Efectos de la COVID-19 en la calidad de la atención de los servicios de salud en Colombia: Revisión de literatura / Effects of COVID-19 on the quality of health care services in Colombia: a literature review / Efeitos da covid-19 na qualidade dos serviços de saúde na colômbia: revisão da literatura

Introducción: La pandemia por COVID-19 ha afectado significativamente la calidad de los servicios de cuidado de la salud. Objetivo: Analizar los efectos en los atributos de la calidad en salud de los servicios de atención de enfermedades diferentes a la COVID-19 en Colombia, durante el periodo 2020-2022. Materiales y métodos: Se analizaron 24 artículos de alcance nacional y otros específicos de departamentos como Antioquia, Córdoba, Santander y Cundinamarca. Resultados: La pandemia por COVID-19 impactó la calidad de los servicios en la atención de enfermedades como cáncer, accidentes cerebrovasculares y de eventos como la interrupción voluntaria del embarazo. Conclusión: La calidad de la salud se vio afectada en todas sus dimensiones durante las fases de la pandemia, especialmente en la población con enfermedades crónicas y relacionadas con la salud infantil y materna. Además, se destacaron respuestas como el uso de la telemedicina y de la atención domiciliaria para contribuir a la calidad de la salud en Colombia.

Introduction: The COVID-19 pandemic has significantly affected the quality of health care services. Objective: To analyze the effects of COVID-19 on the quality of health care services focused on treating diseases other than COVID-19 in Colombia during the 2020-2022 period. Materials and methods: 24 articles were analyzed, which included some studies focused on national issues and others specific to the departments of Antioquia, Cordoba, Santander, and Cundinamarca. Results: The COVID-19 pandemic affected the quality of health services caring for diseases such as cancer, strokes, and critical circumstances like voluntary termination of pregnancy. Conclusion: All dimensions of health care were affected during the pandemic, especially impacting populations with chronic diseases and diseases related to child and maternal health. It is important to highlight that telemedicine and home care contributed to improving the quality of health in Colombia.

Introdução: A pandemia de COVID-19 afetou significativamente a qualidade dos serviços de saúde. Objetivo: Analisar os efeitos da COVID-19 nos atributos de qualidade em saúde dos serviços de atenção a outras doenças além da COVID-19 na Colômbia, durante o período 2020-2022. Materiais e métodos: foram analisados 24 artigos de âmbito nacional e outros específicos de departamentos como Antioquia, Córdoba, Santander e Cundinamarca. Resultados: A pandemia da COVID-19 impactou a qualidade dos serviços no cuidado de doenças como câncer, acidente vascular cerebral e eventos como a interrupção voluntária da gravidez. Conclusão: A qualidade da saúde foi afetada em todas as suas dimensões durante as fases da pandemia, especialmente na população com doenças crônicas e doenças relacionadas à saúde infantil e materna. Além disso, foram destacadas respostas como o uso da telemedicina e do atendimento domiciliar para contribuir para a qualidade da saúde na Colômbia.

Democracy, citizenship and health in Brazil: challenges to strengthening the Unified Health System (SUS). / Democracia, cidadania e saúde no Brasil: desafios para o fortalecimento do Sistema Único de Saúde (SUS).

Relations among democracy, citizenship and health have shaped the Unified Health System (SUS) over the past four decades. Until 2016, democracy was strengthened and social rights extended, despite structural difficulties, conflicts between projects, and unevenly over time. The SUS has allowed advances in access and improvements to health conditions. Between 2016 and 2022, there were significant reversals in economic, social, and health policies. Since 2020, the situation has been aggravated by the multidimensional crisis associated with the COVID-19 pandemic. The work of the SUS, universities and public scientific institutions was fundamental in tackling the crisis. From 2023 onwards, Brazil has faced enormous challenges in restoring a democratic national project focused on social welfare. Strengthening the SUS depends on the character of social policies and democracy, and on transforming relations among State, market and society, to overcome constraints that have persisted even during progressive governments. The SUS, a universal policy rooted in a broad concept of health and democratic values, is fundamental to establishing a pattern of development aimed at reducing inequalities and building a more just society.

