Individual and social concerns in American surgical education: paying patients, prepaid health insurance, Medicare and Medicaid.

The education of the U.S. surgeon was traditionally based on a system in which surgeons-in-training cared for a population of largely indigent patients in a setting of graded responsibility. To ensure an ethically appropriate bargain, senior surgeons served as mentors, assumed ultimate responsibility for the patient, and supervised the surgical care of the ward patient by the surgical trainee. During the 20th century, changes in health care financing challenged this comfortable accommodation between charity care and medical education. As others have also written, the introduction of prepaid health insurance plans such as Blue Cross/Blue Shield in the early third of the century, the rapid expansion of employment-based health benefits during World War II, and the enactment of the Medicare and Medicaid legislation under Titles XVIII and XIX of the Social Security Act all contributed to a dramatic reduction in hospital ward (i.e., service) populations. The tension between education and patient care remains incompletely resolved; the proper balance between supervision and graded responsibility for the resident is ultimately worked out on an individual basis. Newer issues facing U.S. surgical education, including the justifiable demand for greater transparency, are likely to upset this suspended truce and lead to renewed discussions about such fundamental concepts as the definition of the resident and the role of the patient in the education of future surgeons.

Políticas de saúde no Brasil: um século de luta pelo direito à saúde / Health policies in Brazil: a century of struggle for the right to health

Através de narrativa ficcional, aliada a imagens reais e à linguagem dos meios de comunicação de cada época, conta a história das políticas de saúde no Brasil, mostrando como se articulou, desde 1900 até 2006, com a história política brasileira. Dentre muitos fatos históricos, são retratadas a criação das caixas e dos IAPS; a luta pela criação do SUS e seu estabelecimento em Lei, em 1988, quando a saúde passou a ser um direito do cidadão e um dever do estado; e a situação do SUS e das políticas de saúde já no século XXI.

Planos de saúde no Brasil: origens e trajetórias / Health plan in Brazil: origins and trajectories

Recupera uma parte, pouco conhecida, de nossa história: a constituição do setor privado de saúde e suas inter-relações com as políticas de Previdência Social e Saúde do Estado Brasileiro. As experiências revelam contradições sobre os rumos das discussões sobre a questão da Saúde em nosso país. Refletir sobre essas experiências ajuda-nos a pensar nos êxitos e equívocos do setor. Busca-se a maior compreensão do campo e a maior capacidade de análise, tomada de decisões e implementação de políticas regulatórias.

Planos de saúde no Brasil: origens e trajetórias

Recupera uma parte, pouco conhecida, de nossa história: a constituição do setor privado de saúde e suas inter-relações com as políticas de Previdência Social e Saúde do Estado Brasileiro. As experiências revelam contradições sobre os rumos das discussões sobre a questão da Saúde em nosso país. Refletir sobre essas experiências ajuda-nos a pensar nos êxitos e equívocos do setor. Busca-se a maior compreensão do campo e a maior capacidade de análise, tomada de decisões e implementação de políticas regulatórias.

A formação do campo da saúde suplementar no Brasil

O presente estudo tem por objetivo analisar a evolução dos fatores histórico-institucionais que ensejaram o atual desenho do campo da saúde suplementar no Brasil, tendo, por principal base teórica, a teoria do poder simbólico, de Pierre Bourdieu, complementada, nos seus aspectos não colidentes, com a visão institucional de Anthony Giddens sobre as motivações da gênese dos campos. A pesquisa utilizou o método da análise de documentos e entrevistas semi-estruturadas, aplicadas no período entre 2002 e 2003, envolvendo a análise qualitativa dos dados coletados com vistas à compreensão dos fenômenos estudados, segundo a perspectiva dos atores. Neste sentido, a pesquisa identifica os vários atores que integram o campo e os respectivos objetivos estratégicos externalizados, inferindo sobre aqueles nem sempre evidentes, além dos recursos de poder utilizados para alcançá-los, segundo a abordagem institucional de DiMaggio e Powell, procurando mostrar, por meio de uma descrição histórica linear, com cortes nos fatos determinantes, a evolução da constituição do campo. Ao final, o estudo demonstra que o campo da saúde suplementar se formou a partir de inúmeras ações do Estado, principalmente após a última década de setenta, como fruto de uma estratégia alternativa de disseminação dos serviços de saúde à população brasileira, fortalecendo a institucionalização de estruturas isomórficas dotadas de alto grau de interação e uma hierarquia entre valores e crenças, inerentes ao campo, dentre os quais sobressai o símbolo da saúde como intrínseco à cidadania. O estudo avalia que os fenômenos da crescente longevidade da população brasileira e a conseqüente desalocação do mercado de trabalho poderão acarretar uma elitização do campo da saúde suplementar representando um grave problema futuro para este sensível segmento da política social do governo do Brasil

Community mobilization and empowerment for health.

The present article traces the history of "dana sehat", a scheme of social funding devised in Indonesia three decades ago which has proved to be of particular significance as a means of inducing communities to accept responsibility for decision-making on the development of health care.

PIP: Responding to the inadequacies of official health services in Indonesia during the 1960s, Dr. Gunawan Nugroho proposed that the sick in a poor community near the Panti Waluyo Hospital in Solo be supported by the healthy. Poor public support for the "dana sakit" scheme, however, led to its failure. Dana sakit was reintroduced in 1969 within the framework of a community development program under the name "dana sehat" (health funds) in which members of the scheme paid a monthly fee of 0.5% of average family income, equivalent to US$0.06, which was deposited in a credit cooperative of revolving capital. Members of the cooperative borrowed money at low interest, further increasing the fund. Discussions between health workers and the community indicated that, using available facilities and resources, the short-term objectives of the scheme should be to provide simple, practical, and inexpensive health care appropriate to the local situation, and to maintain adequate health standards. Over the longer term, the population's health status should be raised. The dana sehat approach has helped communities to accept responsibility for decision-making with regard to the development of health care.

Fulfilling the sisters' promise. The heritage of healthcare's early days.

Members of religious orders--the sisters--built not just Catholic healthcare, but healthcare in America. A good 50 years before Henry and Edgar Kaiser got the idea, prepaid capitated health insurance was being offered by sisters who looked at what was needed and realized this was simply the best way to get it done. The sisters also created the integrated healthcare system at a time when the emerging medical elite wanted nothing to do with any patient who was not socially acceptable and potentially curable. They arranged a continuum of care for the aging sisters within their own communities. And they understood the concept of social medicine, of population-based healthcare, of healthy communities, long before these ideas became commonplace. But the sisters are gone, most of them. The question today is, How do we preserve the sisters' heritage and transfer it to a new millennium, a new healthcare system, and a new set of rules? First, it is important to understand that much of what we remember the sisters for--courage, compassion, vision-was not unique. They created many of the structures that today are the new models; but they were not alone. However, three aspects of how they expressed their vision and their faith were unique to the sisters and must be understood by those who wish to treat the path the sisters blazed. The purity of their commitment and its underlying philosophy--that the helpless and the sick must always be the point of the exercise--should pervade Catholic healthcare to its soul. These women, living in poverty, represented, and still represent, a singular group: a group of women who, having told the world that their only wish is to serve others, humble became CEOs of vast systems and trustees of huge enterprises, without ever abandoning that simple, original pledge. Although they bowed to the rule of obedience, and they were humble, the were fighters. They spoke out against poverty, bigotry, the shunning of those with certain diseases, lack of access to healthcare, stupidity, ignorance, and hate.