo) de las zonas más pobres y con 11 funcionarios. No existen políticas sistemáticas de atracción y retención de personal de salud en Ayacucho. Los principales incentivos, en orden de importancia, fueron mejoras salariales, oportunidades de formación y capacitación, estabilidad laboral y nombramiento, mejoras en infraestructura y equipos, e incremento del personal. Se mencionaron también mejoras en la vivienda y alimentación, mayor cercanía con la familia y reconocimiento por el sistema de salud. Existen coincidencias y singularidades entre los distintos grupos sobre los incentivos clave para estimular el trabajo rural, que deben considerarse al diseñar políticas públicas. Las iniciativas del Estado deben comprender procesos rigurosos de monitoreo y evaluación, para asegurar que las mismas tengan el impacto deseado.

The study aimed to identify the main incentives for attracting and retaining health workers in rural and remote health facilities in Ayacucho, Peru. In-depth interviews were performed with 80 physicians, obstetricians, nurses, and nurse technicians in the poorest areas (20 per group), plus 11 health managers. Ayacucho lacks systematic policies for attracting and retaining human resources. The main incentives, in order of relevance, were higher wages, opportunities for further training, longer/permanent contracts, better infrastructure and medical equipment, and more staff. Interviewees also mentioned improved housing conditions and food, the opportunity to be closer to family, and recognition by the health system. Health workers and policymakers share perceptions on key incentives to encourage work in rural areas. However, there are also singularities to be considered when designing specific strategies. Public initiatives thus need to be monitored and evaluated closely in order to ensure the intended impact.

Scale-up of a decentralized HIV treatment programme in rural KwaZulu-Natal, South Africa: does rapid expansion affect patient outcomes?

Objective:To describe the scale-up of a decentralized HIV treatment programme delivered through the primary health care system in rural KwaZulu-Natal, South Africa, and to assess trends in baseline characteristics and outcomes in the study population Methods The programme started delivery of antiretroviral therapy (ART) in October 2004. Information on all patients initiated on ART was captured in the programme database and follow-up status was updated monthly. All adult patients (≥ 16 years) who initiated ART between October 2004 and September 2008 were included and stratified into 6-month groups. Clinical and sociodemographic characteristics were compared between the groups. Retention in care, mortality, loss to follow-up and virological outcomes were assessed at 12 months post-ART initiation.Findings A total of 5719 adults initiated on ART were included (67.9% female). Median baseline CD4+ lymphocyte count was 116 cells/µl (interquartile range, IQR: 53­173). There was an increase in the proportion of women who initiated ART while pregnant but no change in other baseline characteristics over time. Overall retention in care at 12 months was 84.0% (95% confidence interval, CI: 82.6­85.3); 10.9% died (95% CI: 9.8­12.0); 3.7% were lost to follow-up (95% CI: 3.0­4.4). Mortality was highest in the first 3 months after ART initiation: 30.1 deaths per 100 person­years (95% CI: 26.3­34.5). At 12 months 23.0% had a detectable viral load (> 25 copies/ml) (95% CI: 19.5­25.5).Conclusion Outcomes were not affected by rapid expansion of this decentralized HIV treatment programme. The relatively high rates of detectable viral load highlight the need for further efforts to improve the quality of services

Operational feasibility of establishing community reporting systems.

BACKGROUND: In developing countries the absence ofa credible disease surveillance system results in an inappropriate response to an outbreak. Since a functioning and responsive disease surveillance system cannot be provided immediately, some interim surveillance system for early detection of outbreaks is needed to institute a prompt response. This operational research study was conducted to assess the feasibility of establishing community reporting systems involving women self-help groups and members of Panchayati raj institutions through syndromic surveillance at the community level. METHODS: Reporting was initiated from 8 villages in 4 gram panchayats of Begunia block of Khurda district in Orissa during May and June 2005. Members of women self-help groups and Panchayati raj institutions were trained on structured reporting guidelines. In congruence with the state disease surveillance system, weekly reporting was started for comparison where feasible. RESULTS: Completeness of reporting was better achieved by women self-help groups (91.6%) than members of Panchayati raj institutions (66.6%). Data capture was more complete as compared with the existing disease surveillance system. Illnesses among women were better captured and greater ownership of the public health service was noted. CONCLUSION: Establishing community reporting systems using women self-help groups and members of Panchayat raj institutions for disease surveillance in India is a feasible option.

Morbidity profile of paediatric inpatents at a community health centre and a nearby [correction of near by] district hospital in northern India.

The study was conducted to ascertain the morbidity profile among children by retrospective review of inpatient data of children admitted to Comprehensive Rural Health Services Project (CRHSP), Ballabgarh, a model CHC and Badshah Khan (B.K.) hospital, Faridabad, a district hospital over a period of one year. Diarrhea and pneumonia comprised 64% of all admissions at the model CHC and 30% at the district hospital. Thalassemics requiring blood transfusion formed 21% of inpatients at the district hospital. Common paediatric ailments can be managed appropriately at CHC level, provided the infrastructure as recommended by Indian Public Health sandards for CHC under National Rural Health Mission (NRHM) is available. The blood bank or blood storage facility at a CHC is desirable.

Knowledge, Perception and Health Behavior about Metabolic Syndrome for an at Risk Group in a Rural Community Area / 간호학회지

PURPOSE: This study was to identify knowledge, perception and health behavior about metabolic syndrome for an at risk group in a rural community area. METHODS: A descriptive cross-sectional survey design was used. A total of 575 adults with hypertension, diabetes mellitus, dyslipidemia, and/or abdominal obesity were recruited from 11 rural community health care centers. A questionnaire was developed for this study. Anthropometric measures were measured and blood data was reviewed from the health record. RESULTS: Knowledge about the metabolic syndrome was low as evidenced by only a 47% correct answer rate. Only 9% of the subjects ever heard about the disease, and 87% answered they do not know the disease at all. 87% of the subjects were not performing regular exercise, 31% drank alcohol more than once a month, 12.5% were current smokers, and 33.6% are did not have a regular health check-up. CONCLUSION: Development of systematic public health care programs are needed to prevent future increases in cardiovascular complications and to decrease health care costs. These might include educational programs for the primary health care provider and an at risk group, a therapeutic lifestyle modification program, and a health screening program to identify potential groups.

Oral healthcare for elderly: identifying the needs and feasible strategies for service provision.

The aim of the present study was to assess the oral health practices, status and treatment needs of the rural elderly in national capital territory of Delhi. An effort was also made to identify patterns of utilization of dental services and test alternate strategies for service provision. A total of 96 elderly subjects (47 males and 49 females) in 5 rural areas were interviewed and clinically examined using Basic Oral Health Survey criteria of W.H.O. This was followed by a community trial in which the 5 villages were divided into control and test groups. Results of the survey found that both traditional as well as modern oral health practices co-exist in the rural community. Dental services were available to a majority (mostly through private sector), and edentulousness was a condition of primary concern among the elderly as a result of unmet treatment needs for dental caries and periodontal diseases. Age was a variable that was statistically significantly associated with edentulousness (p=0.005). Results of the community trial showed that higher utilization of care can be achieved by providing on-site dental care as compared to referring cases to tertiary care centers. Nevertheless provision of treatment alone is not a suitable policy recommendation since many elderly did not avail care even at on-site community dental health programmes that were operated free of cost. This emphasizes the need of health education over treatment in order to empower the elderly, especially the non-ambulatory patients, to practice prevention and develop favourable attitudes towards accepting prompt treatment at primary health care level.