Lacunas e retrocessos em programas de provimento médico na Amazônia: desafios para os gestores federais / Gaps and setbacks in medical provision programs in the Amazon: challenges for the federal managers / Lagunas y retrocesos en los programas de ayuda médica en la Amazonía: desafíos para los administradores federales

Resumo O objetivo desta nota de conjuntura é analisar o desenvolvimento dos Programas Mais Médicos e Médicos pelo Brasil em áreas remotas e rurais amazônicas, apontando desafios e disputas decorrentes de implementações locais. Realizou-se levantamento bibliográfico e de dados observacionais sobre esses programas na Amazônia Legal e o provimento médico na Atenção Primária à Saúde brasileira entre 2013 e 2022. Identificou-se literatura com tendências positivas sobre o processo de trabalho, além de indicadores de cuidados primários com a implantação do Mais Médicos nessas localidades, mas que foram drasticamente afetados após a ruptura da cooperação Brasil-Cuba em 2018. Alternativas como a contratação de médicos brasileiros graduados no exterior pelo Mais Médicos e a promessa de carreira do Médicos pelo Brasil não se mostraram suficientes para garantir cobertura razoável das equipes locais. Percebe-se o esvaziamento progressivo do Mais Médicos na região sem equivalente reposição de profissionais do Médicos pelo Brasil. Reconhece-se a carência de estudos sobre o Mais Médicos na Amazônia, em especial após 2018, bem como de dados sobre os desdobramentos iniciais do Médicos pelo Brasil. Mostram-se necessários o preenchimento de lacunas e a superação dos retrocessos no provimento médico local, sob risco de perpetuação de iniquidades graves no campo da saúde.

Abstract The objective of this conjuncture note is to analyze the development of the Programs Mais Médicos and Médicos pelo Brasil in remote and rural Amazonian areas, pointing out challenges and disputes arising from local implementations. A bibliographical and observational survey was carried out on these programs in the Legal Amazon and the medical provision in the Brazilian Primary Health Care between 2013 and 2022. Literature with positive trends on the work process was identified, as well as primary care indicators with the implementation of Mais Médicos in these localities, but were drastically affected after the rupture of Brazil-Cuba cooperation in 2018. Alternatives such as hiring Brazilian physicians graduates abroad by the Mais Médicos and the promise of career of doctors in Brazil were not enough to ensure reasonable coverage of local teams. Progressive emptying is noticed in Mais Médicos in the region, without the equivalent replacement of Médicos pelo Brasil. Lack of studies is recognized on the Mais Médicos in the Amazon, especially after 2018, as well as data on the initial developments of Médicos pelo Brasil. Filling gaps and overcoming setbacks are necessary in the local medical provision, at risk of perpetuating serious inequalities in the health field.

Resumen El objetivo de esta nota coyuntural es analizar el desarrollo de los programas Mais Médicos y Médicos pelo Brasil en áreas remotas y rurales amazónicas, señalando los desafíos y disputas que surgen de las implementaciones locales. Entre 2013 y 2022 se realizó una encuesta bibliográfica y de datos observacionales sobre estos programas en la Amazonía Legal y la atención médica en la Atención Primaria de la Salud Brasileña. Se identificó literatura con tendencias positivas en el proceso de trabajo, además de indicadores de atención primaria con el despliegue de Mais Médicos en estas localidades, pero que se vieron dramáticamente afectados después de la ruptura de la cooperación Brasil-Cuba en 2018. Alternativas como la contratación de médicos brasileños graduados en el extranjero por el Mais Médicos y la promesa de carrera de Médicos pelo Brasil no han demostrado ser suficientes para asegurar una cobertura razonable de los equipos locales. Se percibe el progresivo vaciado de Mais Médicos de la región sin el equivalente reemplazo de profesionales de Médicos pelo Brasil. Se reconoce la falta de estudios sobre los Mais Médicos de la Amazonía, en particular después de 2018, así como de datos sobre los primeros despliegues de Médicos pelo Brasil. Es necesario llenar las lagunas y superar los retrocesos en la atención médica local, bajo el riesgo de perpetuación de graves iniquidades en el ámbito de la salud.

