[Leadership and strategic management in health systems based on primary health care]. / Liderazgo y gestión estratégica en sistemas de salud basados en atención primaria de salud.

OBJECTIVES: To identify and analyze various types of leadership and management that could contribute to the strengthening of health systems based on primary health care (PHC). METHODS: A structured review of the literature on management and leadership applicable to PHC-based health systems was conducted. Of the 19 articles identified, relevant details were extracted using a standardized methodology. RESULTS: PHC-based health systems should establish optimal management practices to achieve quality, efficiency, and effectiveness. Strategic planning and management facilitate the development of a common identity, although some organizations are overmanaged and poorly led. Universal health is a strategic driver that requires transformational leadership to move toward PHC-based systems. Leadership in these systems must focus on identifying adaptive challenges, linking staff and protecting grassroots leadership, as well as adapting to the times and combining the logic of action of the strategist to achieve a sector transformation. The quality models establish leadership criteria similar to other theories, emphasizing innovation and organizational identity. CONCLUSIONS: Latin America must move towards health systems based on PHC, with leaders with emotional intelligence who discover their own transformative events, seek quality, and combine various types of leadership. They must be strategists to lead the system in its transition to resilient organizations, and "alchemists" to achieve true transformations in health, with the willingness and humility of those who work to achieve universal health.

Liderazgo y gestión estratégica en sistemas de salud basados en atención primaria de salud

[RESUMEN]. Objetivos. Identificar y analizar varios tipos de liderazgo y de gestión que podrían aportar al fortalecimiento de los sistemas de salud basados en atención primaria en salud (APS). Métodos. Se realizó una revisión estructurada de literatura en gestión y liderazgo aplicable a los sistemas de salud basados en APS. De los 19 artículos identificados se extrajeron detalles relevantes usando una abstracción estandarizada. Resultados. Los sistemas de salud basados en APS deben establecer prácticas de gestión óptimas para alcanzar la calidad, la eficiencia y la efectividad. La planeación y gestión estratégica facilitan la formación de una identidad común, aunque existen organizaciones sobregerenciadas y pobremente lideradas. La salud universal es un impulso estratégico que requiere de un liderazgo transformador para avanzar hacia sistemas basados en APS. El liderazgo en ellos debe centrarse en identificar los desafíos adaptativos, vincular al personal y proteger el liderazgo de las bases, al igual que debe adaptarse a los momentos y combinar las lógicas de acción del estratega para lograr una transformación sectorial. Los modelos de calidad establecen criterios de liderazgo similares a otras teorías, destacando como aportes la innovación y la identidad organizacional. Conclusiones. América Latina debe encaminarse hacia sistemas de salud basados en APS participativos, con líderes con inteligencia emocional, que descubran sus propios eventos transformadores, busquen la calidad y combinen varios tipos de liderazgo. Deben ser estrategas para liderar al sistema en su transición hacia organizaciones resilientes, y “alquimistas” para lograr verdaderas transformaciones en salud, con la voluntad y humildad de quien trabaja para alcanzar la salud universal.

[ABSTRACT]. Objectives. To identify and analyze various types of leadership and management that could contribute to the strengthening of health systems based on primary health care (PHC). Methods. A structured review of the literature on management and leadership applicable to PHC-based health systems was conducted. Of the 19 articles identified, relevant details were extracted using a standardized methodology. Results. PHC-based health systems should establish optimal management practices to achieve quality, efficiency, and effectiveness. Strategic planning and management facilitate the development of a common identity, although some organizations are overmanaged and poorly led. Universal health is a strategic driver that requires transformational leadership to move toward PHC-based systems. Leadership in these systems must focus on identifying adaptive challenges, linking staff and protecting grassroots leadership, as well as adapting to the times and combining the logic of action of the strategist to achieve a sector transformation. The quality models establish leadership criteria similar to other theories, emphasizing innovation and organizational identity. Conclusions. Latin America must move towards health systems based on PHC, with leaders with emotional intelligence who discover their own transformative events, seek quality, and combine various types of leadership. They must be strategists to lead the system in its transition to resilient organizations, and “alchemists” to achieve true transformations in health, with the willingness and humility of those who work to achieve universal health.

[International health and new forms of association: the Multipartite Dialogue and the Partners Forum]. / Salud internacional y nuevas formas de asociación: el Diálogo Multipartito y el Foro de Socios.

