The resilience of the Brazilian Unified Health System is not (only) in responding to disasters / A resiliência do Sistema Único de Saúde não está (somente) nas respostas aos desastres

ABSTRACT Coping with the recent COVID-19 pandemic has shown that the Brazilian Unified Health System (SUS) needs to improve its resilience to handle the rapid spread of communicable diseases while ensuring the necessary care for an aging population with comorbidities and in a vulnerable situation. This article identifies, analyzes, and discusses critical aspects of the resilience of the SUS, calling into question the prevailing focus on the robustness and volume of resources mobilized during the outbreak of major disasters. Recent studies demonstrate that the skills that favor adaptation to unexpected situations emerge from the daily functioning of organizations. Restricting the discussion to the mobilization of structures to respond to adverse events has the effect of limiting their potential, inhibiting the emergence of the transformative, adaptive, anticipatory, and learning skills necessary for the sustainable development of resilience.

RESUMO O enfrentamento da recente pandemia da covid-19 mostrou que o Sistema Único de Saúde (SUS) precisa aprimorar sua resiliência para lidar com o rápido alastramento de enfermidades transmissíveis sem deixar de garantir o cuidado necessário a uma população envelhecida, com comorbidades e em situação vulnerável. Este artigo identifica, analisa e discute aspectos críticos da resiliência do SUS, colocando em xeque o foco prevalente sobre a robustez e o volume dos recursos mobilizados emergencialmente na deflagração de grandes desastres. Recentes estudos demonstram que as habilidades que favorecem a adaptação a situações inesperadas emergem a partir do funcionamento cotidiano das organizações. Restringir a discussão ao simples dimensionamento das estruturas para reagir aos eventos adversos tem o efeito de engessar o seu potencial, inibindo o afloramento de habilidades transformadoras, adaptativas, de antecipação e de aprendizado necessárias para o desenvolvimento sustentável da resiliência.

Eliminação das hepatites virais: o que a enfermagem brasileira pode contribuir? / Elimination of viral hepatitis: what can brazilian nursing contribute? / Eliminación de las hepatitis virales: ¿qué puede aportar la enfermería brasileña?

Objetivo: Refletir acerca das contribuições da enfermagem para a eliminação das hepatites virais no Sistema Único de Saúde. Métodos: Estudo reflexivo de abordagem qualitativa sustentado na prática do enfermeiro em sistemas de saúde organizado em três categorias. Resultados: Na categoria Ampliação do escopo de prática: percurso para fortalecer a atuação do enfermeiro na Rede de Atenção à Saúde, aborda-se atuação na agenda estratégica do Ministério da Saúde e do Conselho Federal de Enfermagem em prover condições para ampliação do acesso por meio da gestão, assistência, ensino e pesquisa. Na categoria Subsídios da gestão e coordenação do cuidado para guiar a prática do enfermeiro aborda-se a dimensão individual e familiar, profissional, organizacional, sistêmica e societária com reconhecimento da necessidade de ampliar a reflexão. Na categoria O enfermeiro na gestão de programas de enfrentamento às hepatites virais pontua-se aspectos intrínsecos construídos desde a formação com ênfase para a gestão e gerência, em uma dinâmica real de responsabilidade técnica em programas, serviços e equipes. Conclusão: A reflexão da contribuição do enfermeiro possui relação com a gestão e coordenação do cuidado, prática já estabelecida ao profissional, mas que requer diretrizes e investimento para às hepatites por meio da educação permanente. (AU)

Objective: To reflect on the contributions of nursing to the elimination of viral hepatitis in the Unified Health System. Methods: This was a reflexive study with a qualitative approach based on the practice of nursing in health systems, organized into three categories. Results: In the category Expansion of the scope of practice: path to strengthen the role of nurses in the Health Care Network, the strategic agenda of the Ministry of Health and the Federal Council of Nursing is addressed in providing conditions for expanding access through management, care, teaching and research. In the category subsidies of care management and coordination to guide nursing practice, the individual and family, professional, organizational, systemic and societal dimensions are addressed, with recognition of the need to broaden reflection. In the category Nurses in the management of programs to combat viral hepatitis, intrinsic aspects built since training are highlighted, with emphasis on management and management, in a real dynamic of technical responsibility in programs, services and teams. Conclusion: The reflection on the contribution of nurses is related to the management and coordination of care, a practice already established for professionals, but which requires guidelines and investment for hepatitis through continuing education. (AU)

