Primary health care as a tool to promote equity and sustainability; a review of Latin American and Caribbean literature.

Primary health care (PHC) has increased in global relevance as it has been demonstrated to be a useful strategy to promote community access to health services. Multilateral organizations and national governments have reached a consensus regarding the basic principles of PHC, but the application of these varies from country to country due to the particularities of local health systems.This article aims to review and summarize PHC strategies and the configuration of health networks in Latin American and Caribbean countries.The review was carried out using keywords in at least 9 databases. Papers in languages other than English, Portuguese, and Spanish were excluded, while non-refereed articles and regional gray literature were incorporated. As a result, 1,146 papers were identified. After three instances of analysis, 142 articles were selected for this investigation. Data were analyzed according to an analysis by theme.The evidence collected on health reforms in the region reflects the need to intensify care strategies supported by PHC and care networks. These must be resilient to changes in the population's needs and must be able to adapt to contexts of epidemiological accumulation.

Digital pathology structure and deployment in Veneto: a proof-of-concept study.

Nowadays pathology laboratories are worldwide facing a digital revolution, with an increasing number of institutions adopting digital pathology (DP) and whole slide imaging solutions. Despite indeed providing novel and helpful advantages, embracing a whole DP workflow is still challenging, especially for wide healthcare networks. The Azienda Zero of the Veneto Italian region has begun a process of a fully digital transformation of an integrated network of 12 hospitals producing nearly 3 million slides per year. In the present article, we describe the planning stages and the operative phases needed to support such a disruptive transition, along with the initial preliminary results emerging from the project. The ultimate goal of the DP program in the Veneto Italian region is to improve patients' clinical care through a safe and standardized process, encompassing a total digital management of pathology samples, easy file sharing with experienced colleagues, and automatic support by artificial intelligence tools.

Unravelling collaborative governance dynamics within healthcare networks: a scoping review.

In many countries, healthcare systems suffer from fragmentation between hospitals and primary care. In response, many governments institutionalized healthcare networks (HN) to facilitate integration and efficient healthcare delivery. Despite potential benefits, the implementation of HN is often challenged by inefficient collaborative dynamics that result in delayed decision-making, lack of strategic alignment and lack of reciprocal trust between network members. Yet, limited attention has been paid to the collective dynamics, challenges and enablers for effective inter-organizational collaborations. To consider these issues, we carried out a scoping review to identify the underlying processes for effective inter-organizational collaboration and the contextual conditions within which these processes are triggered. Following appropriate methodological guidance for scoping reviews, we searched four databases [PubMed (n = 114), Web of Science (n = 171), Google Scholar (n = 153) and Scopus (n = 52)] and used snowballing (n = 22). A total of 37 papers addressing HN including hospitals were included. We used a framework synthesis informed by the collaborative governance framework to guide data extraction and analysis, while being sensitive to emergent themes. Our review showed the prominence of balancing between top-down and bottom-up decision-making (e.g. strategic vs steering committees), formal procedural arrangements and strategic governing bodies in stimulating participative decision-making, collaboration and sense of ownership. In a highly institutionalized context, the inter-organizational partnership is facilitated by pre-existing legal frameworks. HN are suitable for tackling wicked healthcare issues by mutualizing resources, staff pooling and improved coordination. Overall performance depends on the capacity of partners for joint action, principled engagement and a closeness culture, trust relationships, shared commitment, distributed leadership, power sharing and interoperability of information systems To promote the effectiveness of HN, more bottom-up participative decision-making, formalization of governance arrangement and building trust relationships are needed. Yet, there is still inconsistent evidence on the effectiveness of HN in improving health outcomes and quality of care.

Co-constructing effective collective intelligence networks in rare diseases: a mixed method approach to identify the parameters that matter for patients, professionals and policy-makers, piloted in Cyprus.

