Analysing changes to the flow of public funding within local health and care systems: An adaptation of the System of Health Accounts framework to a local health system in England.

Financial flows relating to health care are routinely analysed at national and international level. They have rarely been systematically analysed at local level, despite sub-national variation due to population needs and decisions enacted by local organisations. We illustrate an adaptation of the System of Health Accounts framework to map the flow of public health and care funding within local systems, with an application for Greater Manchester (GM), an area in England which agreed a health and social care devolution deal with the central government in 2016. We analyse how financial flows changed in GM during the four years post-devolution, and whether spending was aligned with local ambitions to move towards prevention of ill-health and integration of health and social care. We find that GM decreased spending on public health by 15%, and increased spending on general practice by 0.1% in real terms. The share of total local expenditure paid to NHS Trusts for general and acute services increased from 70.3% to 71.6%, while that for community services decreased from 11.7% to 10.3%. Results suggest that GM may have experienced challenges in redirecting resources towards their goals. Mapping financial flows at a local level is a useful exercise to examine whether spending is aligned with system goals and highlight areas for further investigation.

The impact of performance-based financing within local health systems: Evidence from Mozambique.

Most evidence on Performance Based Financing (PBF) in low-income settings has focused on services delivered by providers in targeted health administrations, with limited understanding of how effects on health and care vary within them. We evaluated the population effects of a program implemented in two provinces in Mozambique, focusing on child, maternal and HIV/AIDS care and knowledge. We used a difference-in-difference estimation strategy applied to data on mothers from the Demographic Health Surveys, linked to information on their closest health facility. The impact of PBF was limited. HIV testing during antenatal care increased, particularly for women who were wealthier, more educated, or residing in Gaza Province. Knowledge about transmission of HIV from mother-to-child, and its prevention, increased, particularly for women who were less wealthy, less educated, or residing in Nampula Province. Exploiting the roll-out by facility, we found that the effects were concentrated on less wealthy and less educated women, whose closest facility was in the referral network of a PBF facility. Results suggest that HIV testing and knowledge promotion increased in the whole district, as a strategy to boost referral for highly incentivized HIV services delivered in PBF facilities. However, demand-side constraints may prevent the use of those services.

Exploring indirect impacts of COVID-19 on local health systems from the perspectives of health workers and higher education stakeholders in the Philippines using a phenomenological approach.

Background: Our study aimed to explore the experiences of stakeholders from local government units, health facilities and higher education institutions on the delivery of non-COVID-19 health services after the initial wave of the pandemic. Methods: Twenty-nine public health workers, thirteen university staff, and four hospital administrators in the Philippines participated. Using a descriptive phenomenological approach, we analysed transcripts from six focus group discussions conducted online between March and June 2021. Findings: The COVID-19 pandemic made the routine health programs inaccessible due to hesitancy among patients to visit health facilities, a shift in public health priorities, and lack of students to augment the existing workforce.Public health workers reported stress and mental health exhaustion. Apart from fear of infection during service provision, public health workers and university staff experienced work overload, pressure to learn new technology, and webinar fatigue. Mental health problems have surfaced as health workers and young people have become more affected while support services remain insufficient.Public health workers have reported actions to maintain service delivery in the new normal such as use of telehealth and social media. However, issues on workforce wellbeing and digital equity posed adaptation challenges. Participants suggested partnership with higher education institutions as pivotal to position local health systems towards recovery. Interpretation: The rapid change in the service landscape highlights the importance of sustainable partnerships, effective workforce management, equitable digital innovations, and promoting mental wellbeing to preserve community, school, and occupational health and rebuild resilient local health systems in low-resourced areas. Funding: This research is proudly supported by the Australia-ASEAN Council, Australian Government Department of Foreign Affairs and Trade.

Repasses financeiros para o enfrentamento da COVID-19 na perspectiva de gestores municipais do estado de São Paulo, Brasil / Fund transfers for combating COVID-19 from the perspective of municipal managers in São Paulo state, Brazil

Resumo O objetivo do estudo foi identificar a percepção dos gestores municipais sobre os recursos extraordinários e seus usos no enfrentamento à COVID-19. Trata-se de estudo de casos múltiplos, de métodos mistos incorporados. Foram realizadas entrevistas semiestruturadas com seis municípios-caso do estado de São Paulo. Foram analisados dados secundários extraídos de sistemas de informação no período de 2020 a 2022. As distintas realidades municipais em termos populacionais, de gastos em saúde e de acesso aos recursos federais permitiram observar diferentes estratégias de gestão financeira e alocação dos recursos. Além dos recursos extraordinários, foi possível identificar, no período analisado, a presença relevante de repasses por Emendas Parlamentares. No contexto de desfinanciamento do SUS, esses recursos e repasses significaram, em muitos casos, a possibilidade de os gestores organizarem o sistema de saúde municipal segundo seu entendimento das necessidades de saúde e as respostas possíveis a essas necessidades. Evidenciou-se que os recursos para o enfrentamento à COVID-19 foram alocados principalmente na média e alta complexidade e na contratação de empresas privadas.