As relações entre democracia, cidadania e saúde permearam a conformação e a trajetória do Sistema Único de Saúde (SUS) nas últimas quatro décadas. Em que pesem dificuldades estruturais, conflitos entre projetos e diferenças entre momentos, até 2016 observou-se o fortalecimento da democracia e a expansão de direitos sociais. O SUS permitiu avanços no acesso e melhorias nas condições de saúde. Entre 2016 e 2022, os retrocessos nas políticas econômicas, sociais e de saúde foram expressivos. A situação foi agravada pela crise multidimensional associada à pandemia de COVID-19 a partir de 2020. A atuação do SUS, de universidades e de instituições científicas públicas foi fundamental para o enfrentamento da crise. A partir de 2023, os desafios de retomada de um projeto nacional democrático e voltado ao bem-estar social são imensos. O fortalecimento do SUS depende do caráter das políticas sociais e da democracia, e de transformações nas relações Estado-mercados-sociedade, para superar limites que persistiram mesmo durante governos progressistas. O SUS, como política universal ancorada em uma concepção ampla de saúde e em valores democráticos, é um pilar fundamental para a consolidação de um padrão de desenvolvimento orientado para a redução das desigualdades e a construção de uma sociedade mais justa.

Federal transfers to municipalities through parliamentary amendments: implications for SUS funding. / Transferências federais por emendas parlamentares aos municípios: implicações para o financiamento do SUS.

The present article analyzes the transfers from parliamentary amendments by the Ministry of Health to municipalities to finance public health actions and services from 2015 to 2021. A descriptive and exploratory study was carried out with secondary data, including all Brazilian cities. Resources from amendments showed an increase, particularly from 2018 onwards, indicating the expansion of their relevance for financing SUS. From 2016 to 2021, over 80% was allocated to municipalities, representing 9.5% of all federal transfers, with 91.2% for operational expenses. Transfers from amendments differ from regular transfers due to greater instability and per capita variation among the amounts collected by municipalities and due to the fact that they allocate most resources to the Northeast and primary care to the detriment of the Southeast and medium and high complexity care. These transfers represent a differentiated modality of resource allocation in SUS that produces new distortions and asymmetries, with implications for intergovernmental relations, as well as between the executive and legislative powers, increasing the risk of the discontinuity of actions and services and imposing challenges for the municipal management.

O artigo tem como objetivo analisar as transferências por emendas parlamentares do Ministério da Saúde aos municípios para o financiamento de ações e serviços públicos de saúde, de 2015 a 2021. Foi realizado estudo descritivo e exploratório com dados secundários, abrangendo a totalidade de municípios brasileiros. Os recursos provenientes de emendas apresentaram aumento, em especial a partir de 2018, indicando a expansão de sua relevância para o financiamento do SUS. No período de 2016 a 2021, mais de 80% foram alocados aos municípios, representando 9,5% dos repasses federais, com 91,2% de natureza de custeio. As transferências por emendas diferem dos repasses regulares por possuir maior instabilidade e variação per capita entre os montantes captados pelos municípios, e por destinar a maior parte dos recursos ao Nordeste e à atenção primária, em detrimento do Sudeste e da média e alta complexidade. Configura-se uma modalidade diferenciada de alocação de recursos no SUS que produz novas distorções e assimetrias, com implicações para as relações intergovernamentais e entre os poderes executivo e legislativo, ampliando o risco de descontinuidade de ações e serviços e impondo desafios para as gestões municipais.

Analysis of the performance of health services in a group of vulnerable municipalities. / Análise do desempenho dos serviços de saúde em um grupo de municípios vulneráveis.