Access to maternal reproductive health care services in remote hinterland regions of Guyana / Acesso à serviços de saúde maternal e reprodutiva nas regiões remotas da Guiana

Access to reproductive health care services is critical to the life of a woman, her family, and the society as a whole. Women who live in remote hinterland Regions of Guyana experience many challenges relative to their access to reproductive health care services. This has resulted in higher rates of home deliveries, high maternal mortality rates, and higher teenage pregnancies rates than their counterparts who live in coastal settings. There is still a paucity of literature in Guyana that scientifically explored the critical issues affecting "access of reproductive health care services from the perspective of Indigenous women who live in remote hinterland regions". Aim: To identify the challenges to access to Reproductive Health care services from the prospective of women, ages 18 to 49 years who live in remote hinterland regions of Guyana. Methodo: This study was based on a sample of 85 Indigenous women, age 18 - 49 years who resided in three remote hinterland regions of Guyana. Data was collected by means of an interview schedule. Simple quantitative study analysis - Frequency distribution; Univariate and bivariate analysis; Correlation analysis - Pearson's r correlation (r) was used to determine the challenges in a wide variety of reproductive health care services. Results: Some reproductive health services were accessed on a sporadic basis by women who live in remote hinterland regions of Guyana. These include: cervical cancer screening (34%) and 91% never had a breast examination; 60% had no access to family planning and contraceptives within the last 12 months of the study. Further, 92% of respondents had obtained prenatal care at a health facility during their last pregnancy, while only 52% of reported having delivered at the health facilities where they first sought health care services from, and 28% did not have prenatal appointments at a government public health facility. Some of the challenges to access to these reproductive health services (as identified by women) including: Inadequate health facilities to allow for easy access to reproductive health care; Inadequate competent providers to provide skilled midwifery care; Unavailability or lack of consistent supply of equipment and supplies to provide for clinical and laboratory tests; Lack of consistent supply of contraceptives; Poor referral system to allow for the receipt of test results not done in the regions and for timely interventions; and lack of information and counselling services, among others. Conclusion: Many challenges exist in relation to access to a number of reproductive health care services in remote hinterland regions of Guyana. The identification of these challenges can help to validate what obtains in hinterland regions - relevant to reproductive health care services, and help to form the basis to better inform the provision and strengthening of specific and targeted interventions, policies, and services that are of high quality, and that meets the needs of women who live in remote hinterland regions of the country

O acesso aos serviços de saúde reprodutiva é fundamental para a vida das mulher, sua família e a sociedade como um todo. As mulheres que vivem em regiões remotas do interior da Guiana enfrentam muitos desafios em relação ao acesso a serviços de saúde reprodutiva. Isso resultou em taxas mais altas de partos domiciliares, altas taxas de mortalidade materna e taxas mais altas de gravidez na adolescência do que entre aquelas que vivem em áreas costeiras. Ainda há uma escassez de literatura na Guiana que explorou cientificamente as questões críticas que afetam o "acesso a serviços de saúde reprodutiva a partir da perspectiva de mulheres indígenas que vivem em regiões remotas do interior". Objetivo: Identificar os desafios para o acesso aos serviços de saúde reprodutiva na perspectiva de mulheres de 18 a 49 anos que vivem em regiões remotas do interior da Guiana. Método: Este estudo foi baseado em uma amostra de 85 mulheres indígenas, com idades entre 18 e 49 anos, que residiam em três regiões remotas do interior da Guiana. Os dados foram coletados por meio de um roteiro estruturado. Análise de estudo quantitativo simples - Distribuição de frequência; Análise univariada e bivariada; Análise de correlação - A correlação r de Pearson (r) foi usada para determinar os desafios em uma ampla variedade de serviços de saúde reprodutiva. Resultados: Alguns serviços de saúde reprodutiva foram acessados esporadicamente por mulheres que vivem em regiões remotas do interior da Guiana. Estes incluem: rastreio do cancer do colo do útero (34%) e 91% nunca fizeram um exame de mama; 60% não tiveram acesso a planejamento familiar e contraceptivos nos últimos 12 meses anteriores ao estudo. Além disso, 92% das entrevistadas obtiveram atendimento pré-natal em uma unidade de saúde durante a última gravidez, enquanto apenas 52% relataram ter feito o parto nas unidades de saúde onde procuraram pela primeira vez e 28% não tiveram consultas de pré-natal em unidade de saúde pública. Alguns dos desafios para o acesso a esses serviços de saúde reprodutiva (conforme identificados pelas mulheres) incluem: instalações de saúde inadequadas para facilitar o acesso aos cuidados de saúde reprodutiva; provedores competentes inadequados para fornecer cuidados obstétricos qualificados; indisponibilidade ou falta de fornecimento consistente de equipamentos e insumos para realização de exames clínicos e laboratoriais; falta de fornecimento consistente de contraceptivos; sistema de encaminhamento deficiente para permitir o recebimento de resultados de exames não realizados nas regiões e para intervenções oportunas; e falta de serviços de informação e aconselhamento, entre outros. Conclusão: Existem muitos desafios em relação ao acesso a vários serviços de saúde reprodutiva em regiões remotas do interior da Guiana. A identificação desses desafios pode ajudar a validar o que se obtém nas regiões do interior, relevantes para os serviços de saúde reprodutiva, além de ajudar a formar a base para melhorar o fornecimento de informações e o fortalecimento de intervenções, de políticas e serviços específicos, e que atendam às necessidades de mulheres que vivem em regiões remotas do interior do país