Objetivo: Reflexionar sobre las contribuciones de la enfermería a la eliminación de las hepatitis virales en el Sistema Único de Salud. Métodos: Se trata de un estudio reflexivo con abordaje cualitativo basado en la práctica de enfermería en los sistemas de salud, organizado en tres categorías. Resultados: En la categoría Ampliación del ámbito de la práctica: camino para fortalecer el papel de los enfermeros en la Red de Atención a la Salud, se aborda la agenda estratégica del Ministerio de Salud y del Consejo Federal de Enfermería en la provisión de condiciones para ampliar el acceso a través de la gestión, el cuidado, la enseñanza y la investigación. En la categoría Subsidios de gestión y coordinación del cuidado para orientar la práctica de enfermería, se abordan las dimensiones individual y familiar, profesional, organizacional, sistémica y social, reconociendo la necesidad de ampliar la reflexión. En la categoría Enfermeras en la gestión de programas de combate a las hepatitis virales, se destacan aspectos intrínsecos construidos desde la formación, con énfasis en la gestión y gestión, en una dinámica real de responsabilidad técnica en programas, servicios y equipos. Conclusión: La reflexión sobre la contribución de los enfermeros se relaciona con la gestión y coordinación de los cuidados, una práctica ya establecida para los profesionales, pero que requiere directrices e inversión para la hepatitis a través de la educación continua. (AU)

Lanzamiento de la campaña Choosing Wisely Argentina: primeros pasos hacia la desimplementación de prácticas de bajo valor / Launch of the Choosing Wisely Argentina campaign: first steps towards the de-implementation of low-value practices

En esta editorial, la autora aborda la problemática de las prácticas de bajo valor en la medicina contemporánea: aquellas intervenciones terapéuticas o diagnósticas carentes de respaldo científico, que aumentan la probabilidad de daños, generan desperdicio de recursos y amenazan la eficiencia del sistema de salud. En un contexto de preocupación global por el exceso médico y las consecuencias del sobreuso de intervenciones inefectivas, resalta la relevancia del concepto de prevención cuaternaria en la atención sanitaria, y señala la iniciativa internacional Choosing Wisely como una estrategia para identificar y revertir las prácticas de bajo valor, destacando la importancia del cambio cultural y la participación activade los pacientes. Finalmente, la autora presenta el lanzamiento de Choosing Wisely Argentina, una colaboración entre asociaciones científicas locales con el compromiso de transformar la práctica médica en este país, priorizando el bienestar del paciente y adoptando un enfoque integral hacia la atención sanitaria. (AU)

In this editorial, the author addresses the problem of low-value practices in contemporary medicine: those therapeutic or diagnostic interventions that lack scientific support and increase the probability of damage, generate waste of resources,and threaten the efficiency of the health system. In a context of global concern about medical excess and the consequences of the overuse of ineffective interventions, she highlights the relevance of the concept of quaternary prevention in healthcare, and points to the international Choosing Wisely initiative as a strategy to identify and reverse low-value practices, highlighting the importance of cultural change and active patient participation. Finally, the author presents the launch of Choosing Wisely Argentina, a collaboration amongst local scientific associations with the commitment to transform medical practice in this country, prioritizing patient well-being and adopting a comprehensive approach to health care. (AU)

Experiencia de los cuidadores informales en Colombia: Revisión sistemática y metasíntesis / The informal caregiver experience in Colombia: A systematic review and meta-synthesis / Experiência de cuidadores informais na Colômbia: revisão sistemática e metassíntese

Introducción: Los cuidadores tienen una forma particular de vivir la experiencia de cuidar, adaptándose al sistema de salud que no los reconoce como sujetos de cuidado, y que descarga en ellos labores para las cuales no están preparados ni acompañados en su trayectoria. Objetivo: Integrar los hallazgos de estudios primarios en una metasíntesis cualitativa para describir la experiencia de los cuidadores informales en Colombia. Materiales y métodos: Revisión sistemática de literatura cualitativa o metasíntesis cualitativa. Búsqueda sistemática en metabuscadores incluyendo los descriptores: cuidadores, experiencia, investigación cualitativa, Colombia. La selección de los estudios se realizó con base en la metodología PRISMA y la herramienta COREQ, disponible en la red EQUATOR. Resultados: Se incluyeron 20 estudios primarios cualitativos, se codificaron en 250 códigos nominales, clasificados en 6 categorías centrales: relación entre la diada con su contexto, tocar fondo para fortalecerse espiritualmente, entrega, sobreprotección y limitación propia, momentos claves para adaptarse a cuidar, relación consigo mismo, sistema de salud, políticas y apoyo institucional. Conclusión: Los cuidadores comparten la experiencia de enfermedad junto con su ser querido. Se necesita transformar el sistema de salud para satisfacer las necesidades de las diadas en lugar de las necesidades del enfermo o discapacitado.

Introduction: Caregivers have a particular way of experiencing their caring roles. They have to adapt to a health system that does not recognize them as subjects of care and, at the same time, makes them responsible for tasks for which they are not prepared, without any support. Objective: To incorporate primary studies findings into a qualitative meta-synthesis to describe informal caregivers experience in Colombia. Materials and methods: Systematic review of qualitative literature. A systematic search was carried out using meta-search engines with the following descriptors: caregivers; experience; qualitative research; and Colombia. The study selection followed the PRISMA methodology and the COREQ tool, which is available on the EQUATOR network. Results: 20 qualitative studies were included, which were encoded with 250 nominal codes and classified in 6 central categories: relationship between the dyad and its context; hitting rock bottom to strengthen spiritually; commitment; overprotection and self-limitation; key moments to adapt to the caregiving task; relationship with self; health system; policies and institutional support. Conclusion: Caregivers share the illness experience with their loved ones. The health system needs to change in order to meet the needs of the dyads rather than the needs of the sick of disabled.

