Conflictos éticos en un contexto de gestión pública: objeción de conciencia y aborto en la red sanitaria pública española

En este artículo se sostiene, en primer lugar, que (1) la persistencia a nivel internacional de debates éticos en torno al estatus moral del nasciturus y (2) el tradicional compromiso deontológico de los profesionales sanitarios con la salud, tanto de la embarazada como del hijo que espera, dotan de pleno sentido y vigencia al derecho a la objeción de conciencia de dichos profesionales. Sin embargo, donde el aborto legal se configura como prestación sanitaria, surge entonces la dificultad de gestionar esa prestación y, al tiempo, el conflicto moral que expresa la objeción de conciencia. Si en una institución sanitaria pública la objeción es generalizada, se plantea una disyuntiva con implicaciones éticas entre derivar a las gestantes a otras instituciones o aplicar estrategias de integración de personal a nivel de servicio de salud. En el caso de España, se ha aprobado este año una reforma de la Ley Orgánica de salud sexual y reproductiva y de la interrupción voluntaria del embarazo (LOSSRIVE), que manifiesta una voluntad más taxativa de que la objeción de conciencia no impida el acceso al aborto en las instituciones sanitarias públicas, estableciéndose previsiones específicas al efecto. A partir de los trabajos parlamentarios identificamos los principales puntos de discrepancia política que remiten a dispares posiciones de fondo sobre el aborto y afectan al propio planteamiento de la reforma, así como a otros elementos no siempre novedosos -algunos de ellos ya estaban en la LOSSRIVE o se venían aplicando a nivel autonómico con el plácet del Constitucional.

This article argues, first, that (1) the persistence at the international level of ethical debates on the moral status of nasciturus and (2) the traditional ethical commitment of health professionals to the health of both the pregnant woman and the unborn child, give full sense and validity to the right to conscientious objection of these professionals. However, where legal abortion is configured as a health care service, the difficulty of managing this service and, at the same time, the moral conflict expressed by conscientious objection arises. If, in a public health institution, objection is widespread, there is a dilemma with ethical implications between referring pregnant women to other institutions or implementing staff integration strategies at the health service level. In the case of Spain, a reform of the Organic Law on Sexual and Reproductive Health and the Voluntary Interruption of Pregnancy (LOSSRIVE) was approved this year, which shows a more stringent willingness that conscientious objection does not prevent access to abortion in public health institutions, establishing specific provisions to that effect. Based on the parliamentary work, we identified the main points of political discrepancy, which remit to different basic positions on abortion and affect the very approach of the reform, as well as other not always new elements -some of them were already in the LOSSRIVE or were already being applied at the regional level with the approval of the Constitutional Court.

Este artigo argumenta, em primeiro lugar, que (1) a persistência, em nível internacional, de debates éticos sobre o status moral do nascituro e (2) o tradicional compromisso deontológico dos profissionais de saúde com a saúde da gestante e do filho que ela espera, dão pleno sentido e vigência ao direito à objeção de consciência desses profissionais. Entretanto, quando o aborto legal é configurado como um serviço de saúde, surge a dificuldade de gerir esse serviço e, ao mesmo tempo, gerir o conflito moral expresso pela objeção de consciência. Se, em uma instituição de saúde pública, a objeção for generalizada, haverá uma escolha com implicações éticas entre encaminhar as gestantes a outras instituições ou aplicar estratégias de integração de pessoal no nível do serviço de saúde. No caso da Espanha, foi aprovada este ano uma reforma da Lei Orgânica de Saúde Sexual e Reprodutiva e a Interrupção Voluntária da Gravidez (LOSSRIVE) que expressa uma vontade mais constrangedora de garantir que a objeção de consciência não impeça o acesso ao aborto em instituições públicas de saúde, estabelecendo disposições específicas para esse fim. Com base no trabalho parlamentar, identificamos os principais pontos de discrepância política, que remetem a diferentes posições de fundo sobre aborto e afetam a própria aproximação da reforma, assim como outros elementos que nem sempre são novos -alguns deles já estavam no LOSSRIVE ou já estavam sendo aplicados em nível regional com a aprovação do Tribunal Constitucional-.

Real-world evidence of the burden of sickle cell disease: a 5-year longitudinal study at a Brazilian reference center.

