G20’s commitment to telehealth for reducing global health disparities: from a global commitment to regional actions

[ABSTRACT]. The G20, representing the world’s largest economies, plays a critical role in shaping global health policies, initiatives and innovative solutions. As these nations navigate the complexities of digital transformation in the health sector, engagement with the Global Initiative on Digital Health (2), aligned with the Pan American Health Organization ́s (PAHO) eight guiding principles for the digital transformation of the health sector (3), becomes imperative not only for advancing technology adoption but also for promoting health equity and universal access to health and universal health coverage. The inclusion of telehealth in the G20 agenda, championed by Brazil’s presidency, underscores the group’s commitment to leveraging digital innovations to improve health outcomes in G20 countries and globally, as telehealth is a key area of the digital transformation of the health sector. Because countries worldwide vary widely in the capacity of their digital health infrastructure and their development stages, there lies a unique opportunity to foster international collaboration, share knowledge and drive global standards that support the widespread adoption of telehealth solutions for leaving no one behind. This strategic focus is predicated on the understand- ing that telehealth serves as both a catalyst for health equity and a critical tool for reinforcing health systems grounded in primary health care (PHC). The scientific rationale behind this concerted effort is clear: by enhancing digital infrastructure and fostering the adoption of telehealth solutions, there is potential to bridge the global digital divide and democratize access to health services. The G20, representing the world’s largest economies, plays a critical role in shaping global health policies, initiatives and innovative solutions (1). As these nations navigate the complexities of digital transformation in the health sector, engagement with the Global Initiative on Digital Health (2), aligned with the Pan American Health Organization ́s (PAHO) eight guiding principles for the digital transformation of the health sector (3), becomes imperative not only for advancing technology adoption but also for promoting health equity and universal access to health and universal health coverage. The inclusion of telehealth in the G20 agenda, championed by Brazil’s presidency, underscores the group’s commitment to leveraging digital innovations to improve health outcomes in G20 countries and globally, as telehealth is a key area of the digital transformation of the health sector. Because countries worldwide vary widely in the capacity of their digital health infrastructure and their development stages, there lies a unique opportunity to foster international collaboration, share knowledge and drive global standards that support the widespread adoption of telehealth solutions for leaving no one behind. This strategic focus is predicated on the understand- ing that telehealth serves as both a catalyst for health equity and a critical tool for reinforcing health systems grounded in primary health care (PHC). The scientific rationale behind this concerted effort is clear: by enhancing digital infrastructure and fostering the adoption of telehealth solutions, there is potential to bridge the global digital divide and democratize access to health services. In envisioning the future of global health, the fourth pillar of the vision of PAHO’s Director emerges with critical importance: the construction of resilient national health systems is firmly rooted in the implementation of the PHC strategy. This vision is not just an aspiration but a necessary evolution, with PAHO standing ready to guide countries towards achieving this goal. PAHO’s commitment involves supporting countries in the organization of health services networks based on PHC, targeting public financing to foster universal access and coverage, and bolstering governance in health under the leadership of health ministries. Moreover, it calls for the rapid deployment of technological innovations such as telehealth and also broader digital transformation initiatives (4). Digital transformation, emerging as a key innovative strategy, offers significant improvements to the strengthening of PHC. Through the adoption of inclusive digital health solutions, it is possible to enhance the delivery of health services, ensuring they become more accessible, efficient and equitable for everyone, everywhere (5, 6). Among the priorities leading this transformation, telehealth emerged at the G20 as a key opportunity in the mission to leave no one behind and as a cornerstone of the digital transformation of the health sector. Telehealth improves access to care and health information, thereby empowering individuals and communities (7). It effectively extends health services to underserved populations, encourages collaborative practices among health professionals, and broadens access to health for the wider community. It can support reduced waiting times and costs through efficiencies in care management. Through telehealth, the transition to a new era of PHC can be accelerated through technological advancements that drive us towards a more inclusive and accessible health care system for all. Concrete efforts should be focused on modernizing normative and legislative frameworks, investment in digital infrastructure, prioritizing the development of robust digital health infrastructures while ensuring that reliable internet access and digital tools are available across urban and rural areas alike. Enhancing digital literacy and telehealth competencies among health professionals and the population will maximize the utilization and effectiveness of digital health services. However, the lack of standardized policies and frameworks for telehealth is a significant barrier to its global adoption and, therefore, G20 nations can lead by example, working towards (a) developing international telehealth guidelines that consider ethical, privacy and security standards for telehealth services to facilitate cross-border healthcare delivery and secure data exchange; and (b) promoting interoperable telehealth platforms that can seamlessly exchange information, thus enhancing the continuity and quality of care. The G20’s leadership and commitment to integrating telehealth into the global health agenda can set an unprecedented opportunity for international cooperation in digital health. G20 countries can significantly impact global health outcomes by integrating telehealth at all levels of care and health service delivery networks, impacting the lives of billions around the world. Equity must remain central to our efforts as telehealth services are integrated into the model of care. This means ensuring the adoption of differentiated approaches in digital health based on (a) the characteristics of a territory (geographical dis- persion, status of infrastructure), (b) the beneficiary population to be served (their health needs, and cultural, racial and ethnic considerations) and (c) the health system capacities and organization (the health services network, coverage capacity and availability of multiprofessional teams). Health outcomes can be significantly positively impacted by undertaking bottom-up planning processes that take into account the latter considerations and by adapting the model of care to leverage the capacity of digital health. Embracing the Regional Roadmap for the Digital Transformation of the Health Sector in the Region of the Americas is imperative for countries aiming to develop expansive, resilient and inclusive health systems based on PHC (8,9). This comprehensive framework, backed by lessons learned and suc- cessful experiences, underscores the significant potential that digital transformation holds for improving health outcomes. Brazil's commitment to the consolidation of the Unified Health System (the Sistema Único de Saúde, or SUS) and its well-established Family Health Strategy as the foundation for the health and well-being of its population is being expressed through the rapid deployment of telehealth, and serves as a model of innovation and effectiveness, showcasing the transformative impact of digital health solutions on accessibility, efficiency and quality of care (10). This editorial, jointly prepared by rep- resentatives of the government of Brazil and PAHO advocates for global standardization of telehealth practices that ensures the scalability and sustainability of health interventions while addressing the core determinants of health equity.

