A competência normativa frente aos novos atores políticos: um estudo de caso da telemedicina / The normative competence in the face of new political actors: a case study of telemedicine

Resumo A regulação da prática de telemedicina no Brasil tem se mostrado tortuosa desde seu reconhecimento pela Resolução nº 1.643/2002, do Conselho Federal de Medicina (CFM), havendo questionamentos quanto à competência deste para inserção da prática. Em 2018, o conselho editou nova resolução, mas que foi revogada em função da repercussão negativa. A pandemia de covid-19 pressionou os serviços de saúde de tal forma que o Poder Legislativo Federal foi impelido ao conflito e editou a Lei nº 13.989/2020, permitindo a prática de telemedicina durante o período da crise sanitária. O art. 6º da lei delegou ao CFM a competência para regulação da prática pós-pandemia, acirrando ainda mais as discussões. Este trabalho constitui um estudo de caso sobre a regulação da telemedicina no Brasil, buscando identificar os conflitos jurídicos impostos pela atuação do CFM em substituição ao Poder Legislativo. Utiliza o modelo político de implementação de políticas públicas de William Clune como base da análise, empregando o método da pesquisa documental qualitativa. Conclui-se que a implementação da telemedicina deve considerar as forças políticas em atuação, compreendendo o papel do CFM no processo normativo, para que se obtenha, no texto legal, uma política pública compatível com a realidade e apta a ser implementada.

Abstract The regulation of telemedicine in Brazil has been tortuous since its recognition by the Resolution No. 1,643/2002, of the Federal Council of Medicine (CFM), with issues regarding its competence to insert this practice. In 2018, the council issued a new resolution but it was revoked due to negative repercussions. The covid-19 pandemic put pressure on health services in such a way that the National Congress was pushed into conflict and enacted the Federal Law No. 13,989/2020, which allowed the practice of telemedicine during the period of health crisis. The article 6 of the law delegated the competence to regulate the post-pandemic practice to the CFM, further intensifying the discussions. This work is a case study on the regulation of telemedicine in Brazil, seeking to identify the legal conflicts imposed by the action of CFM in substitution of the Legislative Power. It uses the political model of implementation of public policies by William Clune as the basis for the analysis, using the qualitative documentary research method. In conclusion, the implementation of telemedicine must consider the political forces involved, understanding the CFM's role in the normative process, to obtain, in the legal text, a public policy compatible with reality and capable of being implemented.

Sexual misconduct by health professionals in Australia, 2011-2016: a retrospective analysis of notifications to health regulators.

OBJECTIVES: To assess the numbers of notifications to health regulators alleging sexual misconduct by registered health practitioners in Australia, by health care profession. DESIGN, SETTING: Retrospective cohort study; analysis of Australian Health Practitioner Regulation Agency and NSW Health Professional Councils Authority data on notifications of sexual misconduct during 2011-2016. PARTICIPANTS: All registered practitioners in 15 health professions. MAIN OUTCOME MEASURES: Notification rates (per 10 000 practitioner-years) and adjusted rate ratios (aRRs) by age, sex, profession, medical specialty, and practice location. RESULTS: Regulators received 1507 sexual misconduct notifications for 1167 of 724 649 registered health practitioners (0.2%), including 208 practitioners (18%) who were the subjects of more than one report during 2011-2016; 381 notifications (25%) alleged sexual relationships, 1126 (75%) sexual harassment or assault. Notifications regarding sexual relationships were more frequent for psychiatrists (15.2 notifications per 10 000 practitioner-years), psychologists (5.0 per 10 000 practitioner-years), and general practitioners (6.4 per 10 000 practitioner-years); the rate was higher for regional/rural than metropolitan practitioners (aRR, 1.73; 95% CI, 1.31-2.30). Notifications of sexual harassment or assault more frequently named male than female practitioners (aRR, 37.1; 95% CI, 26.7-51.5). A larger proportion of notifications of sexual misconduct than of other forms of misconduct led to regulatory sanctions (242 of 709 closed cases [34%] v 5727 of 23 855 [24%]). CONCLUSIONS: While notifications alleging sexual misconduct by health practitioners are rare, such misconduct has serious consequences for patients, practitioners, and the community. Further efforts are needed to prevent sexual misconduct in health care and to ensure thorough investigation of alleged misconduct.

