Restricted access to assisted reproductive technology and fertility preservation: legal and ethical issues.

Access to assisted reproductive technology (ART) and fertility preservation remains restricted in middle and low income countries. We sought to review the status of ART and fertility preservation in Brazil, considering social indicators and legislative issues that may hinder the universal access to these services. Although the Brazilian Constitution expressly provides the right to health, and ordinary law ensures the state is obliged to support family planning, access to services related to ART and fertility preservation is neither easy nor egalitarian in Brazil. Only a handful of public hospitals provide free ART, and their capacity far from meets demand. Health insurance does not cover ART, and the cost of private care is unaffordable to most people. Brazilian law supports, but does not command, the state provision of ART and fertility preservation to guarantee the right to family planning; therefore, the availability of state-funded treatments is still scarce, reinforcing social disparities. Economic projections suggest that including ART in the Brazilian health system is affordable and may actually become profitable to the state in the long term, not to mention the ethical imperative of recognizing infertility as a disease, with no reason to be excluded from a health system that claims to be 'universal'.

Now Is Our Time to Act: Why Academic Medicine Must Embrace Community Collaboration as Its Fourth Mission.

In his Leadership Plenary at the Association of American Medical Colleges (AAMC) annual meeting, "Learn Serve Lead 2020: The Virtual Experience," president and CEO David Skorton emphasized that the traditional tripartite mission of academic medicine-medical education, clinical care, and research-is no longer enough to achieve health justice for all. Today, collaborating with diverse communities deserves equal weight among academic medicine's missions. This means going beyond "delivering care" to establishing and expanding ongoing, two-way community dialogues that push the envelope of what is possible in service to what is needed. It means appreciating community assets and creating ongoing pathways for listening to and learning from the needs, lived experiences, perspectives, and wisdom of patients, families, and communities. It means working with community-based organizations in true partnership to identify and address needs, and jointly develop, test, and implement solutions. This requires bringing medical care and public/population health concepts together and addressing upstream fundamental causes of health inequities. The authors call on academic medical institutions to do more to build a strong network of collaborators across public and population health, government, community groups, and the private sector. We in academic medicine must hold ourselves accountable for weaving community collaborations consistently throughout research, medical education, and clinical care. The authors recognize the AAMC can do better to support its member institutions in doing so and discuss new initiatives that signify a shift in emphasis through the association's new strategic plan and AAMC Center for Health Justice. The authors believe every area of academic medicine could grow and better serve communities by listening and engaging more and bringing medical care, public health, and other sectors closer together.

Discretion, power and the reproduction of inequality in health policy implementation: Practices, discursive styles and classifications of Brazil's community health workers.

This article explores the mobilization of power by health workers during policy implementation, showing how in a context of discretion and resource scarcity they can reproduce inequalities in access to health services. The argument innovates theoretically by supplementing the 'street-level bureaucracy' literature, which emphasizes frontline worker discretion, with a conceptualization of power as domination encompassing the shaping of behavior, the constitution of subjects and the reproduction of inequality. Empirically, the article focuses on Brazilian community health workers (agentes comunitários desaúde, CHWs). CHWs are a neglected but highly important segment of the health workforce that traditionally functions as a link between the health system and disadvantaged groups. The article examines how Brazilian CHWs act as street-level bureaucrats mobilizing power in their interactions with users. They operate within a severely under-resourced public health system, the Sistema Único de Saúde, which places constraints upon their action and forces them to make allocation decisions with little training and support. The article highlights the ways in which inequalities in access to health services are reproduced (inadvertently or not) through the practices, discursive styles and classifications of CHWs. Methodologically, the paper is based on ethnography with 24 CHWs and interviews with 77 other CHWs in Brazil.

Pacientes ilegítimos: Acceso a la salud de los inmigrantes indocumentados en Chile / Illegitimate patients: Undocumented immigrants' access to health care in Chile

RESUMEN Chile se ha ido convirtiendo en un país de destino para las migraciones sudamericanas, las cuales generan un impacto en los servicios públicos, en particular en salud, a nivel económico, social y cultural. El objetivo de este artículo es aportar información documentada sobre los problemas de acceso a la salud de los inmigrantes indocumentados. Trabajamos desde una metodología cualitativa, basada principalmente en una etnografía del espacio clínico. Para el análisis de los resultados nos hemos basado en las teorías de las relaciones asimétricas de poder, así como en las de las relaciones interétnicas. En los resultados de la investigación, se destaca el incumplimiento de la normativa y el ejercicio del criterio personal discrecional como barreras en el acceso. Concluimos que, en Chile, los inmigrantes en general e indocumentados, en particular, son considerados pacientes ilegítimos.