Introdução: Os cuidadores possuem uma forma particular de viver a experiência de cuidar, adaptando-se ao sistema de saúde que não os reconhece como sujeitos do cuidado, e que descarrega sobre eles tarefas para as quais não estão preparados ou acompanhados em sua jornada. Objetivo: Integrar os resultados dos estudos primários em uma metassíntese qualitativa para descrever a experiência dos cuidadores informais na Colômbia. Materiais e métodos: Revisão sistemática de literatura qualitativa ou metassíntese qualitativa. Pesquisa sistemática em motores de metabusca incluindo os descritores: cuidadores, experiência, pesquisa qualitativa, Colômbia. A seleção dos estudos foi realizada com base na metodologia PRISMA e na ferramenta COREQ, disponível na rede EQUATOR. Resultados: Foram incluídos 20 estudos primários qualitativos, codificados em 250 códigos nominais, classificados em 6 categorias centrais: relação da díade com seu contexto, atingir o fundo do poço para se fortalecer espiritualmente, entrega, superproteção e autolimitação, momentos-chave para adaptação ao cuidado, relacionamento consigo mesmo, sistema de saúde, políticas e apoio institucional. Conclusão: Os cuidadores compartilham a experiência do adoecimento junto ao seu ente querido. O sistema de saúde precisa de ser transformado para satisfazer as necessidades das díades e não as necessidades dos doentes ou deficientes.

Relevancia y contribución de la Atención Primaria de Salud / Contributions and relevance of Primary Health Care

Primary Health Care (PHC) constitutes the basis of the Chilean public health system. For more than 30 years, Primary Health Care (PHC) has been internationally recognized as one of the key components of an effective health system, since it is considered a development strategy to achieve better levels of health, which is why WHO strongly encourages countries to strengthen the primary level of care. However, despite the relevance of PHC and the evidence in its favor, there are important barriers to the implementation of the family medicine model in the health system in Chile. Therefore, it is important to know in detail the benefits of a strong PHC and the difficulties that plague the public care system for its development.

La Atención Primaria de Salud (APS) constituye la base del sistema público de salud chileno. Desde hace más de 30 años la Atención Primaria de Salud (APS) es reconocida internacionalmente como uno de los componentes claves de un sistema de salud efectivo, puesto que se considera una estrategia de desarrollo para alcanzar mejores niveles de salud, razón por la cual la OMS promueve enfáticamente que los países fortalezcan el nivel primario de atención. Sin embargo, a pesar de la relevancia de la APS y la evidencia a favor, existen barreras importantes para la implementación del modelo de medicina familiar en el sistema de salud en Chile. Por lo tanto, es importante conocer a detalle los beneficios de una APS fuerte y las dificultades que aquejan el sistema público de atención para el desarrollo de ésta.

Exceso de mortalidad durante la pandemia de COVID-19 en Ecuador. Análisis espacio temporal del exceso de mortalidad durante la pandemia de COVID-19 en Ecuador / Excess Mortality during the COVID- 19 Pandemic in Ecuador. Spatiotemporal Analysis of Excess Mortality During the Covid-19 Pandemic in Ecuador

Introducción: La pandemia de COVID-19 causó una elevada mortalidad en el mundo y en el Ecuador. Esta investigación se propuso analizar el exceso de mortalidad debido a la pandemia de COVID-19 en Ecuador. Método: Estudio observacional, longitudinal, cuantitativo y descriptivo. Clasificado como estudio ecológico en el campo de la epidemiología. Este estudio se centra en la medición del exceso de mortalidad durante los años 2020, 2021 y 2022, tomando como período base el promedio de defunciones ocurridas en el intervalo de 2015 a 2019. Resultados: Ecuador, en el período de enero 2020 a octubre 2022, acumuló un exceso total de muertes de 98.915. En el año 2020, el exceso de mortalidad fue mayor a 46.374, siendo el mes de abril el valor más alto de 15.484. En el año 2021, el exceso de muertes fue de 35.859, siendo abril el mes con mayor exceso de 7.330. Y el año 2022 el exceso de mortalidad fue de 16.682, el mes con mayor exceso fue enero con 4.204. Conclusión: Se evidenció un subregistro de defunciones, así como variaciones temporales y geográficas en el exceso de mortalidad. La provincia con mayor número de fallecidos y exceso de mortalidad fue Guayas seguida de Pichincha. Los resultados proporcionan un análisis del panorama durante la emergencia sanitaria, destacando la importancia de evaluar la capacidad de respuesta de los sistemas de salud en momentos de crisis y la necesidad imperativa de implementar medidas correctivas para el futuro.

