Ethical and Human Rights Foundations of Health Policy: Lessons from Comprehensive Reform in Mexico.

This paper discusses the use of an explicit ethical and human rights framework to guide a reform intended to provide universal and comprehensive social protection in health for all Mexicans, independently of their socio-economic status or labor market condition. This reform was designed, implemented, and evaluated by making use of what Michael Reich has identified as the three pillars of public policy: technical, political, and ethical. The use of evidence and political strategies in the design and negotiation of the Mexican health reform is briefly discussed in the first part of this paper. The second part examines the ethical component of the reform, including the guiding concept and values, as well as the specific entitlements that gave operational meaning to the right to health care that was enshrined in Mexico's 1983 Constitution. The impact of this rights-based health reform, measured through an external evaluation, is discussed in the final section. The main message of this paper is that a clear ethical framework, combined with technical excellence and political skill, can deliver major policy results.

[The law of rights and duties of persons in health care from the viewpoint of bioethics]. / Ley de derechos y deberes de las personas en la atención de salud: Una mirada bioética.

The enactment of Law 20.584 in April of 2012 promotes a change in the physician-patient relationship, with recognition of people's rights and duties in healthcare by all the health professional and entities. The legal obligation, and not only the ethical one, as it currently happens, for humane treatment and regard for the dignity of the sick, informed consent, medical data confidentiality, the possibility to reject treatments, etc., is established. This review analyzes the contents of this law, especially those parts affecting physicians. It exposes its limitations, especially those related to minors' consent, living wills and research in people with mental disabilities. It also highlights positive aspects such as the promotion of a humane healthcare. This Law begins to consider patients' autonomy shyly. However, from a bioethical viewpoint, there are still many issues to be perfected such as healthcare humanization, excellence of patient care, healthcare quality and medical professionalism, considering competence, social service, charity and solidarity. It is a first step that must be supplemented with a greater development of medical deontology, and the development of clinical and institutional bioethics.

A integralidade na formação dos profissionais de saúde: tecendo valores / The integral health care in the training of health professionals: building values

A integralidade da assistência, um dos princípios doutrinários do sistema de saúde brasileiro, constitui uma das principais metas para se alcançar uma assistência de qualidade e humanizada. O presente trabalho tem por objetivo analisar a percepção dos professores dos cursos de graduação que formam profissionais de saúde na Universidade Federal de Juiz de Fora, sobre a formação orientada pela integralidade. Trata-se de uma pesquisa qualitativa, na qual foi utilizada a técnica da entrevista semiestruturada com docentes dos referidos cursos. Como estratégia de análise dos dados, propõese a modalidade de análise temática. A categoria em torno da qual são trazidas as reflexões sobre a percepção dos docentes sobre o ensino voltado para o princípio da integralidade foi nomeada "os princípios do SUS orientando a formação". Os resultados do estudo apontam que os docentes expressam um envolvimento com os valores da Reforma Sanitária brasileira, no contexto das mudanças necessárias na formação em saúde.

Integral healthcare, one of the doctrinal principles of the Brazilian health care system, is one of the main ways to reach high-quality and humanized care. This work aims to analyze the perception of teachers of undergraduate courses who train health professionals at Juiz de Fora Federal University, Brazil, when it comes to integral care-oriented training. It is a qualitative research, employing the semi-structured interview technique with teachers of the studied courses. The thematic analysis is suggested as the data analysis method. The reflections on the perception of teachers about the principle of the integral healthcare have been centered on the category "trainingorienting principles of the Unified Health System". The study results show that teachers express involvement with the Brazilian Health Reform values, in the context of necessary changes in health training.

Política de atenção ao indivíduo em sofrimento mental em um município do oeste do Paraná / Policy attention to individuals with mental suffering in a western city of Paraná