Abstract The study examined municipal managers' perceptions of extraordinary funding and its use to address COVID-19. In this multiple-case, quantitative and qualitative study, using embedded mixed methods, semi-structured interviews were conducted in six case-municipalities in São Paulo state. Secondary data for 2020 to 2022, drawn from information systems, were analysed. The municipalities differed by population, health expenditures and access to federal funding, making it possible to observe different financial management strategies and resource allocation. In addition to the extraordinary funding, considerable budget transfers were found to have been made by Parliamentary Amendments during the study period. In a context where the national Unified Health System is underfunded, extraordinary funding and budget transfers by Parliamentary Amendments often enabled managers to organise municipal health systems to meet their understanding of health needs and possible responses to those needs. Funding to address COVID-19 was allocated mainly to medium- and high-complexity services and to engaging private companies.

O mundo do trabalho não é automático: o que pode operar como dispositivo para a gestão do cuidado em municípios de pequeno porte? / The world of work is not automatic: what can operate as a device for managing care in small municipalities?

Resumo Este artigo pretende explorar experiências de dispositivos para a gestão do cuidado fabricadas pelas equipes gestoras de municípios de pequeno porte que podem ser aprendizados na produção de conhecimento e fazeres no SUS. A abordagem cartográfica foi utilizada para a construção do campo de pesquisa em dois pequenos municípios do estado de São Paulo, percorrendo diferentes espaços, formais e não formais, da saúde e intersetoriais, no período de 2018 a 2020. Analisadores foram produzidos a partir da vivência no campo e discutidos à luz da micropolítica do trabalho e do cuidado em saúde, dando visibilidade aos campos de disputa, desafios e potências dos municípios pequenos articulado à problematização sobre o eixo da integralidade e da gestão do cuidado. O mundo do trabalho está em plena disputa pelos atores-viventes do Sistema Único de Saúde, sendo atravessado pelo instituído e pela força médico-hegemônica. A fabricação de dispositivos para a gestão do cuidado é fundamental para favorecer deslocamentos e escapes em relação às capturas que são muitas e diversas no âmbito do trabalho e cuidado.

Abstract This article intends to explore experiences of devices for the management of care carried out by the management teams of small municipalities that can be learned in the production of knowledge and actions in the Brazilian National Health System. The cartographic approach was used to build the research field in two small municipalities in the state of São Paulo, covering different formal and non-formal health and intersectoral spaces in the period from 2018 to 2020. Analyzers were produced from the experience in the field and discussed in the light of the micropolitics of work and of health care, giving visibility to the fields of dispute, challenges, and powers of small municipalities. articulated with the problematization on the axis of comprehensiveness and of care management. The world of work is in full dispute for the living actors of the Brazilian National Health System, and is crossed by the established and by the hegemonic medical force. The manufacture of care management devices is fundamental to favor displacements and escapes in relation to captures that are many and diverse in the scope of work and care.

Strengthening primary health care in low- and middle-income countries: furthering structural changes in the post-pandemic era.

Strengthening primary health care (PHC) is the most cost-effective approach in low- and middle-income countries (LMICs) to achieve sustainable universal health coverage (UHC), protect against health shocks, and promote health and wellbeing for all people. It has been 45 years since PHC was put on the global agenda followed by multiple efforts to advocate for more funding and improved performance of PHC. Yet, investment in PHC is still insufficient and overall performance of PHC systems is weak in LMICs, resulting in increased vulnerability and poor health outcomes especially among marginalized populations. As countries recover from the COVID-19 pandemic, which exposed the fragility of PHC platforms, it is imperative to go beyond advocacy for PHC investments and make systemic changes to strengthen PHC as the foundation of resilient and equitable health systems. We propose five gamechangers to facilitate structural changes for strengthening PHC through a focused health systems approach: (i) integration of client-centered health services at PHC level; (ii) digitization of PHC services; (iii) efficiency gains invested in essential health services; (iv) strengthening management practices for PHC at district and facility levels; and (v) advancing community engagement for PHC. To be successful, the implementation of the gamechangers must be contextualized and focus on achieving sustainable health outcomes, and therefore use implementation approaches that link essential health services to health outcomes. Through this way countries will maximize the possibility of achieving UHC and attaining the ambitious health targets of the Sustainable Development Goals (SDGs) by 2030.

Sentidos do suicídio para profissionais de um distrito sanitário / Suicide senses for professionals of a sanitary district / Sentidos del suicidio para profesionales de un distrito del salud

Este estudo buscou compreender os sentidos atribuídos ao comportamento suicida por profissionais de um Distrito Sanitário de uma cidade do sul do Brasil. Participaram 15 profissionais, com diferentes formações, lotados em três pontos de atenção à saúde. Os dados foram coletados por meio de entrevistas semiestruturadas e submetidos à análise das práticas discursivas. Foram discutidos os sentidos: desamparo social, isolamento de idosos, vulnerabilidades dos adolescentes, dificuldades socioeconômicas e transtornos mentais. Os resultados indicaram o suicídio como um fenômeno que é atravessado por questões sociais e econômicas, geradoras de desamparo. Idosos e adolescentes foram descritos como os grupos etários mais vulneráveis. Em menor escala, o suicídio foi considerado como consequência de um transtorno mental e associado ao discurso psiquiátrico. Discute-se a necessidade de os profissionais que atuam no campo da saúde contribuírem para a promoção e o fortalecimento comunitário e estarem implicados tanto no desenvolvimento humano e social, como atentos para os fatores geradores de sofrimento psíquico (AU).