BACKGROUND: Rare diseases are a particular field of public health that is characterized by scattered, often insufficient knowledge and infrastructure. The scarcity of specialized knowledge often forces clinicians and patients to an incomplete picture of the diseases and their associated risks. Effective person-centred networks appear promising for solving such real world and life-defining problems by purposely sourcing expert knowledge that is geographically-dispersed. The design and implementation of the RARE-e-CONNECT network technology is described. The project was funded to create collaborative spaces for the development of international partnerships in Cyprus' healthcare, promoting the dissemination of expert knowledge on rare diseases while saving resources through teleconsultation. Parameters that matter for patients, providers and policy-makers through the RARE-e-CONNECT experience were evaluated through a participatory mixed-method approach, consisting of (1) a needs assessment survey with 27 patients/families and 26 healthcare professionals at the two referral hospitals for the diagnosis and management of rare diseases in Cyprus; (2) interviews with 40 patients, families and patient representatives, as well as 37 clinicians and laboratory scientists, including national ERN coordinators/members; (3) activity metrics from 210 healthcare professionals and 251 patients/families/patient representatives who participated on the platform at the time of the research. RESULTS: Our results indicate usage and intention by both healthcare professionals and patients/families to openly provide decentralized specialized information for raising suspicion amongst clinicians to facilitate the necessary referrals, as well as peer to peer psychosocial support to help cope with the everyday challenges of living with the disease. User behavior was largely affected by the prevailing social norm favoring individual practice, as well as missing policies for telemedicine and shared care. This article discusses how telehealth is inextricably linked to social, cultural, organizational, technological and policy factors affecting uptake. CONCLUSIONS: We argue that collective intelligence tools need to be formally considered and work hand in hand with national and European policies/regulatory frameworks to promote proactiveness amongst the healthcare community with regard to the timely diagnosis of rare diseases and the facilitation of patients' pathway to specialists. Collaborative channels between countries need to be established to source collective intelligence on complex cases and save resources through teleconsultation/telementoring.

'Real-world' priority setting for service improvement in English primary care: a decentred approach.

This article develops an analysis of population-level priority setting informed by Bevir's decentred theory of governance and drawing on a qualitative study of priority setting for service improvement conducted in the complex multi-layered governance context of English primary care. We show how powerful actors, operating at the meso-level, utilize pluralistic and contradictory elements of complex governance networks to discursively construct, legitimize and enact service improvement priorities. Our analysis highlights the role of situated agency in integrating top-down, bottom-up and horizontal influences on priority setting, which leads to variation in local priorities despite the continuous presence of strong hierarchical influences.

Implementação da Rede de Cuidados à Pessoa com Deficiência: na periferia da governança de São Paulo / Implementation of the Care Network for People with Disabilities: in the periphery of the São Paulo, Brazil, governance

Resumo A Rede de Cuidado à Pessoa com Deficiência (RCPD) foi implementada no Sistema Único de Saúde (SUS) para expandir o acesso aos serviços às pessoas com deficiência (PCD). Uma vez que seu funcionamento depende de mecanismos robustos de cooperação e pactuação entre os entes federados, este artigo analisa a dinâmica da Comissão Intergestores Bipartite (CIB) de São Paulo na condução da implementação da RCPD. Realizou-se uma análise documental das atas da CIB-SP de 2011 a 2019. O referencial teórico se pautou na análise de políticas públicas, utilizando abordagem multidimensional a partir das dimensões política, estrutura e organização. Na dimensão política, as pautas centrais são referentes à responsabilidade dos entes federados e demandas originárias do Ministério da Saúde e Ministério Público. A dimensão estrutura ocorre prioritariamente por pautas protocolares de informes de credenciamento/descredenciamento. Já na dimensão organização, foram classificadas como centrais: avaliação dos serviços; necessidades populacionais; oferta, fluxos, regulação assistencial e dispensação de órteses, próteses e meios auxiliares. Conclui-se que, quando não induzida por atores externos, a discussão é protocolar, reduzida aos informes de credenciamento de ações e serviços e adquire centralidade com demandas de órgãos externos e com o surgimento de novos problemas de saúde pública.

Abstract The Care Network for People with Disabilities (RCPD) was implemented in the Brazilian National Health System (SUS) to expand the access to services to people with disabilities (PWD). Since its functioning depends on robust cooperation and pact mechanisms between federated states, this article analyzes the dynamic of the Bipartite Inter-manager Commission (CIB) of São Paulo in implementing RCPD. Document analysis of the records of the CIB-SP from 2011 to 2019 was carried out. The theoretical referential was based on the analysis of public policies, using a multidimensional approach from the political, structural, and organizational dimensions. In the political dimension, the main rulings relate to the responsibilities of federated states and demands from the Ministry of Health and Public Ministry. The structural dimension comprises mainly protocol rulings regarding accreditation/de-accreditation. In the organizational dimension, at last, were classified as central: service evaluation; populational needs; offer, flow, regulation of assistance and dispensing of orthotics, prostheses, and auxiliary means. In conclusion, when it is not conducted by external actors, the discussion follows protocol, being reduced to accreditation informs of actions and services and gains centrality with demands from external organs and the emergence of new public health problems.