Untamed Jianghu or Emerging Profession: Diagnosing the Psycho-Boom amid China's Mental Health Legislation.

This article focuses on the psychotherapy debate in China that was triggered by the country's mental health legislation. Seeing the release of the draft Mental Health Law in 2011 as a "diagnostic event" (Moore in Am Ethnol 14(4):727-736, 1987), I examine the debate in order to unravel the underlying logic and ongoing dynamics of the psycho-boom that has become a conspicuous trend in urban China since the early 2000s. Drawing on my fieldwork in Beijing and Shanghai, I use the two keywords of the debate-"jianghu" (literally "rivers and lakes"), an indigenous term that evokes an untamed realm, and "profession," a foreign concept whose translation requires re-translation-to organize my delineation of its contours. I describe how anticipation of state regulation prompted fears and discontents as well as critical reflections and actions that aimed to transform the field into a profession. The efforts to mark out a professional core against the backdrop of unruly jianghu further faced the challenge of an alternative vision that saw popularization as an equally noble cause. The Mental Health Law came into effect in 2013; ultimately, however, it did not introduce substantive regulation. Finally, I discuss the implications of this debate and the prospects of the psycho-boom.

Regulação do exercício de profissões de saúde: fragmentação e complexidade do modelo regulatório brasileiro e desafios para seu aperfeiçoamento / Health professions regulation: Fragmentation and complexity of the Brazilian model and challenges for its improvement

A regulação jurídica das profissões de saúde no Brasil é composta por um conjunto normativo amplo, complexo e fragmentado, que encontra sua base na Constituição Federal de 1988 e se complementa por uma extensa quantidade de leis, decretos, portarias e, principalmente, resoluções editadas pelos conselhos profissionais. O presente artigo tem como objetivo identificar os principais marcos legais que estruturam a regulação do exercício profissional no setor da saúde brasileiro, delineando, a partir dos resultados obtidos, o modelo de regulação do exercício de profissões de saúde no Brasil. o método utilizado foi de pesquisa normativa e jurisprudencial, com análise qualitativa dos dados selecionados. A partir das leis atualmente vigentes, foram identificadas as diferentes instituições estatais com competência legal para regular as profissões de saúde no Brasil e as principais normas editadas para a regulação das profissões de saúde. Em seguida, buscaram-se conflitos regulatórios judicializados por essas instituições e levados até os tribunais superiores. A análise das leis e decisões selecionadas permitiu a caracterização do que denominamos Modelo de Regulação de Profissões de Saúde Brasileiro, com a identificação e análise das diferentes instituições estatais reguladoras e das principais normas vigentes que regulam as 14 profissões de saúde reconhecidas pelo Conselho Nacional de Saúde. Os resultados apresentados neste artigo delineiam o atual modelo de regulação de profissões de saúde vigente no Brasil e contribuem para o aprofundamento dos conhecimentos sobre o tema, possibilitando reflexões para o aperfeiçoamento do atual modelo jurídico-institucional brasileiro.

The legal regulation of health professions in Brazil is composed by a set of broad, complex and fragmented norms, based on the Federal Constitution of 1988 (CF 88) and complemented by an extensive amount of laws, decrees, ordinances, and mainly resolutions issued by the professional councils. This article aims to identify the main legal frameworks that structure the regulation of professional practice in the Brazilian health sector, using the results to outline a model of regulation of the Health Professions in Brazil. The method used was normative and jurisprudential research followed by a qualitative analysis of the selected data. Based on the current laws, we first identified the different state institutions with legal competence to regulate the health professions in Brazil and the main edited norms for that purpose. Next, we searched for the regulatory conflicts brought by these institutions before the higher courts. The analysis of the selected laws and decisions allowed the characterization of what we call the Brazilian Health Professions Regulation Model, with the identification and analysis of the different state regulatory institutions and the main current norms that regulate the 14 health professions recognized by the National Health Council. The results presented in this article outline the current Model of Regulation of Health Professions in force in Brazil and contribute to the deepening of knowledge on the subject, allowing reflections for the improvement of the current Brazilian legal-institutional model.

Acting in the Public Interest: The Heart of Professional Regulation.

