Gobernanza y rectoría de la calidad en los servicios de salud en el Perú / Governance and stewardship of quality in health services in Peru

RESUMEN El cuidado de las personas y de su salud es una función primaria de la familia y de la sociedad como lo demuestran estudios sobre los humanos primitivos, así como en el Perú prehispánico. La conquista y los siglos posteriores de colonización quebraron la forma tradicional del cuidado de las personas, reemplazando la solidaridad social por acciones de caridad principalmente de órdenes religiosas que propiciaron hospicios luego denominados hospitales. Durante la colonia y hasta principios del siglo XX el cuidado de los enfermos siguió siendo responsabilidad de las instituciones de caridad, como las Beneficencias creadas luego de la independencia. Los derechos sociales como la educación y la salud recién surgen en las primeras décadas del pasado siglo, plasmándose en la Constitución de 1933. Sin embargo, tanto en esa Constitución como en la de 1979 y la de 1993 el derecho a la educación fue reconocido más plenamente, siendo más limitado en salud. La ley de Aseguramiento Universal en Salud del 2009 propone garantizar para todos el derecho al acceso a servicios de salud con calidad, como parte del derecho a la salud en sentido amplio. Las limitaciones actuales obligan a redefinir el derecho de todas las personas al cuidado integral de su salud y la rectoría del Estado para garantizarlo.

ABSTRACT The care of people and their health is a primary function of the family and of society as shown by studies on primitive humans, as well as in pre-Hispanic Peru. The conquest and subsequent centuries of colonization fractured the traditional way of caring for people, replacing social solidarity with charity actions mainly from religious orders that provided hospices later called hospitals. During the colony and until the beginning of the 20th century, the care of the sick continued to be the responsibility of charitable institutions, such as the Charities created after independence. Social rights such as education and health only emerged in the first decades of the last century and were enshrined in the 1933 Constitution. However, both in that Constitution as in those from 1979 and 1993, the right to education was recognized more fully, while the right to heath was limited. The Universal Health Coverage Act of 2009 propounds guaranteeing the right to access quality healthcare services for everybody, as part of the right to health in the broadest sense. The current limitations force us to redefine the right of every citizen to comprehensive care of their health and the State's guidance to guarantee it.

Cobertura universal y acceso efectivo a los servicios de salud: ¿Qué ha pasado en Colombia después de diez años de la Sentencia T-760? / Universal coverage and effective access to health care: What has happened in Colombia ten years after Sentence T-760?

RESUMEN La política pública de salud ha estado guiada en Colombia por el propósito de alcanzar la cobertura universal. La Ley 100 de 1993 planteó la meta de garantizar a toda la población el acceso a los servicios de salud en todos los niveles de atención, con un plan de beneficios igual para todos. No obstante esta promesa, la cobertura universal no se logró en el año 2000 como estaba establecido, y han existido barreras para el acceso efectivo, por lo que los ciudadanos han acudido a la acción de tutela como un mecanismo por el cual los jueces protegen el derecho a la salud. En 2008, en medio de un crecimiento desbordado de las tutelas, la Corte Constitucional profirió la Sentencia T-760 por la cual reconoció la salud como derecho fundamental y estableció órdenes a varios organismos del Estado para garantizar su goce efectivo y hacer cumplir la cobertura universal y el acceso efectivo. Después de diez años, el cumplimiento de estas órdenes es medio, con avances importantes en cuanto a cobertura e igualación del plan de beneficios, pero persisten barreras al acceso y preocupaciones respecto a la sostenibilidad y el flujo de recursos.(AU)

ABSTRACT Public health policy in Colombia has been guided by the purpose of achieving universal coverage. Law 100 of 1993 set the goal of guaranteeing access to health services for the entire population, at all levels of care, with a plan of equal benefits for all. Despite this promise, universal coverage was not achieved in the year 2000 as established, and there have been barriers to effective access. In consequence, citizens have resorted to tutela (writ for the protection of fundamental rights) as a mechanism by which judges protect the right to health. In 2008, amidst an overwhelming growth in the number of actions for immediate protection of constitutional rights, the Constitutional Court issued Sentence T-760, by which health was recognized as a fundamental right and ordered several State agencies to guarantee its effective enjoyment and enforce universal coverage and effective access. After ten years, compliance with these orders is medium, with important advances in terms of coverage and equalization of the benefits plan, but there are still barriers to access and concerns regarding sustainability and the flow of resources.(AU)

La reforma de salud chilena a diez años de su implementación / Chilean health reform ten years since its implementation

Resumen: Objetivo: Analizar el proceso de diseño e implementación del Acceso Universal con Garantías Explícitas (AUGE). Material y métodos: Revisión de bibliografía sobre antecedentes prerreforma, arquitectura de diseño y proceso de implementación de la reforma AUGE y, complementariamente, entrevistas a ocho informantes involucrados en su desarrollo. Resultados: La valoración de la equidad en la salud fue un elemento clave prerreforma; existen cuatro dimensiones fundamentales en el diseño y nueve fases en la implementación. Conclusión: Los resultados del AUGE muestran un fortalecimiento en la salud pública por la inversión en equipamiento para tratamientos costo-efectivos; también por las guías clínicas que estandarizan y orientan la gestión de los profesionales de la salud con los pacientes.

Abstract: Objective: To analyze the process of design and implementation of AUGE. Materials and methods: Literature review of pre-reform background, architecture design and implementation process of reform AUGE and complementary interviews to eight informants involved in its development. Results: The assessment of health equity was a key element in pre-reform, there are four fundamental dimensions in the design, and the implementation has nine phases. Conclusion: The results show AUGE strengthening public health by investing in equipment for cost-effective treatments, and also through clinical guidelines that standardize and guide the management of health professionals with patients.