An integrative perspective on interorganizational multilevel healthcare networks: a systematic literature review.

BACKGROUND: Interorganizational networks in healthcare do not always attain their goals. Existing models outline the factors that could explain poor network performance: governance; structure; and the alignment of professional, organizational and network levels. However, these models are very generic and assume a functional approach. We investigate available empirical knowledge on how network structure and governance relate to each other and to network performance in a multilevel context, to get deeper insight, supported with empirics, of why networks (fail to) achieve their goals. METHOD: A systematic literature review based on a search of Web of Science, Business Source Complete and PubMed was executed in May 2021 and repeated in January 2022. Full papers were included if they were written in English and reported empirical data in a healthcare interorganizational setting. Included papers were coded for the topics of governance, structure, performance and multilevel networks. Papers from the scientific fields of management, administration and healthcare were compared. Document citation and bibliographic coupling networks were visualized using Vosviewer, and network measures were calculated with UCINET. RESULTS: Overall, 184 papers were included in the review, most of which were from healthcare journals. Research in healthcare journals is primarily interested in the quality of care, while research in management and administration journals tend to focus on efficiency and financial aspects. Cross-citation is limited across different fields. Networks with a brokered form of governance are the most prevalent. Network performance is mostly measured at the community level. Only a few studies employed a multilevel perspective, and interaction effects were not usually measured between levels. CONCLUSIONS: Research on healthcare networks is fragmented across different scientific fields. The current review revealed a range of positive, negative and mixed effects and points to the need for more empirical research to identify the underlying reasons for these outcomes. Hardly any empirical research is available on the effects of different network structures and governance modes on healthcare network performance at different levels. We find a need for more empirical research to study healthcare networks at multiple levels while acknowledging hybrid governance models that may apply across different levels.

Intersectoral collaboration at a decentralized level: information flows in child welfare and healthcare networks.

BACKGROUND: As needs of families with social and behavioral health problems often exceed the expertise and possibilities of a single professional, service or organization, cross-service collaboration is indispensable to adequately meeting those needs. Despite the progressive focus on organizing integrated care, service fragmentation and service duplication remain persistent problems in child welfare and healthcare service delivery systems. A crucial factor to overcome these problems is information exchange between organizations. This study explores and compares the development over time of structures of information exchange in networks, concerning both material and knowledge-based information. METHODS: A comparative case study and social network analysis of three inter-organizational networks of child welfare and healthcare services in different-sized municipalities in the Netherlands. The research population consisted of organizations from various sectors participating in the networks. Data were collected at two moments in time with a mixed method: semi-structured interviews with network managers and an online questionnaire for all network members. Density and degree centralization were used to examine the information exchange structures. Ucinet was used to analyze the data, with use of the statistical tests: Compare Density Procedure and Quadratic Assignment Procedure. RESULTS: This study shows that different structures of information exchange can be distinguished, concerning both material and knowledge-based information. The overall connectedness of the studied structures of the networks are quite similar, but the way in which the involvement is structured turns out to be different between the networks. Over time, the overall connectedness of those structures appears to be stable, but the internal dynamics reveals a major change in relationships between organizations in the networks. CONCLUSIONS: Our study yields empirical evidence for the existence of and the differences between structures and dynamics of both material and knowledge-based information exchange relationships. With a loss of more than a half of the relations in a year, the relationships between the organizations in the network are not very stable over time. The contrast between major internal dynamics and the stable overall connectedness is an important point of concern for network managers and public officials, since this impermanence of relations means that long-term integrated care cannot be guaranteed.