In their article, Wilke and Tzountzouris (2017) describe the traditional and emerging approaches to professional regulation as restrictive (e.g., setting entry to practice requirements for registration), reactive (responding to complaints and where necessary restricting, suspending or revoking registration) or proactive (ensuring continuing competency and supporting registrants to adapt to changes in practice environments). They note the tension that exists with proactive approaches to regulation that can be seen as professional advocacy. We argue that by ensuring best practices in organizational governance and day-to-day regulatory operations that clearly situate the regulator to be acting solely in the public interest, regulatory colleges can manage the proactive regulatory approach and eliminate any perception of professional advocacy. This is critical for sustaining the professionally led model for health regulation that exists in Canada as it does today.

[Criminal liability in case of medical acts considered to be incompetent: article 6 of the new Italian Law 8 March 2017, n.24]. / Perizia ed imperizia sanitaria. Esimenti di responsabilità: art. 6 della legge 8 marzo 2017, n.24.

In Italy, Law n. 24 of 8 March 2017, Article 6, introduces in the current criminal code, Article 590 sexies entitled "Medical liability in case of death and personal lesions", which follows article 590 quinquies. The new article states that a healthcare professional who has acted in accordance with guidelines approved by the National Health Institute or, if no such guidelines exist, in accordance with good clinical practices, is not criminally liable in case of death or personal lesions due to actions that could be considered to be incompetent. We discuss criminal liability of health professionals in Italy in light of this new law, and decriminalization in case of adverse event due to incompetence, also in the context of medical care provided by different health professionals.

A regulação das profissões de saúde por conselhos profissionais no direito da França e da Europa / La régulation des professions de santé par les ordres professionnels en droit Français et Européen / The regulation of health professions by professional councils in the law of France and Europe

Este artigo tem por objetivo analisar o poder normativo dos conselhos profissionais da área da saúde, à luz do Direito francês e europeu, destacando os limites impostos a estes organismos. Os conselhos profissionais de saúde têm a missão de integrar as suas categorias na sociedade e suas decisões estão necessariamente sujeitas ao controle do Estado, embora o campo de atuação dos conselhos seja mais amplo do que aquele dos sindicatos. Apesar de limitado pelo seu próprio objetivo, o poder normativo dos conselhos se mostra presente e vem evoluindo e assumindo diferentes formas

Cette contribution vise à analyser les formes que peut prendre le pouvoir normatif des ordres professionnels en santé en France et en droit de l'Union Européenne et les raisons pour lesquelles ce pouvoir est limité. Les ordres des professionnels de santé ont pour mission d'intégrer leur profession dans la société. Nous verrons que, par conséquent, l'activité des ordres professionnels est nécessairement subordonnée au contrôle de l'Etat mais que le champ de cette activité est aussi, de ce fait, plus large que celle d'un syndicat. Bien que limité par son objet même, le pouvoir normatif n'est néanmoins pas inexistant et nous verrons que ce pouvoir évolue et peut prendre des formes variées

Strengthening health professions regulation in Cambodia: a rapid assessment.

BACKGROUND: This paper describes a rapid assessment of Cambodia's current system for regulating its health professions. The assessment forms part of a co-design process to set strategic priorities for strengthening health profession regulation to improve the quality and safety of health services. A health system approach for strengthening health professions' regulation is underway and aims to support the Government of Cambodia's plans for scaling up its health workforce, improving health services' safety and quality, and meeting its Association of South East Asian Nations (ASEAN) obligations to facilitate trade in health care services. METHODS: The assessment used a mixed methods approach including: A desktop review of key laws, plans, reports and other documents relating to the regulation of the health professions in Cambodia (medicine, dentistry, midwifery, nursing and pharmacy); Key informant interviews with stakeholders in Cambodia (The term "stakeholders" refers to government officials, people working on health professional regulation, people working for the various health worker training institutions and health workers at the national and provincial level); Surveys and questionnaires to assess Cambodian stakeholder knowledge of regulation; Self-assessments by members of the five Cambodian regulatory councils regarding key capacities and activities of high-performing regulatory bodies; and A rapid literature review to identify: The key functions of health professional regulation; The key issues affecting the Cambodian health sector (including relevant developments in the wider ASEAN region); and "Smart" health profession regulation practices of possible relevance to Cambodia. RESULTS: We found that the current regulatory system only partially meets Cambodia's needs. A number of key regulatory functions are being performed, but overall, the current system was not designed with Cambodia's specific needs in mind. The existing system is also overly complex, with considerable duplication and overlap between governance and regulatory arrangements for the five regulated professions. CONCLUSIONS: There is considerable scope for reform to the current regulatory system to better align the system to Cambodia's: Current needs and circumstances; Health system strategic priorities; and International obligations. Cambodia is also well placed to base its reformed regulatory system on recent developments of "smart regulatory practices" for health professionals.