A assistência psiquiátrica a indivíduos com sofrimento psíquico, em seu campo político, passou por um longo processo de discussão e formulação de estratégias a fim de garantir condição de humanidade aos indivíduos assistidos. A Reforma Psiquiátrica brasileira, como ficou conhecida, ocorreu concomitante ao processo de Reforma Sanitária e formulou leis para a garantia da integralidade e do acesso universal à saúde em território nacional sob a responsabilidade das esferas governamentais. No município de Cascavel – PR, o processo de formulação das políticas assistenciais para o indivíduo com transtorno mental se inicia na década de 90, porém só é efetivamente estruturado a partir de 2003 com o fechamento do Hospital Psiquiátrico São Marcos, que forçou o município a agilizar o processo de implantação da rede assistencial e de serviços complementares com moldes psicossociais. Com isso o município estrutura a assistência ao portador de transtorno mental através da implantação de ambulatório especializado, serviço de urgência e centros de atenção psicossocial para adultos, crianças e usuários de álcool e outras drogas, todos estruturados com suporte assistencial realizado pela Unidade Básica de Saúde (UBS). Em cada UBS foi nomeado um profissional de referência para o acompanhamento desses usuários e de seus familiares com o intuito de fortalecer o vínculo e manter a relação entre os serviços complementares e atenção primária. O presente estudo é centrado na pesquisa bibliográfica e de campo, com caráter qualitativo, cujo ponto de partida é a coleta de dados por meio de aplicação de questionário semi-estruturado com a finalidade de conhecer o processo de formulação das políticas municipais de atenção ao doente mental através do questionamento sobre as práticas assistenciais desenvolvidas pela atenção primária à saúde...

The psychiatric care to individuals with psychological distress, based on its political area, went through a long process of discussion and formulation of strategies to ensure human condition for assisted individuals. Psychiatric Reform in Brazil, as it was known, happened concomitantly with the Sanitary Reform and stated laws to guarantee the completeness anduniversal access to health in the country under the responsibility of the civil cabinet. In the city of Cascavel, Paraná State, the process of formulating welfare policies for individuals withmental illness has started in the 90s, but, it is only effectively structured up from 2003, when São Marcos Hospital was closed. This forced the municipality to expedite the implementing process concerning the care network and additional services with psychosocial patterns. Thus, the municipality structures assistance to the ones who were mentally ill through theimplementation of an outpatient clinic, emergency department and psychosocial care centers for adults, children and users of alcohol and other drugs, all structured to support careconducted by the Basic Health Unit (BHU). In each BHU, it was designated a professional of reference for the monitoring of users and their families in order to strengthen the bond and keep the relationship among complementary services and primary care. This study is focused on literature and field research, with qualitative approach, whose starting point is the collection of data through the application of semi-structured questionnaire in order to know the process for formulation of municipal policies to mental patient care through the questioning of care practices developed by primary health care.

Aprendendo a caminhar na cidade: idosos em residências terapêuticas / Learning to walk in the city: elders in therapeutic residences

O presente estudo é uma pesquisa qualitativa que emprega técnicas do trabalho de campo etnográfico, realizada nos serviços residenciais terapêuticos do Instituto Municipalde Assistência à Saúde Juliano Moreira, com o objetivo de estudar indivíduos idosos portadores de transtornos mentais crônicos que passaram pelo processo de desinstitucionalização. Procura conhecer de que forma estes idosos reconstroem suas relações com o novo território onde passam a circular e com o contexto social aonde vão seinserir, enquanto envelhecem e recriam a vida fora do asilo. De forma a atingi-lo, foram escolhidos, dentre os dispositivos que compõem o programa, 14 residências onde residem idosos. Os 30 indivíduos estudados representam 81 por cento do total de idosos e 36 por cento da clientela do programa, tendo sido observados em seu cotidiano dentro e fora das moradias, em suas relações entre si, com os membros da equipe e com o território, onde re-estabelecem suas redes sociais e recuperam sua capacidade de agir segundo a lógica da reciprocidade nas trocas com outras pessoas. Os dados foram coletados pela observação participante dentro efora das residências, assim como pelas entrevistas abertas, semi-estruturadas, as quais foram gravadas, transcritas e analisadas. Observou-se que os idosos apresentam ganhos em diversos aspectos de suas vidas com relação às trocas sociais e ao domínio sobre o território, mas ainda guardam resquíciosde seu período de institucionalização presentes nas suas rotinas diárias. Notou-se dentro das moradias, a existência de laços sociais baseados na reciprocidade e na ajuda mútua,possibilitando o cuidado e o apoio às necessidades dos idosos mais dependentes...