This study aimed to understand the senses attributed to suicidal behavior by professionals from a Sanitary District in a southern Brazilian city. 15 professionals with different trainings and from three health care points participated. Data were collected through semi-structured interviews and were analyzed by analysis of discursive practices. The following senses were discussed: social helplessness, elderly' isolation, adolescents' vulnerability, socioeconomic difficulties and mental disorders. The results indicated suicide as a phenomenon that is crossed by social and economic issues, generating helplessness. Elderly and adolescents were described as the most vulnerable age groups. On a smaller scale, suicide was attributed to the individual with mental disorder, contemplating the psychiatric discourse. It discusses the need to promote community strengthening and to be involved in both human and social development as well as to be attentive to the factors generating psychic suffering (AU)

Este estudio buscó comprender los sentidos atribuidos al comportamiento suicida por profesionales de un Distrito de Salud em una ciudad del sur del Brasil. 15 profesionales con diferentes formaciones y de tres puntos de atención de salud participaron. Los datos fueron recolectados a través de entrevistas semiestructuradas y sometidos a análisis de prácticas discursivas. Se discutieron los sentidos: impotencia social, aislamiento de los ancianos, la vulnerabilidad de los adolescentes, dificultades socioeconómicas y trastornos mentales. Los resultados indicaron el suicidio como un fenómeno superpuesto por cuestiones sociales y económicas, generando impotencia. Los ancianos y los adolescentes fueron descritos como los grupos de edad más vulnerables. Em menor medida, el suicidio se atribuyó al individuo con trastorno mental, contemplando el discurso psiquiátrico. Se discute la necesidad de promover el empoderamiento de la comunidad y participar en el desarrollo humano y social, así como estar atento a los factores que generan sufrimiento psicológico (AU).

Levantamento da organização e do funcionamento dos Conselhos Distritais de Saúde de João Pessoa ­ PB

Objetivo: apresentar à organização e funcionamento dos Conselhos Distritais de Saúde (CDS) de João Pessoa-Paraíba-Brasil, a participação social em saúde, suas dificuldades e potencialidades, particularmente aquelas observadas em espaços institucionalizados de controle social. Método: estudo qualitativo e descritivo utilizando observação participante, pesquisa documental e entrevistas individuais. Resultado: identificou-se o número, distribuição e organização dos CDS; número e periodicidade de reuniões; pautas abordadas; estratégias de mobilização; e composição; dificuldades e potencialidades. Conclusão: os resultados mostram que há diferentes dinâmicas de funcionamento, resultantes de níveis distintos de responsabilização e envolvimento de gestores, usuários e trabalhadores. Todos os CDS apresentam dificuldades e potencialidades.

Objective: To present to the organization and functioning of the District Health Councils (CDS) of João Pessoa­Paraíba­Brazil, social participation in health, its difficulties and potentialities, particularly those observed in institutionalized spaces of social control. Method: qualitative and descriptive study using participant observation, documentary research and individual interviews. Result: the number, distribution and organization of CDS were identified; number and frequency of meetings; guidelines addressed; mobilization strategies; and composition; difficulties and potentialities. Conclusion: the results show that there are different dynamics of functioning, resulting from different levels of accountability and involvement of managers, users and workers. All CDS present difficulties and potentialities.

Consórcios públicos de saúde: uma revisão da literatura / Public Health consortia: a literature review

Resumo A regionalização é uma estratégia de hierarquização dos serviços de saúde que orienta a descentralização das ações e serviços. Existem, entretanto, desafios para efetivar a regionalização, tais como as dificuldades para integrar e coordenar as ações e serviços, em diferentes espaços geográficos, com distintas gestões para atender as necessidades de saúde na escala, qualidade e custos adequados. Nesse contexto, surgem os consórcios públicos enquanto solução organizacional para suprir as necessidades de coordenação e integração entre os entes federativos. Os benefícios dos consórcios são o ganho de escala na prestação de serviços, a racionalidade de processos e de despesas, a realização de projetos conjuntos que seriam inviáveis de forma isolada. O objeto deste artigo é realizar uma investigação sobre como os consórcios intermunicipais de saúde conseguem obter melhor desempenho no que tange aos processos de aquisição e contratação de serviços de forma cooperativa, através de uma revisão bibliográfica narrativa. Os resultados da revisão foram divididos em 3 blocos: i) definições e conceitos dos consórcios públicos, ii) definições e conceitos sobre consórcios intermunicipais de saúde (CIS), iii) estudos de caso de CIS no Brasil.

Abstract Regional Health Planning is a health services' hierarchization strategy that allows actions and services decentralization. Nonetheless, some challenges to implementing regional health planning are identified, such as difficulties in coordinating actions and services in different geographic locations, with different managements to meet population health needs with adequate scale, quality, and cost. In this context, intercity health consortia emerge as an organizational solution that allows better coordination and integration between federative entities, and their main benefits are scale gain in public services delivery; rationalization of processes and expenses; and realization of joint projects that would be impossible to be implemented if managed and funded in isolation. This paper aims to understand how health consortia reach better performance in the procurement and hiring of services by cooperative action through a narrative literature review. The results are organized into three parts: i) definition and concepts of public consortium; ii) definition and concepts of intercity health consortium (CIS); iii) health consortium case studies in Brazil.

