Processo transexualizador no sus: questões para a psicologia a partir de itinerários terapêuticos e despatologização / Proceso transexualizador en el sus: cuestiones para la psicología desde itinerarios terapêuticos y despatologización / Transexualizing process in the sus: questions for psychology from therapeutic itinetaries and depathologization

RESUMO. Trata-se de uma pesquisa qualitativa, des critiva e exploratória, realizada no Tratamento Fora de Domicílio, na cidade de Cuiabá-MT, Brasil, que objetivou levantar reflexões sobre os itinerários terapêuticos de pessoas trans, na busca pelo Processo Transexualizador. Participaram três homens trans, duas mulheres trans e uma mulher travesti, com faixa etária de 21 a 32 anos. Os da dos foram coletados por entrevistas semiestruturadas e analisados mediante análise de conteúdo. Os resultados mostram que essas pessoas trans seguem trajetórias diver sas, procurando serviços institucionalizados ou informais (redes de socialidade trans), para a afirmação de suas identidades de gênero. Destacam-se entraves atinentes à patologização, ao acolhimento, à continuidade do cuidado, à resolutividade e à referência na rede de atenção do processo transexualizador. Observaram-se importantes pontos críticos na assistência social, endocrinológica e para a psicologia, sendo a peregrinação pelos serviços de saúde demarcada por constantes discriminações institucionais, permitindo a compreensão de como o sistema de saúde se organiza em relação ao atendimento dessas pessoas, elencando questões para o trabalho da psicologia, nesse campo, a partir de uma perspectiva da experiência e materialidade do gênero.

RESUMEN. Esta es una investigación cualitativa, descriptiva y exploratoria realizada en el tratamiento fuera del domicilio en la ciudad de Cuiabá, Brasil, que tuvo como objetivo plantear reflexiones sobre los itinerarios terapéuticos de las personas trans en la búsqueda del proceso transexual. Participaron tres hombres trans, 2 mujeres trans y 1 mujer travesti de 21 a 32 años. Los datos fueron recogidos a través de entrevistas semiestructuradas y fueron analizados mediante el Análisis de Contenido. Los resultados muestran que estas personas trans siguen caminos divergentes en busca de servicios institucionalizados o informales (redes sociales trans) para afirmar sus identidades de género. Se destacan los obstáculos relacionados con la patologización, acogida, la continuidad de la atención, la resolución y la referencia en la red de atención del Proceso Transexualizador. Se observaron puntos críticos importantes en la asistencia social, la endocrinología y la psicología, em que la peregrinación por los servicios de salud es delimitada por la constante discriminación institucional que permite comprender cómo se organiza el sistema de salud en relación con la atención de estas personas que señalan los problemas para el trabajo de la Psicología en este campo desde una perspectiva de experiencia y materialidad de género

ABSTRACT. This qualitative, descriptive and exploratory research conducted in the Away from Home Treatment (Tratamento Fora de Domicílio [TFD]), in Cuiabá, Brazil, aimed to raise reflections on the therapeutic process itineraries of trans people in the search for the Transsexualizer Process (Processo Transexual [PT]). Three transgender men, two transgender women and one transvestite woman participated. They were aged between 21 and 32 years. Data were collected through semi-structured interviews and analyzed using Content Analysis. The results show that trans people follow different itineraries, looking for institutionalized or informal services (trans sociality networks) to affirm their gender identities. Obstacles related to pathologization, reception, continuity of care, resolution and reference in the care network of the Transsexualizer Process stand out. Important critical points were observed in social, endocrinological and psychological care. The pilgrimage by health services was marked by constant institutional discrimination, allowing for the understanding of how the health system is organized concerning the care of these people, listing issues for the work of Psychology, in this field, from a perspective of the experience and materiality of gender.

Managing the healthcare demand-supply gap during and after COVID-19: The need to review the approach to healthcare priority-setting in South Africa.

Healthcare demands are rising globally, and regardless of the approach to financing and delivering healthcare services, no country can meet all the healthcare demands of its population. The demand-supply gap for healthcare services in South Africa (SA) is large, particularly for the public sector. The objectives of this article are to examine some of the underlying factors contributing to this gap, and how the COVID- 19 pandemic is likely to impact on them, and to describe why SA needs to adopt an explicit and equity-informed approach to healthcare priority-setting to assist in managing the gap.