Introduction: The COVID-19 pandemic caused a significant mortality in the world and in Ecuador. This research aimed to analyze the excess mortality due to the COVID-19 pandemic in Ecuador. Method: An observational, longitudinal, quantitative and descriptive study, classified as an ecological study in the field of epidemiology. This study focuses on measuring excess mortality during the years 2020, 2021 and 2022, using the average number of deaths that occurred in the period from 2015 to 2019 as the baseline. Results: From January 2020 to October 2022, Ecuador accumulated a total excess of deaths of 98,915. In 2020, the excess mortality was higher at 46,374, with the highest value occurring in April at 15,484. In 2021, the excess deaths amounted to 35,859, with April having the highest excess of 7,330. In 2022, the excess mortality was 16,682, with January recording the highest excess at 4,204. Conclusion: Evidence of underreporting of deaths, as well as temporal and geographi-cal variations in excess mortality, was observed. The province with the highest number of deaths and excess mortality was Guayas, followed by Pichincha. The results provide an analysis of the situation during the health emergency, emphasizing the importance of evaluating the healthcare system's capacity to respond during times of crisis and the imperative need to implement corrective measures for the future.

Crise global da atenção primária à saúde / Global crisis in primary health care / Crisis global de la atención primaria

Enquanto no Norte Global se discute uma crise na Atenção Primária à Saúde, a maioria dos países nunca chegou a constituir sistemas de saúde baseados propriamente numa atenção primária robusta. Nesse cenário, o Brasil apresenta uma tendência mais favorável, com conquistas importantes para a atenção primária e a medicina de família e comunidade nos últimos dez anos. Restam desafios a serem superados para que o Sistema Único de Saúde alcance níveis satisfatórios de acesso a seus serviços, com profissionais adequadamente formados e valorizados pela população.

While the Global North is discussing a crisis in primary health care, the majority of countries have never managed to establish health systems based on robust primary care. Brazil presents a more favorable trend, with important achievements for primary care and family practice over the last ten years. There are still challenges to be overcome so that the Unified Health System achieves satisfactory levels of access to its services, with professionals who are properly trained and valued by the public.

Mientras que en el Norte Global se habla de una crisis de la atención primaria, la mayoría de los países nunca han creado realmente sistemas sanitarios basados en una atención primaria robusta. Brasil, muestra una tendencia más favorable, con importantes logros para la atención primaria y la medicina familiar y comunitaria en los últimos diez años. Aún quedan retos por superar para que el Sistema Único de Salud alcance niveles satisfactorios de acceso a sus servicios, con profesionales debidamente formados y valorados por la población.

The supply and demand for rehabilitation health workforce in Saudi Arabia

Background:Adequate supply of rehabilitation health workforce is a prerequisite for enhancing access to rehabilitation care. However, there is a lack of comprehensive data regarding the supply of rehabilitation health workers in Saudi Arabia.Aims:To determine the need for, and supply of, rehabilitation workforce, and investigate the relationship between rehabilitation workforce supply and rehabilitation needs in Saudi Arabia.Methodology:This cross-sectional study measured the ratio of physiotherapists and occupational therapists per 1000 population. Data were obtained from the Ministry of Health, family health survey and census data of the General Authority for Statistics and published literature. To assess the need for rehabilitation services, we computed a composite disability index based on 3 variables: count of individuals with physical disabilities, those with chronic diseases, and those aged > 65 years. Determinants of the supply potential were population size, rural population percentage, and physician supply. Data were analysed using descriptive statistics and simple linear regression.Results:The ratios of physiotherapists and occupational therapists working at the Ministry of Health facilities were 0.69 and 0.03 per 10 000 population, respectively. Overall rehabilitation health workforce ratio was 0.73 per 10 000. Supply varied across regions, from 0.4 for Riyadh to 2.5 for Al Jouf. Nine regions exceeded the overall ratio. Rehabilitation need index ranged from 0.144 in Najran to 0.212 in Aseer. No significant associations were found between rehabilitation workforce supply on one hand, and need and other potential determinants on the other hand.Conclusion:The rehabilitation workforce supply in Saudi Arabia surpassed the regional and global averages, but was lower than the average for high-income countries. Workforce distribution varied by region across the country and was not related to need. It is important to consider the need for rehabilitation services and context-specific factors when determining the optimal size and distribution of the rehabilitation health workforce in Saudi Arabia.

Beliefs and practices of physicians in Lebanon regarding promotional gifts and interactions with pharmaceutical companies

Background:Pharmaceutical companies invest greatly in promotional gifts to influence prescription of medications by physicians, yet there is limited published information evaluating its impact on healthcare.Aim:This study aimed to assess the beliefs and practices of physicians in Lebanon regarding promotional gifts and their interactions with representatives of pharmaceutical companies.Methods:This cross-sectional study was conducted between December 2019 and January 2020 through an email-based questionnaire sent to 5936 physicians of different specialties registered in the Lebanese Order of Physicians. Assessment was done using a validated tool and data analysis was conducted using SPSS version 26.0.Results:Of the 268 respondents, 188 (70.4%) reported that physicians in Lebanon accepted gifts from representatives of pharmaceutical companies. Most of the physicians (31.7%) interacted with company representatives more than once a week. Medication samples (251 respondents) and stationary items (222 respondents) were the most common gifts accepted by physicians who admitted accepting gifts. Overall, 225 (84.9%) respondents believed that prescriptions by physicians in Lebanon were influenced by the gifts. Only 74 (40.0%) of those who accepted gifts from pharmaceutical companies believed that it was unethical, and around half did not know if the Lebanese Code of Medical Ethics allowed them to accept gifts from pharmaceutical companies .Conclusion:Although physicians in Lebanon were aware of the e ffect that gifts from pharmaceutical companies could have on their prescription behaviours, many of them still accepted the gifts. This study provides evidence to policymakers for decision-making regarding ethical guidance on interactions between physicians and pharmaceutical companies in Lebanon.