Intersetorialidade nas Políticas Públicas sobre Drogas: Relações entre Saúde e Assistência Social / Intersectoriality in Drug Public Policies: Relations between Healthcare and Welfare Resources / Intersectorialidad en las Políticas Públicas sobre Drogas: Relaciones entre Salud y Asistencia Social

As políticas, programas e serviços no campo de álcool e outras drogas devem ocorrer a partir dos princípios da integralidade e intersetorialidade, assegurando a participação social. Nessa direção, o objetivo do presente trabalho foi compreender como se dão as relações entre as redes de saúde e assistência social, com vistas a assegurar ações orientadas pela intersetorialidade no cuidado aos usuários de substâncias psicoativas em um município de Minas Gerais, Brasil. Foram realizadas entrevistas individuais com os gestores destes setores, além de um grupo focal com profissionais que atuam no Sistema Único de Saúde e Sistema Único de Assistência Social. Os resultados foram organizados nos seguintes eixos de análise: (1) (des)articulação da rede: impasse para o trabalho intersetorial; (2) redes em movimento: práticas profissionais no cotidiano de cuidado; (3) tensões entre diferentes atores na rede de cuidado em álcool e drogas. Tais resultados expressam a realidade de grande parte dos municípios brasileiros, em que as ações no âmbito das políticas públicas ocorrem de maneira desarticulada, sendo ainda o princípio da intersetorialidade um horizonte a ser construído. (AU)

Policies, programs and services in the field of alcohol and other drugs (AOD) must be based upon the principles of integrality and intersectoriality, ensuring social participation. These aspects might guide Brazilian psychosocial care network. In this direction, the present study aimed to understand the relationship between health networks and social assistance regarding the health care of psychoactive substances users in a city at Minas Gerais, Brazil. Individual interviews were conducted with the managers of these sectors, as well as a focus group with professionals working in Brazilian National Systems of Healthcare and Social Services. The results were organized in the following axes of analysis: (1) (dis)articulation of the network: challenge for intersectoral work; (2) networks in movement: professional practices in daily care; (3) tensions between different actors in the alcohol and other drugs (AOD) network. These results express the reality of most Brazilian municipalities, in which public policies occur in a disjointed way, and the principle of intersectoriality is a horizon to be constructed. (AU)

Las políticas, programas y servicios en el campo de alcohol y otras drogas deben ocurrir a partir de los principios de la integralidad e intersectorialidad, asegurando la participación social. En esta dirección, el objetivo del presente trabajo fue comprender la relación entre las redes de salud y asistencia social en cuanto a la atención a los usuarios de sustancias psicoactivas en un municipio de Minas Gerais, Brasil. Se realizaron entrevistas individuales con los gestores de estos sectores, además de un grupo focal con profesionales que actúan en el Sistema Único de Salud y Sistema Único de Asistencia Social. Los resultados se organizaron en los siguientes ejes analíticos: (1) (des)articulación de la red: impasse para el trabajo intersectorial; (2) redes en movimiento: prácticas profesionales en el cotidiano de cuidado; (3) tensiones entre los diferentes actores de la red de atención de alcohol y drogas. Tales resultados expresan la realidad de gran parte de los municipios brasileños, en los que las acciones en el ámbito de las políticas públicas ocurren de manera desarticulada, siendo aún el principio de la intersectorialidad un horizonte a ser construido. (AU)

Inter-organizational collaboration between healthcare providers.

Across OECD countries, healthcare organizations increasingly rely on inter-organizational collaboration (IOC). Yet, systematic insight into the relations across different healthcare sectors is lacking. The aim of this explorative study is twofold. First, to understand how IOC differs across healthcare sectors with regards to characteristics, motives and the role of health policy. Second, to understand which potential effects healthcare executives consider prior to the establishment of the collaborations. For this purpose, a survey was conducted among a representative panel of Dutch healthcare executives from medium-sized or large healthcare organizations. Almost half (n = 344, 48%) of the invited executives participated. Our results suggest that differences in policy changes and institutional developments across healthcare sectors affect the scope and type of IOC: hospitals generally operate in small horizontal collaborations, while larger and more complex mixed and non-horizontal collaborations are more present among nursing homes, disability care and mental care organizations. We find that before establishing IOCs, most healthcare executives conduct a self-assessment including the potential effects of the collaboration. The extensive overview of policy developments, collaboration types and intended outcomes presented in our study offers a useful starting point for a more in-depth assessment of the effectiveness of collaborations among healthcare organizations.

[Patients on oral anticancer drugs and coordinated pathway: CHIMORAL, feedback from care providers]. / Patients sous anticancéreux oraux et parcours coordonné : CHIMORAL, retour des acteurs de soins.