Atención Primaria en Salud en una región de la Amazonía colombiana: una aproximación al cotidiano / Primary Health Care in a region of the Colombian Amazon: an approach to everyday life

RESUMEN En 2016 comenzó en Colombia la implantación de un nuevo modelo de salud con foco en la atención primaria, siendo Guainía, en la Amazonía colombiana, la primera región en iniciar el test piloto. El objetivo de este estudio fue comprender el cotidiano de implementación de la atención primaria, en el marco del Modelo Integral de Atención en Salud, desde la perspectiva de indígenas y profesionales de la salud en Guainía, Colombia. Se trata de un estudio de caso único, con abordaje cualitativo, fundamentado en la sociología comprensiva del cotidiano. Los datos, recolectados mediante observación directa y entrevistas semiestructuradas con 26 profesionales de salud y 22 usuarios indígenas, fueron sometidos a análisis de contenido temático. Emergieron cinco categorías: 'vivir en el puesto', 'resolver solo', 'el desafío de la cobertura territorial', 'comisiones de salud: solventando vacíos' y 'apoyo de líderes locales'. A pesar de la propuesta reestructurante traída por el nuevo modelo, se evidenció en el cotidiano la persistencia de un enfoque asistencialista y basado en la lógica curativista en la prestación de los servicios. Aunque los atributos de la atención primaria se ven comprometidos, se identificaron acciones cotidianas que pueden favorecer la integralidad en la atención y aportar a una transición exitosa.

ABSTRACT In 2016, the implementation of a new health model focused on primary health care began in Colombia, being Guainía, in the Colombian Amazon, the first region to start the pilot test. The objective of this study was to understand the daily implementation of primary care, within the framework of the Comprehensive Health Care Model, from the perspective of indigenous people and health professionals, in Guainía, Colombia This is a single case study with a qualitative approach, based on the comprehensive sociology of everyday life. The data, collected through direct observation and semi-structured interviews with 26 health professionals and 22 indigenous users, were subjected to thematic content analysis. Five categories emerged: 'living at the post', 'solving alone', 'the challenge of territorial coverage', 'health commissions: filling gaps' and 'support from local leaders'. Despite of the restructuring proposal brought by the new model, the persistence of a care approach based on curativist logic in the provision of services was evidenced in daily life. Although the attributes of primary care are compromised, daily actions that can favor comprehensive care and contribute to a successful transition were identified.