This work is a qualitative research which employs techniques of ethnographic field work carried out at residential facilities of Instituto Municipal de Assistência à Saúde Juliano Moreira, focusing on elder subjects who have undergone psychiatric deinstitutionalization in search of how they rebuild their relationships in the territory and with their social context in which they live, while they get old and recreate life outside the mental asylum. In order to achieve it, 14 facilities where old people live were chosen among the other residential devices. The 30 elders represent 81% of the total of old people and 36% of the total amount of residents, having been observed in their daily activities inside and outside their houses in their relationships among themselves, other people and with the territory, where they reconstruct their social ties and recover their ability of acting according to the logic of reciprocity and gift. The data were collected by participant observation and open, half-structured interviews, which were recorded, transcribed and analyzed. Observations have shown that elders show improvements in several aspects of their lives but the internment period remains in their daily routines. There are social bonds based on reciprocity and mutual help providing care and social support, especially for the more dependent ones. The stimulus of gift and reciprocity plays a pivotal role on planning residential facilities for elders with mental disorders. Their social networks develop in theneighborhood, accomplishing their roommates and other deinstitutionalized individuals, although neighbors and friends with no connections to the psychiatric institution are increasing their participation. They visit the asylum and circulate well in their surroundings,demanding support from the staff to go to more distant places. Their relation with the territory is an ongoing process, based on each one’s ability...

O processo de construção de uma rede de atenção em saúde mental: desafios e potencialidades no processo de reforma psiquiátrica / Building a process of mental health care network: challenges and potentialities of the psychiatric reform

O objetivo deste trabalho foi investigar como vem sendo o processo de construção da rede de atenção em saúde mental no município de Santa Maria-RS, tendo como foco sua articulação com os ideais da Reforma Psiquiátrica e do SUS. O referencial metodológico utilizado foi o da Pesquisa-Ação Integral e Sistêmica. Os sujeitos da pesquisa constituíram-se por gestores e trabalhadores vinculados à Secretaria de Saúde do município, sendo que a coleta de dados ocorreu a partir da observação participante das reuniões da Comissão Municipal de Saúde Mental e de entrevistas com informantes. Os dados apontam que o sistema de referência e contra-referência é pouco efetivo e os processos de trabalho são fragmentados, gerando descontinuidade dos tratamentos e desresponsabilização profissional. As estratégias de construção e articulação da rede, pactuadas entre gestores e trabalhadores de saúde, envolvem a implantação de serviços substitutivos, a criação de uma Comissão de Saúde Mental e a capacitação em saúde mental para a atenção básica. Encontramos ainda uma série de estratégias agenciadas no cotidiano dos processos de trabalho, determinando uma rede informal não prevista pela macropolítica de saúde. Problematizamos os efeitos da adequação dos serviços substitutivos ao SUS, assim como os efeitos ambíguos do modo como as estratégias de construção e articulação da rede são efetivadas.

This work aims to investigate how the mental health care network has been built in Santa Maria, State of Rio Grande do Sul, focusing on its articulation with the ideals of the Psychiatric Reform and the SUS. The methodology was the Systemic and Integral Action Research. The research subjects were managers and workers of the municipal Health Department. Data collection was carried out through participant observation in Mental Health Commission meetings, as well as in interviews with informants. Data points out that the reference and counter-reference system is little effective and that the working processes are fragmented (causing treatment discontinuity, lack of professional responsabilization etc). Strategies towards the construction and articulation of the network, agreed among health managers and workers, involve the implantation of substitute services, implementation of a Mental Heath Care Commission and the process of training capabilities regarding mental heath care towards basic health care. Yet, we found a series of strategies grounded on the routine of the working processes, determining an informal network - not foreseen by health macro-politics. Hereby, we problematize some principles that underline the network organization concerning SUS and the Psychiatric Reform, as well as the ambiguous effects of the way the network construction and articulation are accomplished.

Cidadania, subjetividade e reforma psiquiátrica / Citizenship, subjectivity and psychiatric reform

O presente trabalho pretende retomar a discussão das relações entre cidadania e subjetividade, com o objetivo de contribuir para uma compreensão mais rica do tema da cidadania como inerente aos objetivos a que se propõe a reforma psiquiátrica, especialmente no Brasil, onde essa preocupação aparece de forma singularmente explícita. Para alcançar tal objetivo, o trabalho se propõe a recuperar o conceito de cidadania em suas origens e acompanhar sua trajetória ao lado do itinerário percorrido pela idéia de subjetividade, apoiando-se na contribuição de vários autores e, destacadamente, nas teses de Hannah Arendt sobre a constituição da política. Como conclusão, pretende-se propor que as próprias noções de reabilitação e de empowerment adotadas na condução da reforma psiquiátrica podem ser revistas com inegável proveito no plano assistencial e com considerável ganho ético.