[RESUMEN]. Sin resumen disponible Texto completo en inglés

[RESUMO]. Não existe resumo disponível Texto completo em inglês

Auditory cues modulate the short timescale dynamics of STN activity during stepping in Parkinson's disease.

BACKGROUND: Gait impairment has a major impact on quality of life in patients with Parkinson's disease (PD). It is believed that basal ganglia oscillatory activity at ß frequencies (15-30 Hz) may contribute to gait impairment, but the precise dynamics of this oscillatory activity during gait remain unclear. Additionally, auditory cues are known to lead to improvements in gait kinematics in PD. If the neurophysiological mechanisms of this cueing effect were better understood they could be leveraged to treat gait impairments using adaptive Deep Brain Stimulation (aDBS) technologies. OBJECTIVE: We aimed to characterize the dynamics of subthalamic nucleus (STN) oscillatory activity during stepping movements in PD and to establish the neurophysiological mechanisms by which auditory cues modulate gait. METHODS: We studied STN local field potentials (LFPs) in eight PD patients while they performed stepping movements. Hidden Markov Models (HMMs) were used to discover transient states of spectral activity that occurred during stepping with and without auditory cues. RESULTS: The occurrence of low and high ß bursts was suppressed during and after auditory cues. This manifested as a decrease in their fractional occupancy and state lifetimes. Interestingly, α transients showed the opposite effect, with fractional occupancy and state lifetimes increasing during and after auditory cues. CONCLUSIONS: We show that STN oscillatory activity in the α and ß frequency bands are differentially modulated by gait-promoting oscillatory cues. These findings suggest that the enhancement of α rhythms may be an approach for ameliorating gait impairments in PD.

Optimization in Visual Motion Estimation.

Sighted animals use visual signals to discern directional motion in their environment. Motion is not directly detected by visual neurons, and it must instead be computed from light signals that vary over space and time. This makes visual motion estimation a near universal neural computation, and decades of research have revealed much about the algorithms and mechanisms that generate directional signals. The idea that sensory systems are optimized for performance in natural environments has deeply impacted this research. In this article, we review the many ways that optimization has been used to quantitatively model visual motion estimation and reveal its underlying principles. We emphasize that no single optimization theory has dominated the literature. Instead, researchers have adeptly incorporated different computational demands and biological constraints that are pertinent to the specific brain system and animal model under study. The successes and failures of the resulting optimization models have thereby provided insights into how computational demands and biological constraints together shape neural computation.

Evaluation of 3D C-Arm Fluoroscopy versus Diagnostic CT for Deep Brain Stimulation Stereotactic Registration and Post-Operative Lead Localization.

