[Specialized care in health regions: challenges to ensure comprehensive health care in Brazil]. / Atención especializada en regiones de salud: desafíos para garantizar el cuidado integral en Brasil.

OBJECTIVE: To analyze aspects of specialized health care provision in the context of incipient regional integration, as well as barriers to offering comprehensive health care. MATERIALS AND METHODS: Case studies in tree municipal seats of health regions in the state of Bahia, Brazil. 31 semi-structured interviews were conducted with health managers and surveys were applied to 201 physicians and nurses of family health care teams and 1 590 users. RESULTS: The participants agreed on the lack of the specialized health care, considering limitations in regional planning due to low public funding and difficulties to attract specialized physicians. A significant percentage of users seek specialized health care directly in private services. CONCLUSIONS: The provision of comprehensive health care faces not only the challenge of strengthening the essential characteristics of primary health care (PHC), but also the lack of specialists, the fragmentation between different points of the network and communicational disarticulation between levels of the health system.

OBJETIVOS: Analizar aspectos de la provisión de asistencia especializada en el contexto de incipiente integración regional y barreras para la oferta de atención integral en salud. MATERIALES Y MÉTODOS: Estudios de caso en tres municipios sedes de regiones de salud del estado de Bahía, Brasil, con realización de 31 entrevistas semiestructuradas con gestores de salud, encuestas a 201 médicos y enfermeros de EqSF y 1 590 usuarios. RESULTADOS: Hubo convergencia en cuanto a la escasez de retaguardia terapéutica, considerando las limitaciones que sufre el planeamiento local por el bajo financia-miento público y las dificultades para atraer especialistas. Un porcentaje expresivo de usuarios busca servicios especializados directamente en el sector privado. CONCLUSIONES: La oferta de atención integral en salud enfrenta, además del desafío de fortalecer la APS en sus atributos esenciales, escasez de oferta en especialidades, fragmentación entre diferentes puntos de la red y desarticulación comunicacional entre niveles del sistema de salud.

[Assessment of access to the Family Health Strategy from the perspective of users in Santo Antônio de Jesus-Bahia, Brazil]. / Avaliação do acesso à Estratégia Saúde da Família na perspectiva dos usuários no município de Santo Antônio de Jesus-Bahia, Brasil.

OBJECTIVE: To assess access to the Family Health Strategy (FHS) in Santo Antônio de Jesus - Brazil from the perspective of its users. METHODS: Cross-sectional study conducted with a representative sample of users registered by 21 family healthcare teams of the municipality, for a total of 430 questionnaires. A family-based survey was applied between December 2012 and January 2013. Indicators considered as the most powerful to evaluate access were selected and, subsequently, divided into two dimensions: knowledge and evaluation of the Family Health Strategy Program from the perspective of its users. RESULTS: The results point to decreasing barriers and increasing access to healthcare services, as well as to a greater organization of enrollment in the system. Changes observed after the implementation of the FHS in the districts are evident in the overall satisfaction with the primary health care service, which legitimizes the organization of the health system based on primary comprehensive care.

Mapping primary health care renewal in South America.

BACKGROUND: Primary health care (PHC) renewal processes are currently ongoing in South America (SA), but their characteristics have not been systematically described. OBJECTIVE: The study aimed to describe and contrast the PHC approaches being implemented in SA to provide knowledge of current conceptions, models and challenges. METHODS: This multiple case study used a qualitative approach with technical visits to health ministries in order to apply key-informant interviews of 129 PHC national policy makers and 53 local managers, as well as field observation of 57 selected PHC providers and document analysis, using a common matrix for data collection and analysis. PHC approaches were analysed by triangulating sources using the following categories: PHC philosophy and conception, service provision organization, intersectoral collaboration and social participation. RESULTS: Primary health care models were identified in association with existing health system types and the dynamics of PHC renewal in each country. A neo-selective model was found in three countries where coverage is segmented by private and public regimes; here, individual and collective care are separated. A comprehensive approach similar to the Alma-Ata model was found in seven countries where the public sector predominates and individual, family and community care are coordinated under the responsibility of the same health care team. CONCLUSIONS: The process of implementing a renewed PHC approach is affected by how health systems are funded and organized. Both models face many obstacles. In addition, care system organization, intersectoral coordination and social participation are weak in most of the countries.