INTRODUCTION: Oral anticancer drugs have raised the question of how to follow-up these patients and how to coordinate this follow-up. The CHIMORAL study evaluated the involvement of primary care providers and a coordination by territorial health networks. Training/information tools were provided, as well as weekly nursing follow-up at home. METHODS: The operational feasibility of this model was assessed through a qualitative/quantitative analysis of territorial health network intervention and feedback from primary care providers. RESULTS: One hundred and fifty four patients received coordinated care, with nursing follow-up for 89% of them (average 6.3 weeks). One in three nurses, one in five pharmacists and one in ten doctors used the tools provided, 41% of which were used for training and 16% for the management of an adverse event. The main reasons for using the networks concerned adverse effects (34%) and came mainly from nurses (45%) and patients and their relatives (47%). Patients felt safe, with more responsive management. DISCUSSION: This intervention has strengthened the networks' links with primary care providers. The use of the community-based care system for adverse events was more frequent, with improved detection and patient awareness, with no observed impact on compliance. A proposed evolution is to maintain an in-home assessment for all patients and to define a frequency and duration of follow-up according to the patient's profile.

Designing a novel hybrid healthcare teleconsultation network: a benchtop study of telepathology in Iran and a systematic review.

BACKGROUND: Growing demand for medical services has increased patient waiting time due to the limited number or unbalanced distribution of healthcare centers. Healthcare teleconsultation networks are one of the potentially powerful systems to overcome this problem. Medical pathology can hugely benefit from teleconsultation networks because having second opinions is precious for many cases; however, resource planning (i.e., assignment and distribution of pathology consultation requests) is challenging due to bulky medical images of patients. This results in high setup and operational costs. The aim of this study is to design an optimal teleconsultation network for pathology labs under the supervision of medical sciences universities in Tehran, Iran. METHODS: To avoid the setup cost, we first propose a modified hybrid peer-to-peer (P2P) overlay architecture for our telepathology network, using Iran's National Healthcare Information Network (SHAMS) as the underlying infrastructure. Then we apply optimization techniques to solve the request assignment and distribution problems in the network. Finally, we present a novel mathematical model with the objective of minimizing the variable operational costs of the system. RESULTS: The efficiency of the proposed method was evaluated by a set of practical-sized network instances simulated based on the characteristics of SHAMS. The results show that the presented model and architecture can obtain optimal solutions for network instances up to 350 nodes, which covers our target network. CONCLUSIONS: We believe that the proposed method can be beneficial for designing large-scale medical teleconsultation networks by adjusting the constraints according to the rules and conditions of each country. Our findings showed that teleconsultation networks in countries with strong information technology (IT) infrastructures are under the influence of consultation fees, while in countries with weak IT infrastructure, the transmission costs are more critical. To the best of our knowledge, no research has so far addressed resource planning in medical teleconsultation networks using optimization techniques. Besides, the target network, i.e., pathology labs under the supervision of medical sciences universities in Tehran and the SHAMS network, are discussed for the first time in this work.

Regulação do cuidado em redes de atenção: importância de novos arranjos tecnológicos / Regulation of care in care networks: the importance of new technological arrangements

Resumo Um dos maiores desafios para os sistemas de saúde é a garantia de acesso integral. Os processos regulatórios em saúde no Brasil priorizam a organização de listas de espera e fluxos assistenciais com caráter normativo, mas se distanciam das necessidades dos usuários no sentido de uma produção de cuidado integral. No presente estudo, de caráter qualitativo, analisou-se as implicações da regulação em saúde na produção do cuidado no município de São Bernardo do Campo, utilizando-se as técnicas observação participante, grupo focal e usuário-guia, construídas a partir de um processo cartográfico. Foram identificados arranjos tecnológicos em três cenários: Complexo Regulador, Observatório de Redes e Apoio de Redes, que puderam ser apreendidos em conjunto com gestores, trabalhadores e usuários. Os arranjos tecnológicos relacionados ao matriciamento da pneumologia e à linha de cuidado da dor osteomuscular permitiram a análise da relação entre as ações de regulação e a produção do cuidado em redes. O estudo concluiu que as ações de regulação foram capazes de produzir cuidado centrado no usuário, que o Complexo Regulador atuou de forma coadjuvante na garantia do acesso e que os mecanismos regulatórios nos serviços de saúde potencializaram uma regulação produtora do cuidado em redes de atenção.