INTRODUCTION: DBS efficacy depends on accuracy. CT-MRI fusion is established for both stereotactic registration and electrode placement verification. The desire to streamline DBS workflows, reduce operative time, and minimize patient transfers has increased interest in portable imaging modalities such as the Medtronic O-arm® and mobile CT. However, these remain expensive and bulky. 3D C-arm fluoroscopy (3DXT) units are a smaller and less costly alternative, albeit incompatible with traditional frame-based localization and without useful soft tissue resolution. We aimed to compare fusion of 3DXT and CT with pre-operative MRI to evaluate if 3DXT-MRI fusion alone is sufficient for accurate registration and reliable targeting verification. We further assess DBS targeting accuracy using a 3DXT workflow and compare radiation dosimetry between modalities. METHODS: Patients underwent robot-assisted DBS implantation using a workflow incorporating 3DXT which we describe. Two intra-operative 3DXT spins were performed for registration and accuracy verification followed by conventional CT post-operatively. Post-operative 3DXT and CT images were independently fused to the same pre-operative MRI sequence and co-ordinates generated for comparison. Registration accuracy was compared to 15 consecutive controls who underwent CT-based registration. Radial targeting accuracy was calculated and radiation dosimetry recorded. RESULTS: Data were obtained from 29 leads in 15 consecutive patients. 3DXT registration accuracy was significantly superior to CT with mean error 0.22 ± 0.03 mm (p < 0.0001). Mean Euclidean electrode tip position variation for CT to MRI versus 3DXT to MRI fusion was 0.62 ± 0.40 mm (range 0.0 mm-1.7 mm). In comparison, direct CT to 3DXT fusion showed electrode tip Euclidean variance of 0.23 ± 0.09 mm. Mean radial targeting accuracy assessed on 3DXT was 0.97 ± 0.54 mm versus 1.15 ± 0.55 mm on CT with differences insignificant (p = 0.30). Mean patient radiation doses were around 80% lower with 3DXT versus CT (p < 0.0001). DISCUSSION: Mobile 3D C-arm fluoroscopy can be safely incorporated into DBS workflows for both registration and lead verification. For registration, the limited field of view requires the use of frameless transient fiducials and is highly accurate. For lead position verification based on MRI co-registration, we estimate there is around a 0.4 mm discrepancy between lead position seen on 3DXT versus CT when corrected for brain shift. This is similar to that described in O-arm® or mobile CT series. For units where logistical or financial considerations preclude the acquisition of a cone beam CT or mobile CT scanner, our data support portable 3D C-arm fluoroscopy as an acceptable alternative with significantly lower radiation exposure.

How medical students' trauma histories affect their clinical clerkship experiences.

BACKGROUND: As the gender demographics of medical students have evolved over the past decades, it is important to understand potential stressors and challenges that may affect clinical learning experiences. This study investigated the prevalence of prior sexual assault (SA) and interpersonal violence (IPV) in medical students and how these affect their clinical clerkship experiences. METHODS: A survey was distributed to third- and fourth-year medical students at a single institution in August 2022 querying respondents on demographics and prior experiences with SA/IPV at any point in their lives. Respondents who indicated they had previously experienced SA/IPV were directed to questions about how these experiences affected clerkships. FINDINGS: Of 419 students, 125 responded to the survey (30.8% response rate). Forty (31.1%) reported a history of SA/IPV-32 (80.0%) women, five (12.5%) men, and three (7.5%) who did not report gender or identified as non-binary. Of the 40 respondents with a history of SA/IPV, 20 (50.0%) reported that their prior history affected their overall clinical experience, and nine (22.5%) felt that it affected their performance. Only seven (17.5%) reported using any resources, such as counselling, during their clerkships. Narrative responses discussed significant effects on performing physical exams, taking a history, interacting with team members, and engaging during clerkships. DISCUSSION: This work demonstrates the high number of students affected by SA/IPV and how these prior experiences affected core components of their clerkship experiences. CONCLUSIONS: Institutions must be proactive to create better supports for learners with histories of trauma, including SA/IPV.

Closed-loop parameter optimization for patient-specific phrenic nerve stimulation.

BACKGROUND: Ventilator-induced diaphragm dysfunction occurs rapidly following the onset of mechanical ventilation and has significant clinical consequences. Phrenic nerve stimulation has shown promise in maintaining diaphragm function by inducing diaphragm contractions. Non-invasive stimulation is an attractive option as it minimizes the procedural risks associated with invasive approaches. However, this method is limited by sensitivity to electrode position and inter-individual variability in stimulation thresholds. This makes clinical application challenging due to potentially time-consuming calibration processes to achieve reliable stimulation. METHODS: We applied non-invasive electrical stimulation to the phrenic nerve in the neck in healthy volunteers. A closed-loop system recorded the respiratory flow produced by stimulation and automatically adjusted the electrode position and stimulation amplitude based on the respiratory response. By iterating over electrodes, the optimal electrode was selected. A binary search method over stimulation amplitudes was then employed to determine an individualized stimulation threshold. Pulse trains above this threshold were delivered to produce diaphragm contraction. RESULTS: Nine healthy volunteers were recruited. Mean threshold stimulation amplitude was 36.17 ± 14.34 mA (range 19.38-59.06 mA). The threshold amplitude for reliable nerve capture was moderately correlated with BMI (Pearson's r = 0.66, p = 0.049). Repeating threshold measurements within subjects demonstrated low intra-subject variability of 2.15 ± 1.61 mA between maximum and minimum thresholds on repeated trials. Bilateral stimulation with individually optimized parameters generated reliable diaphragm contraction, resulting in significant inhaled volumes following stimulation. CONCLUSION: We demonstrate the feasibility of a system for automatic optimization of electrode position and stimulation parameters using a closed-loop system. This opens the possibility of easily deployable individualized stimulation in the intensive care setting to reduce ventilator-induced diaphragm dysfunction.

A mixed-methods SWOT analysis of a medical student Balint group programme.