ABSTRACT In recent decades, Chile has become a destination for immigrants from other South American countries, which has significantly impacted public services - particularly the public health system - at the economic, social, and cultural levels. The aim of this paper is to provide substantiated information on issues concerning undocumented immigrants' access to health care in Chile. A qualitative methodology, fundamentally an ethnography of the clinical setting, was used. Results were then analyzed in relation to theories of power asymmetries and interethnic relations. The research results highlight the lack of compliance with existing regulations and the exercise of discretionary personal judgment as barriers to access. It is concluded that in Chile immigrants in general, and undocumented immigrants in particular, are considered to be illegitimate patients.

Dialectics of a medical provision policy in priority areas in Brazil.

INTRODUCTION:: The people living in vulnerable areas that are difficult to access in Brazil represent a portion of the population that has proven very sensitive to lack of medical and health services. The government, seeking to solve the situation urgently, implemented the More Doctors Program [Programa Mais Médicos, in the Portuguese original] in 2013. OBJECTIVE:: To discuss the More Doctors Program, with the purpose of contributing to the debate on the provision of medical policies in Brazil. METHOD:: Study based on the review of official documents: Programa Mais Médicos - dois anos: mais saúde para os brasileiros, 2015 [More Doctors Program - two years: more health for Brazilians, 2015]; Operational Audit Report, TC Nº 005391/2014-8, the Court of Auditors of Brazil; and Medical Demography in Brazil 2015. RESULTS:: The import of exchange physicians without diploma revalidation has cast a shadow on the technical quality of services offered to the population. In terms of infrastructure, the reduction of resources paralyzed works and made the care network maintenance projects impossible. The creation of new medical schools has created uncertainty about the possibility of quality education being offered, with minimum and sufficient structure including laboratories, clinics and teaching hospitals indispensable to medical training. CONCLUSION:: The regional inequalities of concentration and dispersion of physicians, showed by studies on medical demography in Brazil, stem from several factors, including the lack of a career path and working conditions. There is no point in having physicians if they do not have safe and ethical conditions to establish the diagnosis and a treatment plan, as well as to monitor the rehabilitation of the patient.

Neoliberal reforms in health systems and the construction of long-lasting inequalities in health care: A case study from Chile.

The aim of this article is to discuss how neoliberal policies implemented in the Chilean health system during the Pinochet regime have a lingering effect on equal access to health care today. The two-tier health system - public and private - that was introduced in the early 1980s as a means to improve efficiency and lower health-related costs, has led instead to inequality of access and dehumanisation of health care. Health has changed from being a right to being a marketable need, thus creating a structural disadvantage for several parts of the population - particularly the poor, the elderly, and women - who cannot afford the better-quality services and timely attention of private health providers, and thus, are not adequately protected against health risks. Despite the recent health reforms that aim at improving equity in health care access and financing, we argue that the Chilean health system is still biased against the poorer segments of the population, while it favours the more affluent groups that can afford private health care.

[Illegitimate patients: Undocumented immigrants' access to health care in Chile]. / Pacientes ilegítimos: Acceso a la salud de los inmigrantes indocumentados en Chile.

In recent decades, Chile has become a destination for immigrants from other South American countries, which has significantly impacted public services - particularly the public health system - at the economic, social, and cultural levels. The aim of this paper is to provide substantiated information on issues concerning undocumented immigrants' access to health care in Chile. A qualitative methodology, fundamentally an ethnography of the clinical setting, was used. Results were then analyzed in relation to theories of power asymmetries and interethnic relations. The research results highlight the lack of compliance with existing regulations and the exercise of discretionary personal judgment as barriers to access. It is concluded that in Chile immigrants in general, and undocumented immigrants in particular, are considered to be illegitimate patients.

Chile se ha ido convirtiendo en un país de destino para las migraciones sudamericanas, las cuales generan un impacto en los servicios públicos, en particular en salud, a nivel económico, social y cultural. El objetivo de este artículo es aportar información documentada sobre los problemas de acceso a la salud de los inmigrantes indocumentados. Trabajamos desde una metodología cualitativa, basada principalmente en una etnografía del espacio clínico. Para el análisis de los resultados nos hemos basado en las teorías de las relaciones asimétricas de poder, así como en las de las relaciones interétnicas. En los resultados de la investigación, se destaca el incumplimiento de la normativa y el ejercicio del criterio personal discrecional como barreras en el acceso. Concluimos que, en Chile, los inmigrantes en general e indocumentados, en particular, son considerados pacientes ilegítimos.

[Alternatives to the drug research and development model]. / Alternativas al modelo de investigación y desarrollo de medicamentos.