Evaluation of antibiotic prescription patterns using WHO AWaRe classification

Background:Antimicrobial resistance is a rising problem worldwide and it poses a serious risk to public health. In Pakistan, about 70.0% of the Acinetobacter group of bacteria were resistant to all antibiotics and were responsible for high mortality among neonates within the first week of life.Aim:To evaluate the pattern of antibiotic prescription in the Ear, Nose and Throat (ENT) Department of Shalamar Hospital, Lahore, Pakistan, using the WHO AWaRe 2021 classification.Methods:We collected prescription data from the ENT outpatient department of Shalamar Hospital from October to December 2021. We compared the quantitative analysis of antibiotics with the WHO AWaRe classification. We analysed the data using SPSS version 26 and discussed the results with the ENT Department for possible improvements.Results:Some 862 (12.1%) of the total 7126 entries were assessed. Others were excluded because they had some missing data or had no antibiotic prescription. Of all the antibiotics prescribed, around 54.9% belonged to the access category. The WHO 13th General Programme of Work 2019–2023 recommends a country-level target of at least 60% of the total antibiotic consumption in the access group antibiotics.Conclusion:The outpatient department of the ENT did not prescribe any reserve or not recommended antibiotics. The use of watch antibiotics was higher than recommended by the WHO AWaRe classification. More efforts should be made to increase prescriptions from the AWaRe access group to achieve the 60% minimum target recommended by WHO for the country.

Situation analysis of the quality of primary health care services in Pakistan

Background:Primary health care services to promote the mental and physical health of communities include preventive, promotive, curative, general hygiene, and nutritional elements.Aim:To assess the quality of service delivery at primary healthcare settings in Punjab, Pakistan.Methods:Quantitative surveys were conducted at 106 health facilities: 92 basic health units (BHUs) and 14 rural health centres (RHCs) across Punjab in 2020. Data from the survey were supplemented with information from observations by the researchers and all data were analysed using SPSS version 25.Findings:All the 7 district health authorities surveyed had monthly targets for number of normal deliveries and the outpatient department. Systems for safe transportation and storage of medicines were deficient except in 2 districts. Anti-venom and anti-rabies vaccines were either limited or not available at most of the health units visited. Some 14% of clinical equipment examined at the BHUs and RHCs were non-functional, and no BHU had ultrasonic machines to improve the quality of antenatal care. Sterilization of surgical instruments was unsatisfactory at most health units. Several key positions at BHU and RHC were vacant. Most health units did not have fence and their main buildings were in poor condition.Conclusions:Several gaps were identified at the primary healthcare level in Punjab that need to be addressed to improve the quality of service delivery.

Assessment of the impact of integrated disease surveillance and response system on surveillance management at healthcare facilities in Pakistan

Background:Disease surveillance is very crucial especially in high vulnerability settings like Pakistan. However, surveillance and outbreak response management are still evolving in the country and research studies are needed to assess the existing system.Aim:To assess the impact of integrated disease surveillance and response system (IDSRS) implemented by the provincial government to strengthen infectious disease surveillance and reporting in 6 districts of Pakistan in 2016.Methods: A baseline cross-sectional assessment of health facilities and the healthcare workforce was conducted in 2016 to identify needs and gaps in public sector health facilities and the health system of 6 selected districts of Khyber Pakhtunkhwa Province, Pakistan. This was followed by a 2018 endline survey of the same facilities using the same variables.Results:Overall, there was improvement in district management and facility level performance (χ2(1, 314) = 21.19, P < 0.001, V = 0.26). District level management improved significantly in areas with relatively lower Gross Domestic Product (GDP)? χ2(1, 154) = 30.41, P <0.001, V = 0.44). Facilitation domain variables improved in the lower GDP districts (χ2(1, 74) = 5.76, P =0 .016, V = 0.28) and showed counterintuitive deterioration (χ2(1, 74) = 4.80, P = 0.028, V = 0.25) in relatively higher GDP areas.Conclusion:IDSRS is effective in improving surveillance and response systems, however, its effectiveness appears to depend on l ocale-specific economies and can be enhanced by modifying the implementation approach. Better empowerment of the local workforce can contribute to such improvement

River water pollution in Lebanon: the country’s most underestimated public health challenge