Supervisão acadêmica e apoio pedagógico do Programa Mais Médicos em áreas indígenas e remotas da Amazônia Legal: vivências, desafios e perspectivas / Academic supervision and pedagogical support of the More Doctors Program in indigenous and remote areas of the Legal Amazon: experiences, challenges and perspectives

Este artigo busca analisar a supervisão acadêmica do Grupo Especial de Supervisão (GES) do Programa Mais Médicos (PMM) em áreas remotas e territórios indígenas da Amazônia Legal, com foco na realidade dos profissionais dessas localidades e nas possibilidades de suporte pedagógico para regiões de difícil acesso. O trabalho foi desenvolvido a partir de entrevistas semiestruturadas com médicos do PMM e da narrativa autobiográfica da pesquisadora. Os dados foram submetidos à análise de conteúdo textual, que resultou em três categorias: o "ser médico" do PMM (trajetórias, expectativas e perspectivas de trabalho); a contextualização do trabalho médico nas áreas indígenas e remotas da Amazônia Legal; e as características de funcionamento da supervisão acadêmica do GES/PMM que a tornam "especial" e fundamental para o país. A pesquisa, com isso, ajudou na compreensão da realidade da região, dos desafios enfrentados pelos profissionais e supervisores edas possibilidades de aprimoramento do suporte pedagógico para o PMM e outros programas de provimento médico. Por fim, discute-se o imperativo das questões estruturais de trabalho e vida nesses locais sobre o alcance real da supervisão, o que exige dela uma postura crítica e engajada por melhorias para a região.

The article seeks to analyze the academic supervision of the Special Supervision Group (GES, in Portuguese) from the More Doctors Program (PMMin Portuguese) in remote areas and indigenous territories of the Legal Amazon, focusing on the reality of professionals in these locations and the possibilities of pedagogical support for regions of difficult access. The work was developed from semi-structured interviews with PMM doctors and the autobiographical narrative of the researcher. The data were subjected to textual content analysis, which yielded three categories: the PMM's "being a doctor" (trajectories, expectations, and work perspectives); the contextualization of medical work in indigenous and remote areas of the Legal Amazon; and the characteristics of the GES/PMM's academic supervision functioning that distinguish it as "special" and fundamental to the country.The research thereby helped in understanding the reality of the region, the challenges faced by practitioners and supervisors, and the possibilities for improving pedagogical support for the PMM and other medical provider programs. Finally, it discusses the imperative of the structural issues of work and life in these places on the actual scope of supervision, which requires it to take a critical and engaged stance for improvements in the region.

Perceptions about the "Mais Médicos" Program and the Academic Supervision Process / Percepções acerca do Programa Mais Médicos e do Processo de Supervisão Acadêmica

Abstract: Introduction: This study aims to analyze the perceptions of the involved actors about the "Mais Médicos" Program (PMM) and the academic supervision process, its strengths and weaknesses aiming to improve Primary Heath Care practices. Method: Qualitative study carried out through 05 in-depth interviews with PMM supervising doctors, and 24 interviews with unit managers, 12 Primary Heath Care coordinators, and 07 Secondary Health Care doctors. Results: Three thematic axes emerged from de analysis: benefits of the program for the municipalities and for the population; the challenges of the supervisory process and the difficulties of the fragmented health system. Conclusions: The actors' perception of the "Mais Médicos" Program are positive, especially because it brought doctors to municipalities with vulnerable areas, where doctors did not go to and where they did not stay. Supervision is an important support for continuing in-service training; however, it requires a better articulation with the different levels of the health system management. The precariousness of the service network limits the performance of both doctors and supervisors, demonstrating that it is necessary to invest in a solid and effective care network. Moreover, it was once again evident that the population will face a shortage of doctors due to changes in health policies. It is necessary to build more comprehensive policies, that will not only result in sporadic provision of medical care. There is a need for continuous actions, better integrated to the healthcare networks, aiming at an efficient and effective healthcare system.