Financiamento em saúde indígena: uma análise dos planos distritais de saúde do interior sul e do litoral sul / Financing for indigenous health: an analysis of district health plans south interior and south coast

Os povos indígenas possuem vulnerabilidades próprias que demandam um modelo de gestão de saúde que contemple suas necessidades étnico-culturais. A atenção à saúde indígena deve primar pela diferenciação assistencial que considere o caráter multiétnico dos indígenas. Com a criação dos Distritos Sanitários Especiais Indígenas (DSEI), surgiu a necessidade de uma estrutura administrativa que atendesse as demandas da saúde indígena. A Secretaria de Saúde Indígena (SESAI) foi criada considerando a descentralização dos recursos administrativos, gerenciais, financeiros e orçamentários do Ministério da Saúde para os DSEI, com a finalidade de contemplar essa pluralidade étnica e especificidades loco-regionais. Em vista disto, o presente estudo tem como objetivo analisar os Planos Distritais de Saúde dos Distritos Sanitários Especiais Indígenas (PDSI) Interior Sul e Litoral Sul no período de 2012 a 2015. Utilizou-se como fonte de dados o PDSI do DSEI Interior Sul e o PDSI do DSEI Litoral Sul, ambos relativos a 2012-2015. Trata-se de um estudo de cunho documental qualiquantitativo realizado a partir da análise da dotação orçamentária de gestão compartilhada dos DSEIs. Foram criadas planilhas para avaliação do comprometimento do financiamento de saúde com as despesas de custeio e de capital. Demonstrou-se preponderância com gastos de custeio em terceirizações com atividades administrativas e gerenciais em ambos os DSEIs nos períodos de análises. Após a descentralização dos recursos da SESAI, evidenciaram-se incrementos de repasses públicos à iniciativa privada. A autonomia e a descentralização orçamentária para a operacionalização da assistência de saúde indígena deveriam implicar na afirmação do setor público em relação aos gastos com o setor privado e a importância da manutenção da função do Estado como provedor e administrador dos recursos públicos ao invés de repasses para iniciativa privada.

Indigenous peoples have their own vulnerabilities that demand a health management model that addresses their ethnic-cultural needs. Attention to indigenous health must excel in the assistance differentiation that considers the multiethnic character of the Indians. With the creation of the Special Indigenous Health Districts (DSEI), the need for an administrative structure that met the demands of indigenous health emerged. The Secretariat of Indigenous Health (SESAI) was created considering the decentralization of the Ministry of Health's administrative, managerial, financial and budgetary resources to the DSEI, with the purpose of contemplating this plurality of ethnicity and loco-regional specificities. In view of this, the present study aims to analyze the District Health Plans of the Special Indigenous Sanitary Districts (PDSI) Interior Sul and Litoral Sul from 2012 to 2015. The PDSI of the DSEI Interior and the PDSI of the DSEI Litoral Sul were used as data source, both related to 2012-2015. It is a qualitative and quantitative documentary study carried out based on the analysis of the budgetary allocation for shared management of the DSEIs. Spreadsheets were created to assess the commitment of health financing to current and capital expenditures. There was a preponderance of costing expenses in outsourcing with administrative and managerial activities in both DSEIs during the period analysis. After the decentralization of SESAI resources, there was an increase in public transfers to the private sector. Budgetary autonomy and decentralization for the operationalization of indigenous health care should imply the affirmation of the public sector in relation to expenditures with the private sector and the importance of maintaining the role of the State as provider and administrator of public resources to the public rather than transfer to private initiative.

Atuação dos hospitais de pequeno porte de pequenos municípios nas redes de atenção à saúde / Performance of small-sized hospitals from small municipalities in health care networks

Resumo O objetivo deste artigo é compreender os valores sociais e a atuação e inserção dos hospitais de pequeno porte em municípios pequenos nas redes de atenção à saúde. Realizou-se estudo de natureza qualitativa, entrevistando os secretários de saúde e diretores dos hospitais de pequeno porte localizados em 14 municípios de até 20 mil habitantes do estado do Paraná, tendo como referencial teórico conceitos bourdieusianos de capital simbólico, habitus e campo. Verificou-se que há o discurso pela manutenção destes hospitais, ainda que não respondam de forma resolutiva às demandas da população, pois o seu fechamento causaria um impacto negativo para a legitimação do gestor em exercício. Os hospitais de pequeno porte participam da rede de urgência, mesmo que não resolvam muitos dos problemas demandados. Entretanto, ao fazer parte do complexo regulador, seus usuários podem ser encaminhados para hospitais de maior porte. Quanto à Rede Mãe Paranaense, a maioria dos hospitais de pequeno porte atuam como encaminhadores de gestantes para hospitais/maternidades de referência, embora o desejo da população local seja que a atenção às parturientes ocorra nos municípios de residência. Conclui-se que a organização destes hospitais e sua inserção nas redes de atenção ainda é incipiente.