Understanding the use and impact of allied health services for people with chronic health conditions in Central and Eastern Sydney, Australia: a five-year longitudinal analysis.

AIM: To describe the characteristics of people in Central and Eastern Sydney (CES), NSW, who had a General Practice Management Plan (GPMP) and claimed for at least one private allied health service item; and to examine if allied health service use results in less hospitalisations over a five-year period. BACKGROUND: The number of people living with chronic health conditions is increasing in Australia. The Chronic Disease Management programme was introduced to the Medicare Benefits Schedule (MBS) to provide a more structured approach to managing patients with chronic conditions and complex care needs. The programme supports general practitioners claiming up to one GPMP and one Team Care Arrangement every year, and the patient additionally claiming for up to five private allied health services visits. METHODS: A prospective longitudinal study was conducted. The sample consisted of 5771 participants in CES who had a GPMP within a two-year health service utilisation baseline period (2007-2009). The analysis used the 45 and Up Study questionnaire data linked to the MBS, hospitalisation, death and emergency department data for the period 2006-2014. FINDINGS: Of the eligible participants, 43% (2460) had at least one allied health service item claim in the subsequent 12 months. Allied health services were reported as physiotherapy, podiatry and other allied health services. The highest rates of allied health service use were among participants aged 85 years and over (49%). After controlling for confounding factors, a significant difference was found between having claimed for five or more physiotherapy services and emergency admissions (HR: 0.83; 95% CI: 0.72-0.95) and potentially preventable hospitalisations (HR: 0.79; 95% CI: 0.64-0.96) in the subsequent five years. Use of allied health service items was well targeted towards those with chronic and complex care needs, and use of physiotherapy services was associated with less avoidable hospitalisations.

Developing an adequate supply of health services: Taiwan's path to Universal Health Coverage.

Universal Health Coverage (UHC) calls for universal effective coverage, which emphasizes that people must have reasonably equal access to covered services. A critical question then arises: what policies can a nation adopt to assure an adequate supply of services and distribute them reasonably to each community and socioeconomic strata? Taiwan relied on incentives, public and private partnership and effective regulations to produce the adequate supply for UHC and distributed them. Taiwan's experience holds a valuable lesson for other nations. Taiwan was the last state in the 20th century to achieve UHC when it implemented the National Health Insurance (NHI) program in 1995. Political timing was crucial in the government's decision to achieve UHC, but the key to its success in providing effective coverage to its 23 million population was the readiness of the health service sector, the result of two decades of planning and development in the pre-NHI period. This paper analyzes how Taiwan historically built up the supply of health services that made achieving UHC possible. We identified four key strategies adopted in the health service sector development, namely: 1) enhancing public-private partnerships in developing medical resources with tax incentives and subsidies; 2) ameliorating regional disparities in medical resource distribution through incentives and effective regulation; 3) safeguarding quality of care by regulating providers through licensing and accreditation programs; and 4) promoting an evidence-based policy-making process.

Advancing indigent healthcare services through adaptive reuse: repurposing abandoned buildings as medical clinics for disadvantaged populations.

BACKGROUND: Challenges abound for healthcare providers engaged in initiatives directed toward disadvantaged populations, with financial constraints representing one of the most prominent hardships. Society's less fortunate typically lack the means to pay for healthcare services and even when they are covered by government health insurance programs, reimbursement shortcomings often occur, placing funding burdens on the shoulders of establishments dedicated to serving those of limited means. For such charitably-minded organizations, efficiencies are required on all fronts, including one which involves significant operational costs: the physical space required for care provision. DISCUSSION: Newly constructed buildings, whether owned or leased, are expensive, consuming a significant percentage of funds that otherwise could be directed toward patient care. Such costs can even prohibit the delivery of services to indigent populations altogether. But through adaptive reuse-the practice of repurposing existing, abandoned buildings, placing them back into service in pursuit of new missions-opportunities exist to economize on this front, allowing healthcare providers to acquire operational space at a discount. In an effort to shore up related knowledge, this article profiles Willis-Knighton Health System's development of Project NeighborHealth, an indigent clinic network which was significantly bolstered by the economies associated with adaptive reuse. CONCLUSIONS: Despite its potential to bolster healthcare initiatives directed toward the medically underserved by presenting more affordable options for acquiring operational space, adaptive reuse remains relatively obscure, diminishing opportunities for providers to take advantage of its many benefits. By shedding light on this repurposing approach, healthcare providers will have a better understanding of adaptive reuse, enabling them to make use of the practice to improve the depth and breadth of healthcare services available to disadvantaged populations.