INTRODUCTION: Sickle cell disease (SCD) is an inherited and multisystem blood disorder characterized by hemolytic anemia, vaso-occlusive crises (VOCs), progressive multiorgan damage and increased mortality. In Brazil, it is one of the most common monogenic diseases afflicting 60,000 to 100,000 individuals, however, there are sparse epidemiological data, as well as information on the utilization of public healthcare resources. METHOD: This was a 5-year (2016 - 2020) retrospective study conducted at one Brazilian reference center on SCD - Santa Casa de Sao Paulo, in Sao Paulo, Brazil. RESULTS: Among a total of 100 eligible adult patients, the median age was 31.0 years old, 84% of the patients were aged between 18 and 45 years old; 59% were women and 91% presented the genotype HbSS. The number of hematologist and non-hematologist visits at the outpatient unit were 2,198 and 1,436, respectively. The number of hospital ER visits was 758, of which 51% required 864 days of hospitalization. The main cause for seeking hospital medical care was the VOCs. The numbers and ratios of VOCs were: 1 to 10 VOCs, 64%; 11 to 20, 15%, and; 21 or more, 1%. There was a statistically significant difference between the number of VOCs and hospitalizations, as well as infection. CONCLUSION: Results indicate the burden of SCD on Brazilian patients' daily lives, the impact of VOCs on public healthcare resources, the importance of having a national surveillance program to improve resource utilization and clinical outcomes of patients with SCD and the urgent need for the revitalizing of the current national comprehensive SCD care programs.

Real-world evidence of the burden of sickle cell disease: a 5-year longitudinal study at a Brazilian reference center

ABSTRACT Introduction: Sickle cell disease (SCD) is an inherited and multisystem blood disorder characterized by hemolytic anemia, vaso-occlusive crises (VOCs), progressive multiorgan damage and increased mortality. In Brazil, it is one of the most common monogenic diseases afflicting 60,000 to 100,000 individuals, however, there are sparse epidemiological data, as well as information on the utilization of public healthcare resources. Method: This was a 5-year (2016 - 2020) retrospective study conducted at one Brazilian reference center on SCD - Santa Casa de Sao Paulo, in Sao Paulo, Brazil. Results: Among a total of 100 eligible adult patients, the median age was 31.0 years old, 84% of the patients were aged between 18 and 45 years old; 59% were women and 91% presented the genotype HbSS. The number of hematologist and non-hematologist visits at the outpatient unit were 2,198 and 1,436, respectively. The number of hospital ER visits was 758, of which 51% required 864 days of hospitalization. The main cause for seeking hospital medical care was the VOCs. The numbers and ratios of VOCs were: 1 to 10 VOCs, 64%; 11 to 20, 15%, and; 21 or more, 1%. There was a statistically significant difference between the number of VOCs and hospitalizations, as well as infection. Conclusion: Results indicate the burden of SCD on Brazilian patients' daily lives, the impact of VOCs on public healthcare resources, the importance of having a national surveillance program to improve resource utilization and clinical outcomes of patients with SCD and the urgent need for the revitalizing of the current national comprehensive SCD care programs.

Intestinal complications in patients with Crohn's disease in the Brazilian public healthcare system between 2011 and 2020.

BACKGROUND: This is a secondary database study using the Brazilian public healthcare system database. AIM: To describe intestinal complications (ICs) of patients in the Brazilian public healthcare system with Crohn's disease (CD) who initiated and either only received conventional therapy (CVT) or also initiated anti-tumor necrosis factor (anti-TNF) therapy between 2011 and 2020. METHODS: This study included patients with CD [international classification of diseases - 10th revision (ICD-10): K50.0, K50.1, or K50.8] (age: ≥ 18 years) with at least one claim of CVT (sulfasalazine, azathioprine, mesalazine, or methotrexate). IC was defined as a CD-related hospitalization, pre-defined procedure codes (from rectum or intestinal surgery groups), and/or associated disease (pre-defined ICD-10 codes), and overall (one or more type of ICs). RESULTS: In the 16809 patients with CD that met the inclusion criteria, the mean follow-up duration was 4.44 (2.37) years. In total, 14697 claims of ICs were found from 4633 patients. Over the 1- and 5-year of follow-up, 8.3% and 8.2% of the patients with CD, respectively, presented at least one IC, of which fistula (31%) and fistulotomy (48%) were the most commonly reported. The overall incidence rate (95%CI) of ICs was 6.8 (6.5-7.04) per 100 patient years for patients using only-CVT, and 9.2 (8.8-9.6) for patients with evidence of anti-TNF therapy. CONCLUSION: The outcomes highlighted an important and constant rate of ICs over time in all the CD populations assessed, especially in patients exposed to anti-TNF therapy. This outcome revealed insights into the real-world treatment and complications relevant to patients with CD and highlights that this disease remains a concern that may require additional treatment strategies in the Brazilian public healthcare system.

Intestinal complications in Brazilian patients with ulcerative colitis treated with conventional therapy between 2011 and 2020.