One-third of the global population lacks access to medications; the situation is worse in poor countries, where up to 50% of the population lacks access. The failure of current incentive systems based in intellectual property to offer the necessary pharmaceutical products, especially in the global south, is a call to action. Problems related to drug access cannot be solved solely through improvements or modifications in the existing incentive models. The intellectual property system model does not offer sufficient innovation for developing countries; new mechanisms that effectively promote innovation and drug access simultaneously are needed. A binding international agreement on research and development, negotiated under the auspices of the World Health Organization, could provide an adequate framework for guaranteeing priority-setting, coordination, and sustainable financing of drugs at reasonable prices for developing countries.

[The judicialisation of health as a means ensuring access to medicines]. / Judicialização da saúde na garantia do acesso ao medicamento.

OBJECTIVE: A systematic review, focusing on the judicialisation of health regarding gaining access to medicines, was aimed at understanding the impact of lawsuits on the organisation of public health services. METHOD: Original articles published between 2007 and 2011 in the pertinent national and international literature were analysed, resulting in 49,239 articles being found in Science Direct and BIREME databases. Results The survey indicated a predominance of literature from Brazil, mainly the southeast, as well as a study from Colombia. DISCUSSION: The aforementioned chronic disease-related claims involved diabetes, high blood pressure, cancer and rheumatoid arthritis. Forming part of specific Unified Healthcare System programmes highlighted the difficulty in gaining access to the appropriate medicine and consequent health judicialisation demonstrated the fragility of existing public policy. CONCLUSION: It was concluded that the courts (despite being a strategy for ensuring access to medicine) were unable to deal with the current spate of lawsuits, thereby leading to disruption regarding the flow of public systems.

[Transsexuality: law and health-related aspects in the Spanish legal system]. / La transexualidad: aspectos jurídico-sanitarios en el ordenamiento español.

The social weight of transsexual groups has been and continues to be crucial in many aspects regarding transsexuality, from the progressive elimination of discrimination to influence in the legislative branch. This paper especially discusses a classic demand of these groups, comprehensive medical treatment of transsexual people within the National Health System. Thus, progress in the development of an adequate healthcare system for these groups, their treatment in the legal systems of Spain in general and of some of its autonomous communities with more noteworthy laws (especially in Andalusia, an autonomous community that has been pioneering in this regard, as well as the Basque Country and Navarre) and remaining challenges will be observed in this work. The article will also take particular note of the substantial developments that the publication of the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders has established in this area.

When constitutional justice has the last word on health care: the case of Chile.

The Chilean health care system is in crisis. Since the recent ruling of the Constitutional Court that declared the risk rating (actuarial insurance) of private health insurers unconstitutional, all of the social actors related to health care have tried to agree on a legislative reform that would overcome the existing highly segmented and inequitable system, which is a legacy of Pinochet's dictatorship. Here we demonstrate how the social and political demands for legislative reform in the health care sector have been supported by the decisions of the courts. To achieve its goals of reducing equity gaps in health and ending the judicialization of health care (claims for protection represent almost 70% of total resources of the courts), the National Congress of Chile is trying to create a new national health insurance system that guarantees the right to a minimum level of health care. Part of this effort involves obtaining the constitutional approval of the courts. In Chile, justice has the final word on health care.

[Private health insurance systems, constitution and the right to receive an equitable health care]. / Isapres, tribunal constitucional y distribución del derecho a cuidado sanitario.

This paper analyzes the constitutional problems that the private health system has faced as a result of the recent decisions of the Constitutional Court and the Supreme Court of Chile in defense of the right to health care and nondiscrimination. It also reviews the comparative literature on health systems that have been successful in the task of reconciling the demands of equity and efficiency in the delivery of health care in the private health sector, in accordance with the constitutional principles of equality and nondiscrimination.

Human rights and maternal health: exploring the effectiveness of the Alyne decision.

This article explores the effectiveness of the decision of the Committee on the Elimination of Discrimination against Women in the case of Alyne da Silva Pimentel Teixeira (deceased) v. Brazil, concerning a poor, Afro-Brazilian woman. This is the first decision of an international human rights treaty body to hold a state accountable for its failure to prevent an avoidable death in childbirth. Assessing the future effectiveness of this decision might be undertaken concretely by determining the degree of Brazil's actual compliance with the Committee's recommendations, and how this decision influences pending domestic litigation arising from the maternal death. Alternative approaches include: determining whether, over time, the decision leads to the elimination of discrimination against women of poor, minority racial status in the health sector, and if it narrows the wide gap between rates of maternal mortality of poor, Afro-Brazilian women and the country's general female population. Determining the effectiveness of this decision will guide whether to pursue a more general strategy of judicializing maternal mortality.