The impact of delays on maternal and neonatal outcomes in Ugandan public health facilities: the role of absenteeism.

Maternal mortality in low- and middle-income countries continues to remain high. The Ugandan Ministry of Health's Strategic Plan suggests that little, if any, progress has been made in Uganda in terms of improvements in Maternal Health [Millennium Development Goal (MDG) 5] and, more specifically, in reducing maternal mortality. Furthermore, the UNDP report on the MDGs describes Uganda's progress as 'stagnant'. The importance of understanding the impact of delays on maternal and neonatal outcomes in low resource settings has been established for some time. Indeed, the '3-delays' model has exposed the need for holistic multi-disciplinary approaches focused on systems change as much as clinical input. The model exposes the contribution of social factors shaping individual agency and care-seeking behaviour. It also identifies complex access issues which, when combined with the lack of timely and adequate care at referral facilities, contributes to extensive and damaging delays. It would be hard to find a piece of research on this topic that does not reference human resource factors or 'staff shortages' as a key component of this 'puzzle'. Having said that, it is rare indeed to see these human resource factors explored in any detail. In the absence of detailed critique (implicit) 'common sense' presumptions prevail: namely that the economic conditions at national level lead to inadequacies in the supply of suitably qualified health professionals exacerbated by losses to international emigration. Eight years' experience of action-research interventions in Uganda combining a range of methods has lead us to a rather stark conclusion: the single most important factor contributing to delays and associated adverse outcomes for mothers and babies in Uganda is the failure of doctors to be present at work during contracted hours. Failure to acknowledge and respond to this sensitive problem will ultimately undermine all other interventions including professional voluntarism which relies on local 'co-presence' to be effective. Important steps forward could be achieved within the current resource framework, if the political will existed. International NGOs have exacerbated this problem encouraging forms of internal 'brain drain' particularly among doctors. Arguably the system as it is rewards doctors for non-compliance resulting in massive resource inefficiencies.

Assessment of health system challenges and opportunities for possible integration of diabetes mellitus and tuberculosis services in South-Eastern Amhara Region, Ethiopia: a qualitative study.

BACKGROUND: The double burden of tuberculosis (TB) and diabetes mellitus (DM) is a significant public health problem in low and middle income countries. However, despite the known synergy between the two disease conditions, services for TB and DM have separately been provided. The objective of this study was to explore health system challenges and opportunities for possible integration of DM and TB services. METHODS: This was a descriptive qualitative study which was conducted in South-Eastern Amhara Region, Ethiopia. Study participants included health workers (HWs), program managers and other stakeholders involved in TB and DM prevention and control activities. Purposive sampling was applied to select respondents. In order to capture diversity of opinions among participants, maximum variation sampling strategy was applied in the recruitment of study subjects. Data were collected by conducting four focus group discussions and 12 in-depth interviews. Collected data were transcribed verbatim and were thematically analyzed using NVivo 10 software program. RESULT: A total of 44 (12 in-depth interviews and 32 focus group discussion) participants were included in the study. The study participants identified a number of health system challenges and opportunities affecting the integration of TB-DM services. The main themes identified were: 1. Unavailability of system for continuity of DM care. 2. Inadequate knowledge and skills of health workers. 3. Frequent stockouts of DM supplies. 4. Patient's inability to pay for DM services. 5. Poor DM data management. 6. Less attention given to DM care. 7. Presence of a well-established TB control program up to the community level. 8. High level of interest and readiness among HWs, program managers and leaders at different levels of the health care delivery system. CONCLUSION: The study provided insights into potential health systems challenges and opportunities that need to be considered in the integration of TB-DM services. Piloting TB and DM integrated services in selected HFs of the study area is needed to assess feasibility for possible full scale integration of services for the two comorbid conditions.