BACKGROUND: This was an observational, descriptive, and retrospective study from 2011 to 2020 from the Department of Informatics of the Brazilian Healthcare System database. AIM: To describe the intestinal complications (IC) of patients with ulcerative colitis (UC) who started conventional therapies in Brazil´s public Healthcare system. METHODS: Patients ≥ 18 years of age who had at least one claim related to UC 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) code and at least 2 claims for conventional therapies were included. IC was defined as at least one claim of: UC-related hospitalization, procedures code for rectum or intestinal surgeries, and/or associated disease defined by ICD-10 codes (malignant neoplasia of colon, stenosis, hemorrhage, ulcer and other rectum or anus disease, megacolon, functional diarrhea volvulus, intussusception and erythema nodosum). Descriptive statistics, annual incidence, and incidence rate (IR) [per 100 patient-years (PY)] over the available follow-up period were cal-culated. RESULTS: In total, 41229 UC patients were included (median age, 48 years; 65% women) and the median (interquartile range) follow-up period was 3.3 (1.8-5.3) years. Conventional therapy used during follow-up period included: mesalazine (87%), sulfasalazine (15%), azathioprine (16%) or methotrexate (1%) with a median duration of 1.9 (0.8-4.0) years. Overall IR of IC was 3.2 cases per 100 PY. Among the IC claims, 54% were related to associated diseases, 20% to procedures and 26% to hospitalizations. The overall annual incidence of IC was 2.9%, 2.6% and 2.5% in the first, second and third year after the first claim for therapy (index date), respectively. Over the first 3 years, the annual IR of UC-related hospitalizations ranged from 0.8% to 1.1%; associated diseases from 0.9% to 1.2% - in which anus or rectum disease, and malignant neoplasia of colon were the most frequently reported; and procedure events from 0.6% to 0.7%, being intestinal resection and polyp removal the most frequent ones. CONCLUSION: Study shows that UC patients under conventional therapy seem to present progression of disease developing some IC, which may have a negative impact on patients and the burden on the health system.

Reabilitação física/funcional no Brasil: análise espaço-temporal da oferta no Sistema Único de Saúde / Physical/functional rehabilitation in Brazil: spatiotemporal analysis of the offer in the Public Healthcare System

Resumo O complexo perfil epidemiológico do país, o envelhecimento populacional e a proporção de pessoas com deficiência apontam para o aumento substancial da demanda por reabilitação. Nesse contexto, foi analisada a distribuição espaço-temporal da oferta de profissionais de fisioterapia, fonoaudiologia e terapia ocupacional no Sistema Único de Saúde (SUS) de 2007 a 2019 nas cinco regiões do Brasil. Foram utilizados dados do Cadastro Nacional de Estabelecimentos em Saúde, as estimativas censitárias do Instituto Brasileiro de Geografia e Estatística e calculados os indicadores da oferta potencial de profissionais e sua evolução relativa. Foi realizada a distribuição espacial da evolução relativa da oferta potencial de profissionais. Para a análise da tendência temporal, adotou-se o modelo de regressão por pontos de inflexão. Houve tendência temporal crescente na oferta potencial das três categorias profissionais no Brasil e em todas as regiões, mas com uma desaceleração do crescimento. Observaram-se diferenciais entre as profissões e as regiões do país, representando um quadro de desigualdade de oferta que precisa ser superado. Resultados que podem subsidiar o controle social e o planejamento nacional para a ampliação do acesso aos serviços de reabilitação

Abstract The complex epidemiological profile of Brazil, the aging population and the proportion of individuals with disabilities have led to a substantial increase in the demand for rehabilitation. The spatiotemporal distribution of the offer of physiotherapy, speech therapy and occupational therapy in the Brazilian public healthcare system from 2007 to 2019 was analyzed for the five macro-regions of the country. Data from the National Register of Health Establishments and census estimates from the Brazilian Institute of Geography and Statistics were used. Indicators of the offer of professionals in these fields services and relative changes in the offer were calculated. The spatial distribution of the relative change in the offer was also determined. A regression model with inflection points was adopted for the analysis of the temporal trend. A growing temporal trend was found in the offer of the three professionals in Brazil as a whole and in all regions of the country, but with a slowdown in growth. Differences were observed in the offer among the regions of the country, revealing healthcare inequality that needs to be overcome. The present findings can assist in planning to expand access to rehabilitation services in the country.

Discrepancies Between the Cost of Advanced Lung Cancer Treatment and How Much Is Reimbursed by the Brazilian Public Healthcare System.

OBJECTIVE: Lung cancer is the leading cause of cancer-related death worldwide, and most patients are diagnosed of advanced disease. Molecular-targeted therapy and immunotherapy increase survival among these patients. In this study, we compared the cost of the best treatments available with the amount reimbursed by the Brazilian public healthcare system (Sistema Único de Saúde [SUS]) to treat advanced lung cancer. METHODS: The authors divided lung cancer into 10 subtypes according to histology and molecular profile. A panel of experts defined the best treatment sequencing for each subtype. The authors considered only drug costs retrieved from the Brazilian Health Regulatory Agency official data. The progression-free survival of each regimen was considered as treatment duration. The cost estimate included all postprogression therapies weighted by each subtype proportional frequency. The amount reimbursed by SUS was the sum of the monthly budget accumulated during the estimated treatment duration and then for the proportional frequency of each subtype. RESULTS: The budget reimbursed by SUS for treating each advanced lung cancer case in Brazil is R$8000.00 in average whereas the cost estimate for the best treatment available is R$729 454.00 per case, which represents a difference of 9118%. The budget impact to ensure the reimbursement needed to acquire the best treatments available was estimated in near R$13 billion annually. CONCLUSIONS: The cost estimate of the best treatment available for advanced lung cancer in Brazil is much higher than the amount reimbursed by SUS. This budgetary gap leads to a major access barrier that may compromise the survival outcomes of SUS users.

