En la montaña rusa: breve historia del modelo de atención de salud mental en España. Informe SESPAS 2020 / On the roller coaster: an abridged history of mental health planning in Spain. SESPAS Report 2020

El cambio efectivo de la salud mental en España se inició en 1985 con el Informe de la Comisión Ministerial para la Reforma Psiquiátrica, que recomendaba integrar la asistencia psiquiátrica dentro de sistema sanitario general, proveer una atención integral en el entorno del paciente y atender a grupos diagnósticos específicos. El Informe SESPAS 2002 analizó la reforma y recomendó crear una comisión ministerial permanente, diseñar un mapa nacional de servicios sociosanitarios de salud mental, crear una agencia de coordinación y de promoción de la salud mental, y analizar la financiación de los recursos y la investigación. Desde 2004, el Comité Técnico de la Estrategia de Salud Mental impulsó la elaboración de un marco teórico y normativo que desafortunadamente no se siguió de una hoja de ruta para la mejora del sistema. Después de 2011, el impulso inicial se disipó y el Ministerio de Sanidad declinó liderar la transformación del sistema partiendo de la evidencia informada. Actualmente, el modelo de salud mental comunitaria de 1985 sigue vigente con la adición de algunas mejoras derivadas del modelo de la recuperación (Recovery) y en línea con el modelo del equilibrio de la atención (Balance of care). Asimismo, se ha avanzado en el desarrollo de métodos de evaluación de sistemas y de modelación basada en datos. Sin embargo, la brecha entre la atención general y la de salud mental ha vuelto a aumentar y no se ha avanzado en el desarrollo de una nueva estrategia de salud mental en España

Effective mental health change in Spain started in 1985 with the Report of the Ministerial Commission for the Psychiatric Reform that recommended integrating psychiatric care into the general health system, providing care in the patient's context and for specific diagnoses. The SESPAS 2002 Report carried out an analysis of this reform and recommended the creation of a permanent ministerial commission, the design of a national map of socio-sanitary mental health services, the creation of a coordination and promotion agency for and carrying out a financial analysis of resource provision and research. Since 2004, the Technical Committee for the Mental Health Strategy boosted the elaboration of a theoretical and normative framework that unfortunately did not lead to a road map for the improvement of the system. After 2011, during the financial crisis, the Ministry of Health lost the opportunity to lead a second phase of change of the mental health care, which was evidence-based: no key technical reports were published nor was an action plan based on data developed. Currently, the 1985 community mental health model is still the general framework of mental health care with the addition of aspects related to the recovery model and the balance of care model. Significant progress has been made in developing care systems assessment methods and data-based models that could advance mental health planning. The gap between general health attention and mental health care has increased and the expected reform of the mental health system will not take place in the near future

Todo está en el mapa: Atlas Integrales de Salud Mental para la planificación de servicios. Informe SESPAS 2020 / Everything is on the map: Integrated Mental Health Atlases as support tools for service planning. SESPAS Report 2020

OBJETIVO: Este artículo revisa y evalúa el uso de los Atlas Integrales de Salud Mental como herramientas de apoyo a la planificación de servicios dentro del modelo de investigación de ecosistemas de atención de salud. MÉTODO: Se describen los tipos de atlas y el procedimiento para su elaboración. Se presentan los realizados en España y se evalúa su impacto en la planificación de servicios de salud mental. Los atlas agregan información sobre las características locales del sistema de atención, la disponibilidad geográfica de recursos recogida mediante el instrumento DESDE-LTC, y su uso. Utilizan un sistema de información geográfica y otras herramientas visuales. Siguen una metodología de abajo arriba con colaboración de personas decisoras de agencias de planificación para su elaboración y validación externa. RESULTADOS: Desde 2005 se han realizado Atlas Integrales de Salud Mental en nueve comunidades autónomas que comprenden alrededor del 65% de la población de España. Los atlas han tenido un impacto desigual en la planificación de servicios, con un mayor impacto en Cataluña, Vizcaya y Guipúzcoa, y Andalucía, donde responsables sociales han participado activamente en su codiseño y su aplicación a la planificación de servicios sociosanitarios. CONCLUSIONES: Los atlas permiten detectar carencias o duplicidades en la atención, monitorizar cambios a lo largo del tiempo, realizar comparaciones nacionales e internacionales, modelar la eficiencia y hacer análisis benchmark. Este conocimiento puede incorporarse a los sistemas de apoyo a la decisión para una más eficaz planificación de los servicios de salud mental basada en evidencia informada