Two cooperative public health initiatives involving representatives of civil society, academia, and the public and private sectors of the Americas are described and analyzed. One of them-the Multipartite Dialogue-promotes an intersectoral approach in its broadest sense, and the other-the Partners Forum-while it represents an institutional initiative, pays particular attention to chronic noncommunicable diseases. Both are a call to action for governments and offer alternatives to tackle regional health problems more effectively.

Salud internacional y nuevas formas de asociación: el Diálogo Multipartito y el Foro de Socios / International health and new forms of association: the Multipartite Dialogue and the Partners Forum

Se describen y analizan dos iniciativas de cooperación en salud pública en las cuales participan representantes de la sociedad civil, la academia, el sector público y sector privado de las Américas. Una de ellas -el Diálogo Multipartito- promueve la aproximación intersectorial en su más amplio concepto, mientras que la otra -el Foro de Socios- si bien representa una iniciativa institucional, asigna mayor atención a las enfermedades crónicas no transmisibles. Ambas constituyen un llamado a la acción para los gobiernos y ofrecen alternativas para enfrentar más efectivamente los problemas de la salud regional.

Two cooperative public health initiatives involving representatives of civil society, academia, and the public and private sectors of the Americas are described and analyzed. One of them-the Multipartite Dialogue-promotes an intersectoral approach in its broadest sense, and the other-the Partners Forum-while it represents an institutional initiative, pays particular attention to chronic noncommunicable diseases. Both are a call to action for governments and offer alternatives to tackle regional health problems more effectively.

The Chilean infant mortality decline: improvement for whom? Socioeconomic and geographic inequalities in infant mortality, 1990-2005.

OBJECTIVE: To measure socioeconomic inequalities and differential risk in infant mortality on national and regional levels in Chile from 1990 to 2005, and propose new policy targets. METHODS: The study analysed Chilean vital events registries from 1990 to 2005 for infant mortality by maternal education, head of household occupational status, cause, age and location of death. Annual infant mortality rates and relative risk were calculated by maternal education and head of household occupational status for each cause and age of death. Socioeconomic inequalities were then mapped to 29 regional health services. FINDINGS: Reductions in the national infant mortality rate were driven by reductions among highly educated mothers, while recent stagnation in the national rate is caused by high levels of infant mortality among uneducated mothers. These vulnerable households are particularly prone to infant mortality risk due to infectious disease and trauma. We also identify clustering of high socioeconomic inequalities in infant mortality throughout the poorer north, indigenous south and densely populated metropolitan centre of Santiago. Finally, we report large inequities in vital statistics coverage, with infant deaths among vulnerable households much more likely to be inadequately defined than in the remaining population. CONCLUSION: These results indicate that the socioeconomically disadvantaged in Chile are at a significantly higher risk for infant mortality by infectious diseases and trauma during the first month of life. Efforts to reduce national infant mortality in Chile and other countries must involve policies that target child survival for at-risk populations for specific diseases, ages and locations.

Situación de la equidad en salud

Muestra que las diferencias en los ingresos provinciales per cápita se han incrementado en los últimos años. Que con excepción de casos aislados, las provincias incluidas en cada grupo de ingresos se han mantenido dentro de esos grupos y que existe una clara correlación entre estos indicadores de ingresos e indicadores de condiciones de vida y de salud.

En busca de los resultados de la cooperación técnica / In search of the results of technical cooperation

For the Pan American Health Organization (PAHO), technical cooperation (TC) is the process by which teh PAHO Member States work with the Organization, as equal partners, to identify and reach their own health goals and to promote self-sufficiency in health development, through programs that respond to those countries' needs and national priorities. Since 1978, PAHO has used the American Regional Planning, Programming, Monitoring, and Evaluation System (AMPES) to establish management procedures and to facilitate decision-making in health TC. As part of AMPES, PAHO uses a "logical approach to project management" to structure the work program of the Organization and to identify the expected results from TC activities and TC resource investments. This project management approach, which replaces the "functional approaches" system used to date, also helps establish a causative relationship between the programmed activities and the results that PAHO expects, and between the activities and the hoped-for outcomes in the countries. As part of an ongoing process of rethinking international health TC, several years ago PAHO began a four-phase study on the usefulness and validity of functional approaches and on the need to propose new ones or to modify existing ones. The results of the initial phase showed it was difficult to classify the activities because the functional approaches categories were not mutually exclusive and the TC activities were complex. Further, the expected results did not specify the product for which the PAHO Secretariat was accountable within a certain time frame nor the Secretariat's level of responsibililty. Thus, a new and more flexible classification of expected results was proposed, with the following categories: cooperation networks and alliances; surveillance and information systems; standards and guidelines; research and evaluation studies; plans, projects, and policies; methods, models, and technologies; training programs; promotional campaigns and advocacy; and direct support. In the second phase of the study, it was concluded that the proposed classification system made it possible to more precisely identify the products of PAHO technical cooperation projects, the Organization's degree of responsibility, and the bases for estimating needed resources. The new system could also facilitate monitoring and evaluation. In addition, the third pahse of analyzing the functional approaches has begun. Its objective is to evaluate the effect of technical cooperation based on the changes incorporated in the programming of activities