Resumo: Introdução: Este estudo teve como objetivo analisar as percepções dos atores envolvidos acerca do Programa Mais Médicos (PMM) e do processo de supervisão acadêmica, as suas fragilidades e pontencialidades para a melhoria das práticas na atenção primária à saúde. Método: Trata-se de estudo qualitativo, realizado por meio de cinco entrevistas em profundidade com médicos supervisores do PMM, analisados com auxílio do software Iramuteq, e 24 entrevistas com gestores de unidades, 12 coordenadores da atenção básica e sete médicos da atenção secundária, que foram submetidas à análise de conteúdo. Resultados: Da análise surgiram três eixos temáticos: benefícios do programa para os municípios e a população, os desafios do processo de supervisão e as dificuldades do sistema de saúde fragmentado. Conclusões: As percepções dos atores acerca do PMM são positivas, sobretudo porque o programa levou médicos para os municípios com áreas vulneráveis. Antes do PMM, os médicos não tinham interesse em deslocar-se para essas áreas e, quando o faziam, não permaneciam muito tempo nesses locais. A supervisão é importante apoio de formação continuada em serviço, contudo requer que seja mais bem articulada com os diversos níveis de gestão do sistema de saúde. A precariedade da rede de serviços limita a atuação tanto dos médicos como da supervisão, demonstrando que é preciso investir em uma rede de atenção sólida e eficaz. Ademais, ficou evidente que, mais uma vez, a população enfrentará a falta de médicos por causa das mudanças nas políticas de saúde que não priorizam a garantia do acesso universal aos serviços de saúde. É necessária a construção de políticas mais abrangentes que não se limitem ao provimento esporádico de médicos. É imprescindível que haja ações contínuas e mais bem integradas às redes de atenção, visando a um sistema de saúde eficiente e eficaz.

Health care delivery system in remote areas of Japan and its enlightenment to China / 中华医院管理杂志

This paper summarized health care delivery system in remote areas of Japan including criteria for underserved areas, regular adjustment to the list, comprehensive national plans, integrated provision system, governmental responsibilities, establishment of Jichi Medical University, participation of social organizations.We raise such suggestions as leading role of the government, precision listing underserved areas,implementing special plan, financing and payment policy, human resources for health, and regional co-ordination of medical resource.

Investigation report on the effect of large hospital's group teaching in a hospital located in the remote area / 中国中西医结合急救杂志

Objective To evaluate the effectiveness of group teaching of Third Hospital of Peking University (Beijing Medical Third Hospital) for a hospital located in remote area. Methods From 2016 to 2017, 19 medical staff from Peking University Third Hospital gave their support to Huanxian People's Hospital and provided respectively the theoretical support, guidance of clinical skills, medical consultation, free paid clinic, outpatient service, and teaching rounds, etc. A questionnaire survey was carried out to realize the subjective evaluation of the 155 clinical front-line staff who had participated in the class regarding the effect of group teaching and the most welcome teaching mode and contents; the objective data on the monthly outpatient visits, number of patients admitted into the hospital, the number of surgical patients, etc were calculated and compared between the pre-support (2014 to 2015) and post-support (2016 to 2017) period to evaluate the effect of counterpart support. Results One hundred and fourteen of the 155 medical staff in their respective departments were trained by the experts, and the percentage of medical staff believed that the counterpart support helped clinical work very much accounting for [58.8% (67/114)] being significantly higher than those who considered of no help [9.6% (11/114)], a little help [16.7% (19/114)] and some help [14.9% (17/114), χ2= 94.082, P = 0.000]; after support, the number of monthly outpatient visits compared to that of pre-support period (case times:43 816.5±3 406.9 vs. 37 319.5±4 302.1) and the number of monthly patients hospitalized compared to that of pre-support period (case times: 2 978.3±235.1 vs. 2 250.9±218.1) were significantly higher than those before the support (all P < 0.05), no statistical significant difference in monthly surgery volume (case times: 449.8±107.3 vs. 459.0±85.4, P > 0.05) between the above 2 periods was seen. The survey showed that the mostly demanding teaching method was theoretical teaching [65.8% (102/155)], followed by teaching rounds [50.3% (78/155)] and outpatient teaching the least [18.1% (28/155)]. That the ratios of various teaching contents with their sequence from high to low the medical personnel required were as follows: to learn new technologies [76.8% (119/155)], medical frontier knowledge [68.4% (106/155)], and standard diagnosis and treatment manipulations [67.7% (105/155)], cultivation of clinical thinking [66.5% (103/155)] and passing on surgical skills [56.1% (87/155)]. There were statistical significant differences between each teaching method and teaching content (all P < 0.05). Conclusions Teaching to cultivate qualified health personnel is the key to the development of hospitals located in remote areas, according to their needs, combining local conditions and the establishment of long-term cooperation mechanisms, we can comprehensively improve the professional quality of medical personnel and the overall strength of hospitals located in remote areas.