OBJECTIVE: This article reviews the usability of the Integrated Atlases of Mental Health as a decision support tool for service planning following a health ecosystem research approach. METHOD: This study describes the types of atlases and the procedure for their development. Atlases carried out in Spain are presented and their impact in mental health service planning is assessed. Atlases comprise information on the local characteristics of the health care system, geographical availability of resources collected with the DESDE-LTC instrument and their use. Atlases use geographic information systems and other visualisation tools. Atlases follow a bottom-up collaborative approach involving decision-makers from planning agencies for their development and external validation. RESULTS: Since 2005, Integrated Atlases of Mental Health have been developed for nine regions in Spain comprising over 65% of the Spanish inhabitants. The impact on service planning has been unequal for the different regions. Catalonia, Biscay and Gipuzkoa, and Andalusia reach the highest impact. In these areas, health advisors have been actively involved in their co-design and implementation in service planning. CONCLUSIONS: Atlases allow detecting care gaps and duplications in care provision; monitoring changes of the system over time, and carrying out national and international comparisons, efficiency modelling and benchmarking. The knowledge provided by atlases could be incorporated to decision support systems in order to support an efficient mental health service planning based on evidence-informed policy

The Likely Impact of Congenital Zika Syndrome on Families: Considerations for Family Supports and Services.

Congenital Zika virus infection has obvious implications for infants, and considerable research has addressed the nature and consequences of congenital Zika syndrome (CZS). Children with classic CZS meet the criteria for "children with medical complexity," and ongoing research is required to understand the range of needs and optimal treatment options. Far less attention has been given to the consequences of CZS for families, which are both immediate and lifelong. Although families of children with CZS have much in common with families of other children with disabilities, at least 4 features of CZS have special family implications: (1) the severity of the impact on children with obvious abnormalities at birth, coupled with the anticipation of a lifetime of caregiving and economic burdens; (2) uncertainty about the unfolding consequences, both for obviously affected children and for exposed children with no symptoms at birth; (3) a lack of specialized professional knowledge about the course of the disease or treatment options; and (4) social isolation, a lack of social or community supports, and potential stigma. Supporting families will require a family-centered approach to services, extensive care coordination, access to evolving new information, ongoing surveillance, formal and informal supports, and individualized child and family services.

Revolving Loan Fund: A Novel Approach to Increasing Access to Long-Acting Reversible Contraception Methods in Community Health Centers.

OBJECTIVE: The aim of this study was to assess the impact of a revolving loan fund (RLF) on timing of device insertion and long-acting reversible contraception (LARC) access among a high-risk urban population at 3 Boston community health centers. DESIGN: Three health centers were identified to implement a RLF. Each clinic received $5000 from the RLF to purchase LARC devices. Data collected through medical record review retrospectively 1 year prior to start of the RLF and prospectively for 1 year thereafter included patient demographics, type of LARC selected, patient's date of documented interest in a LARC device, and date of insertion. The effect of a RLF on delay to LARC insertion was tested using negative binomial regression, controlling for site and potential confounding variables between the pre- and post-RLF periods. SETTING: Three urban community health centers. PARTICIPANTS: Reproductive-aged women who received family planning services at the 3 participating health centers. MAIN OUTCOME MEASURES: Increasing access to LARC and decreasing wait times to LARC insertion after implementation of the RLF. RESULTS: Data on 133 patients in the pre-RLF group and 205 in the post-RLF group were collected. There were no statistically significant differences in demographic or clinical characteristics between the 2 time periods. LARC uptake increased significantly from the pre- to post-RLF period, specifically among implant users. There was a statistically significant decrease in the mean number of days in delay from interest to insertion from the pre- to post-RLF period (pre-RLF: 31.3 ± 50.6 days; post-RLF: 13.6 ± 16.7 days, adjusted P < .001). The reasons for the delay did not differ significantly between the 2 time periods. CONCLUSION: The RLF decreased wait time for the devices and increased overall insertion rates. This may serve as a promising solution to improve LARC access in community health centers. This project could be expanded to include more health centers, creating a city wide RLF. This expansion could allow for further data analysis, including unintended pregnancy rates with LARC delay, LARC continuation rates, and sustainability of a RLF.