Time interval between diagnosis to treatment of breast cancer and the impact of health insurance coverage: a sub analysis of the AMAZONA III Study (GBECAM 0115).

PURPOSE: Breast cancer (BC) is the most common type of cancer among women in Brazil. Evidence shows that delayed treatment onset is associated with increased mortality. This study aimed to evaluate median days between diagnosis and treatment and factors associated with delayed start of treatment (> 60 days after diagnosis): stage, treatment received, subtype, epidemiological characteristics, and type of healthcare coverage. METHODS: This analysis included 1709 stage I-III BC patients from AMAZONA III, a prospective, observational study, diagnosed from January 2016 to March 2018 in 22 centers in Brazil. RESULTS: The median number of days from diagnosis to beginning of first oncologic treatment was 46 days (IQR 28-75) overall, 43 days (IQR 25-75) for stage I disease, 49 days (IQR 28-81) for stage II, and 44 days (IQR 30-68) for stage III, (p = 0.1180). According to first treatment received, diagnosis-to-treatment interval was 43 days (IQR 29-65) for neoadjuvant chemotherapy and 48 days (IQR 26-81) for surgery. Diagnosis-to-treatment interval was higher in women treated in the public system versus the private system (56 vs. 34 days, p < 0.0001). Patients in the public system had an increased odds of delayed treatment initiation (OR 4.74 95% CI 3.09-7.26, p < .0001). The longer interval from diagnosis to treatment in the public system was independent of clinical stage, type of treatment (systemic vs surgery first), subtype and region of the country. CONCLUSION: By characterizing the delays in care delivery, our study will aid stakeholders to better design interventions and allocate resource to improve timely treatment for breast cancer in Brazil. CLINICALTRIALS: gov Identifier: NCT02663973, registered on January, 26th, 2016.

Feasibility of a Hospital Information System for a Military Public Organization in the Light of the Multi-Criteria Analysis.

The healthcare environment presents a large volume of personal and sensitive patient data that needs to be available and secure. Information and communication technology brings a new reality to healthcare, promoting improvements, agility and integration. Regarding high-level and complex decision-making scenarios, the Brazilian Navy (BN), concerning its healthcare field, is seeking to provide better management of its respective processes in its hospital facilities, allowing accurate control of preventive and curative medicine to members who work or have served there in past years. The study addresses the understanding, structure and clarifying variables related to the feasibility of technological updating and installing of a Hospital Information System (HIS) for BN. In this scenario, through interviews and analysis of military organization business processes, criteria and alternatives were established based on multi-criteria methodology as a decision aid. As methodological support for research and data processing, THOR 2 and PROMETHEE-SAPEVO-M1 methods were approached, both based on the scenarios of outranking alternatives based on the preferences established by the stakeholders in the problem. As a result of the methodological implementation, we compare the two implemented methods in this context, exposing the Commercial Software Purchase and Adoption of Free Software, integrated into Customization by the Marine Studies Foundation, as favorable actions to be adopted concerning HIS feasibility. This finding generates a comprehensive discussion regarding the BN perspective and changes in internal development in the military environment, prospecting alignment to the culture of private organizations in Information Technology for healthcare management. In the end, we present some conclusions concerning the study, exploring the main points of the decision-making analysis and for future research.

Preliminary assessment of antivenom availability and management in the public health system of Costa Rica: An analysis based on a survey to pharmacists in public health facilities.

Availability and accessibility of safe and effective antivenoms are key elements for the successful treatment of snakebite envenoming (SBE). This study provides a preliminary analysis on the way antivenoms are managed by the public health system in Costa Rica and on the role played by pharmacists in the overall management of antivenoms. This was an observational, cross-sectional study based on an online survey sent to pharmacists working at Caja Costarricense de Seguro Social (Costa Rican Social Security System; CCSS) in different locations in Costa Rica. Characteristics and location of health facilities, as well as antivenom availability and management details, were analyzed. Responses from a total of 96 pharmacists, corresponding to 55 different healthcare facilities, were included in this study. Most respondents worked at pharmacies located in urban communities (69.0%) and in the secondary level of care, which includes clinics, and regional and peripheral hospitals (55.2%). Overall, participants reported antivenom availability at all levels of care and in centers having various operating schedules, although they were not available in some facilities in regions where SBE is uncommon or do not attend SBE cases because of the proximity of more complex health centers. On average, the stocks of anticoral and polyvalent antivenoms per health facility were compatible with the dose of antivenom required for treating a SBE case. More than half of participants reported knowing the availability of protocols for the management of SBE and the correct use of antivenom at their healthcare facilities. Of the total respondents, 49% agreed on possessing all the resources needed for the correct management of these medicines at their facilities, and 65.6% indicated that they know the procedures for antivenom storage and management. Our findings provide a first description of the availability of antivenoms in the public health system of Costa Rica, including the primary care level. Results also underscore the perceived role of participating pharmacists in the management of these life-saving drugs and the need to improve their knowledge on this topic.