Abstract The purpose of this article is to comprehend the social values and the performance and insertion of small-sized hospitals in small cities in health care networks. A qualitative study was carried out, with interviews to health secretaries and directors of these hospitals located in 14 municipalities of up to 20,000 inhabitants of the state of Paraná, having as theoretical reference bourdesian concepts of symbolic capital, habitus and field. It was verified that there is a discourse for the maintenance of these hospitals, although they do not respond in a resolutive way to the demands of the population, since their closure would have a negative impact on the legitimacy of the current manager. The small-sized hospitals participate in the emergency network, even though they do not solve many of the problems required. However, as a part of the regulatory complex, their users can be referred to larger hospitals. Regarding the Mãe Paranaense Network, most small-sized hospitals act as referrers of pregnant women to reference hospitals/maternities, although the desire of the local population was that the attention to the parturient occurred in the municipalities of residence. It is concluded that the organization of these hospitals and their inclusion in the Care Networks is still incipient.

The governance of local health systems in the era of Sustainable Development Goals: reflections on collaborative action to address complex health needs in four country contexts.

This analysis reflects on experiences and lessons from four country settings-Zambia, India, Sweden and South Africa-on building collaborations in local health systems in order to respond to complex health needs. These collaborations ranged in scope and formality, from coordinating action in the community health system (Zambia), to a partnership between governmental, non-governmental and academic actors (India), to joint planning and delivery across political and sectoral boundaries (Sweden and South Africa). The four cases are presented and analysed using a common framework of collaborative governance, focusing on the dynamics of the collaboration itself, with respect to principled engagement, shared motivation and joint capacity. The four cases, despite their differences, illustrate the considerable challenges and the specific dynamics involved in developing collaborative action in local health systems. These include the coconstruction of solutions (and in some instances the problem itself) through engagement, the importance of trust, both interpersonal and institutional, as a condition for collaborative arrangements, and the role of openly accessible information in building shared understanding. Ultimately, collaborative action takes time and difficulty needs to be anticipated. If discovery, joint learning and developing shared perspectives are presented as goals in themselves, this may offset internal and external expectations that collaborations deliver results in the short term.

The complex challenge of providing patient-centred perinatal healthcare in rural Uganda: A qualitative enquiry.

RATIONALE: Increasing research and reflections on quality of healthcare across the perinatal period slowly propels the global community to lobby for improved standards of quality perinatal healthcare, especially in low- and middle-income countries. OBJECTIVE: The purpose of this qualitative study was to obtain a deeper understanding of how interpersonal dimensions of the quality of care relate to real-life experiences of perinatal care, in a resource-constrained local health system. METHODS: In total, 41 in-depth interviews and five focus group discussions (N = 34) were conducted with perinatal women and local health system health professionals living and working in rural Uganda. Data analysis used an emergent and partially inductive, thematic framework based on the grounded theory approach. RESULTS: The results indicated that interpersonal aspects of quality of perinatal care and service delivery are largely lacking in this low-resource setting. Thematic analysis showed three interrelated process aspects of quality of perinatal care: negative reported patient-provider interactions, the perceptions shaping patient-provider interactions, and emergent consequences arising out of these processes of care. Further reflections expose the central, yet often-unheeded, role of perinatal women's agency in their own health seeking behaviours and overall well-being, as well as that of underlying practical norms surrounding health worker attitudes and behaviours. CONCLUSION: These findings highlight the complexity of patient-centred perinatal healthcare provision in rural Uganda and point to the relevance of linking the interpersonal dimensions of quality of care to the larger systemic and structural dimensions of perinatal healthcare.

Agentes de salud en el contexto de pluralidad medica de Haquira. Apurímac, Perú / Health agents in the context of medical plurality of Haquira. Apurimac, Peru

Introducción. Nuestra investigación tuvo como objetivo describir la presencia y rol social de los agentes de salud en el contexto dinámico del distrito de Haquira en la región de Apurímac, Perú. Métodos. Estudio de carácter cualitativo en el que se empleó la técnica etnográfica. Se recurrió al trabajo de campo en el que se hizo uso de las entrevistas a profundidad, conversaciones y observación participante. Resultados. Se evidencia un contexto de pluralidad de los sistemas de salud por la diversidad de agentes y el empleo de repertorios terapéuticos. La concepción holística de la salud se basa en la búsqueda del equilibrio. La población se caracteriza por la autoatención y ello permite la formación de "curiosos" que sobresalen en conocimientos sobre salud. Los agentes locales inician como curiosos y sus opciones son convertirse en aficionados, especialistas o profesionales. Proliferan los aficionados, hay preferencia para la formación de profesionales y hay una baja tasa para la formación de especialistas tradicionales. Con los cambios acelerados del contexto y la concepción holística de salud se da acogida a la llegada de nuevos agentes foráneos. Conclusiones. Existe una gran diversidad de agentes de salud. Los agentes locales vienen disminuyendo, por el avance de la modernidad, la subordinación de estos frente al sistema oficial, la proliferación de la oferta médica, mayor acceso a la información de la población. No hay trabajo de rectoría de la salud, no existe reconocimiento de agentes tradicionales, no hay fiscalización a quienes ofertan servicios o medicamentos. Se necesita hacer un mapeo de los agentes de salud como primer paso para establecer trabajos en base al dialogo intercultural.

