Análise crítica do modelo de atenção à saúde das pessoas privadas de liberdade no Brasil / Critical analysis of the health care model for persons deprived of liberty in Brazil / Análisis crítica del modelo de atención de la salud para personas privadas de libertad en Brasil

Objetivo: a universalidade e a integralidade do direito à saúde devem ser garantidas no contexto prisional como princípios constitucionais. A pesquisa teve como objeto o conjunto de leis e portarias construídas sobre o tema por mais de trinta anos, a fim de analisar criticamente o modelo de atenção à saúde das pessoas privadas de liberdade no sistema prisional, a partir do levantamento normativo, sua cronologia e hierarquia. Metodologia: o estudo qualitativo documental utilizou as bases de dados da Presidência da República, Câmara dos Deputados, Senado Federal e Biblioteca Virtual em Saúde do Ministério da Saúde, para identificar normas vigentes que envolvem as questões do sistema de saúde no âmbito penal e de atenção aos presos propriamente dita. Resultados: foram analisadas 11 normas federais, de acordo com seus fundamentos e definição de parâmetros de implementação pelos órgãos de segurança e de saúde. Destacam-se o Plano Nacional de Saúde no Sistema Penitenciário e a Política Nacional de Atenção Integral à Saúde das Pessoas Privadas de Liberdade no Sistema Prisional (PNAISP). Conclusão: são urgentes medidas efetivas intersetoriais dispostas a modificar o quadro de violência institucional e iniquidades nas unidades prisionais, em um processo de corresponsabilização, por meio da Rede Atenção à Saúde, segundo os parâmetros do Sistema Único de Saúde (SUS).

Objective: the universality and comprehensiveness of the right to health must be guaranteed in the prison context as constitutional principles. The research had as its object the set of laws and regulations built about this theme over more than thirty years. The purpose was to critically analyze the health care model of persons deprived of liberty in the prison system, based on the normative survey, its chronology and hierarchy. Methods: the qualitative documentary study used the databases of Federal Government, Chamber of Representatives, Federal Senate, and Virtual Health Library of the Ministry of Health, to identify current norms that involve issues of the health system in the criminal scope and care to arrested people. Results: eleven federal norms were analyzed, according to their fundamentals and definition of implementation parameters by the security and health agencies. The National Health Plan in the Penitentiary System and the National Policy for Comprehensive Health Care for Persons Deprived of Liberty in the Prison System (PNAISP) are highlighted. Conclusion: effective intersectoral measures are urgent to change the situation of institutional violence and inequities in prisons, in a process of co-responsibility, through the health care network, according to the parameters of the Unified Health System (SUS).

Introducción: la universalidad e integralidad del derecho a la salud debe garantizarse en el contexto penitenciario como principios constitucionales. La investigación tuvo como objeto el conjunto de leyes y ordenanzas construidas sobre el tema durante más de treinta años. El objetivo fue analizar críticamente el modelo de atención a la salud de las personas privadas de libertad en las prisiones, a partir de la encuesta normativa, su cronología y jerarquía. Metodología: el estudio documental cualitativo utilizó las bases de datos de la Presidencia, Cámara de Diputados, Senado Federal y Biblioteca Virtual en Salud del Ministerio de Salud, para identificar las normas vigentes que involucran temas del sistema de salud en el ámbito penal y atención a los reclusos. Resultados: se analizaron 11 normas federales, según sus fundamentos y definición de parámetros de implementación por parte de los organismos de seguridad y salud. Destacan el Plan Nacional de Salud en el Sistema Penitenciario y la Política Nacional de Atención Integral de Salud a las Personas Privadas de Libertad en el Sistema Penitenciario (PNAISP). Conclusión: existe una urgente necesidad de medidas intersectoriales efectivas dispuestas a modificar la situación de violencia institucional e inequidades en las unidades penitenciarias, en un proceso de corresponsabilidad, a través de la Red de Salud, de acuerdo con los parámetros del Sistema Único de Salud (SUS).

[Motherhood behind bars: the struggle for citizens' rights and health for women inmates and their children in Brazil]. / Maternidade atrás das grades: em busca da cidadania e da saúde. Um estudo sobre a legislação Brasileira.

This study analyzes the links between health, rights, legislation, and public policies based on document research on legal safeguards for women and their children residing in prison. The research was conducted at the Federal level and in four States of Brazil: Rio Grande do Sul, Mato Grosso, Paraná, and São Paulo. The study aims to back measures by public agencies to guarantee such rights and to raise awareness of the problem, given the extreme vulnerability of women inmates and their children and the issue's legal and administrative invisibility. The authors identified 33 different legal provisions as points of tension, such as the possibility of house arrest and disparities in the terms and conditions for children to remain inside the prison system. Various provisions cite the Constitutional guarantee of women inmates' right to breastfeed in prison. Meanwhile, the study found gaps in other issues pertaining to motherhood in prison, expressed as dual incarceration (imprisonment arbitrarily extended to their children). It is necessary to expand and enforce the existing legislation to prevent such violations of rights.

A public policy approach to local models of HIV/AIDS control in Brazil.