Reasons behind declining of cases during the COVID-19 wavelets in Pakistan: public healthcare system or government smart lockdown policy? / Razões do declínio de casos durante as ondas de COVID-19 no Paquistão: sistema público de saúde ou política de bloqueio inteligente do governo?

Abstract The latest statistics show that COVID-19 is still very active, and cases are on the rise across various countries and regions. On the other hand, statistics from Pakistan show a declining trend, especially during the first wave of the COVID-19 pandemic. To understand this declining trend and answering our established question, "What are the reasons behind the decline of the COVID-19 cases in Pakistan - public healthcare facilities or government smart lockdown policy?" narrative literature-based evidence collected from government official websites, reports and also Google Scholar. Our findings suggest that the government's innovative smart lockdown strategy and its execution at the right time with the consensus of all stakeholders accompanied with the observing of COVID-19 standard operation procedures resulted in controlling the pandemic. Effective smart lockdown policy allows the government to identify shortcomings of and improve the capabilities of healthcare for the continuation of balanced socio-economic activities to avoid future spread-out of the pandemic in the time of crisis under national and World Health Organization guidelines.

Resumo As últimas estatísticas mostram que a COVID-19 ainda está muito ativa, e os casos estão aumentaando em vários países e regiões. Por outro lado, as estatísticas do Paquistão mostram uma tendência decrescente, em especial durante a primeira onda da pandemia de COVID-19. Para compreender esta tendência decrescente e responder à nossa pergunta estabelecida, "Quais são as razões por detrás do declínio do caso COVID-19 no Paquistão - instalações públicas de saúde ou política de encerramento inteligente do governo?" - foi compilada evidências narrativas baseadas em literatura recolhida de websites oficiais do governo, relatórios e também no Google Scholar. As nossas conclusões sugerem que a estratégia inovadora de encerramento inteligente do governo e a sua execução no momento certo, com o consenso de todos os interessados acompanhados pela observação dos procedimentos de operação padrão da COVID-19, resultou no controle da pandemia. Uma política eficaz de encerramento inteligente permite ao governo identificar deficiências e melhorar as capacidades dos cuidados de saúde para a continuidade de atividades socioeconômicas equilibradas, a fim de evitar a propagação futura da pandemia em tempo de crise, sob as diretrizes nacionais e da Organização Mundial de Saúde.

Publicly versus privately funded cardiac rehabilitation: access and adherence barriers. A cross-sectional study

ABSTRACT BACKGROUND: Cardiac rehabilitation (CR) barriers are well-understood in high-resource settings. However, they are under-studied in low-resource settings, where access is even poorer and the context is significantly different, including two-tiered healthcare systems and greater socioeconomic challenges. OBJECTIVE: To investigate differences in characteristics of patients attending publicly versus privately funded CR and their barriers to adherence. DESIGN AND SETTING: Observational, cross-sectional study in public and private CR programs offered in Brazil. METHODS: Patients who had been attending CR for ≥ 3 months were recruited from one publicly and one privately funded CR program. They completed assessments regarding sociodemographic and clinical characteristics and the CR Barriers Scale. RESULTS: From the public program, 74 patients were recruited, and from the private, 100. Participants in the public program had significantly lower educational attainment (P < 0.001) and lower socioeconomic status (P < 0.001). Participants in the private program had more cognitive impairment (P = 0.015), and in the public program more anxiety (P = 0.001) and depressive symptoms (P = 0.008) than their counterparts. Total barriers among public CR participants were significantly higher than those among private CR participants (1.34 ± 0.26 versus 1.23 ± 0.15/5]; P = 0.003), as were scores on 3 out of 5 subscales, namely: comorbidities/functional status (P = 0.027), perceived need (P < 0.001) and access (P = 0.012). CONCLUSION: Publicly funded programs need to be tailored to meet their patients' requirements, through consideration of educational and psychosocial matters, and be amenable to mitigation of patient barriers relating to presence of comorbidities and poorer health status.

Rapid establishment of a dedicated COVID-19 hospital in Mexico city during a public health crisis.

Healthcare systems worldwide have adapted and reorganized during the coronavirus disease 2019 (COVID-19) pandemic. Here, we provide a framework based on a public-private partnership that funded, developed, and operated a temporary COVID-19 hospital in Mexico City. We describe the creation of a collaborative network of primary healthcare triage centers and hospitals distributed throughout the city in recognition of demographic and geographic patterns that correlate with COVID-19 infections, including marginalized and impoverished areas of Mexico City. Additionally, we also report the hospital's cumulative outcomes over the 14 months of operation and show that it is feasible to transform a large public venue into a specialized hospital that incorporates a digital platform with robust clinical protocols to provide positive clinical outcomes.