BACKGROUND: Balint groups use case-based discussions to explore, reflect on, and enhance the clinician-patient relationship. They facilitate the development of empathy and reflective practice and reduce burnout. This study aimed to explore how the benefits of a traditional Balint group format can be accessed and optimised for medical students during a one-year pilot programme. METHODS: Eight medical student Balint groups ran for six weeks during 2022-2023, with 90 students participating. Themes were identified from student feedback using qualitative content analysis. Group leaders kept reflective session notes and used these alongside student feedback to undertake a strengths, weaknesses, opportunities, and threats analysis. RESULTS: Strengths of the programme were emotional containment, learning to reflect, and community identity. Weaknesses were themed as strange situations, dragging along, and facilitator as an object. Opportunities were identified in expanding the scope and sharpening focus. Psychological defences and the engagement dilemma threatened the future success of the Balint group programme. DISCUSSION: Medical student Balint groups provide a unique space to combine learning and emotional support with personal, professional and community development. However, the traditional Balint group format may need adapting to be widely accessible to undergraduate learners. Sustainably integrating Balint groups into the medical school curriculum requires ongoing engagement work at both an individual and organisational level.

Seeing Is Believing: Photon Counting Computed Tomography Clearly Images Directional Deep Brain Stimulation Lead Segments and Markers After Implantation.

BACKGROUND AND OBJECTIVES: Directional deep brain stimulation (DBS) electrodes are increasingly used, but conventional computed tomography (CT) is unable to directly image segmented contacts owing to physics-based resolution constraints. Postoperative electrode segment orientation assessment is necessary because of the possibility of significant deviation during or immediately after insertion. Photon-counting detector (PCD) CT is a relatively novel technology that enables high resolution imaging while addressing several limitations intrinsic to CT. We show how PCD CT can enable clear in vivo imaging of DBS electrodes, including segmented contacts and markers for all major lead manufacturers. MATERIALS AND METHODS: We describe postoperative imaging and reconstruction protocols we have developed to enable optimal lead visualization. PCD CT images were obtained of directional leads from the three major manufacturers and fused with preoperative 3T magnetic resonance imaging (MRI). Radiation dosimetry also was evaluated and compared with conventional imaging controls. Orientation estimates from directly imaged leads were compared with validated software-based reconstructions (derived from standard CT imaging artifact analysis) to quantify congruence in alignment and directional orientation. RESULTS: High-fidelity images were obtained for 15 patients, clearly indicating the segmented contacts and directional markers both on CT alone and when fused to MRI. Our routine imaging protocol is described. Ionizing radiation doses were significantly lower than with conventional CT. For most leads, the directly imaged lead orientations and depths corresponded closely to those predicted by CT artifact-based reconstructions. However, unlike direct imaging, the software reconstructions were susceptible to 180° error in orientation assessment. CONCLUSIONS: High-resolution photon-counting CT can very clearly image segmented DBS electrode contacts and directional markers and unambiguously determine lead orientation, with lower radiation than in conventional imaging. This obviates the need for further imaging and may facilitate anatomically tailored directional programming.

Developing RPC-Net: Leveraging High-Density Electromyography and Machine Learning for Improved Hand Position Estimation.

OBJECTIVE: The purpose of this study was to develop and evaluate the performance of RPC-Net (Recursive Prosthetic Control Network), a novel method using simple neural network architectures to translate electromyographic activity into hand position with high accuracy and computational efficiency. METHODS: RPC-Net uses a regression-based approach to convert forearm electromyographic signals into hand kinematics. We tested the adaptability of the algorithm to different conditions and compared its performance with that of solutions from the academic literature. RESULTS: RPC-Net demonstrated a high degree of accuracy in predicting hand position from electromyographic activity, outperforming other solutions with the same computational cost. Including previous position data consistently improved results across subjects and conditions. RPC-Net showed robustness against a reduction in the number of electromyography electrodes used and shorter input signals, indicating potential for further reduction in computational cost. CONCLUSION: The results demonstrate that RPC-Net is capable of accurately translating forearm electromyographic activity into hand position, offering a practical and adaptable tool that may be accessible in clinical settings. SIGNIFICANCE: The development of RPC-Net represents a significant advancement. In clinical settings, its application could enable prosthetic devices to be controlled in a way that feels more natural, improving the quality of life for individuals with limb loss.

Identification of motor progression in Parkinson's disease using wearable sensors and machine learning.

