Política Nacional de Promoção da Saúde (PNPS): revisão da Portaria MS/GM nº 687, de 30 de março de 2006 / National Health Promotion Policy (PNPS)/Brazil: revision of the MS/GM Ordinance nº 687, of March 30th, 2006

A promoção da saúde vem sendo discutida desde o processo de redemocratização do Brasil, noqual a 8ª Conferência Nacional de Saúde se constituiu como o grande marco da luta pela universalizaçãodo sistema de saúde e pela implantação de políticas públicas em defesa da vida, tornando a saúde umdireito social irrevogável, como os demais direitos humanos e de cidadania.Nesse contexto, a Constituição Federal de 1988 instituiu o SUS e veio a assegurar o acesso universaldos cidadãos às ações e aos serviços de saúde, a integralidade da assistência com igualdade, sempreconceitos ou privilégios de qualquer espécie e com ampla participação social, capaz de responderpela promoção, prevenção, proteção e recuperação da saúde, conforme as necessidades das pessoas.O SUS, na Lei Orgânica da Saúde (Lei nº 8.080, de 19 de setembro de 1990), incorporou o conceitoampliado de saúde resultante dos modos de vida, de organização e de produção em um determinadocontexto histórico, social e cultural, buscando superar a concepção da saúde como ausência de doença,centrada em aspectos biológicos.Para se operar a política de saúde, incluindo a de promoção da saúde, é necessária a consolidaçãode práticas voltadas para indivíduos e coletividades, em uma perspectiva de trabalho multidisciplinar,integrado e em redes, de forma que considere as necessidades em saúde da população, em uma açãoarticulada entre os diversos atores, em um determinado território...

Estruturação de serviço de atendimento ao paciente com hanseníase em Unidade Básica de Saúde: relato de experiência / Structuring of assistance service to leprosy patient in Primary Health Care unit: experience report / Estructuración de servicio de atención al paciente con lepra en la Unidad de Atención Primaria de Salud: relato de experiencia

Objetivo: propor planejamento para estruturação e avaliação da qualidade de um serviço de atendimento ao paciente com hanseníase. Método: estudo do tipo relato de experiência, ancorado na pesquisa-ação, de caráter intervencionista, desenvolvido em Unidade Básica de Saúde (UBS) pertencente ao município de Fortaleza (CE), que envolveu 27 profissionais da unidade de diferentes categorias, no período de novembro de 2010 a fevereiro de 2011. Como ferramenta gerencial para a estruturação de um serviço de atendimento ao portador de hanseníase utilizou-se o ciclo PDCA, que abrange as seguintes etapas: planejamento, execução, verificação, e ação. Resultados: As causas críticas encontradas que mereceram plano de ação imediato foram o conhecimento insuficiente reconhecido por alguns profissionais e a inadequação de estrutura assistencial de seguimento para portadores de hanseníase. Conclusão: Destaca-se a utilização de plano gerencial condizente à realidade vivenciada pelos profissionais, como meio ideal para o alcance de metas, que contribuem para a melhoria da qualidade da assistência em saúde.(AU)

Objective: to propose the planning for structuring and assessing the quality of an assistance service to patient with leprosy. Method: experience report type study, based on research-action of interventionist nature, carried out in the Basic Health Unit (BHU) in the city of Fortaleza (CE, Brazil), which involved 27 professionals of the unity from different categories, from November 2010 to February 2011. As management tool for structuring a care service to people with leprosy was used the PDCA cycle, including the following steps: planning, implementation, verification and action. Results: the critical causes found that deserved immediate action plan were: insufficient knowledge recognized by some professionals and inadequate assistance structure for people with leprosy. Conclusion: we emphasize the use of management plan appropriate to the reality experienced by professionals as an ideal way for achieving goals that contribute to improve the quality of health care.(AU)