Introduction. Our research was objetive to describe the presence and social role of health agents in the dynamic context of district Haquira, Apurímac region, Peru. Methods. Qualitative study in which the ethnographic technique was used. Fieldwork was used in which in-depth interviews, conversations and participant observation were used. Results. A context of plurality of health systems is evidenced by the diversity of agents and the use of therapeutic repertoires. The holistic conception of health is based on the search for balance. The population is characterized by self-care and this allows the formation of "curious" people who excel in health knowledge. Local agents start as curious and their options are to become amateurs, specialists or professionals. There is a proliferation of amateurs, there is a preference for the training of professionals and there is a low rate for the training of traditional specialists. With the accelerated changes in the context and the holistic conception of health, the arrival of new foreign agents is welcomed. Conclusions. There is a great diversity of health agents. Local agents are decreasing, due to the advancement of modernity, the subordination of these to the official system, the proliferation of the medical offer, greater access to information for the population. There is no health rectorial work, there is no recognition of traditional agents, there is no control to those who offer services or medicines. It is necessary to make a mapping of the health agents as a first step to establish works based on intercultural dialogue.

Desafios às ações educativas das Equipes de Saúde Bucal na Atenção Primária à Saúde: táticas, saberes e técnicas / Challenges of oral health teams educational activities in Primary Health Care: tactics, knowledge and techniques

Resumo Estudo sobre as práticas educativas das Equipes de Saúde Bucal na Atenção Primária à Saúde em Salvador, Bahia. A pesquisa teve como objetivos a análise das táticas das Equipes de Saúde Bucal para envolvimento da comunidade nas práticas de educação em saúde e discutir os saberes e técnicas desenvolvidas nas ações educativas. Optou-se pela abordagem qualitativa, por meio de 22 entrevistas semiestruturadas, envolvendo sete cirurgiões-dentistas, sete auxiliares de saúde bucal, seis gerentes das unidades de saúde e dois gestores distritais. A análise de conteúdo temática orientou a análise e interpretação dos resultados. O modelo educativo estava centrado no saber do cirurgião-dentista, revelado no caráter prescritivo e burocrático das atividades desenvolvidas na comunidade. Tais práticas educativas tendem a não incentivar a autonomia dos usuários, fazendo-os, de certa forma, reféns do modelo hegemônico de produção do cuidado focado na doença.

Abstract Study on the educational practices of Oral Health Teams, members of the Primary Health Care in Salvador, Bahia state, Brazil. The research aimed to analyze the tactics used by Oral Health Teams for community involvement in health education programs and discuss pedagogical practices (knowledge and techniques) developed in educational activities. Qualitative approach was carried out by using 22 semi-structured interviews involving seven dentists, seven oral health assistants, six managers of health facilities and two district managers. Thematic content analysis guided the outcomes discussion. The educational model was centered on dentist's knowledge, revealed in prescriptive and bureaucratic nature of the activities in the community. Such educational practices tend not to encourage the users' autonomy, making them, in a sense, hostage to the hegemonic model of care focused on disease.

A framework to assess management performance in district health systems: a qualitative and quantitative case study in Iran / Um modelo para avaliar a gestão dos distritos sanitários no Irã: um estudo de caso qualitativo e quantitativo / Un marco para evaluar el desempeño de la gestión en el área de sistemas de salud: un estudio de caso cualitativo y cuantitativo en Irán

The aim was to design a district health management performance framework for Iran's healthcare system. The mixed-method study was conducted between September 2015 and May 2016 in Tabriz, Iran. In this study, the indicators of district health management performance were obtained by analyzing the 45 semi-structured surveys of experts in the public health system. Content validity of performance indicators which were generated in qualitative part were reviewed and confirmed based on content validity index (CVI). Also content validity ratio (CVR) was calculated using data acquired from a survey of 21 experts in quantitative part. The result of this study indicated that, initially, 81 indicators were considered in framework of district health management performance and, at the end, 53 indicators were validated and confirmed. These indicators were classified in 11 categories which include: human resources and organizational creativity, management and leadership, rules and ethics, planning and evaluation, district managing, health resources management and economics, community participation, quality improvement, research in health system, health information management, epidemiology and situation analysis. The designed framework model can be used to assess the district health management and facilitates performance improvement at the district level.

O estudo teve como objetivo desenvolver um modelo para avaliar a gestão dos distritos sanitários no sistema de saúde iraniano. Um estudo de métodos mistos foi realizado entre setembro de 2015 e maio de 2016 em Tabriz, Irã. Os indicadores de desempenho da gestão dos distritos sanitários foram obtidos a partir da análise de 45 entrevistas semiestruturadas com especialistas no sistema público de saúde. A validade do conteúdo dos indicadores de desempenho gerados pelo componente qualitativo foi revisada e confirmada com base no índice de validade de conteúdo (IVC). A razão de validade de conteúdo (RVC) foi calculada com os dados adquiridos em entrevistas com 21 especialistas durante a etapa quantitativa. Os resultados do estudo indicam que, inicialmente, 81 indicadores foram considerados no modelo de desempenho de gestão dos distritos sanitários, e que, no final, 53 indicadores foram validados e confirmados. Estes indicadores foram classificados em 11 categorias: recursos humanos e criatividade organizacional, gestão e liderança, regras e ética, planejamento e avaliação, gestão distrital, gestão de recursos de saúde e economia, participação comunitária, melhoria de qualidade, pesquisa no sistema de saúde, gestão da informação em saúde, epidemiologia e análise situacional. O modelo projetado pode ser usado para avaliar a gestão dos distritos sanitários, além de facilitar a melhoria do desempenho em nível distrital.