This work was a descriptive study that analyzed the performance of health services in 112 municipalities (g100) characterized by more than 80,000 inhabitants, low public revenue, and socioeconomic vulnerability. Based on the Projeto de Avaliação de Desempenho do Sistema de Saúde, 31 indicators of funding, resources, access, effectiveness, acceptability, and appropriateness were selected for the period of 2017-2020, and were compared to the variations of each year's indicators year on year. In 2020, an increase in funding, especially SUS transfers (31.6%), was observed. The availability of hospital beds had been decreasing between 2017 and 2019, but began to increase again in 2020; likewise, the availability of health professionals also showed a slight increase. A decline was observed in cervical and breast cancer screening exams of nearly 40% (2020), as well as a decrease in surgical procedures, such as cataracts and angioplasties. The hospitalizations due to conditions manageable by primary care were 15.8% in 2020, 14.1% lower than in 2019. A 55.8% increase in mortality due to diabetes and greater tuberculosis treatment non-adherence was also observed. The pandemic context calls for caution when interpreting results, which highlight access barriers and postponements of proper health care.

Estudo descritivo que analisou o desempenho dos serviços de saúde de um grupo de 112 municípios denominado g100 caracterizado por mais de 80 mil habitantes, baixa receita pública e vulnerabilidade socioeconômica. Do Projeto de Avaliação de Desempenho do Sistema de Saúde, foram selecionados 31 indicadores de financiamento, recursos, acesso, efetividade, aceitabilidade e adequação, para o período 2017-2020, e comparadas variações de cada ano em relação ao anterior. Em 2020, houve aumento no aporte financeiro, especialmente por transferências SUS (31,6%). A disponibilidade de leitos vinha decaindo entre 2017 e 2019, aumentou em 2020 e a oferta de profissionais de saúde apresentou leve aumento. Houve redução nos exames de rastreamento de câncer de colo do útero e mama de quase 40% (2020), e reduções de internações cirúrgicas, como cataratas e angioplastias. O percentual de internações por condições sensíveis à atenção primária foi 15,8% em 2020, 14,1% menor do que em 2019. Houve aumento de 55,8% na mortalidade por diabetes e maior abandono do tratamento de tuberculose. O contexto pandêmico exige cautela na interpretação de resultados, que apontam para barreiras de acesso e postergação na prestação de cuidados.

Telecare in the Brazilian Unified Health System: where we are and where we are heading. / Teleassistência no Sistema Único de Saúde brasileiro: onde estamos e para onde vamos?

This article explores telecare from telehealth developments and the recent acceleration of the digital health transformation caused by the COVID-19 pandemic, focusing on the Brazilian Unified Health System (SUS). It addresses terminological issues, the scope of actions, the potential use for healthcare, and constraints and contingencies for telecare in Brazil, focusing on teleconsultations and interactions between health professionals and patients. Finally, it presents a set of propositions for the development of telecare policies and practices in Brazil, considering SUS principles, in two central themes: organizational political guidelines and operational propositions to organise services and healthcare delivery. The importance of clarifying the scope and limits of new technologies is highlighted in the attempt to avoid idealizations with proposed solutions to complex health problems. Telecare solutions should be compatible with SUS principles and with the recommended model of care, with the healthcare network coordinated and organised by primary care, ensuring access to health services and integrated and quality healthcare for the Brazilian society.

O artigo explora a teleassistência a partir dos desenvolvimentos da telessaúde e da aceleração da transformação digital na saúde provocada pela pandemia de COVID-19, com foco no Sistema Único de Saúde (SUS). Aborda questões terminológicas, escopo de ações, potencialidades do uso para atenção à saúde e condicionantes e contingências para a utilização da teleassistência no Brasil, concentrando-se nas teleconsultas e nas interações entre profissionais de saúde e pacientes. Por fim, apresenta um conjunto de proposições para o desenvolvimento das políticas e práticas de teleassistência no Brasil, tendo em vista os princípios do SUS, organizados em dois eixos estratégicos centrais: diretrizes político organizacionais e proposições operacionais e de organização dos serviços e do cuidado. Destaca-se a importância de ponderar e elucidar os alcances e os limites das novas tecnologias para evitar idealizações e deslumbramentos com suas propostas de solução para os complexos problemas de saúde. As soluções de teleassistência devem ser compatíveis com princípios e diretrizes do SUS e com o modelo de atenção preconizado, que prevê a organização da rede a partir da atenção primária, para garantir acesso, integralidade e qualidade da atenção à saúde para a sociedade brasileira.

Health policy and regulatory authorities: challenges of technology regulation in Public Health Emergencies. / Política de saúde e Autoridades Reguladoras: desafios da regulação de tecnologias nas Emergências em Saúde Pública.