Primary Health Care: care coordinator in regionalized networks?

OBJECTIVE: To analyze the breadth of care coordination by Primary Health Care in three health regions. METHODS: This is a quantitative and qualitative case study. Thirty-one semi-structured interviews with municipal, regional and state managers were carried out, besides a cross-sectional survey with the administration of questionnaires to physicians (74), nurses (127), and a representative sample of users (1,590) of Estratégia Saúde da Família (Family Health Strategy) in three municipal centers of health regions in the state of Bahia. RESULTS: Primary Health Care as first contact of preference faced strong competition from hospital outpatient and emergency services outside the network. Issues related to access to and provision of specialized care were aggravated by dependence on the private sector in the regions, despite progress observed in institutionalizing flows starting out from Primary Health Care. The counter-referral system was deficient and interprofessional communication was scarce, especially concerning services provided by the contracted network. CONCLUSIONS: Coordination capacity is affected both by the fragmentation of the regional network and intrinsic problems in Primary Health Care, which poorly supported in its essential attributes. Although the health regions have common problems, Primary Health Care remains a subject confined to municipal boundaries. OBJETIVO: Analisar o alcance da coordenação do cuidado pela Atenção Primária à Saúde em três regiões de saúde. MÉTODOS: Trata-se de estudo de caso, com abordagem quantitativa e qualitativa. Foram realizadas 31 entrevistas semiestruturadas com gestores municipais, regionais e estaduais e estudo transversal com aplicação de questionários para médicos (74), enfermeiros (127) e amostra representativa de usuários (1.590) da Estratégia Saúde da Família em três municípios-sede de regiões de saúde do estado da Bahia. RESULTADOS: A função de porta de entrada preferencial pela Atenção Primária à Saúde deparava-se com forte concorrência de serviços ambulatoriais hospitalares e de pronto-atendimento, desarticulados da rede. Problemas de acesso e oferta de atenção especializada eram agravados pela dependência do setor privado nas regiões, ainda que tenham sido observados avanços na institucionalização de fluxos desde a Atenção Primária à Saúde. A contrarreferência era deficiente e a comunicação interprofissional escassa, principalmente quando o usuário era atendido na rede contratada ou conveniada. CONCLUSÕES: A capacidade de coordenação mostra-se afetada tanto pela fragmentação da rede regional, quanto por problemas intrínsecos à Atenção Primária à Saúde, pouco fortalecida em seus atributos essenciais. Apesar de as regiões de saúde apresentarem problemas em comum, a Atenção Primária à Saúde continua sendo um tema circunscrito aos limites municipais.

Primary health care: care coordinator in regionalized networks? / Atenção primária à saúde: coordenadora do cuidado em redes regionalizadas?

RESUMO OBJECTIVE To analyze the breadth of care coordination by Primary Health Care in three health regions. METHODS This is a quantitative and qualitative case study. Thirty-one semi-structured interviews with municipal, regional and state managers were carried out, besides a cross-sectional survey with the administration of questionnaires to physicians (74), nurses (127), and a representative sample of users (1,590) of Estratégia Saúde da Família (Family Health Strategy) in three municipal centers of health regions in the state of Bahia. RESULTS Primary Health Care as first contact of preference faced strong competition from hospital outpatient and emergency services outside the network. Issues related to access to and provision of specialized care were aggravated by dependence on the private sector in the regions, despite progress observed in institutionalizing flows starting out from Primary Health Care. The counter-referral system was deficient and interprofessional communication was scarce, especially concerning services provided by the contracted network. CONCLUSIONS Coordination capacity is affected both by the fragmentation of the regional network and intrinsic problems in Primary Health Care, which poorly supported in its essential attributes. Although the health regions have common problems, Primary Health Care remains a subject confined to municipal boundaries.