The present work aims to revive discussions on the relationship between citizenship and subjectivity as a means to enrich the comprehension on this theme, one of the psychiatric reform's main objectives. This discussion in Brazil is especially meaningful as it is quite explicit. This work is targeted to bring back the concept of citizenship in its own origin at the same time as it follows the trajectory of this concept along with the idea of subjectivity, based on many writers' papers but mainly on Hannah Arendt's thesis on the constitution of politics. The author intends, in the conclusion, to show that the notions of rehabilitation and of empowerment currently assumed on the psychiatric reform politics can be profitably reviewed within the assistance frame and with considerable ethical benefits.

Sistemas sanitarios y reforma AUGE en Chile / Health care systems and AUGE reform in Chil

A partir de la clasificación de los sistemas sanitarios en términos de su financiamiento, número de actores y consecuencias en equidad, este ensayo pretende analizar algunas de las transformaciones producidas en Chile con la reforma del sistema de salud llamada Plan AUGE (Acceso Universal de Garantías Explícitas). Se examinan las tareas pendientes para la conversión de un sistema que, manteniendo su carácter mixto, sea capaz de superar sus actuales consecuencias fuertemente regresivas.

Through the classification of health care systems in terms of their financing, number of stakeholders and consequences for health care equity, this essay pretends to analyze some of the changes that have taken place in Chile due to the health care reform system AUGE (Universal Access to Explicit Guarantees). Pending tasks are examined for conversion to the system that, while maintaining its mixed character, may be able to overcome its present strongly regressive consequences.

A partir da classificação de dois sistemas sanitários em termos de seu financiamento, número de atores e conseqüências em termos de equidade, este ensaio pretende analisar algumas das transformações produzidas no Chile com a reforma do sistema de saúde chamado Plano AUGE (Acesso Universal de Garantias Explícitas). São examinados as tarefas pendentes para a conversão de um sistema que, mantendo seu caráter misto, seja capaz de superar suas conseqüências fortemente regressivas.

Modos de subjetivação dos trabalhadores de saúde mental em tempos de Reforma Psiquiátrica / Modes of subjectification of mental health workers in the context of the Psychiatric Reform

O artigo discute os modos de subjetivação dos trabalhadores de saúde mental no contexto da Reforma Psiquiátrica. A partir da revisão da literatura, da análise de documentos e de 40 entrevistas com trabalhadores de serviços de saúde mental, busca analisar, por meio da utilização das ferramentas teóricas construídas por Michel Foucault, os jogos de verdades e os desafios e dificuldades presentes na implementação dos princípios da Reforma Psiquiátrica. Aponta para o jogo político e a disputa em torno das verdades sobre as formas de atenção, assim como para a necessidade de reflexão permanente com relação às formas de implicação com o trabalho como forma de evitar o adoecimento dos trabalhadores.

The article discusses the modes of subjectification of mental health workers in the context of the Psychiatric Reform. Based on the scientific literature review, document analysis and 40 interviews with mental health services workers, we intended to analyze, using the theoretical tools constructed by Michel Foucault, the truth games, challenges and difficulties present in the implementation of Psychiatric Reform's principles. We describe the political games and the dispute around the truth about the forms of health attention, as well as the need of permanent reflexive attitude towards work implication in order to avoid occupational diseases on workers.

A alteridade no discurso da Reforma Psiquiátrica brasileira face à ética radical de Lévinas / Alterity in the brazilian Psychiatric Reform discourse in view of Lévinas's radical ethics

Este artigo trata das premissas éticas da Reforma Psiquiátrica, mais especificamente, da desinstitucionalização enquanto desconstrução, a partir do pensamento de Emmanuel Lévinas, e a concepção de alteridade postulada a partir da proposta de uma ética radical. O resgate dos pressupostos éticos da Reforma Psiquiátrica, considerados sob novos enfoques teóricos, pode contribuir para desvelar e compreender os diversos caminhos que esse processo vem tomando com a diversidade de práticas em construção e a disseminação de serviços substitutivos em saúde mental.