Public Health Emergencies (PHE) have had repercussions on health systems on a global scale, and timely access to new health technologies is a challenge for health policy. The national regulatory authorities (NRA) play a key role in the evaluation and regulation of these technologies. The present study aims to analyze the main strategies and regulatory instruments used to deal with the challenges of regulating new technologies necessary for the health system's effective response during a PHE. This research, based on WHO and Brazilian NRA norms and documents, considered dimensions related to strategies for strengthening regulatory activities and regulatory instruments used to accelerate access to technologies, especially during PHEs. International cooperation between the NRA and the WHO were important strategies for strengthening the NRA, with emphasis on the use of reliance, regionalization, accelerated assessments, and work/information sharing, as well as the processes of regulatory harmonization and convergence. In addition to the use of existing regulatory instruments, efforts were also identified in order to implement new ones.

As Emergências em Saúde Pública (ESP) têm repercutido nos sistemas de saúde em escala global. O acesso às novas tecnologias em saúde em tempo oportuno é um desafio para a política de saúde. As autoridades reguladoras nacionais (ARN) têm papel fundamental na avaliação e regulação dessas tecnologias. O estudo objetiva analisar as principais estratégias e instrumentos regulatórios utilizados para lidar com os desafios da regulação de novas tecnologias necessárias à resposta do sistema de saúde durante as ESP. Trata-se de uma pesquisa normativa e documental, tendo como fonte a OMS e a ARN brasileira. Foram consideradas as dimensões relacionadas às estratégias para o fortalecimento das atividades regulatórias e os instrumentos regulatórios utilizados para acelerar o acesso às tecnologias, especialmente durante as ESP. A cooperação e a colaboração internacional entre as ARN e com a OMS foram importantes estratégias para o fortalecimento das ARN, com destaque para o uso de confiança, regionalização, avaliações aceleradas e compartilhamento de trabalho/informações, bem como os processos de harmonização e convergência regulatória. Identificou-se, além da utilização de instrumentos regulatórios já existentes, esforços na implementação de novos, com destaque para Autorização de Uso Emergencial.

Care resignification in the pandemic context. / A ressignificação do cuidado no contexto de pandemia.

This essay discusses the care process of health professionals in the context of COVID-19 from the perspectives of psychoanalysis, under the prism of Donald Winnicott's transitional space, and of collective health, under the prism of the practical wisdom of José Ricardo Ayres, the micropolitics of live work in action by Emmerson Merhy, and prudent care by Ruben Mattos. It suggests elaborating a care perspective to propose a possible resignification of illness in a pandemic, where health is marked with calamity, health catastrophe, and suffering and anguish, whether in the body or subjectively. In this way, understanding the manifestation of care by health professionals in a pandemic context brought about with narcissistic and heroic meanings and feelings of impotence and helplessness contributes to elaborating a creative conception of care. We conclude that the perspective of expanded care favors the creative possibility of new productions of meaning and support for professionals, resignifying their life experiences through love, creativity, practical wisdom, prudent care, live work in action, and motor imaginary.

Esse ensaio discute o processo de cuidado de profissionais de saúde no contexto da COVID-19 a partir das perspectivas da psicanálise, sob o prisma do espaço transicional de Donald Winnicott, e da saúde coletiva, sob o prisma da sabedoria prática de José Ricardo Ayres, da micropolítica do trabalho vivo em ato de Emmerson Merhy, e do cuidado prudente de Ruben Mattos. Propõe a elaboração de uma perspectiva de cuidado que se apresenta enquanto proposta de ressignificação possível ao adoecimento no contexto de pandemia, onde a saúde foi marcada com sentidos de calamidade e catástrofe sanitária, e expressões de sofrimento e angústia, no corpo e/ou mesmo subjetivamente. Desse modo, uma compreensão sobre a manifestação do cuidado do profissional de saúde, no contexto de pandemia, trazido com sentidos narcísicos e heroicos, e com sentidos de impotência e desamparo, contribui para a elaboração de uma concepção criativa do cuidado. Conclui-se que a perspectiva de um cuidado ampliado favorece a possibilidade criativa de novas produções de sentido e de sustentação para os profissionais, ressignificando suas experiências de vida, através do amor, da criatividade, da sabedoria prática, do cuidado prudente, do trabalho vivo em ato e do imaginário motor.