En busca de los resultados de la cooperación técnica / In search of the results of technical cooperation

For the Pan American Health Organization (PAHO), technical cooperation (TC) is the process by which teh PAHO Member States work with the Organization, as equal partners, to identify and reach their own health goals and to promote self-sufficiency in health development, through programs that respond to those countries' needs and national priorities. Since 1978, PAHO has used the American Regional Planning, Programming, Monitoring, and Evaluation System (AMPES) to establish management procedures and to facilitate decision-making in health TC. As part of AMPES, PAHO uses a "logical approach to project management" to structure the work program of the Organization and to identify the expected results from TC activities and TC resource investments. This project management approach, which replaces the "functional approaches" system used to date, also helps establish a causative relationship between the programmed activities and the results that PAHO expects, and between the activities and the hoped-for outcomes in the countries. As part of an ongoing process of rethinking international health TC, several years ago PAHO began a four-phase study on the usefulness and validity of functional approaches and on the need to propose new ones or to modify existing ones. The results of the initial phase showed it was difficult to classify the activities because the functional approaches categories were not mutually exclusive and the TC activities were complex. Further, the expected results did not specify the product for which the PAHO Secretariat was accountable within a certain time frame nor the Secretariat's level of responsibililty. Thus, a new and more flexible classification of expected results was proposed, with the following categories: cooperation networks and alliances; surveillance and information systems; standards and guidelines; research and evaluation studies; plans, projects, and policies; methods, models, and technologies; training programs; promotional campaigns and advocacy; and direct support. In the second phase of the study, it was concluded that the proposed classification system made it possible to more precisely identify the products of PAHO technical cooperation projects, the Organization's degree of responsibility, and the bases for estimating needed resources. The new system could also facilitate monitoring and evaluation. In addition, the third pahse of analyzing the functional approaches has begun. Its objective is to evaluate the effect of technical cooperation based on the changes incorporated in the programming of activities

El presente estudio tuvo por objetivo evaluar la calidad de los servicios de anticoncepción en la ciudad de El Alto, Bolivia. En su diseño se han contemplado cuatro elementos: 1) las relaciones entre los proveedores de servicios y sus clientes, 2) la disponibilidad de métodos anticonceptivos, 3) las condiciones de los servicios, y 4) la satisfacción de las usuarias. También se han tenido en cuenta las opiniones de los proveedores y de las usuarias y no usuarias de estos servicios, quienes se clasificaron como gubernamentales o no gubernamentales, de acuerdo con la administración de la institución a la que pertenecían. Los datos provinieron de un análisis de la situación de dichos servicios y de testimonios obtenidos de las participantes durante 1995. En cuanto a las relaciones interpersonales, se encontró que los proveedores percibían el trato del médico más favorablemente que las clientas, en tanto que las no usuarias lo percibían desfavorablemente. La percepción de un trato igualitario se correlacionó positivamente con la vestimenta que usaban las clientas. En cuanto a la disponibilidad de los métodos anticonceptivos, 15 de las 36 instituciones encuestadas no disponían de métodos modernos, a pesar de la existencia de una política nacional para proveerlos a la población. La oferta de estos servicios a parejas y a adolescentes es escasa, principalmente en las instituciones gubernamentales. El análisis de las condiciones de los servicios demostró que en algunas instituciones había problemas graves en la provisión de una atención de mínima calidad. Finalmente, este trabajo describe cómo la mayoría de estas limitaciones en la prestación de servicios de anticoncepción en El Alto pueden subsanarse mediante estrategias de costo moderado.