El objetivo del presente estudio fue diseñar un marco para evaluar el desempeño de la gestión en el ámbito de la salud dentro del sistema de salud iraní. Se realizó un método mixto de estudio entre septiembre 2015 y mayo 2016 en Tabriz, Irán. En este estudio, los indicadores del desempeño en la gestión dentro del ámbito de la salud se obtuvieron analizando 45 encuestas semiestructuradas de expertos en el sistema público de salud. Los indicadores de rendimiento, respecto a la validez del contenido que se generaron en la parte cualitativa, fueron revisados y confirmados basándose en el índice de validez de contenido (IVC). Asimismo, el content validity ratio (CVR) se calculó usando datos obtenidos de una encuesta a 21 expertos en la parte cuantitativa del estudio. El resultado del mismo indicó que, inicialmente, se consideraron 81 indicadores en el marco del desempeño de la gestión en el ámbito de la salud y, al final, se validaron 53 indicadores y confirmados. Estos indicadores se clasificaron en 11 categorías que incluían: rescusos humanos y creatividad organizativa, gestión y liderazgo, reglas y ética, planificación y evaluación, gestión de área, gestión de recursos de salud y económicos, participación en la comunidad, mejora de la calidad, investigación en sistemas de salud, gestión de información sobre la salud, epidemiología y análisis de situación. El modelo de marco diseñado puede ser usado para evaluar la gestión en el ámbito de la salud y facilitar la mejora del desempeño en el ámbito municipal.

O tempo de percurso a cidades polos regionais influencia na mortalidade em pequenos municípios gaúchos? / Does time spent traveling to regional hub cities to receive healthcare influence mortality in small towns in Rio Grande do Sul State, Brazil? / ¿El tiempo de desplazamiento a ciudades que son polos regionales tiene influencia en la mortalidad en los municipios pequeños del Rio Grande do Sul, Brasil?

Resumo: O presente estudo objetiva responder se o tempo de viagem a municípios polos regionais possui efeito na taxa de óbitos por causas evitáveis (TOCE) e na taxa bruta de mortalidade padronizada (TBMP) em municípios com até 5 mil habitantes do Rio Grande do Sul, Brasil. Sem a utilização de variáveis controles, o maior tempo de percurso até municípios com 100 mil habitantes ou mais está associado com um aumento de ambas as taxas. No entanto, enquanto que o comportamento da TOCE permanece similar após a inserção dos controles, a TBMP inverte seu sinal, sugerindo que, mantendo as demais características socioeconômicas e de atendimento de saúde constantes, a distância a municípios polos está associada, ao mesmo tempo, a uma redução dos óbitos por causas evitáveis e a um aumento nas demais causas de morte.

Abstract: The current study aims to determine whether the time spent travelling to regional hub cities to receive healthcare affects mortality from avoidable causes and the standardized crude mortality rate in towns with up to 5,000 inhabitants in Rio Grande do Sul State, Brazil. Without adjusting for control variables, the longest time spent to reach cities with 100,000 inhabitants or more was associated with an increase in both rates. However, while the pattern in the avoidable mortality rate was similar after including controls, the standardized crude mortality rate reversed its signal. This suggests that if other socioeconomic and healthcare characteristics are kept constant, the distance to reference cities is associated with both a reduction in deaths from avoidable causes and an increase in other causes of death.

Resumen: El objetivo del presente estudio es responder si el tiempo de viaje a municipios que son polos regionales posee un efecto en la tasa de óbitos por causas evitables y en la tasa bruta de mortalidad estandarizada en municipios con hasta 5.000 habitantes del estado de Rio Grande do Sul, Brasil. Sin la utilización de variables de control, el mayor tiempo de desplazamiento -hasta municipios con 100 mil habitantes o más- está asociado con un aumento de ambas tasas. No obstante, mientras que el comportamiento de la tasa de óbitos evitables permanece similar tras la inclusión de los controles, la tasa bruta de mortalidad estandarizada invierte su señal, sugiriendo que manteniendo constantes las demás características socioeconómicas y de atención de salud, la distancia a municipios polos regionales está asociada simultáneamente a una reducción de los óbitos por causas evitables y a un aumento en las demás causas de muerte.

Avaliação da Rede de Atenção à Saúde de pequenos municípios na ótica das equipes gestoras / Evaluation of the Health Care Network in small towns from the perspective of management teams

Estudo de caso com objetivo de analisar a Rede de Atenção à Saúde em dois municípios de pequeno porte, baseado nos elementos institucionais que configuram o padrão de interdependência em rede e na análise de atributos que indicam o nível de integração da rede de serviços de saúde. Foram realizados grupos focais com equipes gestoras dos municípios, bem como entrevistas com informantes-chave da gestão regional e do serviço de referência regional hospitalar, analisadas pelo método de interpretação de sentidos. A análise expôs uma rede parcialmente integrada e relações de interdependência que apresentam interesses divergentes e pouca confiança entre os atores, dificultando a governança.