Wearable devices offer the potential to track motor symptoms in neurological disorders. Kinematic data used together with machine learning algorithms can accurately identify people living with movement disorders and the severity of their motor symptoms. In this study we aimed to establish whether a combination of wearable sensor data and machine learning algorithms with automatic feature selection can estimate the clinical rating scale and whether it is possible to monitor the motor symptom progression longitudinally, for people with Parkinson's Disease. Seventy-four patients visited the lab seven times at 3-month intervals. Their walking (2-minutes) and postural sway (30-seconds,eyes-closed) were recorded using six Inertial Measurement Unit sensors. Simple linear regression and Random Forest algorithms were utilised together with different routines of automatic feature selection or factorisation, resulting in seven different machine learning algorithms to estimate the clinical rating scale (Movement Disorder Society- Unified Parkinson's Disease Rating Scale part III; MDS-UPDRS-III). Twenty-nine features were found to significantly progress with time at group level. The Random Forest model revealed the most accurate estimation of the MDS-UPDRS-III among the seven models. The model estimations detected a statistically significant progression of the motor symptoms within 15 months when compared to the first visit, whereas the MDS-UPDRS-III did not capture any change. Wearable sensors and machine learning can track the motor symptom progression in people with PD better than the conventionally used clinical rating scales. The methods described in this study can be utilised complimentary to the clinical rating scales to improve the diagnostic and prognostic accuracy.

[The importance of a gender focus in building resilient, equitable, and universal health systemsA importância da abordagem de gênero no desenvolvimento de sistemas de saúde resilientes, equitativos e universais]. / La importancia del enfoque de género en la construcción de sistemas de salud resilientes, equitativos y universales.

The coronavirus disease 2019 (COVID-19) pandemic demonstrated the need to strengthen the focus on gender from an integrative and multisectoral perspective to address health care problems. This article seeks to highlight the importance of incorporating and strengthening the gender focus in policies for building resilient, equitable, and universal health care systems. With this objective in mind, the role of women in the health sector is addressed from two directions. The first examines women's conditions of access to health systems in the Region of the Americas and highlights the need to overcome the obstacles that prevent the full realization of their right to health care. The second discusses the preponderant role of women in the health labor market, and the need to expand their leadership in decision-making in the sector. Finally, an appeal is made for progress in the implementation of recommendations to strengthen the focus on gender and the role of women in health policies and systems.

A pandemia da doença do coronavírus de 2019 (COVID-19) demonstrou a necessidade de fortalecer a abordagem de gênero a partir de uma perspectiva integradora e multissetorial ao tratar das questões de saúde. Este artigo procura ressaltar a importância de incorporar e fortalecer a abordagem de gênero nas políticas para o desenvolvimento de sistemas de saúde resilientes, equitativos e universais. Com esse objetivo, este trabalho aborda o papel das mulheres no setor da saúde a partir de duas perspectivas. A primeira está ligada às condições de acesso das mulheres aos sistemas de saúde na Região das Américas, destacando a necessidade de superar os obstáculos que impedem o pleno exercício de seu direito à saúde. A segunda destaca o papel proeminente das mulheres no mercado de trabalho do setor da saúde e a necessidade de aumentar o seu papel de liderança na tomada de decisões no setor. Por fim, é feito um apelo para avançar com a implementação de recomendações destinadas a fortalecer a abordagem de gênero e o papel das mulheres nas políticas e sistemas de saúde.

Reward expectations direct learning and drive operant matching in Drosophila.

Foraging animals must use decision-making strategies that dynamically adapt to the changing availability of rewards in the environment. A wide diversity of animals do this by distributing their choices in proportion to the rewards received from each option, Herrnstein's operant matching law. Theoretical work suggests an elegant mechanistic explanation for this ubiquitous behavior, as operant matching follows automatically from simple synaptic plasticity rules acting within behaviorally relevant neural circuits. However, no past work has mapped operant matching onto plasticity mechanisms in the brain, leaving the biological relevance of the theory unclear. Here, we discovered operant matching in Drosophila and showed that it requires synaptic plasticity that acts in the mushroom body and incorporates the expectation of reward. We began by developing a dynamic foraging paradigm to measure choices from individual flies as they learn to associate odor cues with probabilistic rewards. We then built a model of the fly mushroom body to explain each fly's sequential choice behavior using a family of biologically realistic synaptic plasticity rules. As predicted by past theoretical work, we found that synaptic plasticity rules could explain fly matching behavior by incorporating stimulus expectations, reward expectations, or both. However, by optogenetically bypassing the representation of reward expectation, we abolished matching behavior and showed that the plasticity rule must specifically incorporate reward expectations. Altogether, these results reveal the first synapse-level mechanisms of operant matching and provide compelling evidence for the role of reward expectation signals in the fly brain.

La importancia del enfoque de género en la construcción de sistemas de salud resilientes, equitativos y universales

[RESUMEN]. La pandemia de la enfermedad por el coronavirus 2019 (COVID-19, por su sigla en inglés) demostró la necesidad de reforzar el enfoque de género desde una perspectiva integradora y multisectorial para el abordaje de las problemáticas en salud. Este artículo busca destacar la importancia de incorporar y fortalecer el enfoque de género en las políticas de construcción de sistemas de salud resilientes, equitativos y universales. Con este objetivo, se aborda el papel de las mujeres en el sector de salud desde dos ámbitos. El primero da cuenta de las condiciones de acceso de las mujeres a los sistemas de salud de la Región de las Américas, donde resalta la necesidad de superar los obstáculos que impiden la realización plena de su derecho a la salud. El segundo plantea el papel preponderante de las mujeres en el mercado laboral del sector de salud, y la necesidad de aumentar su liderazgo en la toma de decisiones del sector. Por último, se hace un llamado para avanzar en la implementación de recomendaciones para fortalecer el enfoque de género y el papel de las mujeres en las políticas y los sistemas de salud.