La atención primaria en Francia / Primary care in France

La inadecuada planificación de los profesionales sanitarios en España ha promovido un éxodo de médicos fuera de nuestras fronteras. Francia es uno de los países elegidos por los médicos españoles para desarrollar su actividad profesional. El sistema de salud francés pertenece al modelo bismarkiano. En este modelo los servicios sanitarios están financiados por cuotas de trabajadores y empresarios. El derecho a la asistencia sanitaria está ligado al trabajo y la provisión de servicios se realiza a través de aseguradoras privadas supervisadas por el estado. La atención primaria en Francia es muy diferente a la española. Los médicos generalistas son profesionales liberales que se instalan en cualquier parte del territorio. Esta falta de regulación de la instalación de los médicos a nivel estatal ha generado un grave problema de desertificación médica con problemas graves de acceso y desigualdades sanitarias. Los médicos franceses no se instalan en zonas rurales o en áreas periféricas de grandes ciudades porque «no son rentables». El salario médico está ligado a la actividad profesional. Su función es principalmente curativa y no existe el trabajo en equipo ni coordinación entre atención primaria y atención especializada. El acceso a pruebas diagnósticas, especialistas y hospitales es ilimitado, lo que genera duplicidad de servicios, graves efectos adversos para los pacientes e ineficiencias en el sistema. El paciente elige libremente al profesional sanitario y todas las consultas y estancias hospitalarias están sujetas a un copago. Se requieren 2 años de formación para convertirse en especialista. A partir de ese momento la formación médica continuada es obligatoria, pero apenas existe control. El sistema francés, calificado en el año 2000 por la OMS como el mejor sistema de salud del mundo, no lo es tanto. Aunque la atención primaria en España es mejorable, a Francia le queda todavía mucho camino por recorrer(AU)

The poor planning of health care professionals in Spain has led to an exodus of doctors leaving the country. France is one of the chosen countries for Spanish doctors to develop their professional career. The French health care system belongs to the Bismarck model. In this model, health care system is financed jointly by workers and employers through payroll deduction. The right to health care is linked to the job, and provision of services is done by sickness-funds controlled by the Government. Primary care in France is quite different from Spanish primary care. General practitioners are independent workers who have the right to set up a practice anywhere in France. This lack of regulation has generated a great problem of 'medical desertification' with problems of health care access and inequalities in health. French doctors do not want to work in rural areas or outside cities because 'they are not value for money'. Medical salary is linked to professional activity. The role of doctors is to give punctual care. Team work team does not exist, and coordination between primary and secondary care is lacking. Access to diagnostic tests, hospitals and specialists is unlimited. Duplicity of services, adverse events and inefficiencies are the norm. Patients can freely choose their doctor, and they have a co-payment for visits and hospital care settings. Two years training is required to become a general practitioner. After that, continuing medical education is compulsory, but it is not regulated. Although the French medical Health System was named by the WHO in 2000 as the best health care system in the world, is it not that good. While primary care in Spain has room for improvement, there is a long way for France to be like Spain (AU)

Attitudes towards Advance Care Planning and Healthcare Autonomy among Community-Dwelling Older Adults in Beijing, China.

OBJECTIVES: To investigate the preferences of ACP and healthcare autonomy in community-dwelling older Chinese adults. METHODS: A community-based cross-sectional study was conducted with older adults living in the residential estate of Chaoyang District, Beijing. RESULTS: 900 residents were enrolled. 80.9% of them wanted to hear the truth regarding their own condition from the physician; 52.4% preferred to make their own healthcare decisions. Only 8.9% of them preferred to endure life-prolonging interventions when faced with irreversible conditions. 78.3% of the respondents had not heard of an ACP; only 39.4% preferred to document in an ACP. Respondents with higher education had significantly higher proportion of having heard of an ACP, as well as preferring to document in an ACP, compared to those with lower education. Those aged <70 years had higher proportion of having heard of an ACP, as well as refusing life-prolonging interventions when faced with irreversible conditions, compared to those aged ≥ 70 years. CONCLUSIONS: Although the majority of community-dwelling older Chinese adults appeared to have healthcare autonomy and refuse life-prolonging interventions in terms of end-of-life care, a low level of "Planning ahead" awareness and preference was apparent. Age and education level may be the influential factors.