Background:Due to the several interconnected crises that Lebanon has been facing for the past 4 years, many important social and environmental issues have been overlooked until more “pressing” ones are dealt with. Consequently, water pollution in Lebanon continues to worsen.Aim:This study aimed to describe the microbiological and chemical properties of the 10 main rivers in Lebanon and to assess their suitability for irrigation, while exploring some of the solutions to the problem.Methods:This cross-sectional study evaluated the pollution level of water from 10 rivers in Lebanon in June 2023 and their suitability for irrigation. Samples were collected at 3°C and their quality parameters were measured. Statistical analysis was conducted using R statistical software version 4.0.2.Results:Compared to the Food and Agriculture Organization (FAO) guidelines for safe irrigation water use, 4 out of the 10 samples had pH levels exceeding the permissible threshold, resulting in severe limitations on their usability. Three rivers had nitrate concentrations that exceeded the approved range, thus constraining their severe usage. Among the rivers, 60% had Escherichia coli levels higher than the permissible spectrum and 40% had faecal coliform counts exceeding FAO’s upper limit recommendation. All water sources, however, had total dissolved solid levels that were within the recommended range.Conclusions:Polluted water can have a negative impact on human, wildlife and ecosystem health. Most of the assessed rivers in our study contained bacterial colonies, above the maximum recommended internationally. There is therefore an urgent need to address pollution issues in Lebanese waters to make them suitable for irrigation and other uses.

¿Clima de reforma? / Reform climate?

Revisé el diccionario y encontré en la RAE la definición de persuasión: "Inducir, mover, obligar a alguien con razones a creer o hacer algo". Es generar confianza, convencer e influir en los demás. Es una fuerza poderosa si se enfoca adecuadamente. Susceptible de aprender, pero tiene unas características propias como son la facilidad de comunicar, las relaciones sociales y ese algo que falta que es la capacidad de empatizar. Expertos en persuasión señalan 6 características: coherencia, reciprocidad, prueba social, escasez, autoridad, y gusto. Más que la presentación del funcionario que busca consenso, orientación y apoyo, escuchamos a un provocador que en forma descarnada presentaba los argumentos o hipótesis que daban pie a los cambios que se proponían en la reforma de salud. Así fue la intervención de la ministra de Salud en el foro de la Academia Nacional de Medicina.

Inversión económica en salud en América en los últimos veinte años / Economic investment in health programs in North, Central and South American countries during the last twenty years / Investimento econômico em saúde na América nos últimos vinte anos

Introducción: La inversión en salud es fundamental para brindar una oportuna atención a los pacientes, y a la vez efectuar programas de prevención para el bienestar de la ciudadanía. Objetivo: Comparar la inversión en salud en los países de América en los últimos veinte años. Materiales y métodos: Se empleó el Modelo Lineal General con base en la técnica MANOVA, suplementando con análisis clúster. Las variables evaluadas fueron: gasto invertido por el sector público en salud expresado en porcentaje; porcentaje del gasto total invertido en salud; PIB (Producto Interno Bruto) salud y gasto público salud per cápita expresado en euros. Resultados: Estados Unidos presenta diferencia estadística significativa respecto a las demás naciones del continente (p<0,05), en lo relacionado al PIB y al gasto público per cápita en euros destinado a la salud. Venezuela posee el menor gasto invertido por el sector público en salud expresado en porcentaje. Conclusiones: Existen grandes brechas en la inversión en salud en América; países con mayor poder adquisitivo como Estados Unidos y Canadá, presentan las mayores cifras. Venezuela es el país con la menor inversión del PIB dedicada a gastos de salud, siendo la única nación que en los últimos años ha reducido esta variable.

Introduction:Health investment is essential to provide patient care and develop prevention programs for the wellbeing of citizens. Objective:To compare investment in health programs by American countries during the last twenty years. Methods:A General Linear Model based on the MANOVA technique was applied, which was supplemented with cluster analysis. The assessed variables were: investments in health by the public sector (expressed as a percentage); percentage of the total spending invested in health; and health GDP(Gross Domestic Product) and public health expenditure per capita (presented in Euros). Results:In reference to GDP and public spending per capita allocated to health (in Euros), the United States shows a statistically significant difference compared to other nations of the continents (p<0.05). Venezuela has the lowest public expenditure in health, expressed as percentage. Conclusions:There is a large difference in terms of investment in health in the Americas, where the economically strongest countries such as the United States and Canada show the highest figures. Venezuela is the country with the lowest GDP investment in health, being the only nation that reduced this variable in recent years.

Introdução:O investimento na saúde é fundamental para poder prestar cuidados oportuna aos doentes e ao mesmo tempo realizar programas de prevenção para o bem-estar dos cidadãos. Objetivo: Comparar o investimento em saúde nos países da América nos últimos vinte anos. Materiais e métodos:Foi utilizado o Modelo Linear Geral com base na técnica MANOVA, complementada com análise de cluster. As variáveis avaliadas foram: gastos investidos pelo setor público em saúde expressos em percentual; percentual do gasto total investido em saúde; PIB (Produto Interno Bruto) da Saúde e despesa pública em saúde per capita expressa em euros. Resultados:Os Estados Unidos apresentam uma diferença estatisticamente significativa em relação às demais nações do continente (p<0,05), em relação ao PIB e ao gasto público per capita em euros alocado à saúde. A Venezuela tem o menor gasto investido pelo setor público em saúde expresso em porcentagem. Conclusões:Existem grandes lacunas de investimento em saúde nas Américas, onde os países de maior poder aquisitivo, como Estados Unidos e Canadá, apresentam os valores mais elevados. A Venezuela é o país com menor investimento do PIB dedicado aos gastos com saúde, sendo a única nação que nos últimos anos reduziu esta variável.