[ABSTRACT]. The coronavirus disease 2019 (COVID-19) pandemic demonstrated the need to strengthen the focus on gender from an integrative and multisectoral perspective to address health care problems. This article seeks to highlight the importance of incorporating and strengthening the gender focus in policies for building resilient, equitable, and universal health care systems. With this objective in mind, the role of women in the health sector is addressed from two directions. The first examines women’s conditions of access to health systems in the Region of the Americas and highlights the need to overcome the obstacles that prevent the full realization of their right to health care. The second discusses the preponderant role of women in the health labor market, and the need to expand their leadership in decision-making in the sector. Finally, an appeal is made for progress in the implementation of recommendations to strengthen the focus on gender and the role of women in health policies and systems.

[RESUMO]. A pandemia da doença do coronavírus de 2019 (COVID-19) demonstrou a necessidade de fortalecer a abordagem de gênero a partir de uma perspectiva integradora e multissetorial ao tratar das questões de saúde. Este artigo procura ressaltar a importância de incorporar e fortalecer a abordagem de gênero nas políticas para o desenvolvimento de sistemas de saúde resilientes, equitativos e universais. Com esse objetivo, este trabalho aborda o papel das mulheres no setor da saúde a partir de duas perspectivas. A primeira está ligada às condições de acesso das mulheres aos sistemas de saúde na Região das Américas, destacando a neces- sidade de superar os obstáculos que impedem o pleno exercício de seu direito à saúde. A segunda destaca o papel proeminente das mulheres no mercado de trabalho do setor da saúde e a necessidade de aumentar o seu papel de liderança na tomada de decisões no setor. Por fim, é feito um apelo para avançar com a imple- mentação de recomendações destinadas a fortalecer a abordagem de gênero e o papel das mulheres nas políticas e sistemas de saúde.

Using mixed methods to understand and tackle barriers to accessing health services.

This report describes the experience and lessons learnt from designing and implementing a combined quantitative and qualitative method to assess barriers to accessing health services. This approach was developed to study barriers to access in five dimensions: availability; geographical, financial, and organizational accessibility; acceptability; contact; and effective coverage. The study design was used in six countries in the World Health Organization Region of the Americas. The findings highlight the importance of having a well defined analysis framework and the benefits of adopting a mixed-methods approach. Using existing data and contextualizing findings according to specific population groups and geographical areas were essential for relevance and utilization of the study outcomes. The findings demonstrate the feasibility of using mixed methods to understand the complexity of access problems faced by different subpopulations. By involving decision-makers from the beginning and allowing flexibility for sustained discussions, the analysis and findings had an impact. The engagement of health authorities and key stakeholders facilitated the use of the findings for collaborative identification of policy options to eliminate access barriers. Lessons learnt from the study emphasized the need for active participation of decision-makers, flexibility in the process, and sustained opportunities for discussion to ensure impact. Giving consideration to local priorities and adapting the methods accordingly were important for the relevance and use of the findings. Future efforts could consider incorporating mixed methods into national and local monitoring and evaluation systems.

En este informe se describen la experiencia y las enseñanzas extraídas a partir del diseño y la aplicación de un método que combina elementos cuantitativos y cualitativos para evaluar los obstáculos que dificultan el acceso a los servicios de salud. Este enfoque se ideó para poder analizar estos obstáculos mediante cinco dimensiones: disponibilidad; accesibilidad geográfica, económica y organizativa; aceptabilidad; contacto; y cobertura efectiva. El diseño del estudio se utilizó en seis países de la Región de las Américas de la Organización Mundial de la Salud. Los resultados pusieron de relieve la importancia de contar con un marco de análisis bien definido, así como las ventajas de adoptar un enfoque basado en métodos mixtos. El uso de los datos existentes y la contextualización de los resultados en función de grupos poblacionales y áreas geográficas específicos fueron aspectos esenciales para el interés y la aplicación de los resultados del estudio. Los resultados demuestran la viabilidad del uso de métodos mixtos para comprender la complejidad de los problemas de acceso que afrontan los diferentes subgrupos poblacionales. La involucración desde un primer momento de las personas responsables de la toma de decisiones y la flexibilidad para llevar a cabo deliberaciones prolongadas propiciaron una mayor repercusión del análisis y sus conclusiones. La participación de las autoridades de salud y de las principales partes interesadas favoreció la aplicación de los resultados para determinar, en un marco de colaboración, las opciones políticas necesarias para eliminar los obstáculos que dificultan el acceso. Las enseñanzas extraídas de este estudio subrayan la necesidad de una participación activa de las autoridades responsables de la toma de decisiones, de que el proceso sea flexible y de la existencia de oportunidades permanentes de deliberación para asegurar su eficacia. El hecho de tener en cuenta las prioridades locales y adaptar los métodos en consecuencia fue un elemento importante para el interés y la aplicación de los resultados. Las iniciativas futuras podrían considerar la incorporación de métodos mixtos a los sistemas nacionales y locales de seguimiento y evaluación.