Economic issues and public alcohol abuse prevention policies in France / Enjeux économiques et politiques publiques de lutte contre la consommation nocive d'alcool en France.

Objective: To analyse the impact of the alcohol market on the implementation of strong-willed public alcohol abuse prevention policies based on a critical review of the literature. Method: Documentary research and analysis of the alcohol market economic data were performed. An overview of public alcohol abuse prevention policies was conducted from a historical perspective by distinguishing drunkenness control policies, protection of vulnerable populations, and the fight against drink driving and drinking in the workplace. Results: Public alcohol abuse prevention policies are primarily designed to reduce the harmful consequences of alcohol occurring as a result of a drinking episode (motor vehicle accident, highway accidents, etc.), while neglecting the long-term consequences (cancer, cirrhosis, etc.). Moreover, while taxation is one of the major public health tools used to reduce the costs of alcohol-related damage on society, the State exercises legislative and tax protection for alcoholic beverages produced in France. In particular, wine benefits from a lower tax rate than other stronger forms of alcohol (spirits, liquors, etc.). The economic weight of the alcohol market can provide an explanation for these public alcohol abuse prevention policies. Conclusion: In view of the mortality caused by alcohol abuse, France must implement a proactive public policy. An alcohol taxation policy based on the alcohol content, a minimum unit pricing for alcohol, or higher taxes on alcohol are public policies that could be considered in order to reduce alcohol-related mortality.

[Construction of a professionnal juridiction in Adapted Physical Activity in the medical world]. / Construction du territoire professionnel de l'enseignant en Activité Physique Adaptée dans le monde médical.

Analysis of interactions between professionals and patients with chronic diseases reveals a space invested by professional expertise in which APA teachers occupy their own distinctive position..

Power and practices: questions concerning the legislation of health professions in Brazil.

Developments in professional practice can be related to ongoing changes in relations of power among professionals, which often lead to changes in the boundaries of practices. The differing contexts of practices also influence these changing relations among health professionals. Legislation governing professional practice also differs from country to country. In Brazil, over the past 12 years, in a climate of deep disagreement, a new law to regulate medical practice has been discussed. It was sanctioned, or made into law, but with some notable changes, in July 2013. Of interest to us in this paper are the ways the proposed legislation, by setting out the boundaries and scope of medical practice, 'interfered' in the practices of other health professions, undermining many 'independent' practices that have developed over time. However, even taking into account the multiple routes through which practices are established and developed, the role of legislation that seems able to contradict and deny the historical realities of multiple, intersecting practices should be critically interrogated. In this paper, we use the theoretical resources of poststructuralist thinking to explore gaps, ambiguities, and power relations implicit in the discourses that constituted this law. We argue that although the new law can be understood as a social and political device that will interfere in the organization of other health professions' practices, such legislation is only part of what constitutes change in a consolidated professional practice. And while it is important to understand the effects of such legislation, healthcare practices are also realized or 'made real' through ongoing relations of knowledge and power, including, as we will see in this case, activities of resistance. The problem, then, is to understand the practical arrangements, including legislation, traditions and routines, values and knowledge that come to shape the practices of nursing in a particular context.

Una mirada sobre la atención psicomotriz en los servicios de salud pública / A look at psychomotricity care in public health services / Um olhar sobre os cuidados psicomotrizes nos serviços de saúde pública

En las Instituciones de salud pública de la provincia de Córdoba se observa una participación asimétrica entre las profesiones médicas y otras profesiones como la psicomotricidad. Realidad que se detecta en los centros de atención pública de la ciudad de Río Cuarto. Se reflexiona críticamente acerca de la definición de los procesos de salud-enfermedad confrontando los actuales paradigmas vigentes y la teoría Psicomotríz e indagando las formas en que se concibe la inclusión de la disciplina en las políticas públicas y legislaciones vigentes provinciales. La investigación se desarrolló a través de un trabajo de campo para conocer las opiniones y valoraciones respecto de la atención de la salud, la psicomotricidad y su marco legal en un procedimiento de encuestas y entrevistas a los actores sociales de la salud, entre ellos, médicos y funcionarios locales. Se percibe que la conformación de los equipos de salud es incompleta, existiendo una parcialidad profesional que sigue prioritariamente constituida por las ciencias médicas. La intención de este análisis es poner en contraste el saber médico y el saber psicomotor para instalar espacios de reflexión que motiven posibles transformaciones necesarias para atender la recuperación, la prevención y la promoción de la salud.