Teoría de la complejidad y los sistemas de salud / Complexity theory and health systems

En la investigación en salud es todavía poco frecuente el uso de la Teoría de la Complejidad y de la Fractalidad (más aún en tópicos no relacionados directamente con la biología molecular o con la clínica). La complejidad nos propone complementar con propuestas desde nuevas perspectivas el pensamiento lineal y cuantitativo predominante todavía en la metodología de producción del conocimiento científico. El estudio de los sistemas de salud necesita un enfoque que se aparte de la linealidad, lo rígido y lo direccional, dado que los mismos son sistemas complejos en los que el todo es más que la simple suma de sus partes. La crisis global generada ante la pandemia por COVID-19 nos puso frente a la oportunidad (y a la obligación) de repensar tanto nuestra praxis cotidiana como nuestra forma de producir conocimiento (AU)

In health research, the use of the Complexity and Fractality Theory is still infrequent (even more so in topics not directly related to molecular or clinical biology). The complexity proposes us to complement with proposals from new perspectives the linear and quantitative thinking still predominant in the methodology of production of scientific knowledge. The study of health systems needs an approach that moves away from linearity, rigidity and direction, since they are complex systems in which the whole is more than the simple sum of its parts. The global crisis generated by the COVID-19 pandemic presented us with the opportunity (and the obligation) to rethink both our daily praxis and our way of producing knowledge (AU)

Evolución de la cesárea en Colombia y su asociación con la naturaleza jurídica de la institución donde se atiende el parto / Evolution of cesarean sections in Colombia and its association with the legal standing of the institutions where deliveries take place

RESUMEN Objetivos: Describir la evolución de la frecuencia de la cesárea en Colombia a partir de 1998, tanto global como discriminada según la naturaleza jurídica de las instituciones prestadoras de salud (IPS) donde se atienden los partos, y calcular la magnitud de la asociación entre la naturaleza jurídica de la IPS y la realización de cesáreas entre 2015 y 2017. Materiales y métodos: Estudio de corte transversal que describe la frecuencia de partos por cesárea entre los años 1998 y 2020, y un componente analítico para estimar la asociación entre la naturaleza jurídica y la vía del parto entre los años 2015 y 2017, a partir de las bases de registros de nacimientos del Departamento Administrativo Nacional de Estadística (DANE) de Colombia. Se presentan las proporciones de cesárea por año y el incremento en la proporción de cesárea por tipo de institución; como estimador de esta asociación se utilizó la razón de prevalencia. Resultados: En 1998, la proporción de cesárea fue 25,7 %, incrementó hasta 46,4 % en 2015 y descendió a 44,6 % para 2020. A partir de 1998, la proporción de cesárea en las IPS públicas pasó de 26,2 a 42,9 % para el año 2014 y en las privadas de 45,0 a 57,7 % para el año 2013. La razón de prevalencia de la cesárea de las instituciones privadas con respecto a las públicas fue 1,57 (IC 95 %: 1,56-1,57). Conclusiones: Después de un periodo largo de incremento sostenido, se está presentando una disminución en la proporción de cesáreas en el país; las IPS públicas incrementaron estos procedimientos en mayor proporción durante la mayor parte del tiempo estudiado y en las IPS privadas se realizan con mayor frecuencia a todos los subgrupos de mujeres. Se deberá evaluar en el futuro, mediante metodologías más robustas, si el descenso en la frecuencia de cesárea es una tendencia real o secular.

ABSTRACT Objectives: To describe how the frequency of cesarean section has evolved in Colombia since 1998, both in overall terms as well as discriminated according to the legal standing of the healthcare providers (IPSs) where delivery takes place, and to estimate the size of the association between the legal standing of the institutions and the performance of cesarean sections between 2015 and 2017. Material and methods: A cross-sectional cohort study that describes the frequency of cesarean deliveries between 1998 and 2020, plus an analytical component to estimate the association between the legal nature and the route of delivery between 2015 and 2017, based on the birth records of the Colombian National Statistics Administrative Department (DANE). Proportions of cesarean sections and their increase by institution type are presented. The prevalence ratio was used as an estimator of this association. Results: In 1998, the proportion of cesarean deliveries was 25.7 %; it increased to 46.4 % by 2015 and then dropped to 44.6 % by 2020. After 1998, the proportion of cesarean sections in public hospitals increased from 26.2 % to 42.9 % by 2014, while in private providers it increased from 45.0 % to 57.7 % by 2013. The prevalence ratio of cesarean sections in private versus public institutions was 1.57 (95 % CI: 1.56-1.57). Conclusions: After a long period of sustained growth, there is now a reduction in the proportion of cesarean sections in the country. In public health care institutions, these procedures increased in greater proportion during most of the study period, while in private healthcare providers they are carried out at a higher frequency in all subgroups of women. It will be necessary to evaluate in the future, using more robust methodologies, whether the decrease in the frequency of cesarean section is a real or secular trend.

