Vulnerable populations and the right to health: lessons from the Peruvian Amazon around tuberculosis control.

BACKGROUND: In 2014 the World Health Organization (WHO) launched the "End TB Strategy", setting new ambitious goals for elimination of tuberculosis (TB). In contrast with previous efforts to control TB, the new strategy adopted the protection and promotion of human rights in TB prevention and care as a core pillar. This mandated the development of national programmes that are sensitive to the characteristics of populations and responsive to structural factors that put people at increased risk of exposure to TB, limit access to good quality health services and make people more vulnerable to TB infection. Indigenous people living in the Peruvian Amazon have been identified as a TB vulnerable group by Peruvian health authorities. This article examines the barriers faced by indigenous people and rural settlers from the Peruvian Amazon in obtaining a TB diagnosis and appropriate TB treatment, through the principles of the human rights based approach of accessibility, availability, affordability, adaptability and quality, and thus provides evidence of the utility of such approach in Peru. METHODS: This is a qualitative study. We combined information from policy documents and legal regulations and in-depth interviews with health workers and health authorities. We used Atlas-ti to conduct a thematic analysis and identify interviewees responses to pre-defined topics. RESULTS: Despite having a strong legal framework to protect the right to health of indigenous people and people affected by TB, there are underlying structural factors contributing to delays in detection, diagnosis and TB treatment, which are mostly related to having a health system poorly prepared to provide care for people living in dispersed rural communities. This article shows the limited level of integration of the "End TB Strategy" principles in the Peruvian National TB Programme and identifies the weakness of the health system to improve health care provision for indigenous people and rural settlers from the Peruvian Amazon. CONCLUSIONS: Our study shows the need to go beyond developing a strong legal framework to ensure vulnerable populations such as indigenous people are able to realize their right to health. Governments need to allocate funds, improve training and adapt healthcare provision to the cultural, geographical, and social context of indigenous people.

Realizing the right to health in Brazil's Unified Health System through the lens of breast and cervical cancer.

BACKGROUND: Health is recognized as a fundamental right in Brazil's constitution. In the absence of a clearly defined benefit packages of healthcare services that are financed under the Unified Health System (Sistema Único de Saúde, SUS), courts have become important in adjudicating coverage decisions. Empirical assessments of equity and the right to health tend to focus on simple measures of access. However, these empirical perspectives belie the significant inequalities and rights violations that arise in the case of more complex health needs such as cancer. To shed light on these issues, this paper focuses on the care pathways for breast and cervical cancer and explores access and quality issues that arise at different points along the care pathway with implications for the realization of the right to health in Brazil. METHOD: A mixed method approach is used. The analysis is primarily based on a quantitative analysis of national representative administrative data principally from the cervical and breast cancer information systems and the hospital cancer registry. To gain more insights into the organization of cancer care, qualitative data was collected from the state of Bahia, through document analysis, direct observation, roundtable discussions with health workers (HWs), and structured interviews with health care administrators. RESULTS: The paper reveals that the volume of completed screening exams is well below the estimated need, and a tendency toward lower breast cancer screening rates in poorer states and for women in the lowest income brackets. Only 26% of breast cancer cases and 29% of cervical cancer cases are diagnosed at an early stage (stage 0 or I), thereby reducing the survival prospects of patients. Waiting times between confirmed diagnosis and treatment are long, despite new legislation that guarantees a maximum of 60 days. The waiting times are significantly longer for patients that follow the recommended patient pathways, and who are diagnosed outside the hospital. CONCLUSION: The study reveals that there are large variations between states and patients, where the poorest states and patients fare worse on key indicators. More broadly, the paper shows the importance of collecting data both on patient characteristics and health system performance and carry out detailed health system analysis for exposing, empirically, rights violations and for identifying how they can be addressed.

Judicialização da Saúde: argumentos utilizados nas ações judiciais em desfavor do Sistema Único de Saúde, no Tribunal de Justiça do Distrito Federal e dos Territórios, pelos atores processuais / Judicialization of Health: arguments used in the lawsuits against the SUS, in the Court of Justice of the Federal District and Territories, by the procedural actors

Objetivo: Analisar os discursos dos atores processuais em processos no Tribunal de Justiça do Distrito Federal e dos Territórios em que tramitam ações em desfavor das políticas públicas de saúde, no período entre os anos de 2012 e 2013, a fim de conhecer os argumentos mais comumente utilizados para o julgamento dessas ações. Metodologia: Realizou-se uma pesquisa descritiva, analítica, de base documental e bibliográfica, utilizando dados secundários. Os dados foram coletados através de uma pesquisa sobre judicialização no Brasil, nos anos de 2012 e 2013. Os dados quantitativos disponibilizados já se encontravam tratados em tabelas e gráficos e os dados qualitativos foram disponibilizados sem o devido tratamento, o que foi realizado a partir do método da Análise Idiossincrática. Resultados: Os três atores analisados autor, réu e juiz, tratam de questões lógicas que ocorrem no sistema e que podem ocorrer discrepâncias. Cada autor tem o seu ponto de vista, experiência e suas particularidades que não devem ser descartadas, podendo assim, haver conflitos visíveis, mas, em tratando de saúde, o ponto em comum é a melhor decisão para o usuário. Os pedidos a serem judicializados não condizem diretamente com as doenças que mais acometem os pacientes. Conclusão: É possível aferir, a partir dos discursos, a imprudência acometida com os pacientes que estão no processo e percebesse que muitas das prestações de serviços procuradas ainda estão em déficit com seu atendimento, sendo que o estado brasileiro ainda não é garantidor universal dos usuários em suas necessidades. (AU)