At public health institutions in the province of Cordoba, we can observe an asymmetric participation between medical professions and other professions such as psychomotricity. This reality is observed in public health care centers in the city of Rio Cuarto. We critically think about the definition of the health-illness processes, comparing the current paradigms and Psychmotricity theory and asking about the ways in which the inclusion of this discipline is understood in the provincial public policies and in the legislation in force. The research was carried out through field work to get to know the opinion and assessment regarding health care and psychomotricity care and its legal framework by means of surveys and interviews to health social actors: doctors and local civil servants, among others. It is observed that the constitution of the health teams is incomplete; there exists professional bias which is still priorly constituted by the medical sciences. The intention of our analysis is to contrast medical knowledge and psychomotricity knowledge to set up reflection spaces which will allow the necessary transformations to take care of health recovery, prevention and promotion.

Percebe-se nas instituições de saúde pública da província de Córdoba uma participa- ção assimétrica entre as profissões médicas e outras profissões, como a psicomotricidade. Trata-se de uma realidade que é detectada em centros de saúde públicos da cidade de Rio Cuarto. Reflete-se criticamente sobre a definição dos processos de saúde- doença que confrontando os atuais paradigmas existentes e a teoria Psicomotriz e investigando as formas em que a inclusão da disciplina nas políticas públicas e legislações provinciais é concebida. A pesquisa foi realizada por meio de um trabalho no local analisado para conhecer as opiniões e conceitos sobre cuidados de saúde, a psicomotricidade e seu quadro legal em um processo de enquêtes e entrevistas com as atores sociais da saúde, dentre eles, os médicos e autoridades locais da saúde. Percebe-se que a formação de equipes de saúde é incompleta, existindo um perfil profissional que ainda é essencialmente constituído por profissionais das ciências médicas. A intenção desta análise é contrastar o conhecimento médico e o saber psicomotor para instalar espaços de reflexão que incentivem as mudan- ças necessárias para enfrentar a possível recuperação, prevenção e promoção da saúde.

Mandatory reports of concerns about the health, performance and conduct of health practitioners.

OBJECTIVE: To describe the frequency and characteristics of mandatory reports about the health, competence and conduct of registered health practitioners in Australia. DESIGN AND SETTING: Retrospective review and multivariate analysis of allegations of "notifiable conduct" involving health practitioners received by the Australian Health Practitioner Regulation Agency (AHPRA) between 1 November 2011 and 31 December 2012. MAIN OUTCOME MEASURES: Statutory grounds for reports, types of behaviour reported, and incidence of notifications by profession, sex, age, jurisdiction and geographic area. RESULTS: Of 819 mandatory notifications made during the study period, 501 (62%) related to perceived departures from accepted professional standards, mostly standards of clinical care. Nurses and doctors dominated notifications: 89% (727/819) involved a doctor or nurse in the role of notifier and/or respondent. Health professionals other than the respondents' treating practitioners made 46% of notifications (335/731), and the profession of the notifier and respondent was the same in 80% of cases (557/697). Employers made 46% of notifications (333/731). Psychologists had the highest rate of notifications, followed by medical practitioners, and then nurses and midwives (47, 41 and 40 reports per 10 000 practitioners per year, respectively). Incidence of notifications against men was more than two-and-a-half times that for women (46 v 17 reports per 10 000 practitioners per year; P < 0.001) and there was fivefold variation in incidence across states and territories. CONCLUSIONS: Although Australia's mandatory reporting regime is in its infancy, our data suggest that some of the adverse effects and manifest benefits forecast by critics and supporters, respectively, have not materialised. Further research should explore the variation in notification rates observed, evaluate the outcomes of reports, and test the effects of the mandatory reporting law on whistleblowing and help-seeking behaviour.