[Spatial analysis of leprosy cases treated at public health care facilities in Brazil]. / Análise da demanda de casos de hanseníase aos serviços de saúde através do uso de técnicas de análise espacial.

Hansen disease or leprosy is a major endemic disease in Brazil. Well-designed strategies, including decentralization of basic care, are needed to reduce its prevalence. The article begins by describing the structure and supply of services for treating leprosy cases in the country, after which it analyzes the trends in epidemiological and operational indicators, comparing the periods before and after decentralization of services to the municipal (local) level. Finally, spatial analysis allowed identifying the territorial distribution of this endemic and analyzing the pattern of geographic areas according to care provided by health facilities and its evolution. Based on the location of the geographic centers in the census tracts by place of residence, and using spatial smoothing technique based on Kernel estimation, the study constructed domain areas of care for each health facility or unit. Following municipalization of care, there was an increase in the detection and treatment by the municipalities themselves, reducing patient evasion to neighboring counties and causing changes in demand trends, with an increase in use of services by the clientele and important alterations in the epidemiological and operational indicators.

III Conferência Nacional de Saúde Mental: cuidar, sim. excluir, não. ­ Efetivando a Reforma Psiquiátrica com acesso, qualidade, humanização e controle social: relatório final / Final report of the III National Conference on Mental Health: caring, yes. exclude, no. Implementing the Psychiatric Reform with access, quality, humanization and social control

Com satisfação, apresentamos o Relatório Final da III Conferência Nacional de Saúde Mental a todos os interessados no campo da Saúde Mental e, particularmente, àqueles que participaram diretamente de todas as etapas que culminaram na etapa nacional desta conferência, realizada nos dias 11 a 15 de dezembro de 2001, em Brasília. Não há dúvida de que as Conferências Nacionais de Saúde e Saúde Mental têm constituído dispositivos fundamentais de participação, controle social, debate e síntese democrática das diretrizes políticas principais e de medidas operacionais nestas áreas no País. No campo da saúde mental, as Conferências têm tido um papel crucial de dar continuidade ao processo, iniciado no Brasil nos anos 70, de crítica ao modelo hospitalocêntrico de assistência, e de definir as estratégias e rumos na implementação da Reforma Psiquiátrica a partir dos anos 80, em interlocução com aspirações e experiências já em implantação em diversos países do mundo. Na I Conferência, realizada em 1987, ficou claramente nomeado o impasse do modelo centrado no hospital e predominantemente baseado no modelo médico-psiquiátrico, considerado ineficaz e oneroso para os usuários e a sociedade, violando os direitos humanos fundamentais. Se as indicações aprovadas naquela ocasião para enfrentar este desafio podem ser hoje consideradas incompletas, são ainda assim uma referência para as questões a serem enfrentadas pela Reforma Psiquiátrica Brasileira. É fundamental recordar também que esta I Conferência foi realizada no contexto dos princípios e diretrizes da 8ª Conferência Nacional de Saúde, marco histórico no campo da saúde e da construção do Sistema Único de Saúde (ver III Conferência Nacional de Saúde Mental, Caderno Informativo, 2001).

Health sector reform and tuberculosis control: the case of Zambia.

SETTING: Zambia, 1995-1997. OBJECTIVE: To describe the process leading to the collapse of Zambia's National Tuberculosis Programme NTP). DESIGN: A descriptive analysis of health sector reform in Zambia and its effects on the NTP during the period 1995-1997. RESULTS: By the end of 1997 the NTP had stopped functioning. The main reason was that external support had ended, while the National Strategic Health Plan 1995-1999 had no budget for special programmes according to the policy to integrate these into the general health services. As a consequence, technical support for tuberculosis control to districts ended as staff was reduced to one officer responsible for the national coordination of AIDS/HIV, sexually transmitted diseases (STD), tuberculosis and leprosy. The most serious effect of the transition was the interruption of supplies of anti-tuberculosis drugs in 1998. CONCLUSIONS: The experience in Zambia demonstrates the urgent need for constructive dialogue between 'health reformers' and 'disease controllers'. The aim of this dialogue would be to develop a model that ensures that tuberculosis patients are properly diagnosed and cured in countries that are embarking on a reform of their health services.

Tuberculosis and health sector reform in Bangladesh.

In 1998 the Government of Bangladesh changed its health and population sector strategy from a project-oriented approach (the Fourth Population and Health Project--FPHP) to sector-wide management (the Fifth Health and Population Sector Programme--HPSP). This article describes the development and achievements of the tuberculosis programme during the FPHP, and discusses the potential opportunities and challenges anticipated by the programme from the reformed health service delivery of the HPSP. 'Further strengthening of tuberculosis and leprosy control services' was one of the 66 projects of the FPHP. As part of the FPHP, the National Tuberculosis Programme policy was revised in 1992 and the project was implemented in phases. By mid 1998, 90% of the population was covered, and more than 200,000 tuberculosis cases had been diagnosed and treated with 80% success. We describe the reasons for this success and analyse the pitfalls of the project. The objective of the reforms in HPSP is to provide cost-effective, sustainable, quality services to those in need through an essential service package that includes control of communicable diseases such as tuberculosis and leprosy. Tuberculosis services will become more accessible as community clinics deliver essential health services for every 6000 population. Non-public health care providers, who contribute significantly to health services in the country, will be involved in service delivery. The main challenge is to maintain the quality of successful projects, such as tuberculosis control, during the transition period.

Effective tuberculosis control and health sector reforms in Kenya: challenges of an increasing tuberculosis burden and opportunities through reform.

During the period from 1980 to 1997, the annual number of new tuberculosis cases increased four-fold in Kenya, and had reached approximately 50,000 cases by 1998. During the same time period, the government per capita expenditure on health dropped from US$9.5 to US$3.5. Since 1983, Kenya has been decentralising financial responsibility and decision-making power to the districts. In addition, the late 1980s saw the introduction of cost-sharing schemes for most health services, excluding tuberculosis (TB) treatment. In the midst of these changes, a dual epidemic of TB and HIV/AIDS emerged, and is presently over-burdening the traditional public health system. In response, the National Leprosy and Tuberculosis Control Programme (NLTP) is seeking a wider network of service providers and new approaches to the prevention and treatment of TB in the country. The history of health sector reform in Kenya is summarised and the role of the NLTP in these reforms assessed. Recent approaches taken by the NLTP to sustain effective TB control, which draw on the environment of a changing and flexible health system, are expressed. Participation of the NLTP in components of health sector reform, particularly decentralisation, integration, financing through cost-sharing and public/private mix, are highlighted.