Objective: To analyze the speeches of the procedural actors in lawsuits in the Court of Justice of the Federal District and Territories in which they prosecute actions in detriment of the public health policies, in the period between 2012 and 2013, in order to know the arguments most commonly used for the judgment of these actions. Methodology: A descriptive, analytical, documentary and bibliographic research was carried out using secondary data. The data were collected through a research on judicialization in Brazil in the years of 2012 and 2013. The quantitative data available were already treated in tables and graphs and the qualitative data were made available without due treatment, which was done from the method of Idiosyncratic Analysis. Results: The three actors analyzed author, defendant and judge, deal with logical issues that occur in the system and that discrepancies may occur. Each author has his or her points of view and experience and their particularities that should not be discarded, so that there may be visible conflicts, but if it comes to health, the common ground, is the best decision for the user. The requests to be judicialized do not directly correspond to the diseases that most affect the patients. Conclusion: It is possible to gauge from the discourses the imprudence with the patients that are in the process and it is perceived that many of the services rendered are still in deficit with their care, being that the Brazilian state is not yet universal guarantor of the users in your needs. (AU)

Objetivo: Analizar los discursos de los actores procesales en procesos ante el Tribunal de Justicia del Distrito Federal y de los Territorios en que tramitan acciones en desfavorable de las políticas públicas de salud, en el período entre los años 2012 y 2013, a fin de conocer los argumentos más comúnmente utilizados para el juicio de estas acciones. Métodos: Se realizó una investigación descriptiva, analítica, de base documental y bibliográfica, utilizando datos secundarios. Los datos fueron recolectados a través de una encuesta sobre judicialización en Brasil, en los años 2012 y 2013. Los datos cuantitativos disponibles ya se encontraban tratados en tablas y gráficos y los datos cualitativos fueron disponibilizados sin el debido tratamiento, lo que fue realizado a partir del día el método del análisis idiosincrásico. Resultados: Los tres actores analizados autor, reo y juez, tratan de cuestiones lógicas que ocurren en el sistema y que pueden ocurrir discrepancias, cada autor tiene sus puntos de vista y experiencia y sus particularidades que no deben ser descartadas, pudiendo así existir conflictos visibles, pero si se trata de la salud, el punto en común, es la mejor decisión para el usuario. Los pedidos a ser judicializados no concaten directamente con las enfermedades que más afectan a los pacientes. Conclusión: Es posible aferir a partir de los discursos la imprudencia acometida con los pacientes que están en el proceso y se percibe que muchas de las prestaciones de servicios buscadas, aún están en déficit con su atención, siendo que el estado brasileño aún no es garante universal de los usuarios en sus necesidades. (AU)

Globalizar la salud / Globalize health

En este artículo se exploran diversos aspectos de la relación entre salud y globalización. Se consideran diferentes dimensiones de la globalización (económica, tecnológica, cultural y política) y se discuten sus consecuencias sobre la salud en términos epidemiológicos, éticos, sanitarios, ambientales y en relación con la distribución del poder y la equidad. Se analizan datos que evidencian la globalización de los riesgos y las enfermedades, atribuibles al actual modelo de relaciones internacionales y a la movilidad entre países. En el artículo se defiende la propuesta de globalizar la salud, integrando conceptos renovados y adelantos en las ciencias afines a la salud pública con nuevas estrategias políticas, sociales y organizativas de la práctica sanitaria. Finalmente, se reconocen las oportunidades que nos brinda la globalización, desde mediados del siglo pasado, para redefinir la gobernabilidad mundial y desarrollar movimientos locales, basados en la solidaridad y en una nueva concepción política que favorezcan la universalización de la salud.

In this article diverse aspects of the relationship between health and globalization are explored. Different dimensions of globalization (economic, technological, cultural and political) are considered. Aspects of its effects on health (epidemiological, ethical and environmental), as well as its relationship with public health, power distribution and equity are discussed. Data that demonstrate the globalization of risks and of diseases, due to the current model of international relations and geographical mobility, are analyzed. The article defends the globalization of health and integrates renewed concepts and scientific advances in public health with politics, social strategies and new organizational forms of the practice of public health. Finally, we discuss the opportunities that have been provided by globalization since the middle of the last century for redefining world government and for developing local movements, based on solidarity and a new concept of politics, which could favor the universalization of health.