Objetivo: proponer planificación para estructuración y evaluación de la calidad de servicio de atención al paciente con lepra. Método: relato de experiencia, basado en la investigación-acción, de carácter intervencionista, desarrollado en Unidad Básica de Salud de Fortaleza-CE, con 27 profesionales de la unidad de diferentes categorías, de noviembre de 2010 a febrero de 2011. Como herramienta gerencial para la estructuración de un servicio de atención a personas con lepra se utilizó el ciclo PDCA, que comprende las etapas: planificación, ejecución, verificación y acción. Resultados: Las causas críticas encontradas que requirieron plan de acción inmediato fueron conocimiento insuficiente reconocido por algunos profesionales e inadecuación de estructura de seguimiento de atención a personas con lepra. Conclusión: Se señala en el uso del plan de gestión coherente a la realidad vivida por los profesionales, como un medio ideal para lograr los objetivos que contribuyan para mejorar la calidad de la atención en salud.(AU)

Avaliação dos serviços de saúde em relação ao diagnóstico precoce da hanseníase / Health services assessment of early leprosy diagnosis

Este estudo avaliou os serviços de saúde em relação à descoberta precoce da hanseníase e as dificuldades enfrentadas pela população para iniciar e dar continuidade ao tratamento. Aplicou-se questionário com perguntas abertas e fechadas por meio deentrevista com 234 doentes que iniciaram tratamento para hanseníase no Município de São José do Rio Preto-SP, no período de 1998 a 2006. A média de consultas para diagnosticar a hanseníase foi de 2,7 em unidades de saúde do serviço público e de 4,5 nosserviços privados. A maioria dos pacientes não relatou dificuldades para iniciar o tratamento. Os pacientes se deslocaram em média 9,2km de suas residências até os locais de tratamento e gastaram em média R$0,30/km. Considerando que a distância máxima docentro de saúde/residência nas áreas de sua abrangência seria de 1,5km, a descentralização do tratamento seria uma opção para melhorar o acesso e a precocidade do tratamento.

In the present study, health services were assessed regarding early diagnosis of leprosy and troubles faced by the population to initiate and remain under treatment. Patients (n=234), who initiated leprosy treatment between 1998 and 2006 in Sao Jose do Rio Preto, State of Sao Paulo, Brazil were interviewed and answered to open and closed questions. The mean number of medical appointments to diagnose the disease was 2.7 in public health units and 4.5 in the private sector. Most patients reported that they did not have problems to initiate treatment. They travelled about 9.2 km from their residences to treatment facilities and spent about R$0.30/km. Considering that the maximum distance from the health centers to private residences should be about 1.5 km, decentralization of treatment would be the best option to improve access and facilitate treatment of leprosy patients.

[Health services organization on the elimination of Leprosy in municipalities of São Paulo State]. / Organização de serviços de saúde na eliminação da Hanseníase em municípios do Estado de São Paulo.

The present study aims to analyze actions to control Hansen's disease developed in nine municipalities of the State of São Paulo and one of the health authorities of the city of São Paulo, selected based on their population, geographic location and prevalence coefficients. The study was approved by the Ethics Committee n masculine 514/05 and instruments were administered by means of interviews to 59 professionals, 17 interlocutors and 9 managers. Data were analyzed using the program SPSS (Statistical Package for Social Scientists). It was verified that prevalence is on the decline and detection remains stable. The physical incapacity prevention actions, health education and active search have not been satisfactorily developed. The most qualified professionals are in the reference units and teamwork is fragile.

Organização de serviços de saúde na eliminação da Hanseníase em municípios do Estado de São Paulo / La organización de los servicios de salud en la eliminación de la Lepra en municipios del Estado de São Paulo / Health services organization on the elimination of Leprosy in municipalities of São Paulo State

Este trabalho tem como objetivo analisar as ações de controle da hanseníase desenvolvidas em nove municípios do Estado de São Paulo e uma coordenadoria de saúde da Capital, selecionados a partir de sua população, localização geográfica e coeficientes de prevalência. Foi aprovado pelo Comitê de Ética nº 514/05 e foram aplicados instrumentos por meio de entrevistas em 59 profissionais e 17 interlocutores. Os dados foram analisados utilizando o programa SPSS (Statistical Package for Social Scientists). Verificou-se que a prevalência apresenta declínio e a detecção permanece estável. As ações de prevenção de incapacidade física, educação em saúde e a busca ativa são pouco desenvolvidas. Os profissionais mais capacitados encontram-se nas unidades de referência, há fragilidade quanto ao trabalho em equipe.