Exploration and Consideration of Essential Medicine Supply Guarantee Reform in Poverty and Remote Areas of China: Based on Perspective of Supply Chain Governance / 中国药房

OBJECTIVE:To provide reference for introducing supply chain governance theory into essential medicine supply guarantee reform evaluation system in poverty and remote areas.METHODS:The literatures and reform policies in the field of essential medicine supply guarantee since the New Medical Reform were sorted out to analyze the problems and insufficiency of existing researches,and explore the feasibility of supply chain governance theory in the field of essential medicine supply guarantee.RESULTS:The research boundary of existing studies is not clear,and existing studies are lack of evaluation and analysis method,focus too much on using available data and the result of its quantitative,and lack of comprehensive analysis of combined quantitative and qualitative under theoretical framework.The introduction of supply chain governance theory reveal the mechanism of policy's effectiveness clearly,to provide the reference of policies' tendency.CONCLUSIONS:Through the establishment of theoretical framework based on supply chain governance theory,evaluation system will expand the study strategies and data collection technology in the field of drug circulation.Furthermore,supply chain governance theory and method can be generalized.It not only applies in poverty and remote areas and for the evaluation of essential medicine supply guarantee,but also can be used in the field of drug circulation reform.

A comparative study of general practitioner training patterns in rural and remote areas of Australia and China / 中华医院管理杂志

The manuscript introduced the overview, training objectives, policy advantages, training process,curriculum, examination of the Australian College in Rural and Remote Medicine and further contrasted that with China's domestics.The authors held that Australia's training is better targeted due to its colleges tailored to this end;the training duration for general practitioners of rural and remote areas is longer,and the training schedule is reasonable;the curriculum design and training content are more targeted;and the homogeneous training is better achieved as its examination is run by the college in a standardized manner.The authors therefore hold that China should develop detailed regulations for general practitioners from rural and remote areas and explore the feasibility of setting up second-level disciplines institutes for internal medicine, surgery, gynecology and obstetrics, pediatrics and general at national and provincial level.

A Cross Sectional Study of Intern’s Willingness to Serve in Rural Primary Health Centres of Andhra Pradesh, India

The shortage of health professionals in rural areas is a global problem. The urban and rural maldistribution of doctors results in severe problems regarding access to and performance of health care services. Retaining doctors in rural areas is a challenging task for a number of reasons, ranging from personal preferences to difficult work conditions and low remuneration. The objective of the study was to understand the factors influencing medical and dental intern’s choice to work in rural PHC’s as a basis for designing policies to redress geographic imbalances in health professional’s distribution. A total of 385 dental and medical interns in Andhra Pradesh provided a unique contingent valuation data in a cross sectional survey conducted in 4 medical and 4 dental colleges in Andhra Pradesh, using a questionnaire concerning their preferences, related incentives to work in various rural and remote primary health centres of Andhra Pradesh state, India. The response rate of the study was 89 %, (n= 344), with only 24% of interns expressing their willingness to serve in rural/remote primary health centres. Most of the interns stressed for increase in salary, better accommodation and infrastructure of the hospitals as the factors for increasing their retention in remote rural areas. Although most Indian students are motivated to study medicine and dentistry by the desire to help others, this does not translate into willingness to work in rural areas. Efforts from the government to build intrinsic motivation during medical and dental training to serve in these deprived areas should be in focus with addition to improved working and living conditions and better remuneration.