Este relatório descreve a experiência e as lições aprendidas com o delineamento e implementação de um método combinado (quantitativo e qualitativo) para avaliar barreiras de acesso aos serviços de saúde. Essa abordagem foi desenvolvida para estudar barreiras de acesso em cinco dimensões: disponibilidade; acessibilidade geográfica, financeira e organizacional; aceitabilidade; contato; e cobertura efetiva. O desenho do estudo foi usado em seis países da Região das Américas da Organização Mundial da Saúde. Os achados destacam a importância de ter uma estrutura de análise bem definida e os benefícios de adotar uma abordagem de métodos mistos. O uso de dados existentes e a contextualização dos achados de acordo com grupos populacionais e áreas geográficas específicas foram essenciais para a relevância e a utilização dos resultados do estudo. Os achados demonstram a viabilidade de usar métodos mistos para entender a complexidade dos problemas de acesso enfrentados por diferentes subpopulações. O envolvimento de tomadores de decisão desde o início e a flexibilidade para discussões contínuas permitiram que a análise e os achados tivessem impacto. O envolvimento das autoridades sanitárias e das principais partes interessadas facilitou a utilização dos achados na identificação colaborativa de opções de políticas para eliminar as barreiras de acesso. As lições aprendidas com o estudo enfatizaram a necessidade de participação ativa dos tomadores de decisão, flexibilidade no processo e oportunidades contínuas de discussão para assegurar seu impacto. Foi importante levar em consideração as prioridades locais e adaptar os métodos de acordo com essas prioridades para garantir a relevância e o uso dos achados. Futuros esforços podem considerar a incorporação de métodos mistos em sistemas nacionais e locais de monitoramento e avaliação.

Using mixed methods to understand and tackle barriers to access- ing health services

[ABSTRACT]. This report describes the experience and lessons learnt from designing and implementing a combined quan- titative and qualitative method to assess barriers to accessing health services. This approach was developed to study barriers to access in five dimensions: availability; geographical, financial, and organizational acces- sibility; acceptability; contact; and effective coverage. The study design was used in six countries in the World Health Organization Region of the Americas. The findings highlight the importance of having a well defined analysis framework and the benefits of adopting a mixed-methods approach. Using existing data and contextualizing findings according to specific population groups and geographical areas were essential for relevance and utilization of the study outcomes. The findings demonstrate the feasibility of using mixed methods to understand the complexity of access problems faced by different subpopulations. By involving decision-makers from the beginning and allowing flexibility for sustained discussions, the analysis and find- ings had an impact. The engagement of health authorities and key stakeholders facilitated the use of the findings for collaborative identification of policy options to eliminate access barriers. Lessons learnt from the study emphasized the need for active participation of decision-makers, flexibility in the process, and sustained opportunities for discussion to ensure impact. Giving consideration to local priorities and adapting the methods accordingly were important for the relevance and use of the findings. Future efforts could consider incorporating mixed methods into national and local monitoring and evaluation systems.

[RESUMEN]. En este informe se describen la experiencia y las enseñanzas extraídas a partir del diseño y la aplicación de un método que combina elementos cuantitativos y cualitativos para evaluar los obstáculos que dificultan el acceso a los servicios de salud. Este enfoque se ideó para poder analizar estos obstáculos mediante cinco dimensiones: disponibilidad; accesibilidad geográfica, económica y organizativa; aceptabilidad; contacto; y cobertura efectiva. El diseño del estudio se utilizó en seis países de la Región de las Américas de la Organización Mundial de la Salud. Los resultados pusieron de relieve la importancia de contar con un marco de análisis bien definido, así como las ventajas de adoptar un enfoque basado en métodos mixtos. El uso de los datos existentes y la contextualización de los resultados en función de grupos poblacionales y áreas geográficas específicos fueron aspectos esenciales para el interés y la aplicación de los resultados del estudio. Los resultados demuestran la viabilidad del uso de métodos mixtos para comprender la complejidad de los problemas de acceso que afrontan los diferentes subgrupos poblacionales. La involucración desde un primer momento de las personas responsables de la toma de decisiones y la flexibilidad para llevar a cabo deliberaciones prolongadas propiciaron una mayor repercusión del análisis y sus conclusiones. La participación de las autoridades de salud y de las principales partes interesadas favoreció la aplicación de los resultados para determinar, en un marco de colaboración, las opciones políticas necesarias para eliminar los obstáculos que dificultan el acceso. Las enseñanzas extraídas de este estudio subrayan la necesidad de una participación activa de las autoridades responsables de la toma de decisiones, de que el proceso sea flexible y de la existencia de oportunidades permanentes de deliberación para asegurar su eficacia. El hecho de tener en cuenta las prioridades locales y adaptar los métodos en consecuencia fue un elemento importante para el interés y la aplicación de los resultados. Las iniciativas futuras podrían considerar la incorporación de métodos mixtos a los sistemas nacionales y locales de seguimiento y evaluación.