Abstract One of the biggest challenges for health systems is ensuring full access. Regulatory processes in Brazilian healthcare prioritize the organization of waiting lists and care dynamics with a normative character, but distance themselves from the needs of users in the sense of a production of comprehensive care. In this qualitative study, the implications of health regulation in the production of care in the municipality of São Bernardo do Campo were analyzed, using the techniques of participant observation, focus groups and guide users, constructed from a cartographic process. Technological arrangements were identified in three scenarios: Regulatory Complex, Network Observatory and Network Support, which could be seized jointly by administrators, workers and users. The technological arrangements related to the matrixing of pulmonology and the line of care of musculoskeletal pain allowed the analysis of the relationship between the actions of regulation and care in such networks. The study concluded that regulatory actions were able to produce user-centered care, which the Regulatory Complex acted in an adjunct manner in ensuring access and that regulatory mechanisms in health services enhanced a regulation that produces care in care networks.

[Impact of a coordinated regional organization to secure the management of patients on oral anticancer drugs: CHIMORAL, a comparative trial]. / Impact d'une organisation régionale coordonnée pour sécuriser la prise en charge des patients sous anticancéreux oraux : CHIMORAL, une étude comparative.

INTRODUCTION: Oral anticancer drugs have disrupted hospital and community practices. A better coordination and patient support for medication and adverse events management by primary care providers (general practitioner, community pharmacist and liberal nurse) could improve the situation. The CHIMORAL study evaluated a model of coordination by territorial health networks. METHODS: A here and elsewhere, prospective and multicentric study, comparing coordinated care with standard care. Primary outcome was the use of the hospital structure for adverse events within 6 months of initiating treatment. RESULTS: In all, 283 patients were included. 92% had at least one adverse event, with a higher median number in the coordinated group (12.5 vs. 9.0, P=0.02). No difference in hospital use by arm (P=0.502). Increase in the use of community care for adverse events in the coordinated group (27% vs. 16%, P=0.009). No observed impact on progression rates, quality of life and treatment adherence. The overall survival rate at 6 months is numerically higher in the coordinated group (87% vs. 76%, P=0.064). DISCUSSION: This model does not show any difference on the primary endpoint. The lack of randomization, patient selection, power loss, and local initiatives to monitor these patients may have biased the analysis. A large number of uses of the healthcare system were observed. These results confirm the need for a dedicated care pathway for the patient with oral anticancer drugs.

Integration of clinical pharmacy services into the Brazilian health system using Problematization with Maguerez Arc.

BACKGROUND: Clinical pharmacy services (CPS) have been evolving worldwide. However, it is estimated that CPS are not yet integrated into the Brazilian healthcare system. Thus, the objective of this study is to identify factors that influence the integration of CPS into the healthcare system and propose strategies for this integration. METHODS: A methodological development study was conducted from August 2016 to September 2017. Thus, interviews were conducted with key informants to identify barriers, facilitators, and strategies for CPS integration. Then these collected data were organized and confronted with the literature. Finally, a nominal group defined strategies for the integration of CPS into the Brazilian healthcare system. RESULTS: Interviews were conducted with five managers and seven decision-makers who listed 19 barriers and 20 facilitators. From these results, the nominal group proposed 41 integration strategies and prioritized five: formalize CPS; agree on care flows and referral protocols; evaluate and publicize CPS results/benefits; plan and define CPS; sensitize the health managers CONCLUSION: This study identified factors that influence the integration of CPS into the Brazilian health system and proposed strategies to achieve this integration. These results may contribute to future health decision-making processes.

"Ter câncer mudou minha vida": cartografia de Luiza na micropolítica das redes de cuidado oncológico / "Having cancer changed my life": Luiza's cartography in the micropolitics of cancer care networks

Resumo Garantir cuidado integral à saúde de mulheres com câncer cérvico-uterino ainda é um desafio para a Saúde Coletiva, embora se evidencie o enraizamento de políticas, práticas e saberes na conformação de redes oncológicas de cuidado. Este estudo apostou na necessidade de mergulhar nas experimentações da micropolítica do cuidado para conhecer as nuances do fenômeno investigado. Ao fundamentar-se no aporte teórico-metodológico de Deleuze e Guattari, objetivou-se cartografar linhas de composição da produção de cuidado oncológico, na cidade de São Luís-MA, tendo como dispositivo a rede da usuária-guia Luiza. Investigaram-se 28 participantes através de entrevistas em profundidade e rodas de conversas. Como resultado, desenhou-se uma rede vulnerável, fragmentada e centralizada no cuidado biomédico, tendo um hospital que acolhe demandas da doença e uma atenção primária que abandona prevenção e promoção de saúde. Destaca-se a importância de conhecer a mulher com câncer atrelada à comunidade, à religiosidade e aos vínculos familiares. Ter câncer mudou a vida de Luiza e demandou conexões para além do biomédico. Essa cartografia convoca à percepção dos gargalos existentes na produção de redes oncológicas, convidando a quebrar muros tecnoassistenciais e criar enfrentamentos centrados na promoção de saúde e qualidade de vida.