Perspectives for Primary Health Care public policy in South America. / Perspectivas para las políticas públicas de Atención Primaria en Salud en Suramérica.

We aim to conduct a comparative analysis of the implementation of PHC in nine South American countries. Three dimensions were highlighted from documentary sources: political commitment, leadership, and governance; care model; and engagement of communities and other stakeholders. The results indicate a formal commitment that places PHC at the center of efforts to achieve universal access. The following can be observed: revitalization processes in public subsystems, based on guaranteeing preventive, promotional, curative and rehabilitation actions; PHC as gatekeeper; emphasis on family and community; assigned population and territory; multidisciplinary teams; and, in some cases, the accent on interculturality expressed in the concept of "buen vivir" (good living). The PHC revitalization processes were affected by political changes. Between progress and setbacks, the segmentation of coverage was not overcome. The current moment seeks to recover more inclusive and broad public policies in the context of the return of the progressive and democratic fields. The dissemination of country experiences can contribute to the development of a comprehensive, integrated, and quality approach to PHC in the Region.

El objetivo es realizar un análisis comparativo de la implementación de la APS en nueve países de Suramérica. A partir de fuentes documentales fueron destacadas tres dimensiones: compromiso político, liderazgo y gobernanza; modelo de atención; involucramiento de comunidades y otros actores. Los resultados indican la existencia de compromiso formal que localiza la APS en el centro de los esfuerzos para lograr el acceso universal. Se observan procesos de revitalización en los subsistemas públicos, basados en la garantía de acciones preventivas, promocionales, de cura y rehabilitación; puerta de entrada; enfoque familiar y comunitario; población y territorio adscriptos; equipos multiprofesionales, y, en algunos casos, énfasis en la interculturalidad expresada en la concepción de "buen vivir". Los procesos de revitalización de la APS fueron afectados por cambios políticos. Entre avances y retrocesos, no se logró superar la segmentación de cobertura. El momento actual es de rescate de políticas públicas más inclusivas y amplias, en el contexto de recomposición de los campos progresistas y democráticos. Difundir experiencias de los países puede contribuir para el desarrollo de un enfoque de APS integral, integrada y de calidad en la Región.

Recommendations for Recovery of the COVID-19 Pandemic-related Diagnostic, Screening, and Procedure Backlog in Ontario: A Survey of Healthcare Leaders.

PURPOSE: The COVID-19 pandemic has resulted in a significant diagnostic, screening, and procedure backlog in Ontario. Engagement of key stakeholders in healthcare leadership positions is urgently needed to inform a comprehensive provincial recovery strategy. METHODS: A list of 20 policy recommendations addressing the diagnostic, screening and procedure backlog in Ontario were transformed into a national online survey. Policy recommendations were rated on a 7-point Likert scale (strongly agree to strongly disagree) and organized into those retained (≥75% strongly agree to somewhat agree), discarded (≥80% somewhat disagree to strongly disagree), and no consensus reached. Survey participants included a diverse sample of healthcare leaders with the potential to impact policy reform. RESULTS: Of 56 healthcare leaders invited to participate, there were 34 unique responses (61% response rate). Participants were from diverse clinical backgrounds, including surgical subspecialties, medicine, nursing, and healthcare administration and held institutional or provincial leadership positions. A total of 11 of 20 policy recommendations reached the threshold for consensus agreement with the remaining 9 having no consensus reached. CONCLUSION: Consensus agreement was reached among Canadian healthcare leaders on 11 policy recommendations to address the diagnostic, screening, and procedure backlog in Ontario. Recommendations included strategies to address patient information needs on expected wait times, expand health and human resource capacity, and streamline efficiencies to increase operating room output. No consensus was reached on the optimal funding strategy within the public system in Ontario or the appropriateness of implementing private funding models.

What is known about the role of external facilitators during the implementation of complex interventions in healthcare settings? A scoping review.