The present study aims to analyze actions to control Hansen's disease developed in nine municipalities of the State of São Paulo and one of the health authorities of the city of São Paulo, selected based on their population, geographic location and prevalence coefficients. The study was approved by the Ethics Committee nº 514/05 and instruments were administered by means of interviews to 59 professionals, 17 interlocutors and 9 managers. Data were analyzed using the program SPSS (Statistical Package for Social Scientists). It was verified that prevalence is on the decline and detection remains stable. The physical incapacity prevention actions, health education and active search have not been satisfactorily developed. The most qualified professionals are in the reference units and teamwork is fragile.

El objetivo de este trabajo fue analizar las acciones de control de la Lepra realizadas en nueve Municipios del Estado de Sao Paulo y en una coordinación de salud de la capital, seleccionados a partir de su población, localización geográfica y coeficientes de prevalencia. Este estudio recibió aprobación del Comité de Ética nº 514/05. Se entrevistaron 59 profesionales y 17 coordinadores de área. Para el análisis de los datos se utilizó el programa SPSS (Statistical Package for Social Scientists). Se verificó un declive en la prevalencia, pero la detección permaneció estable; las acciones de prevención de incapacidad física, educación en salud y la busca activa fueron poco ejecutadas; los profesionales más capacitados pertenecían a las unidades de referencia. Hubo fragilidad en cuanto al trabajo en equipo.

Descentralização das ações de controle da hanseníase em João Pessoa (Paraíba): a visão dos gestores / The view of health policy makers regarding the descentralization of the leprosy control program in João Pessoa (Paraíba state)

A implantação da descentralização das ações de controle da hanseníase é vista como uma medida para melhorar as atividades relacionadas à diminuição da doença no país. Deste modo, o presente estudo teve como objetivo identificar a visão dos gestores da área de saúde estadual e do município de João Pessoa (PB) em relação às ações de controle da hanseníase. Foram realizadas entrevistas semi estruturadas com três gestores. Estes reconheceram que a descentralização ainda está em processo de implementação, destacando sua importância para facilitar o acesso dos usuários ao diagnóstico e tratamento e para diminuir o abandono ao tratamento. Acreditaram que a concentração de pacientes no Centro de Referência (o Complexo Hospitalar Clementino, em João Pessoa (PB)) esteja relacionada à baixa resolubilidade da rede básica de saúde e ao conhecimento geral do Complexo como referência em atendimento à hanseníase. Como resultado, os pacientes são encaminhados ou chegam espontaneamente. O nosso estudo contribui para elaborar recomendações e estratégias simples e efetivas para aperfeiçoar o Programa de Controle da Hanseníase.

Concentração do atendimento a pacientes com hanseníase em municípios do estado do Ceará / Concentration of hansen s disease patients care in the state of Ceará

Tem se como objetivo deste estudo identificar os fatores que levam à concentração do atendimento de hanseníase em unidades de saúde da rede no estado do Ceará. Trata-se de uma investigação de caráter operacional, descritivo, realizada em três municípios do estado, referente aos anos de 2004 e 2005. Foram selecionados três municípios que apresentaram a maior taxa de detecção e de prevalência de hanseníase nos últimos cinco anos. Os dados foram coletados nas unidades de saúde com maior concentração de casos, bem como em uma unidade de saúde mais próxima e em uma mais distante geograficamente da unidade de maior concentração. Os dados foram analisados utilizando se o programa EpiInfo 6.04d. Os fatores identificados como facilitadores da concentração nas unidades de saúde foram: (1) acesso dos usuários às unidades de saúde concentradas; (2) encaminhamentos inadequados por parte dos profissionais; (3) desconhecimento dos procedimentos de referência e contra referência pelos profissionais de saúde e gestores; (4) treinamento inadequado ou insuficiente levando à insegurança no diagnóstico; (5) Aliança Municipal de Eliminação da Hanseníase sem atuação; (6) plano municipal inativo; (7) soluções disfarçadas.

[Health service organization during the age of pestilence. 2]. / Excursus sull'organizzazione dell'assistenza in tempi di pestilenza. Seconda parte.