Abstract Ensuring comprehensive health care for women with cervical-uterine cancer remains a challenge for public health, although evidence of the established policies, practices and knowledge in shaping of cancer care networks. This study focused on the need to deepen in the micropolitics of care experiments to know the nuances of the investigated phenomenon. Based on the theoretical and methodological approach of Deleuze and Guattari, it aimed to map the composition lines of cancer care production in the city of São Luis-MA, Brazil, using the network of the guide-user Luiza as a device. Twenty-eight participants were investigated through in-depth interviews and conversation groups. As a result, a vulnerable, fragmented, centralized network of biomedical care was designed, with a hospital that welcomes demands of the disease, and primary care that abandons prevention and health promotion. The importance of knowing women with cancer linked to the community, religiosity and family ties is highlighted. Having cancer changed Luiza's life and required connections beyond the biomedical sphere. This cartography calls for the perception of narrowing in the production of cancer care networks, inviting the breaking of techno-assistance walls and creating confrontations focused on health promotion and quality of life.

Policy networks in metropolitan regions: the case of the health system in Brazil / Redes de políticas nas regiões metropolitanas: o caso do sistema de saúde brasileiro

Abstract Most policies, explicitly or implicitly, involve sharing responsibilities between different organizations, such as departments, government spheres, ministries, or private organizations. Thus, in recent decades, networks have become increasingly common in public policies. The Brazilian health system - given its size and geographic scope - is an example of complexity and sometimes fragmentation in policy implementation. In this context, the government adopts the concept of Healthcare Networks (RASs) in the operation of its health system. A characteristic that defines RASs is their regional character, since it is necessary to go beyond the municipal borders for the optimization of resources. This scenario of interregional relations becomes denser when the territory in question is configured in an urban superstructure, as is the case in metropolitan regions. Thus, this paper proposes the discussion of the case of Healthcare Networks in the Brazilian metropolitan regions and describes, in greater detail, the case of Campinas Metropolitan Region.

Resumo A maior parte das políticas, explícita ou implicitamente, envolve o compartilhamento de responsabilidades entre diferentes organizações, tais como departamentos, esferas governamentais, ministérios ou organizações privadas. Dessa forma, em décadas recentes, as redes têm se tornado cada vez mais comuns nas políticas públicas. O sistema de saúde brasileiro - dado seu tamanho e escopo geográfico - é um exemplo de complexidade e, por vezes, de fragmentação na implementação de políticas. Nesse contexto, o governo adota o conceito de Redes de Atenção à Saúde (RASs) na operação de seu sistema de saúde. Uma característica que define as RASs é seu caráter regional, já que se faz necessário ir além das fronteiras municipais para a otimização de recursos. Esse cenário de relações inter-regionais ganha maior densidade quando o território em questão se encontra configurado numa superestrutura urbana, como é o caso das regiões metropolitanas. Assim, este artigo propõe a discussão do caso das Redes de Atenção à Saúde nas regiões metropolitanas brasileiras e descreve, em maiores detalhes, o caso da Região Metropolitana de Campinas.

A network of networks.