La nueva reforma a la salud en Colombia: el derecho, el aseguramiento y el sistema de salud / Challenges of the right to health in the Colombian model

La salud en Colombia es ahora un derecho fundamental que tiene que ser provisto y protegido por el Estado. A partir de metodologías de análisis de sistemas de salud propuestos por la OMS y el Banco Mundial, se evidencian las falencias, fortalezas y dificultades del sistema de salud con respecto a la ley estatutaria aprobada en febrero de 2015. Éstas incluyen la fragmentación y especialización de los servicios, barreras de acceso, incentivos no alineados con la calidad, débil gobernanza, múltiples actores con poca coordinación y sistema de información que no mide resultados. Es necesario un acuerdo social, un equilibrio y control de la tensión por parte del Estado entre el beneficio particular y el beneficio colectivo.

Health in Colombia is now a fundamental right that has to be provided and protected by the government. We evaluated the strengths and difficulties of the health system with respect to the statutory law enacted in February 2015, using methodologies for analysis of health systems proposed by the WHO and the World Bank. The challenges include the fragmentation and specialization of services, access barriers and incentives that are not aligned with the quality, weak governance, multiple actors with little coordination and information system that does not measure results. The government needs to find a necessary social agreement, a balance between the particular and the collective benefit.

UHC – Universal Health Coverage: avanço ou retrocesso na luta pelo direito humano à saúde? Uma contribuição ao debate político-ideológico da guerra de posições entre comunidades epistêmicas no campo da saúde global / UHC - Universal Health Coverage: forward or backward in the fight for the human right to health? A contribution to the political and ideological debate of positions war between epistemic communities in the field of global health

O trabalho busca caracterizar e analisar as ideias que sustentam as posições das comunidades epistêmicas dominantes que atuam na definição e implementação da proposta de agenda mundial pela Cobertura Universal em Saúde ou Universal Health Coverage (UHC). A análise desenvolvida buscou responder à pergunta se a UHC seria um avanço ou retrocesso na luta pelo direito humano à saúde. A UHC emergiu com força avassaladora na agenda mundial da saúde desde 2010, carregando um conjunto de ambiguidades ou indefinições. Colocando os direitos humanos e o direito humano e social à saúde como referência para a análise dos conceitos e ideias em jogo, pretende-se identificar o perfil de pensamento das comunidades epistêmicas no âmbito da UHC. A análise focou na classificação de conteúdos de documentos selecionados dentre aqueles produzidos, e muitos formalmente adotados, pelas organizações internacionais que possuem liderança no tema – OIT, OMS, Banco Mundial e Assembleia Geral da ONU, e publicados entre 2010 e 2014. Os critérios de classificação dos conteúdos obedeceram ao ordenamento de díades de oposição entre um perfil que foi assumido como afirmativo dos direitos – universalidade, integralidade, igualdade e financiamento por impostos gerais progressivos – e sua oposição representada pela focalização, pacotes de mínimos sociais, equidade exclusiva e financiamento por seguros segmentados. O resultado permite identificar um alinhamento das definições e agendas da UHC no campo conservador das políticas sociais derivados do neoliberalismo, com declarações universalistas e integrais, mas uma forma de implementação centrada na focalização e financiamento por seguros de pacotes mínimos. Identificaram-se nuances na posição entre as instituições examinadas, mas como variações dentro do campo hegemônico...

This study intends to characterize and analyse the ideas that support the positions of the dominant epistemic communities that have been engaged in the definition and implementation of the proposal for a global agenda for the Universal Health Coverage (UHC). The analysis aimed at answering the question if UHC would be a step forwards or backwards in the fight for the human right to health. UHC has emerged with remarkable force in the global agenda for health since 2010, presenting a set of ambiguities or uncertainties. By placing human rights and human and social right to health as reference for the analysis of concepts and ideas at stake, this study proposed to identify the thinking pattern of epistemic communities within UHC. The analysis focused on the classification of contents of some selected documents produced, and formally adopted, by international organizations that play an important role in this area – namely, ILO, WHO, World Bank and General Assembly of the United Nations, published between 2010 and 2014. The classification were based on dyads of opposition between criteria from the human rights perspective – universality, integrality, equality, and funding through progressive taxation –, and opposing criteria represented by targeting, minimum social packages, excluding equity, and funding through segmented insurances. The result shows an alignment of UHC definitions and agendas in the conservative field of social policies originated from neoliberalism, which, although including universal and integral perspective in their statements, argue that UHC implementation should focus on targeting and funding through minimum package insurances. There are nuances in the position of these international organizations, but as variations within the hegemonic field...

Healthcare reform in the USA, 2010: the rocky road ahead.

Historic legislation for healthcare reform in the United States was enacted in March 2010. Reforms in medical practice, payment for services, and access to care and insurance will be introduced by complex processes over time through 2019. The overriding goals of healthcare reform are cost containment and guaranteeing access to all Americans. The contentious political struggle that preceded the legislation is emblematic of the continuous struggle in American society to define who is worthy of services. Understanding the value framework for social and welfare provisions in American society is crucial to making sense of the piecemeal policymaking characteristic of the development of healthcare over the past 50 years. Here some highlights of the reform and the complex organisation of American healthcare are discussed.

Promoción e implementación de la vigilancia ciudadana. Ley Nº 29344 y reglamento: Aseguramiento universal en salud / Promotion and implementation of citizen oversight. Law No. 29344 and regulation: universal health insurance

El presente reglamento describe las disposiciones que desarrollan los mecanismos de implementación y desarrollo del Aseguramiento Universal en Salud, necesarias para el adecuado cumplimiento de los objetivos del aseguramiento universal contenidos en la Ley Nº 29344, Ley Marco del Aseguramiento Universal en Salud