OBJECTIVE: To synthesise current knowledge about the role of external facilitators as an individual role during the implementation of complex interventions in healthcare settings. DESIGN: A scoping review was conducted. We reviewed original studies (between 2000 and 2023) about implementing an evidence-based complex intervention in a healthcare setting using external facilitators to support the implementation process. An information specialist used the following databases for the search strategy: MEDLINE, CINAHL, APA PsycINFO, Academic Search Complete, EMBASE (Scopus), Business Source Complete and SocINDEX. RESULTS: 36 reports were included for analysis, including 34 different complex interventions. We performed a mixed thematic analysis to synthesise the data. We identified two primary external facilitator roles: lead facilitator and process expert facilitator. Process expert external facilitators have specific responsibilities according to their role and expertise in supporting three main processes: clinical, change management and knowledge/research management. CONCLUSIONS: Future research should study processes supported by external facilitators and their relationship with facilitation strategies and implementation outcomes. Future systematic or realist reviews may also focus on outcomes and the effectiveness of external facilitation.

Githinji Gitahi: developing resilient health systems for universal coverage.

Githinji Gitahi talks to Gary Humphreys about the value of cross-sectoral collaboration and health system assessment in the drive towards universal health coverage (UHC).

Assessing health system performance.

The post-pandemic era presents an opportunity to prioritize health system performance assessment. Adèle Sulcas reports.

Evolution of HIV Health Care Workforce Needs in the U.S. Mountain West During the COVID-19 Pandemic: A Mixed Method Study.

ABSTRACT: The COVID-19 pandemic drastically affected health care delivery for vulnerable populations. Many facilities shifted services to telemedicine, and people with HIV or at risk of acquiring HIV experienced interruptions in care. Simultaneously, traditional training approaches to help providers adapt were disrupted. Using a mixed method approach to examine changes over time, we integrated data on trainee needs collected by the Mountain West AIDS Education and Training Center (AETC): a 10-state needs assessment survey in 2020; feedback from a 2020 community of practice; aggregate training data from 2000 to 2022; and a second survey in 2022. HIV care providers' training needs evolved from wanting support on telemedicine and COVID-19 patient care issues, to a later focus on mental health and substance use, social determinants of health, and care coordination. This integrative analysis demonstrates the vital role that AETCs can play in addressing evolving and emergent public health challenges for the HIV workforce.

Vulnerabilities to disasters in healthcare facilities in the face of the COVID-19 pandemic: a scoping review. / Vulnerabilidades a desastres em estabelecimentos de saúde frente à pandemia de COVID-19: revisão de escopo.

This article maps the structural, nonstructural and functional vulnerabilities of healthcare facilities to the COVID-19 pandemic. It reports on a scoping review guided by JBI recommendations and structured by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. The PubMed, CINAHL, LILACS, EMBASE, SciELO, Scopus and Web of Science Repositories and databases were consulted, as was the grey literature. The protocol was registered in the Open Science Framework. The 54 studies included summarised 36 vulnerabilities in three categories in 29 countries. Functional and non-structural vulnerabilities were the most recurrent. Limited material and human resources, service disruption, non-COVID procedures and inadequate training were the items with most impact. COVID-19 exposed nations to the need to strengthen health systems to ensure their resilience in future health crises. Prospective risk management and systematic analysis of health facility vulnerabilities are necessary to ensure greater safety, sustainability and improved standards of preparedness and response to events of this nature.

O objetivo do artigo é mapear as vulnerabilidades estruturais, não-estruturais e funcionais de estabelecimentos de saúde frente à pandemia de COVID-19. Revisão de escopo conduzida mediante recomendações do JBI e estruturada pelos Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Foram consultados repositórios e bases de dados: PubMed, CINAHL, LILACS, EMBASE, SciELO, Scopus e Web of Science, além de literatura cinzenta. O protocolo foi registrado em Open Science Framework, 54 estudos foram incluídos, sumarizando 36 vulnerabilidades entre as três categorias, em 29 países. As vulnerabilidades funcionais e não-estruturais foram as mais recorrentes. Recursos materiais e humanos limitados, interrupção dos serviços e procedimentos não-COVID, além de capacitação profissional insuficiente foram os itens que mais impactaram. A COVID-19 expôs às nações a necessidade de fortalecer os sistemas de saúde para garantir sua resiliência em futuras crises sanitárias. Ações de gestão de risco prospectivas e análise sistematizada de vulnerabilidades dos estabelecimentos de saúde são necessárias para garantir maior segurança, sustentabilidade e melhor padrão de preparação e resposta a futuros eventos dessa natureza.