Purpose To further our insight into the role of networks in health system reform, the purpose of this paper is to investigate how one agency, the NSW Agency for Clinical Innovation (ACI), and the multiple networks and enabling resources that it encompasses, govern, manage and extend the potential of networks for healthcare practice improvement. Design/methodology/approach This is a case study investigation which took place over ten months through the first author's participation in network activities and discussions with the agency's staff about their main objectives, challenges and achievements, and with selected services around the state of New South Wales to understand the agency's implementation and large system transformation activities. Findings The paper demonstrates that ACI accommodates multiple networks whose oversight structures, self-organisation and systems change approaches combined in dynamic ways, effectively yield a diversity of network governances. Further, ACI bears out a paradox of "centralised decentralisation", co-locating agents of innovation with networks of implementation and evaluation expertise. This arrangement strengthens and legitimates the role of the strategic hybrid - the healthcare professional in pursuit of change and improvement, and enhances their influence and impact on the wider system. Research limitations/implications While focussing the case study on one agency only, this study is unique as it highlights inter-network connections. Contributing to the literature on network governance, this paper identifies ACI as a "network of networks" through which resources, expectations and stakeholder dynamics are dynamically and flexibly mediated and enhanced. Practical implications The co-location of and dynamic interaction among clinical networks may create synergies among networks, nurture "strategic hybrids", and enhance the impact of network activities on health system reform. Social implications Network governance requires more from network members than participation in a single network, as it involves health service professionals and consumers in a multi-network dynamic. This dynamic requires deliberations and collaborations to be flexible, and it increasingly positions members as "strategic hybrids" - people who have moved on from singular taken-as-given stances and identities, towards hybrid positionings and flexible perspectives. Originality/value This paper is novel in that it identifies a critical feature of health service reform and large system transformation: network governance is empowered through the dynamic co-location of and collaboration among healthcare networks, particularly when complemented with "enabler" teams of people specialising in programme implementation and evaluation.

Atenção Primária à Saúde na coordenação das Redes de Atenção à Saúde no Rio de Janeiro, Brasil, e na região de Lisboa, Portugal / The role of Primary Healthcare in the coordination of Health Care Networks in Rio de Janeiro, Brazil, and Lisbon region, Portugal

Resumo Considerando a trajetória do Rio de Janeiro e da Região de Lisboa no que tange ao fortalecimento dos seus sistemas de saúde para alcance da saúde para todos e da equidade, propôs-se uma análise comparativa da organização da Atenção Primária à Saúde, buscando identificar os avanços desta em termos de coordenação das Redes de Atenção à Saúde. Trata-se de um estudo de caso, de orientação qualitativa e com dimensões avaliativas. Utilizou-se material disponível online, considerando artigos científicos e literatura cinza. Os resultados acenam para compassos diferentes no tocante às RAS, na região de Lisboa, com maior velocidade, até por questões históricas, foi implementado o modelo de APS abrangente e que hoje alcançou grau de maturidade suficiente no que tange à coordenação do seu sistema, enquanto o Rio de Janeiro sofre influências dos resquícios históricos de uma Atenção Primária à Saúde seletiva. O plano de carreira aparece como estratégia para fixação das equipes de saúde. As regiões têm feito apostas fortes nos prontuários eletrônicos e na telemedicina. Depois do estudo, ficam claras as questões históricas, culturais e políticas e jurídicas que acabam por determinar diferenças na APS coordenadora de RAS no Rio de Janeiro e na região de Lisboa.

Abstract Considering the trajectory of Rio de Janeiro e Lisboa region regarding strengths of the their health local systems to achieve health for all and equity, the study aimed to compare the organization of the Primary Healthcare from both regions, searching to identify the advancement which in terms of the Delivery Health Networks' coordination. It is a case study with qualitative approach and assessment dimensions. It was used material available online such as scientific manuscripts and gray literature. The results showed the different grades regarding Delivery Health Networks. Lisboa region present more advancement, because of its historic issues, it has implemented Primary Healthcare expanded and nowadays it achieved enough maturity related to coordination of its health local system and Rio de Janeiro suffers still influence from historic past regarding Primary Healthcare selective. The both regions has done strong bids in terms of electronic health records and telemedicine. After of the study, it is clearer the historic, cultural and politics and legal issue that determined the differences of the Primary Healthcare coordinator of the Delivery Health Network in Rio de Janeiro and Lisboa region.

Exploring mobile health in a private online social network.

Health information is very vulnerable. Certain individuals or corporate organisations will continue to steal it similar to bank account data once data is on wireless channels. Once health information is part of a social network, corresponding privacy issues also surface. Insufficiently trained employees at hospitals that pay less attention to creating a privacy-aware culture will suffer loss when mobile devices containing health information are lost, stolen or sniffed. In this work, a social network system is explored as a m-health system from a privacy perspective. A model is developed within a framework of data-driven privacy and implemented on Android operating system. In order to check feasibility of the proposed model, a prototype application is developed on Facebook for different services, including: i) sharing user location; ii) showing nearby friends; iii) calculating and sharing distance moved, and calories burned; iv) calculating, tracking and sharing user heart rate; etc.