OBJECTIVES: We investigated involvement and cooperation patterns of local Brazilian AIDS program actors and the consequences of these patterns for program implementation and sustainability. METHODS: We performed a public policy analysis (documentary analysis, direct observation, semistructured interviews of health service and nongovernmental organization [NGO] actors) in 5 towns in 2 states, São Paulo and Pará. RESULTS: Patterns suggested 3 models. In model 1, local government, NGOs, and primary health care services were involved in AIDS programs with satisfactory response to new epidemiological trends but a risk that HIV/AIDS would become low priority. In model 2, mainly because of NGO activism, HIV/AIDS remained an exceptional issue, with limited responses to new epidemiological trends and program sustainability undermined by political instability. In model 3, involvement of public agencies and NGOs was limited, with inadequate response to epidemiological trends and poor mobilization threatening program sustainability. CONCLUSIONS: Within a common national AIDS policy framework, the degree of involvement and cooperation between public and NGO actors deeply impacts population coverage and program sustainability. Specific processes are required to maintain actor mobilization without isolating AIDS programs.

[Health in the prison system: representations and practices by prison guards in Rio de Janeiro, Brazil]. / Saúde em prisões: representações e práticas dos agentes de segurança penitenciária no Rio de Janeiro, Brasil.

The role of prison guards in limiting access to health services by inmates and the impact of their representations on daily health practices were investigated through an action-research program. The program aimed to produce knowledge and improve the guards' involvement in tuberculosis and HIV/AIDS control by raising their awareness. Developed in three prisons and two hospitals, the study included individual interviews and group discussions and showed that representations of health and illness, risk hierarchy, and preventive strategies are related to actors' status in the prison's social organization, the conflicts and tensions between them, and the sense of group belonging that reinforces identities and antagonisms. Such representations have a major influence on the guards' daily practices and inmates' access to health services. The denial of inmates' right to health and their limited autonomy contributed to the implementation of essentially prescriptive health actions. The guards' awareness of their own health representations and practices may contribute to the deconstruction of stereotypes and increase their involvement in prevention and care. Further, improvement of inmates' health depends on changes in prison conditions.

Saúde em prisões: representações e práticas dos agentes de segurança penitenciária no Rio de Janeiro, Brasil / Health in the prison system: representations and practices by prison guards in Rio de Janeiro, Brazil

O papel limitante dos agentes de segurança penitenciária no acesso dos detentos aos serviços sanitários e o impacto de suas representações e práticas de saúde no cotidiano prisional foram objeto de pesquisa-ação visando tanto à produção de conhecimento como à melhoria das ações de controle da tuberculose e HIV/AIDS pela participação e conscientização. Desenvolveu-se em três prisões e dois hospitais por meio de entrevistas individuais e grupos de discussão. Revelou que concepções de saúde e doença, hierarquização de riscos e estratégias de preservação no contexto carcerário relacionam-se às posições nessa organização social, aos conflitos e tensões ali existentes e aos pertencimentos grupais que reforçam identidades e antagonismos, refletindo-se nas práticas rotineiras e no acesso aos serviços. A negação da saúde como um direito dos presos e a restrição de sua autonomia contribuem para ações de saúde prescritivas. A tomada de consciência dos agentes de segurança penitenciária quanto às representações e práticas de saúde pode contribuir para a desconstrução de idéias estereotipadas e aumentar seu envolvimento nas ações de prevenção e assistência. A melhoria das condições de saúde dos detentos implica também mudanças nas condições de encarceramento.

The role of prison guards in limiting access to health services by inmates and the impact of their representations on daily health practices were investigated through an action-research program. The program aimed to produce knowledge and improve the guards' involvement in tuberculosis and HIV/AIDS control by raising their awareness. Developed in three prisons and two hospitals, the study included individual interviews and group discussions and showed that representations of health and illness, risk hierarchy, and preventive strategies are related to actors' status in the prison's social organization, the conflicts and tensions between them, and the sense of group belonging that reinforces identities and antagonisms. Such representations have a major influence on the guards' daily practices and inmates' access to health services. The denial of inmates' right to health and their limited autonomy contributed to the implementation of essentially prescriptive health actions. The guards' awareness of their own health representations and practices may contribute to the deconstruction of stereotypes and increase their involvement in prevention and care. Further, improvement of inmates' health depends on changes in prison conditions.

Reimbursement of malaria chemoprophylaxis for travellers from Europe to Sub-Saharan Africa: Cost-effectiveness analysis from the perspective of the French national health insurance system.

Among Western countries, France has the highest incidence of imported malaria cases, mostly from travellers visiting Sub-Saharan Africa (SSA). Despite related high costs of imported malaria assumed by the public French national health insurance system (FHS), the latter does not reimburse travellers for malaria chemoprophylaxis (MC). This study aims to analyzes, from the FHS perspective, the cost-effectiveness of a 65% reimbursement of MC costs (MC 65%) for French resident travellers, under the assumption that this reimbursement would lead to increased recourse to MC. For that purpose, a decision tree model was developed with variables obtained from the literature, including incidence of malaria among travellers in the absence of MC, probabilities of recourse to MC, MC effectiveness and costs and medical expenses for a case of imported malaria. Data analysis of 1,434,675 travellers to SSA in 2005 estimated, for MC 65% vs. MC 0%, incidence of malaria cases to be 3836 malaria cases (21 deaths)/year vs. 6321 cases (34 deaths)/year, respectively, and cost of Euro 47,071,687/year vs. Euro 17,416,955/year. Incremental cost of MC 65% related to MC 0% was Euro 11,933 per malaria case prevented and Euro 2,281,133 per malaria-related death prevented. Results generated by this model, which can be adapted for other European countries, should be an incentive for the FHS to favourably consider MC 65% for French residents travelling to SSA.