Collapse of Cancer Care Under the Current Conflict in Sudan.

Sudan has been under an armed conflict between the Sudanese Armed Forces and the Rapid Support Forces (RSF) militia since April 15, 2023. The conflict has turned the country into the largest internal displacement humanitarian crisis with 9.05 million internally displaced persons including 2.2 million children younger than 5 years and caused 1.47 million Sudanese to flee the country as refugees. The conflict has had a major destructive impact on the health system, which has incurred targeting with air raids, ground invasion, vandalization, looting of assets and supplies, and killing of doctors, nurses, and other health personnel. Khartoum Oncology Hospital, Sudan's main cancer hub for treatment, diagnostics, and research has become nonfunctional as a result of the conflict. The National Cancer Institute in Wad Medani, the second largest hub, faced a similar fate as the conflict spread to Al-Gezira State. Patients with cancer have been displaced multiple times in Sudan with grave consequences on the continuity of care, worsening of their disease outcomes and palpable negative impacts on children. The oncology workforce in Sudan have themselves been displaced yet are working hard to provide services and care for patients under impossible circumstances. Sudan's doctors in diaspora have rallied to provide support but they face multiple obstacles. As the conflict continues to spread, we call upon the WHO, the United Nations Children's Fund, St Jude Hospital, and all relevant partners to implement an immediate evacuation operation with urgent air lifts of the affected children to continue their cancer care in neighboring countries as was done in Ukraine and Gaza.

Coopetition, exploration and exploitation capabilities, and growth performance in digital healthcare ventures.

Introduction: Studies focusing on coopetition and dynamic capabilities have expanded significantly over the past several decades. Coopetition strategy and dynamic capabilities are increasingly recognised as sources of sustained competitive advantage. The purpose of this paper is to provide a better understanding of the factors driving growth performance in digital healthcare ventures by examining the role of coopetition, exploration and exploitation capabilities, and environmental uncertainty. While numerous studies have examined the competitive advantage of coopetition, its specific contribution to the growth of ventures in the digital realm remains less explored. Clarifying the strategic role of coopetition in driving growth performance is critical for delineating the intricate relationship between coopetition and growth performance, particularly in the context of digital healthcare ventures. To fill in this research gap, this study uses coopetition theory and dynamic capabilities theory to look at how exploration and exploitation capabilities, as well as environmental uncertainty, affect the relationship between coopetition and growth performance in digital healthcare ventures. Methods: We collected a total of 338 questionnaires from Chinese digital healthcare ventures between March 2023 and August 2023. We conducted data analysis using SPSS 26.0 and its macro-program PROCESS. Results: Our results confirm that coopetition has a positive effect on growth performance in digital healthcare ventures. Furthermore, exploration and exploitation capabilities fully mediate the relationship between coopetition and growth performance. Moreover, environmental uncertainty significantly and distinctively moderates the impact of exploration and exploitation capabilities on growth performance. Discussion: This study contributes to the existing literature by providing deeper insight into the relationship between coopetition and growth performance in digital healthcare ventures. It also offers important practical implications for public health improvement and socio-economic development.

Bridging the gap to meet complex needs: an intersectoral action well supported by appropriate policies and governance.

Many people face problems about physical, mental, and social dimensions of health, and may have complex needs. They often experience a mismatch between their needs and the ability of the healthcare system to meet them, resulting in under- or overutilization of the healthcare system. On one hand, improving access to community-based primary healthcare for hard-to-reach populations should bring all healthcare and social services to one point of contact, near the community. On the other hand, better addressing the unmet needs of people who overuse healthcare services calls for integrated care among providers across all settings and sectors. In either case, intersectoral action between healthcare and social professionals and resources remains central to bringing care closer to the people and the community, enhancing equitable access, and improving health status. However, efforts to implement integrated care are unevenly weighted toward clinical and professional strategies (micro level), which could jeopardize our ability to implement and sustain integrated care. The development of appropriate policies and governance mechanisms (macro level) is essential to break down silos, promote a coherent intersectoral action, and improve health equity.