This paper deals with some ethic premises of the Psychiatric Reform, more specifically, with desinstitutionalization as deconstruction, establishing a dialogue with the ideas of Emmanuel Lévinas. The concept of alterity is considered at the interface of radical ethic included in this approach. The discussion points out that the incorporation of ethical premises from the Psychiatric Reform can help understand the different possibilities and social consequences of this process, considering the diversity of practices being constructed and the growing of substitutive services in the Mental Health field.

An evidence-based approach to benchmarking the fairness of health-sector reform in developing countries.

The Benchmarks of Fairness instrument is an evidence-based policy tool developed in generic form in 2000 for evaluating the effects of health-system reforms on equity, efficiency and accountability. By integrating measures of these effects on the central goal of fairness, the approach fills a gap that has hampered reform efforts for more than two decades. Over the past three years, projects in developing countries on three continents have adapted the generic version of these benchmarks for use at both national and subnational levels. Interdisciplinary teams of managers, providers, academics and advocates agree on the relevant criteria for assessing components of fairness and, depending on which aspects of reform they wish to evaluate, select appropriate indicators that rely on accessible information; they also agree on scoring rules for evaluating the diverse changes in the indicators. In contrast to a comprehensive index that aggregates all measured changes into a single evaluation or rank, the pattern of changes revealed by the benchmarks is used to inform policy deliberation aboutwhich aspects of the reforms have been successfully implemented, and it also allows for improvements to be made in the reforms. This approach permits useful evidence about reform to be gathered in settings where existing information is underused and where there is a weak information infrastructure. Brief descriptions of early results from Cameroon, Ecuador, Guatemala, Thailand and Zambia demonstrate that the method can produce results that are useful for policy and reveal the variety of purposes to which the approach can be put. Collaboration across sites can yield a catalogue of indicators that will facilitate further work.

[Equity and fairness in the Mexican health system reform]. / La equidad y la imparcialidad en la reforma del sistema mexicano de salud.

OBJECTIVE: To assess the equity and fairness of the Mexican health system reform that occurred in the late 1990's. MATERIAL AND METHODS: The Mexican reform process was evaluated using the benchmark-system designed by Daniels et al. This benchmark system was adapted to the Mexican setting by adding specific indicators. A documentary review of the Mexican reform process was conducted to score its performance for each benchmark. RESULTS: Except for housing and nutrition components, the reform included few actions related to health determinants. For health care, the main reform initiatives were those related to extending the coverage of essential health services and decentralizing health care provision to the states. Reform initiatives included few activities related to fair financing, tiering, emphasis on second and third level care, accountability, and transparency. CONCLUSIONS: The late nineties reform of the Mexican health system had some positive effect on access of the poor to health care and administrative efficiency, but little impact on fair financing, quality of care, and democratic governance. The English version of this paper is available at: http://www.insp.mx/salud/index.html.

[Bioethical aspects of the Health Care Reform in Chile. The problems of access and costs of resources ]. / Aspectos bioéticos comprendidos en la reforma de la atención de salud en Chile. Los problemas del acceso y el costo de los recursos.

During the process of health reforms there is always the concern that patients rights might be harmed. The bill that is being discussed in the Chilean Parliament contains an special issue dedicated to patient's obligations and rights. However, on the author's opinion, the best protection for patient rights rests on adequate financing and access to a reasonably, good and qualified health care. A thorough revision of the proposals contained in the reform will allow an objective assessment of the eventual ethical problems that it might imply.

[Bioethical aspects of health care reform in Chile. II. Discrimination, free election and informed consent]. / Aspectos bioéticos en la Reforma de la Atención de Salud en Chile. II. Discriminación, libre elección y consentimiento informado.

Bioethical issues emerge each time health care reform projects are discussed. These affect diverse moral values and principles and have an impact on cultural, social and political areas. Thus, they demand more than just organizational, financial or administrative solutions. This review analyses discrimination, free election of professionals and informed consent. All three concepts are alluded in the legislative debate raised upon the actual process for health reform. Having clear ideas about these subjects is crucial to foresee the reactions expected to arise among physicians and the general public, when confronting the proposed changes.