During Mexico's response to the COVID-19 pandemic, the Carlos Slim Foundation (CSF), with a group of local foundations, academic institutions, and the Government of Mexico City, established a synergistic public­private partnership with the purpose of funding, designing, developing, and operating a dedicated COVID-19 hospital. This was achieved in 17 days by rapidly transforming into a hospital the largest convention center in Latin America, which is located in the heart of Mexico City. An ex professo network of eight dedicated respiratory triage community centers in coordination with other 40 federal and state primary health care clinics and hospitals was also established to streamline patient referral, thereby mitigating the impact of the COVID-19 pandemic in Mexico City's metropolitan area. We provide a framework for designing, funding, and executing the operations of a dedicated hospital in response to the COVID-19 pandemic that, from its conception, execution, operation, and closure, involved an exemplary coordination between public-private partnerships during a public health crisis. Referral, admission, treatment, clinical monitoring, discharge, and household follow-up were facilitated by the COVID360 digital health platform. The successful development and implementation of this multi-faceted digital platform allowed a lean patient-centered process, the management of clinical and administrative data, training of healthcare professionals, and the dissemination of accurate health information for data-driven decision making. This rapidly implemented temporary hospital dedicated to the comprehensive care of patients with COVID-19 was critical in coping with the increasing number of cases in Mexico City while achieving outstanding clinical outcomes.

Salud e interculturalidad: saberes, asimetrías y lugares comunes / Saúde e interculturalidade: conhecimento, assimetrias e lugares comuns / Health and interculturality: knowledge, asymmetries and common places

Resumen Ya sea como un efectivo instrumental teórico, cliché discusivo o apelación moral, el análisis de la interculturalidad como parte constitutiva del proceso salud-enfermedad- atención y cuidado forma parte cada vez en mayor medida de las inquietudes cotidianas de los profesionales de la salud. Sin embargo, ese aparente y creciente consenso no siempre es acompañado por una efectiva utilización de los abordajes socioantropológicos que permitan superar las limitaciones del saber biomédico o del empleo del sentido común. En este artículo se analizan algunos de esos frecuentes usos de lo "cultural" que no logran plantear abordajes comprensivos y superadores. Para ello, a partir de algunas experiencias de una terapista ocupacional con formación en antropología, se utilizan algunos casos etnográficos que permiten mostrar la relevancia de contar con sólidas herramientas teóricas y metodológicas con el objeto de reducir al máximo un uso "asimétrico" de la noción de cultura. Ello implica que "lo cultural" tiende a verse como un exotismo o hasta una irracionalidad que sólo merece un análisis cuidadoso cuando los pacientes pertenecen a grupos y colectivos que contrastan notoriamente con la supuesta normalidad del nosotros. Por el contrario, se intenta mostrar que "lo cultural" es constitutivo de esa normalidad cotidiana de las personas que utilizan el sistema de salud.

Resumo Seja como instrumento teórico eficaz, clichê discursivo ou apelo moral, a análise da interculturalidade como parte constitutiva do processo saúde-doença-cuidado e do cuidado faz parte cada vez mais do cotidiano dos profissionais de saúde. No entanto, esse aparente e crescente consenso nem sempre é acompanhado por um uso efetivo de abordagens socioantropológicas que possibilitem superar as limitações do conhecimento biomédico ou do uso do seu sentido comum. Este artigo analisa alguns dos usos frequentes do termo "cultural", que não propõem abordagens abrangentes e de superação do ideário biomédico. Para tanto, a partir de algumas experiências de uma terapeuta ocupacional em formação em antropologia, são utilizados alguns casos etnográficos que permitem mostram a relevância de se contar com sólidos instrumentos teóricos e metodológicos a fim de minimizar um uso "assimétrico" da noção de cultura. Isto implica que "o cultural" tende a ser visto como um exotismo ou mesmo uma irracionalidade que só merece uma análise cuidadosa quando os pacientes pertencem a grupos e coletivos que contrastam marcadamente com a nossa suposta normalidade. Ao contrário, tenta mostrar que "o cultural" é constitutivo dessa normalidade cotidiana das pessoas que utilizam o sistema de saúde.

Abstract Whether as an effective theoretical instrument, a discussion cliché, or a moral appeal, the analysis of interculturality as a constitutive part of the health-disease-care process is increasingly part of the daily concerns of health professionals. However, this apparent and growing consensus is not always accompanied by effective use of socio-anthropological approaches that overcome the limitations of biomedical knowledge or the use of common sense. This article analyzes some of those frequent uses of the "cultural" that fail to propose comprehensive and overcoming approaches. For doing so, some ethnographic cases are used to show the relevance of having solid theoretical and methodological tools to minimize an "asymmetric" use of the notion of culture. This implies that "the cultural" tends to be seen as an exoticism or even an irrationality that only deserves a careful analysis when patients belong to groups and collectives that contrast markedly with our supposed normality. On the contrary, it tries to show that "the cultural" is constitutive of the daily normality of the people who use the health system.