RESUMO OBJETIVO Analisar o alcance da coordenação do cuidado pela Atenção Primária à Saúde em três regiões de saúde. MÉTODOS Trata-se de estudo de caso, com abordagem quantitativa e qualitativa. Foram realizadas 31 entrevistas semiestruturadas com gestores municipais, regionais e estaduais e estudo transversal com aplicação de questionários para médicos (74), enfermeiros (127) e amostra representativa de usuários (1.590) da Estratégia Saúde da Família em três municípios-sede de regiões de saúde do estado da Bahia. RESULTADOS A função de porta de entrada preferencial pela Atenção Primária à Saúde deparava-se com forte concorrência de serviços ambulatoriais hospitalares e de pronto-atendimento, desarticulados da rede. Problemas de acesso e oferta de atenção especializada eram agravados pela dependência do setor privado nas regiões, ainda que tenham sido observados avanços na institucionalização de fluxos desde a Atenção Primária à Saúde. A contrarreferência era deficiente e a comunicação interprofissional escassa, principalmente quando o usuário era atendido na rede contratada ou conveniada. CONCLUSÕES A capacidade de coordenação mostra-se afetada tanto pela fragmentação da rede regional, quanto por problemas intrínsecos à Atenção Primária à Saúde, pouco fortalecida em seus atributos essenciais. Apesar de as regiões de saúde apresentarem problemas em comum, a Atenção Primária à Saúde continua sendo um tema circunscrito aos limites municipais.

[The role of supply-side characteristics of services in AIDS mortality in Mexico]. / Exploración del rol de la oferta de servicios para explicar la variación de la mortalidad por sida en México.

OBJECTIVE: To document the association between supply-side determinants and AIDS mortality in Mexico between 2008 and 2013. MATERIALS AND METHODS: We analyzed the SALVAR database (system for antiretroviral management, logistics and surveillance) as well as data collected through a nationally representative survey in health facilities. We used multivariate logit regression models to estimate the association between supply-side characteristics, namely management, training and experience of health care providers, and AIDS mortality, distinguishing early and non-early mortality and controlling for clinical indicators of the patients. RESULTS: Clinic status of the patients (initial CD4 and viral load) explain 44.4% of the variability of early mortality across clinics and 13.8% of the variability in non-early mortality. Supply-side characteristics increase explanatory power of the models by 16% in the case of early mortality, and 96% in the case of non-early mortality. CONCLUSIONS: Aspects of management and implementation of services contribute significantly to explain AIDS mortality in Mexico. Improving these aspects of the national program, can similarly improve its results.

The public's priorities in health services.

BACKGROUND: Rationing in health services cannot be solved only by cost-effective analysis because social values play a central role in the difficult trade-off dilemma of prioritizing some service over others. OBJECTIVE: To examine the relative importance ascribed by the public to selected components of health services, in the national allocation of resources as well as in their personal insurance. METHODS: A telephone survey of a representative sample of the Israeli adult population (N = 1225). Two versions of the questionnaire were used. At the national level, interviewees were asked to assume they were the Minister of Health. At the personal level, interviewees were asked to choose items to be included in their personal complementary health insurance. RESULTS: Check-ups for early disease detection and nursing care for the frail elderly got the highest support for extra budget as well as to be included in personal insurance. Other items presented were fertility treatments, cardiac rehabilitation, mental health, dental health, programmes for preventive medicine and health promotion, subsidizing supplemental insurance for the poor, additional staff for primary clinics and building a new hospital. The lowest support was for alternative medicine and for cosmetic surgery. No subgroup in the Israeli society presented a different first priority. CONCLUSION: The Israeli public does not give high priority to 'nice to have' services but their selections are 'mature' and responsible. Rationing in health care requires listening to the public even if there are still many methodological limitations on how to reflect the public's opinion.