Criterios de referencia y barreras para la atención de personas con baja visión en Santander / Criteria for referral and barriers to care for people with low vision in Santander

Objetivo: Identificar criterios de derivación y barreras percibidas por los optómetras para la rehabilitación de personas con baja visión en Santander. Métodos: Estudio de corte transversal que incluyó 82 optómetras de municipios de Santander, seleccionados mediante muestreo intencionado. Se diseñó un cuestionario con 36 preguntas para recolectar los datos que son reportados empleando estadística descriptiva. Resultados: El 47,5 % de los profesionales tiene claro el nivel de agudeza visual para clasificar a una persona con baja visión. Las principales barreras identificadas para el acceso a servicios de baja visión fueron: el proceso de derivación dentro del sistema de salud es engorroso (74,39 %), falta de servicios cerca (57,31 %) y considerar que los pacientes no pueden pagar las ayudas (48,78 %). Discusión: Es necesario fortalecer la formación de los optómetras para mejorar los procesos de identificación, atención y rehabilitación. Conclusiones: Es importante ubicar como prioritaria la discapacidad visual en Santander, para así robustecer la red de atención en salud.

Objective: To identify referral criteria and barriers perceived by optometrists for the rehabilitation of people with low vision in Santander. Methods: Cross-sectional study, which included 82 optometrists from municipalities of Santander, selected by purposive sampling. A questionnaire with 36 questions was designed to collect data that are reported using descriptive statistics. Results: A total of 47.5% of the professionals are clear about the level of visual acuity to classify a person with low vision. The main barriers identified for access to low vision services were: the referral process within the health system is cumbersome (74.39%), lack of services nearby (57.31%) and considering that patients cannot afford the aids (48.78%). Discussion: It is necessary to strengthen the training of optometrists to improve the processes of identification, care and rehabilitation. Conclusions: It is important to prioritize visual impairment in Santander in order to strengthen the health care network.

Fortalecimiento de la investigación local para abordar la salud y los derechos sexuales y reproductivos de las personas migrantes de Venezuela y América Central / Strengthening locally led research to respond to the sexual and reproductive health and rights of migrants from Venezuela and Central America

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Distanciamento social em contextos urbanos na pandemia de Covid-19: desafios para o campo da saúde mental / Social distancing in urban contexts in the COVID-19 pandemic: challenges for the field of mental health

Resumo Neste artigo, analisamos o distanciamento social, principal ação preventiva na pandemia de Covid-19, como fenômeno que ultrapassa sua demarcação como medida sanitária, revelando-se como experiência humana desdobrada em sofrimentos psíquicos diversos, desafiando sob muitas formas o campo da saúde mental. Situamos essa problemática no cenário brasileiro, periférico no capitalismo globalizado, contextualizado na hipermodernidade, no qual sobressai o modo de vida urbano, marcado por desigualdades e produtor de vulnerabilidades que se evidenciam no combate à pandemia, expressandose em sofrimentos e transtornos que desafiam o campo da saúde mental coletiva. Apontamos reflexões e subsídios para a ampliação desse campo, sob uma perspectiva crítica e complexa, concernentes à produção de conhecimentos e do cuidado, focalizando a urbanidade como dimensão analítica central na compreensão do distanciamento. Ilustramos com alguns desafios e também possibilidades de reinvenção em saúde mental, no contexto da pandemia de Covid-19, focalizando tanto ações voltadas à esfera coletiva, em escala macro, na rede pública de saúde, como nos encontros constitutivos do processo de cuidado, buscando subsidiar uma clínica ampliada nesse contexto.

Abstract In this article, we examine social distancing, the main preventive action in the Covid-19 pandemic, as a phenomenon that goes beyond its demarcation as a health measure, revealing itself as a human experience unfolded in various psychological sufferings, challenging the field of Mental Health in many ways. The analysis places this subject in the Brazilian scenario, peripheral in globalized capitalism, contextualized in hypermodernity, in which the urban way of life, stands out, marked by inequalities and vulnerabilities that are evident in the fight against the pandemic, expressing itself in suffering and disorders that challenge the field collective mental health. We point out reflections and subsidies for the expansion of this field, from a critical and complex perspective, concerning the production of knowledge and care practices, focusing on urbanity as a central analytical dimension in the understanding of social distancing. We illustrate with some challenges and possibilities of reinventing mental health, in the context of the Covid-19 pandemic, focusing both on actions aimed at the collective sphere, on a macro scale, in the public health network, as well as in the constitutive meetings of the care process, seeking subsidize an expanded clinic in this context.