[RESUMO]. Este relatório descreve a experiência e as lições aprendidas com o delineamento e implementação de um método combinado (quantitativo e qualitativo) para avaliar barreiras de acesso aos serviços de saúde. Essa abordagem foi desenvolvida para estudar barreiras de acesso em cinco dimensões: disponibilidade; acessibilidade geográfica, financeira e organizacional; aceitabilidade; contato; e cobertura efetiva. O desenho do estudo foi usado em seis países da Região das Américas da Organização Mundial da Saúde. Os acha- dos destacam a importância de ter uma estrutura de análise bem definida e os benefícios de adotar uma abordagem de métodos mistos. O uso de dados existentes e a contextualização dos achados de acordo com grupos populacionais e áreas geográficas específicas foram essenciais para a relevância e a utilização dos resultados do estudo. Os achados demonstram a viabilidade de usar métodos mistos para entender a complexidade dos problemas de acesso enfrentados por diferentes subpopulações. O envolvimento de tomadores de decisão desde o início e a flexibilidade para discussões contínuas permitiram que a análise e os achados tivessem impacto. O envolvimento das autoridades sanitárias e das principais partes interessa- das facilitou a utilização dos achados na identificação colaborativa de opções de políticas para eliminar as barreiras de acesso. As lições aprendidas com o estudo enfatizaram a necessidade de participação ativa dos tomadores de decisão, flexibilidade no processo e oportunidades contínuas de discussão para assegurar seu impacto. Foi importante levar em consideração as prioridades locais e adaptar os métodos de acordo com essas prioridades para garantir a relevância e o uso dos achados. Futuros esforços podem considerar a incorporação de métodos mistos em sistemas nacionais e locais de monitoramento e avaliação.

[Recommendations for the development of resilient health systems in the AmericasRecomendações para o desenvolvimento de sistemas de saúde resilientes nas Américas]. / Recomendaciones para el desarrollo de sistemas de salud resilientes en las Américas.

This article offers opinion and analysis outlining strategic lines of action to build resilient health systems while promoting recovery in the post-COVID-19 pandemic period, with a view to maintaining and protecting public health gains. It contextualizes the challenges and opportunities in the Region of the Americas and offers recommendations for implementation of the strategic lines.It is urgent to promote the development of resilient health systems through the implementation of four lines of action defined in the strategy adopted by the Member States of the Pan American Health Organization in September 2021. The transformation of health systems must be based on the adoption of an integrated model of primary health care, a priority focus on the essential public health functions, strengthening of integrated health service networks, and increased public funding, especially for the first level of care. Implementation of these lines of action is focused not only on consolidating immediate crisis response; it is also framed within efforts toward the recovery and sustainable development of health systems, reducing their structural vulnerabilities to better prepare the response to future crises.

Este artigo de opinião e análise descreve linhas de ação estratégicas para desenvolver sistemas de saúde resilientes ao mesmo tempo em que se promove a recuperação pós-pandemia de COVID-19 a fim de manter e proteger os ganhos em saúde pública. Além disso, apresenta uma contextualização dos desafios e oportunidades na região das Américas e oferece recomendações para sua implementação. Há uma necessidade urgente de promover o desenvolvimento de sistemas de saúde resilientes por meio da implementação das quatro linhas de ação definidas na estratégia adotada pelos Estados Membros da Organização Pan-Americana da Saúde em setembro de 2021. A transformação dos sistemas de saúde deve se basear na adoção de um modelo integral de atenção primária à saúde; na priorização das funções essenciais de saúde pública; no fortalecimento de redes integrais de serviços de saúde; e no aumento do financiamento público, especialmente para o primeiro nível de atenção. A implementação dessas linhas de ação busca não apenas consolidar a resposta imediata à crise, mas também enquadrá-la nos esforços de recuperação e desenvolvimento sustentável dos sistemas de saúde, reduzindo suas vulnerabilidades estruturais para que fiquem mais bem preparados para responder a futuras crises.

Organizing memories for generalization in complementary learning systems.

Memorization and generalization are complementary cognitive processes that jointly promote adaptive behavior. For example, animals should memorize safe routes to specific water sources and generalize from these memories to discover environmental features that predict new ones. These functions depend on systems consolidation mechanisms that construct neocortical memory traces from hippocampal precursors, but why systems consolidation only applies to a subset of hippocampal memories is unclear. Here we introduce a new neural network formalization of systems consolidation that reveals an overlooked tension-unregulated neocortical memory transfer can cause overfitting and harm generalization in an unpredictable world. We resolve this tension by postulating that memories only consolidate when it aids generalization. This framework accounts for partial hippocampal-cortical memory transfer and provides a normative principle for reconceptualizing numerous observations in the field. Generalization-optimized systems consolidation thus provides new insight into how adaptive behavior benefits from complementary learning systems specialized for memorization and generalization.