Exploración del rol de la oferta de servicios para explicar la variación de la mortalidad por sida en México / The role of supply-side characteristics of services in AIDS mortality in Mexico

Objetivo. Documentar la asociación entre factores de la oferta de servicios de atención de VIH sobre la mortalidad por sida en México en el periodo 2008-2013. Material y métodos. Se analizaron datos del sistema de administración, logística y vigilancia de antirretrovirales (SALVAR) y de una encuesta aplicada en unidades de atención. Se utilizaron modelos de regresión logit multivariados para estimar la asociación entre características de la oferta de servicios -en particular, de la gerencia de servicios y de la capacitación y experiencia de los prestadores- y la mortalidad por sida, distinguiendo entre mortalidad temprana y no temprana, y controlando por características clínicas de los pacientes. Resultados. Las características clínicas de los pacientes (CD4 inicial y carga viral) explican 44.4% de la variabilidad en la mortalidad temprana entre clínicas y 13.8% de la variabilidad de mortalidad no temprana. Las características de la oferta aumentan 16% del poder explicativo en el caso de la mortalidad temprana y 96% en el de la mortalidad no temprana. Conclusiones. Los aspectos de gerencia e implementación de los servicios de atención de VIH contribuyen significativamente a explicar la mortalidad por sida en México. Mejorar estos aspectos del programa nacional puede mejorar sus resultados.

Objective. To document the association between supply-side determinants and AIDS mortality in Mexico between 2008 and 2013. Materials and methods. We analyzed the SALVAR database (system for antiretroviral management, logistics and surveillance) as well as data collected through a nationally representative survey in health facilities. We used multivariate logit regression models to estimate the association between supply-side characteristics, namely management, training and experience of health care providers, and AIDS mortality, distinguishing early and non-early mortality and controlling for clinical indicators of the patients. Results. Clinic status of the patients (initial CD4 and viral load) explain 44.4% of the variability of early mortality across clinics and 13.8% of the variability in non-early mortality. Supply-side characteristics increase explanatory power of the models by 16% in the case of early mortality, and 96% in the case of non-early mortality. Conclusions. Aspects of management and implementation of services contribute significantly to explain AIDS mortality in Mexico. Improving these aspects of the national program, can similarly improve its results.

Substitutes or complements? An exploration of the effect of wait times and availability of conventional care on the use of alternative health therapies in Canada.

OBJECTIVES: We explore how alternative and complementary care use is affected by wait list length and availability of conventional care in Canada. DESIGN: We use data from the 2003 Canadian Community Health Survey, Statistics Canada and the Fraser Institute to explore the effect of longer wait times on the use of alternative therapies in general and for specific therapies: Registered Massage Therapy, Chiropractics, Physiotherapy, Homeopathy and Acupuncture. OUTCOME MEASURES: We use binary variables indicating whether the individual used various types of alternative care in the year preceding the survey. RESULTS: Wait times for specialists are associated with lower probabilities of using alternative care, but the effect are usually not statistically significant. Longer wait times for non-emergency surgery are associated with lower probabilities of using alternative care when using data from CANSIM, but very small higher probabilities of using alternative care when using data from the Fraser Institute which includes wait times for treatments for other procedures than non-emergency surgery. We find positive but extremely small effects for total wait times from the Fraser Institute. Individuals reporting unmet health care needs are more likely to use alternative care while individuals who do not have a regular physician are less likely to use it. CONCLUSIONS: Reporting unmet health care needs or no family physician have more of an impact on the use of alternative therapies than wait lists do. The evidence is not clear as to whether alternative care is sometimes used as a substitute to conventional care rather than a complement.

Comparing spatial accessibility to conventional medicine and complementary and alternative medicine in Ontario, Canada.

Health care investigations rarely consider conventional medicine (CM) and complementary and alternative medicine (CAM) simultaneously and spatial accessibility empirical research that incorporates both CM and CAM locations is novel. In this study, residents within municipalities of the Ontario province of Canada are compared in terms of spatial accessibility to a range of health care supplier 'destinations'. While areas with larger urban agglomerations generally exhibit superior levels of spatial accessibility to health care and diversity in medical service choice in comparison to more peripheral areas, considerable heterogeneity in accessibility occurs in both urban and rural settings. This study's identification of subtle spatial imbalances appends the literature by more precisely qualifying the typically reported 'urban-rich, rural-poor' assessment of health care service condition and also reinforces the need for policy-makers to appraise health care spatial accessibility differentials as a function of both CM and CAM endowment.