Apoio institucional e militância no Sistema Único de Saúde (SUS): refletindo os desafios da mobilização dos sujeitos na produção de saúde / Institutional support and militancy in the Brazilian Health Sistem: a reflection on the challenges of subjects’ mobilization in health production / Apoyo institucional y militancia en el Sistema de Salud Brasileño: reflexionando los desafíos de la movilización de los sujetos en la producción de salud

A formação de apoiadores institucionais vem sendo um importante método/dispositivo da Política Nacional de Humanização (PNH) na intensificação de ações voltadas ao fortalecimento do SUS. Considerando algumas experiências no território paraense, o texto apresenta reflexões sobre este cenário, levando em conta os processos de formação que vêm sendo implementados no território, analisando alguns de seus desafios e repercussões. Partindo do referencial teórico e metodológico da PNH, mediante sua proposta de inclusão como método de intervenção nos modos de gerir e cuidar, também são levantadas algumas questões sobre a maneira como a formação de apoiadores opera no sentido de fomentar a militância pelo SUS e, consequentemente, a produção do comum por meio da mobilização e transformação dos sujeitos...

The education of institutional supporters has been an important tool of the National Humanization Policy to intensify actions targeted at empowering the Brazilian Health System. In light of some experiences in the State of Pará (Northern Brazil), the text presents some discussions on this scenario, considering the subjects’ education and analyzing some challenges and results. Based on the theoretical and methodological framework of the National Humanization Policy, through its proposal of inclusion as an intervention method for management and care, some questions are raised on how the education of supporters operates towards fostering militancy in the Brasilian Health Sistem and, consequently, the production of the common by means of subjects’ mobilization and transformation...

La formación de apoyadores institucionales ha sido un importante dispositivo de la Política Nacional de Humanización (PNH) en la intensificación de acciones destinadas a fortalecer el Sistema de Salud Brasileño. Teniendo en cuenta algunas experiencias utilizadas en Pará, el texto presenta algunas reflexiones sobre esta situación, teniendo en cuenta los procesos de formación que se han disparado en el territorio, analizando algunos de sus desafíos y repercusiones. Basado en el marco teórico y metodológico de la PNH, a través de su propuesta de inclusión como método de intervención en los modos de administrar y de cuidar, también se plantean algunas cuestiones sobre la manera como la formación de apoyadores opera en el sentido de fomentar la militancia por el Sistema de Salud Brasileño y, por lo tanto, la producción del común a través de la movilización y transformación de los sujetos...

Charting a future for health in the Americas: quadrennial report of the Director

Charting a Future for Health in the Americas describes the work of the Pan American Health Organization in recent years. The report opens with a disquisition on the significance of its title-how PAHO has had, and will continue to need, to chart and steer a steady course, dealing with and even capitalizing on changes along the way, in order to reach its goal: health in the Americas. With pointillistic highlights of the organization's century-long work in its major fields of responsibility, the report brings the accounting of its actions to the present. It describes the resources PAHO has employed and the impact its cooperation with member countries has had on assessing the regional health situation, enhancing health and human development, preventing and controlling diseases, promoting health, protecting the environment, and strengthening health systems and services. Morever, because of the stature it has attained, the organization has been able to strike alliances with other international agencies, nongovernmental organizations, and the private sector-and the story of their shared agenda is recounted here. This, then, is the latest in a series of reports of progress in public health throughout the Americas and, at the same time, of the work of an organization built to last (Back cover)

Public support for medical research in the 21st century.

Key public policies that have contributed to the rise of modern medical research in the 20th Century are reviewed, focusing especially on the United States and the post-World War II period. Drawing on this history, the question is posed: "Are these policies sufficient to insure vigorous medical research in the 21st Century?" Although radical policy changes are not needed, several proposals for policy and medical research portfolio redirection are offered, including a rebalancing of public supported research in all fields of science that contribute to medical advances. Medical research must also invest in a national and international information infrastructure that will allow the linking of researchers, clinical experimenters, practicing physicians, and the public in ways heretofore not imagined. Medical researchers must be leaders and advocates for the whole research enterprise in the 21st Century.

The state of health planning in the '90s.

The art of health planning is relatively new in many developing countries and its record is not brilliant. However, for policy makers committed to sustainable health improvements and the principle of equity, it is an essential process, and in need of improvement rather than minimalization. The article argues that the possibility of planning playing a proper role in health care allocative decisions is increasingly being endangered by a number of developments. These include the increasing use of projects, inappropriate decentralization policies, and the increasing attention being given to NGOs. More serious is the rise of New Right thinking which is undermining the role of the State altogether in health care provision. The article discusses these developments and makes suggestions as to possible action needed to counteract them.

Health promotion and health education: the emerging role of the private sector.

The climate is right for new ventures in health education, especially those in which corporate leaders join forces with other members of the communities where they do business. Working with the public sector and other members of the private sector--with schools, universities, health departments, churches, professional associations, voluntary agencies, and foundations--corporations can become a vital new force in supporting health education not only of their own employees but also of children and adults and the public at large.