The effects of health spending on the propagation of infectious diseases.

We explore the discontinuity in the allocation of the main federal grant to Brazilian municipalities to identify the local effects of health spending and the spillovers into the bordering jurisdictions. Fiscal reactions are asymmetric: small neighbors reduce health spending, while we do not find a significant budgetary response in the largest neighbor. Our results suggest a reduction in the spread of infectious diseases in the neighbors, with fewer residents hospitalized with gastrointestinal infections. In addition, the elderly demand less hospitalization in the largest bordering jurisdictions due to respiratory infectious diseases. Finally, we find a direct and significant reduction in infant mortality, consistent with the observed pediatricians' increase, while the spillover effects on neighbors' mortality rates are not conclusive.

Availability of public dental care service and dental caries increment in children: a cohort study.

OBJECTIVE: Evaluate the impact of the availability of public dental care service on the increment of dental caries in children. METHODS: This is a 2-year cohort study that followed preschool children from southern Brazil. Dental caries was measured at baseline and follow-up evaluation, considering the number of surfaces with untreated dental caries. Demographic and socioeconomic characteristics as well as the use and availability of dental services were assessed. Multilevel Poisson regression analysis through a hierarchical approach and considering a random effect for repeated measures was used to explore the influence of exploratory variables in the increase in the outcome. RESULTS: A total of 419 cases were evaluated at follow-up (91.3% cohort retention rate). The increase in the untreated dental caries was associated with living in places where there is no regular presence of dentists in the public health system. In addition, the increment of dental caries was influenced by age, household income, and dental attendance. CONCLUSION: The results suggest that the availability of dentists in the public health system have an impact the increment of dental caries among children. The integration of the dentist in the primary healthcare can contribute to decrease the barriers that lead to children's oral health.

A consulta do enfermeiro na Estratégia Saúde da Família: um recorte do Rio de Janeiro / Nurses consultation in the Family Health Strategy: a cut-off in Rio de Janeiro / La consulta del enfermero en la Estrategia Salud de la Familia: un recorte del Rio de Janeiro

Objetivo: Este artigo objetiva descrever as características do trabalho da Enfermeira durante a consulta de enfermagem na Estratégia Saúde da Família. Método: Trata-se de uma pesquisa descritiva de abordagem qualitativa cujos dados foram colhidos através de trabalho de campo em quatro unidades básicas de saúde na cidade do Rio de Janeiro, sendo utilizados para tal, os seguintes instrumentos: entrevista semiestruturada e observação simples. Resultados: Os resultados obtidos apontam para uma tendência à realização de abordagens verticais ao indivíduo, com foco nos programas do ministério da saúde, e no modelo biomédico- flexineriano de atenção, além de revelar repetição contínua de interrupções ao longo das consultas, fragmentando os encontros Enfermeiro-paciente. Conclusões: Defende-se uma reorganização do processo de trabalho de modo que o enfermeiro permita o protagonismo do usuário. Reafirma-se que a sobreposição de atendimentos traz graves prejuízos a qualidade do serviço prestado ao indivíduo no consultório, e deslegitima o trabalho do enfermeiro

Objetctive: This article aims to describe the work process of the Nurse during the nursing consultation in the Strategy in Family Health. Method: It is a descriptive study of qualitative approach and its data were obtained from field research in four Basic level medical units in the city of Rio de Janeiro. Semi-structured interviews and plain observation were used to carry it out. Results: the results show that vertical approaches tend to be applied to the subjects focusing on programs of the Ministry of Health and in the Biomedical Model of attention. Besides, there were many interruptions throughout the Nurses' consultations breaking the nurse-and-patients. Conclusion: A reorganization of the nurses' work process allowing the patients to hold main role is required. The fact that the overlap in the appointments seriously damages the consultation in the office and delegitimizes the nurses' work must be highlighted

Objetivo: Este artículo objetiva describir las características del trabajo de la Enfermera durante la consulta de enfermería en la Estrategia Salud de la Familia. Método: Se trata de una investigación descriptiva de abordaje cualitativo cuyos datos fueron recolectados a través de trabajo de campo en cuatro unidades básicas de salud en la ciudad de Río de Janeiro, siendo utilizados para ello, los siguientes instrumentos: entrevista semiestructurada y la observación sencillo. Resultados: Los resultados obtenidos apuntan a una tendencia a la realización de enfoques verticales al individuo, centrándose en los programas del ministerio de salud, y en el modelo biomédico-flexineriano de atención, además de revelar repetición continua de interrupciones a lo largo de las consultas, fragmentando los encuentros Enfermero-paciente. Conclusiones: Se defiende una reorganización del proceso de trabajo de modo que el enfermero permita el protagonismo del usuario. Se reafirma que la superposición de atenciones trae graves perjuicios a la calidad del servicio prestado al individuo en el consultorio, y deslegitima el trabajo del enfermero

Nonparametric estimation of a primary care production function in urban Brazil.