A toolkit for incorporating genetics into mainstream medical services: Learning from service development pilots in England.

BACKGROUND: As advances in genetics are becoming increasingly relevant to mainstream healthcare, a major challenge is to ensure that these are integrated appropriately into mainstream medical services. In 2003, the Department of Health for England announced the availability of start-up funding for ten 'Mainstreaming Genetics' pilot services to develop models to achieve this. METHODS: Multiple methods were used to explore the pilots' experiences of incorporating genetics which might inform the development of new services in the future. A workshop with project staff, an email questionnaire, interviews and a thematic analysis of pilot final reports were carried out. RESULTS: Seven themes relating to the integration of genetics into mainstream medical services were identified: planning services to incorporate genetics; the involvement of genetics departments; the establishment of roles incorporating genetic activities; identifying and involving stakeholders; the challenges of working across specialty boundaries; working with multiple healthcare organisations; and the importance of cultural awareness of genetic conditions. Pilots found that the planning phase often included the need to raise awareness of genetic conditions and services and that early consideration of organisational issues such as clinic location was essential. The formal involvement of genetics departments was crucial to success; benefits included provision of clinical and educational support for staff in new roles. Recruitment and retention for new roles outside usual career pathways sometimes proved difficult. Differences in specialties' working practices and working with multiple healthcare organisations also brought challenges such as the 'genetic approach' of working with families, incompatible record systems and different approaches to health professionals' autonomous practice. 'Practice points' have been collated into a Toolkit which includes resources from the pilots, including job descriptions and clinical tools. These can be customised for reuse by other services. CONCLUSIONS: Healthcare services need to translate advances in genetics into benefits for patients. Consideration of the issues presented here when incorporating genetics into mainstream medical services will help ensure that new service developments build on the body of experience gained by the pilots, to provide high quality services for patients with or at risk of genetic conditions.

[Immigration in Spain and the health system: a fiscal policy perspective]. / El sistema sanitario y la inmigración en España desde la perspectiva de la política fiscal.

The Spanish population has grown by over 6 million people in the last 10 years and immigrants account for 4.5 million of this increase. Although this influx has largely been motivated by economic reasons, stimulated by the sharp growth of the Spanish economy, sociological factors must also be considered to assess the impact of immigration shock on public expenditure and the social welfare system. On the one hand, the demographic growth caused by immigration temporarily balances the pension system, as immigrants have a lower average age and a higher fertility rate. On the other hand, the demographic and economic features of the immigrant community make additional demands on the social welfare system. Universal access to basic public services such as the education and health systems is a crucial asset in the integration policy aimed at the immigrant collective, and compensates for its possible effect as an incentive to immigrate. In the short term, the huge population growth has led to health services' congestion, especially in primary health care, because of the unequal geographic distribution of immigrants. The health expenditure imputable to immigrants is lower than their share in the total population and is highly concentrated in four autonomous regions.

A unique faith-based medical organization: the Christian Medical Fellowship.

The Association of American Medical Colleges has challenged medical educators to be role models for the incorporation of faith into the art and practice of medicine. The Christian Medical Fellowship (CMF) is one approach toward accomplishing this goal. CMF is a nonprofit organization that brings health, hope, and healing, to and through the health-care community, providing transformational love locally and internationally. CMFseeks to support the caregiver while serving the underserved. CMF accomplishes this through a three-fold approach: promoting individual faith, community outreach, and international missions. CMF provides a framework to assist health-care providers in meeting their own spiritual needs along with those of their patients. The Christian ethic teaches that Jesus touched and changed lives by showing love and compassion, while meeting physical as well as spiritual needs. The goal of CMF is to do the same. The CMF vision is to replicate CMF's three-fold ministry by fostering the development of independent, self-supporting CMF chapters to serve throughout the USA and the world. CMF plans to develop a fully functioning faith-based Fellowship Program in conjunction with a CMF faith-based clinic and an international hospital. The growth of CMF and the advancement of the educational experiences are a result of many committed, disciplined, and focused individuals motivated by a deep faith in the original vision. We look to the future with anticipation, as we continue to bridge the gap between faith and the science of medicine.