[Stigma in homelessness and health care: reflections from a Housing First program in Barcelona, Spain]. / Estigma en personas sin hogar y atención en salud: reflexiones desde un programa Housing First en Barcelona, España.

The experience of homelessness is associated with strong stigmatization processes, which are often reflected in the treatment received from professionals and the healthcare system itself. This article aims to analyze the experiences of participants in a program for homeless individuals in Barcelona called Primer la Llar within the healthcare system, and how the stigma they suffer affects the care processes. This program follows the Housing First model, a social intervention that proposes providing housing without preconditions to individuals with long histories of street living, who suffer from severe mental disorders and/or addictions. Based on individual interviews with 20 participants conducted between 2016 and 2020, it is observed that in certain cases, entering the program, having housing availability, support from professionals, and the development of their own strategies had positive effects on improving their health, although they continue to perceive discriminatory attitudes in some medical settings. It is suggested that the transformation regarding stigmatization be understood broadly, affecting individuals, institutions, and society as a whole.

El tránsito por el sinhogarismo está asociado a procesos de fuerte estigmatización que, en muchas ocasiones, tienen su reflejo en el trato que reciben por parte de las y los profesionales y del propio sistema de atención en salud. Este artículo tiene como objetivo analizar las experiencias que tuvieron en el sistema sanitario las y los participantes de un programa para personas sin hogar en Barcelona llamado Primer la Llar, y cómo el estigma que sufren estas personas llega a condicionar los procesos de atención. Dicho programa sigue el modelo Housing First, una intervención social que propone la entrada a una vivienda sin condiciones previas a personas con largas trayectorias de vida en la calle, que sufren trastornos mentales graves y/o adicciones. A partir de entrevistas individuales con 20 participantes, realizadas entre 2016 y 2020, se observa que, en determinados casos, el ingreso en el programa, la disponibilidad de una vivienda, el soporte de profesionales y el desarrollo de estrategias propias tuvieron efectos positivos en la mejora de su salud, aunque continúan percibiendo actitudes discriminatorias en algunos espacios médicos. Se plantea la necesidad de que la transformación respecto a la estigmatización sea entendida en un sentido amplio, en las personas, en las instituciones y en la sociedad.

The role of nurses in implementation of public policy on adolescent health in Colombia, Ecuador, and Peru.

BACKGROUND: In Latin America, interventions aimed at adolescents' health suffer from a shortfall of investment and lack of sustainability. Nurses, as an integral part of health services and systems, can lead the implementation and development of public health policies to improve adolescent health. OBJECTIVE: To identify and analyze the role of nurses in the development and implementation of public policies and in the provision of health care to adolescents in Colombia, Ecuador, and Peru. METHODS: The research was carried out in three phases: a documentary analysis, an online survey, and semi-structured focus groups. A total of 48 documents were analyzed, 288 nurses participated in the survey, and 29 nurses participated in the focus groups. RESULTS: State policies aim to guarantee rights, with special protection for children and adolescents. It is an incremental process, with greater involvement of civil society and governments. Participants reported a lack of synergy between law and practice, as well as differences in regulatory compliance in rural areas and in populations of different ethnicities and cultures. Their perception was that the protection of adolescents is not specifically enshrined in the legal bases and regulatory structures of the countries, meaning that there are both protective factors and tensions in the regulatory framework. While nurses are highly committed to different actions aimed at adolescents, their participation in policy development and implementation is low, with barriers related to a lack of specialized training and working conditions. CONCLUSIONS: Given nurses' involvement in different actions aimed at adolescents, they could play a fundamental role in the development of policies for adolescents and ensure their effective implementation. Policymakers should consider revising the budget to make compliance viable, incorporating and using monitoring indicators, and increasing the involvement of educational institutions and the community.