The author presents the history of the places where patients with epidemic pathologies were isolated. Since the study of medicine began, such places have been known as asclepiei, xenodochi, hospices, lazarettos, sanitary cordons, and quarantine stations and they contributed to controlling epidemics in Europe. Important not only in the context in which they were created, these structures expressed the medical culture and point of view of that age. Although very far from discovering the cause of the pathology due to their lack of scientific knowledge, the medical class sometimes knew how to effectively organize the isolation of patients. The history of such structures interweaves with the long history of Christianity and with the emerging nations of Europe and the city-states of the Italian Renaissance. Previously, in classical Greece and Imperial Rome there had also been "homes for the sick" to isolate patients. Today the world is periodically hit by epidemics. In such moments the medical profession uses its research ability and organizational capabilities but also historical memory to reduce epidemic contagion.

Disease and disease control. International Leprosy Congress, Beijing, 7-12 September 1998. Workshop report.

Four workshops were conducted during the congress under the disease control theme. The workshops were on the issues of defining disease and antibacterial therapy, early case detection, sustaining leprosy control in low endemic situations, and the prevention of disability. These workshops spanned the spectrum of disease and its consequences through from early detection, the definition of disease to the prevention of disability. All of these topics being important contemporary issues challenging leprosy control programmes world wide. Despite the broad spectrum of the topics it was interesting to see that a number of important themes emerged which were common to all topics. It is possible to identify five major themes arising from the output of the workshops which are now described below. Each of the workshops adopted broad and comprehensive approaches to their topic. In the past, there has been narrowness in defining disease in terms of the need for chemotherapy. The approach taken in the workshop now is for a much more comprehensive approach looking at all the consequences of the disease process rather than the requirement for antibacterial chemotherapy. Similarly broad approaches were taken to low endemic situations, considering comprehensive approaches which are inclusive rather than exclusive. Disability prevention also continues this same theme of comprehensive approaches based on multidisciplinary involvement in prevention of the consequences of the disease process. The second major theme to be identified in the output of the workshops was the importance of relevance to patients and people affected by leprosy. It is no longer adequate to view programmes in terms of their acceptance to those running the programmes. Control programmes must be acceptable to the people they are designed to benefit. This even impacts on definitions of disease in terms of what matters to patients rather than only restricting this to disease pathology. Similarly, approaches to disability prevention are not merely about measurement of impairments due to nerve function deficit but rather consider the abilities and functions which are most important to the individuals affected. The third theme which spans all of the workshops is the need to develop partnerships with others in addressing the challenges of leprosy today. Each workshop identified important groups with which partnerships need to be developed included local patient groups, voluntary associations and primary health care services. All of these have a role to play, from early case detection right through to the prevention of disability and the sustaining of control under low endemic situations. The fourth important theme is sustainability of programmes which need to be developed for the long term benefit of those affected by disease rather than short term goals. Again, this impacts an area such as case detection methods which need to be sustained in the long term. Approaches such as intensive case detection through mass survey are not sustainable given changes to the patterns of disease, whereas involvement of communities and community participation in the process of early case detection is a much more sustainable approach. This is important, as programmes attain low endemic status and is also important in preventing disabilities where the progressive nature of secondary impairments following primary impairments may be lifelong. The final theme is that of the importance of training, as each area is recommending new approaches to be taken and for new people to be involved in leprosy programmes. The implications are that those to be involved need to be trained and that the training requirements will be different from those of the last ten years. Training programmes will need to adapt to a wider range of individuals and groups being involved in programmes and to much more comprehensive approaches. These implications for training are profound and training centres and training programmes rapidly

Sustaining leprosy services in the changing context of health sector reform.

National leprosy control programmes currently face a number of changes to the environment within which they operate. This paper examines the issues arising from these. It focuses, in particular, on those arising from changes in the structure of the health sector as a result of policies of health sector reform which are being considered or adopted in many developing countries. These include decentralization, financing strategies, greater role for the private and NGO sectors and the integration of vertical programmes. The paper is structured around a number of key steps in the development of a strategy for sustainability of appropriate leprosy services. These are the assessment of the epidemiological, social and health services context, development of programme objectives, planning of human and financial resources, development of the strategy, mapping the roles of potential actors, development of regulatory and incentive mechanism, action planning and managing change and, finally, re-evaluation of the programme objectives and service delivery organization. The paper stresses the importance of process in developing ownership of a strategy. It concludes with a set of key questions which it suggests need to be addressed by leprosy programme managers in the development of a proactive response to the changes.