BACKGROUND: The Brazilian public health system is one of the largest health systems in the world, with a mandate to deliver medical care to more than 200 million Brazilians. The objective of this study is to estimate a production function for primary care in urban Brazil. Our goal is to use flexible estimates to identify heterogeneous returns and complementarities between medical capital and labor. METHODS: We use a large dataset from 2012 to 2016 (with more than 400 million consultations, 270 thousand physicians, and 11 thousand clinics) to nonparametrically estimate a primary care production function and calculate the elasticity of doctors' visits (output) to two inputs: capital stock (number of clinics) and labor (number of physicians). We benchmark our nonparametric estimates against estimates of a Cobb-Douglas (CD) production function. The CD model was chosen as a baseline because it is arguably the most popular parametric production function model. By comparing our nonparametric results with those from the CD model, our paper shed some light on the limitations of the parametric approach, and on the novelty of nonparametric insights. RESULTS: The nonparametric results show significantly heterogeneity of returns to both capital and labor, depending on the scale of operation. We find that diseconomies of scale, diminishing returns to scale, and increasing returns to scale are possible, depending on the input range. CONCLUSIONS: The nonparametric model identifies complementarities between capital and labor, which is essential in designing efficient policy interventions. For example, we find that the response of primary care consultations to labor is steeper when capital level is high. This means that, if the goal is to allocate labor to maximize increases in consultations, adding physicians in cities with a high number of clinics is preferred to allocating physicians to low medical infrastructure municipalities. The results highlight how the CD model hides useful policy information by not accounting for the heterogeneity in the data.

Direct access endoscopy in a Brazilian public healthcare facility: comparable results with specialist referred endoscopy.

BACKGROUND: Direct access endoscopy (DAE) is the procedure performed without the pre-evaluation of the patient by a specialist. It is widely available in many medical services around the world, but there is lack of data about this strategy in the setting of the public health system in Brazil. Therefore, the aim of this study is to compare the main endoscopic findings of upper gastrointestinal endoscopy requested through DAE and by specialists. METHODS: Longitudinal, retrospective single center study in patients who underwent upper digestive endoscopy in a public healthcare facility at the southern region of the state of Mato Grosso, Brazil, from August 2011 to December 2018. Age, gender, modality of endoscopy request (DAE or endoscopy requested by specialists), and endoscopic findings were analyzed. RESULTS: A total of 2810 patients were included. Most of them were female 65.23% (1833), mean age was 47.36 years, and 50.71% of the exams (1425) were DAE. Only 4.62% of the exams had normal reports. The most frequent endoscopic findings were gastritis (91.99%), bulboduodenitis (43.59%) and reflux esophagitis (14.76%). Patients who underwent endoscopy requested by specialists were older (50.25 ± 16.57 vs. 44.55 ± 16.31 years, p < .0001) and more frequently men (36.61 vs. 32.98%, p = .0437) in comparison to DAE. However, endoscopic findings were similar in both groups. CONCLUSION: This study shows that direct access upper endoscopy had comparable results to specialist requested endoscopy in a public healthcare facility in the southern region of the state of Mato Grosso, Brazil.

Management of Patients with Overactive Bladder in Brazil: A Retrospective Observational Study Using Data From the Brazilian Public Health System.

INTRODUCTION: In Brazil, current data on the use of healthcare resources to manage individuals with overactive bladder (OAB) are lacking. This study aimed to characterize contemporary treatment and the economic burden among patients with OAB managed under the Brazilian public health system (Sistema Único de Saúde [SUS]). METHODS: Population-based data from January to December of 2015 were acquired from Brazil's public health database. Adults at least 18 years of age with an ICD-10 diagnostic code for OAB within the period were included. Records of outpatient visits, hospitalizations, and onabotulinumtoxinA injections were used to calculate estimates of resource use and costs (in Brazilian reals [R$]) among those with OAB (frequency [%] and mean (standard deviation [SD]) as appropriate). Patient identifiers were not available, so a record linkage methodology was used to match medical encounters to individuals. Pharmacologic management of OAB was informed by government medication purchases available from the official Brazilian government databases. RESULTS: During 2015, 26,640 patients with OAB were identified. All cohort members had at least one outpatient visit and 15,349 (57.6%) were hospitalized. Of the study cohort, 10.0% visited a general practitioner (GP), 41.3% visited a specialist, and 52.0% visited other non-medical healthcare practitioners within the year. Mean (SD) healthcare costs among the study cohort totaled R$355 (R$866) per patient per year; and were R$291 (R$654), R$27 (R$130), R$27 (R$30), and R$11 (R$17) for hospitalizations, GP, specialist, and non-medical healthcare practitioner visits per patient per year, respectively. Regional analysis of reported government medication purchases suggested that access to OAB treatments is highly limited. CONCLUSIONS: High resource use and costs were estimated among patients with OAB managed within the SUS. These data provide a snapshot of the management of patients with OAB in Brazil, with the patients seeking treatment under SUS likely representing a more burdened subpopulation.