Case study aiming to analyze the Health Care Network in two small towns, based on the institutional elements that configure the pattern of network interdependence and on the analysis of attributes that indicate the level of integration of the health services network. Focus groups were conducted with management teams of municipalities, as well as interviews with regional management key informant and the regional hospital reference service, analyzed by method of interpretation of meanings. The analysis exposed a partially integrated network and interdependence relations that have divergent interests and a low level of trust between the actors - a condition that hinders governance.

AIDS e as primeiras respostas voltadas para a epidemia: contribuições dos profissionais de saúde / AIDS and early responses to the epidemic: contributions from health professionals / SIDA y las primeras respuestas ante la epidemia: contribuciones de los profesionales de salud

Estudo descritivo qualitativo com perspectiva socio-histórica, que objetivou descrever o contexto em que surgiram as primeiras ações em resposta à epidemia da Síndrome da Imunodeficiência Adquirida (AIDS) em Florianópolis-SC, Brasil. O marco histórico inicial é o ano de 1986, quando o primeiro caso da doença foi notificado, até 1993, quando foi oficializado o Programa Municipal de Doenças Sexualmente Transmissíveis (DST)/AIDS no município. Utilizou-se como referencial teórico-metodológico a nova história, mediante a pesquisa documental e história oral temática. Os sujeitos do estudo foram seis profissionais de saúde que exerceram atividades de assistência e/ou gestão vinculadas às DST/AIDS, no período do estudo. Para tratamento dos dados, utilizamos análise de conteúdo. Destacaram-se, neste estudo, a falta de estrutura do sistema de saúde na época e as iniciativas pessoais de profissionais de saúde que entenderam a emergência da epidemia e passaram a articular ações assistenciais e preventivas, apesar dos poucos recursos disponíveis na época.

This socio-historical, descriptive, qualitative study describes the context in which early action a rose in response to the AIDS epidemic in Florianópolis. The study time frame is from 1986, when the AIDS case was reported, to 1993, when the Municipal Program on Sexually Transmitted Diseases (STDs)/AIDS was officially launched in the city. The theoretical and methodological frame of reference given by ‘new history’ informed documentary research and thematic oral history. The study subjects were six health professionals engaged in STD/AIDS-related care and/or management activities during the study period. Data were processed using content analysis. The study highlighted the inadequate structure of the health system at the time and personal initiatives by health professionals who understood the emergency nature of the epidemic and began to organize care and preventive measures, despite the sparse resources available at the time.

Estudio descriptivo cualitativo con perspectiva socio y histórica, cuyo objetivo fue describir el contexto en que surgieron las primeras acciones en respuesta a la epidemia del SIDA en Florianópolis-SC-Brasil. El marco inicial es el año 1986, cuando se reportó el primer caso de la enfermedad, hasta 1993, cuando fue oficializado el Programa Municipal de Enfermedades de Transmisión Sexual (ETS) / SIDA en la ciudad. Fue utilizado la nueva historia, mediante la investigación documental y la historia oral temática. Los sujetos de estudio fueron seis profesionales de salud que ejercían actividades de atención y/o gestión vinculadas al ETS-SIDA durante el período en estudio. Para el procesamiento de los datos, se utilizó el análisis de contenido. Se destacan, en este estudio, la falta de estructura del sistema de salud en ese momento y las iniciativas personales de profesionales de la salud que comprenden la aparición de la epidemia y empezó a articular acciones y la atención preventiva, a pesar de los limitados recursos disponibles en ese momento.

Políticas de saúde informadas por evidências: relato da cooperação Brasil-Moçambique / Evidence-informed health policy: report of the Brazil-Mozambique cooperation

Neste artigo, descrevem-se os principais elementos da cooperação bilateral entre Brasil e Moçambique na área de desenvolvimento de capacidades em políticas de saúde informadas por evidências. Apresentam-se aspectos relevantes da colaboração multi-institucional, descrevem-se visitas internacionais, incluindo re uniões de trabalho, a oficina sobre as Ferramentas SUPPORT e seus desdobramentos e futuras perspectivas de trabalho. Os principais ganhos da colaboração foram o fortalecimento institucional pela aproximação e o intercâmbio de grupos de pesquisa, a docência e gestão pública de saúde, o aprimoramento metodológi co da oficina e insights sobre as melhores formas de fazer chegar as evidências disponíveis a quem tem o poder de tomar decisões no Ministério da Saúde em Moçambique através da cooperação entre o Instituto Nacional de Saúde e a Faculdade de Medicina da Universidade Eduardo Mondlane.

Evidence-informed health policy: report of the Brazil-Mozambique cooperation Abstract in this article, we describe the main elements of the Brazil-Mozambique bilateral cooperation in the area of capacity building in evidence-informed policy in health. We mapped relevant aspects of multi-institutional collaboration and described international visits, including various meetings, a workshop on the SUPPORT tools and its outputs and perspectives on future jointed work. Key gains from such collaboration were institutional strengthening through gathering and exchange among health research, academics, and policy makers; workshop methodological improvement, and insights on best ways to provide evidence to decision makers in the Ministry of Health of Mozambique through cooperation between the National Institute of Health and the University Eduardo Mondlane's Faculty of Medicine.