[Status of the integration of the antileprosy campaign in the general health services in Senegal]. / Etat de l'intégration de la lutte antilépreuse dans les services de santé généraux au Sénégal.

The survey on the integration of leprosy control in Senegal with the general health services has shown that the level of integration varies according to the services offered. Both strong and weak points have been detected and it is therefore advisable to reinforce the findings that are positive and to seek solutions to the problems. 82.1% of the male nurses in charge of health center included in the survey have already had to refer suspected cases of leprosy to the Leprosy Specialist for confirmation. In 85.7% of the cases, it is the Nurses-Persons in Charge who administer the supervised dose of multidrug therapy. The external validity of this study is problematic; nevertheless, these results could still draw the attention of administrators, decision-makers, and other persons of influence to the problems that could curb the integration of leprosy control with the general health services.

Health resources and management in Korea: development in the past, current issues and perspectives.

PIP: Korea's health system has undergone major changes since the late 1970's due to massive economic growth developments. Compulsory health insurance was initiated for all wage earners in 1977 and was expanded to all rural and urban residents in 1980 and 1989. Health resources in the form of human and physical resources and health expenditures are very important to the success of any health insurance system. Korean economic growth in the past 40 years is staggering. It has gone from a per capita income of US $70 in the 50's to over US $2000 in the 80's. Korea is now an upper middle-income country. Population has more than doubled since 1949. Urbanization has increased from 28% in 1960 to 65% in 1985. Reduction of fertility through family planning practices is currently being promoted. Korea has developed 5 health care plans over a 25 year period -- from the 1954-60 allocation of funds for leprosy and tuberculosis control to the 1982-86 'health for all by 2000" policy. The National Health Insurance Program will be initiated in 1989. Communicable diseases were the major cause of death in the 60's, cardiovascular disease in the 70's, and chronic degenerative diseases in the 80's. Incidences of communicable diseases, tuberculosis and parasite infection have all decreased dramatically in the past few decades. Perceived unhealthiness has increased from 1981-87. The 1980's has ushered in a higher utilization of curative care, safe deliveries and immunizations. Inequalities in health care still exist and result from socioeconomic inequalities. Medical resources must be distributed adequately to alleviate inequality. Middle-level health personnel is lacking in Korea at this time, while upper-level personnel has increased. Physical resources tend to be wasted -- there is a high nonoccupancy rate of hospital beds. Other physical resource problems can be partially eliminated by a more equal distribution of health facilities relative to demand. Health insurance utilization has grown annually, however low income populations usually show a low usage rate. Payment-reimbursement methods include fee-for-service (FFS), capitation, salary, case payment, or a combination. In the future this payment system must be improved in order to achieve comprehensive care. Important policy issues are consensus on rising health expenditure; equity and efficiency of health services; role of the hospital and clinic; priority of primary care; rural health care delivery; rural hospitals; health care delivery system; payment-reimbursement scheme; governmental financial input; primary care reinforcement; and measures for the changes in disease patterns.^ieng

[Human resources in Hansen's disease]. / Recursos humanos em hanseníase.

In the control of endemic leprosy in Brazil, a qualitative and quantitative lack of human resources was felt as one of its most serious difficulties. Consequently, a systematical review on the practices of Human Resources on Leprosy was carried out, covering the period between 1940 and 1980. An interesting paradox was then observed: sectorial authorities always recognized that courses and training are an important tool in order to improve the conditions for operating the leprosy control but when they are put in practice, they result transitory and ineffective. The maintenance of this fact, associated to low salaries and inadequate working conditions indicated the necessity of formulating and implanting a policy for the development of Human Resources in leprosy at a nationwide level. The experience consisted of setting up a sheme of encouragement and support to State Health Departments for training at local level; at regional level, extension courses were organized by the Nacional Departament, in Amazonia, Mid-west, South, Northeast and Southeast. The strengthening and/or development of a referral system at state level were reached through the national specialization course of Sanitary Dermatology; international qualifications were obtained, as a complement, by joint action with Pan-American Organization of health. Results, details, characteristics and strategies of this process are presented and discussed by discursive and tabular forms.