The work of community health workers in major cities in Brazil: mediation, community action, and health care.

This paper examines the role of community health workers (CHWs) and discusses the challenges in performing their multiple functions as: mediators linking the community and health services, community organizers, and care providers. A survey of CHWs was conducted in four towns in Brazil. The results indicate that during their home visits and community actions, the CHW perform educational and care activities for priority groups. Some CHWs work in health centers, where their functions include care management for chronic patients. The results indicate gaps in the work actually done, mainly as regards the expectation that CHWs would play a more political role, mediating between the communities and public policies, especially health policy. The CHWs in Brazil are general-purpose health personnel with a hybrid role that oscillates from technical to political profile.

[Waiting lists in public systems: from expanding supply to timely access? Reflections on Spain's National Health System]. / Listas de espera em sistemas públicos: da expansão da oferta para um acesso oportuno? Considerações a partir do Sistema Nacional de Saúde espanhol.

The paper discusses the issue of waiting times based on a study of Spain's National Health System (Sistema Nacional de Salud, SNS), focusing on the national context, management issues and local practices. Observation visits and interviews with health personnel and managers conducted in the metropolitan areas of the Autonomous Communities of Madrid, Andalusia, Catalonia and Basque Country were complemented by secondary data and a review of the literature. There is unanimity as to the positive results of the SNS, but cutting waiting times seems to be one key aspect requiring improvement. Two directions were identified for complementary measures: guaranteed maximum waiting times in the macro-social sphere associated with local measures to increase service integration and primary care resolution rates. The peculiarities of the Spanish decentralisation process and the existence of economic, political and health profession corporate interests were mentioned as factors hampering waiting list regulation, transparency and management. A comprehensive approach to this issue shows the need to shift discussion from waiting list monitoring and/or expanded supply to guaranteed timely access. That is the quality differential that primary care-oriented systems must bring to public health systems.

[Strengthening primary health care: a strategy to maximize coordination of care]. / Fortalecimento da atenção primária à saúde: estratégia para potencializar a coordenação dos cuidados.

OBJECTIVE: To describe and analyze the actions developed in four large cities to strengthen the family health strategy (FHS) in Brazil. METHODS: Case studies were carried out in Aracaju, Belo Horizonte, Florianópolis, and Vitória based on semi-structured interviews with health care managers. In addition, a cross-sectional study was conducted with questionnaires administered to a sample of FHS workers and services users. RESULTS: Actions needed to strengthen primary health care services were identified in all four cities. These include increasing the number of services offered at the primary health care level, removing barriers to access, restructuring primary services as the entry point to the health care system, enhancing problem-solving capacity (diagnostic and therapeutic support and networking between health units to organize the work process, training, and supervision), as well as improving articulation between surveillance and care actions. CONCLUSIONS: The cities studied have gained solid experience in the reorganization of the health care model based on a strengthening of health primary care and of the capacity to undertake the role of health care coordinator. However, to make the primary care level the customary entry point and first choice for users, additional actions are required to balance supplier-induced and consumer-driven demands. Consumer driven demand is the biggest challenge for the organization of teamwork processes. Support for and recognition of FHS as a basis for primary health care is still an issue. Initiatives to make FHS better known to the population, health care professionals at all levels, and civil society organizations are still needed.

Family health: limits and possibilities for an integral primary care approach to health care in Brazil.

The article analyzes the implementation of the Family Health Strategy (FH) and discusses its potential to guide the organization of the Unified Health System in Brazil, based on the integration of FH to the health care network and intersectorial action, crucial aspects of a comprehensive primary health care. Four case studies were carried out in cities with high FH coverage (Aracaju, Belo Horizonte, Florianópolis e Vitória), using as sources: semi-structured interviews with managers and surveys with health care professionals and registered families. The integration analysis highlighted the position of FH Strategy in the health services network, the integration mechanisms and the availability of information for continuity of care. Intersectoriality was researched in relation to the fields of action, scope, sectors involved, presence of forums, and team initiatives. The results point to advances in the integration of FH to the health care network, strengthening basic services as services that are regularly sought and used as a preferential first contact services, although there are still problems in the access to specialized care. The intersectorial initiatives were broader when defined as integrated municipal government policy for the construction of interfaces and cooperation between the diverse sectors.