[Legal and sanitary aspects conditioning access to medicines in Brazilian courts]. / Aspectos jurídicos e sanitários condicionantes para o uso da via judicial no acesso aos medicamentos no Brasil.

The search for having access to health care and medicines right granted through Judicial Courts has increased in Brazil. What has been nominated "health judicialization" is a multidimensional phenomenon, a need for dealing with it in a multidisciplinary way involving legal-judicial, political-institutional and sanitary approaches has raised. The Health is recognized as a fundamental human right in the Brazilian Constitution giving it a different legal protection under the legal-constitutional order and the country guarantees the right to health are not only the Constitution and the law strictly, but mainly in an normative infralegal arc that define the goals and outcomes to be achieved by public policy. The lawsuits by drugs may be a reflection of the difficulty of access to health services, to empty and downgrading of health care. Therefore, this turns out to affect the judicialization of pharmaceutical care in Brazil.

Derecho a la salud: un modelo para la determinación de los contenidos mínimos y periféricos / The right to health: a model for determining the contents of the minimum core and the periphery

El derecho a la salud ha sido fuertemente reconocido por los tribunales argentinos, pero lo cierto es que solo goza de dicho derecho quien tiene posibilidad de acceder a la justicia. Por lo tanto, los grupos tradicionalmente excluidos, que por diferentes motivos no pueden hacer oír sus reclamos en sede judicial, no se benefician con el reconocimiento logrado hasta ahora en las diferentes resoluciones judiciales. Teniendo en cuenta estas prácticas desigualitarias institucionalizadas se plantea aquí un modelo que implica entender el derecho a la salud como verdadero derecho. Para esto se realiza una distinción entre el derecho a la salud como regla (en lo que se refiere al contenido mínimo o esencial de dicho derecho) y el derecho a la salud como principio (respecto del contenido periférico), demostrándose así cómo el derecho a la salud considerado como regla y como principio podría llegar a otorgar mayor igualdad en el reconocimiento de este derecho respecto de los grupos desaventajados, que carecen de acceso a la justicia.(AU)

The right to health has been widely recognized in the Argentine courts, however only those who have the ability to access the justice system are able to fully enjoy that right. Therefore traditionally excluded groups, who for different reasons have not been able to make their demands heard in a judicial court, do not benefit from the recognition gained up to this point in the different judicial resolutions. Taking into account these institutionalized unequal practices, this article suggests a model for understanding the right to health truly as a right. A distinction is made between the right to health as a rule (understood as the minimum or essential core of that right) and the right to health as a principle (understood as the periphery of the right). In this way, it is shown how considering the right to health as both a rule and as a principle could offer greater equality in recognition of that right for disadvantaged groups that lack access to the justice system.(AU)

Derecho a la salud: un modelo para la determinación de los contenidos mínimos y periféricos / The right to health: a model for determining the contents of the minimum core and the periphery

El derecho a la salud ha sido fuertemente reconocido por los tribunales argentinos, pero lo cierto es que solo goza de dicho derecho quien tiene posibilidad de acceder a la justicia. Por lo tanto, los grupos tradicionalmente excluidos, que por diferentes motivos no pueden hacer oír sus reclamos en sede judicial, no se benefician con el reconocimiento logrado hasta ahora en las diferentes resoluciones judiciales. Teniendo en cuenta estas prácticas desigualitarias institucionalizadas se plantea aquí un modelo que implica entender el derecho a la salud como verdadero derecho. Para esto se realiza una distinción entre el derecho a la salud como regla (en lo que se refiere al contenido mínimo o esencial de dicho derecho) y el derecho a la salud como principio (respecto del contenido periférico), demostrándose así cómo el derecho a la salud considerado como regla y como principio podría llegar a otorgar mayor igualdad en el reconocimiento de este derecho respecto de los grupos desaventajados, que carecen de acceso a la justicia.

The right to health has been widely recognized in the Argentine courts, however only those who have the ability to access the justice system are able to fully enjoy that right. Therefore traditionally excluded groups, who for different reasons have not been able to make their demands heard in a judicial court, do not benefit from the recognition gained up to this point in the different judicial resolutions. Taking into account these institutionalized unequal practices, this article suggests a model for understanding the right to health truly as a right. A distinction is made between the right to health as a rule (understood as the minimum or essential core of that right) and the right to health as a principle (understood as the periphery of the right). In this way, it is shown how considering the right to health as both a rule and as a principle could offer greater equality in recognition of that right for disadvantaged groups that lack access to the justice system.

[The right to health: a model for determining the contents of the minimum core and the periphery]. / Derecho a la salud: un modelo para la determinación de los contenidos mínimos y periféricos.

The right to health has been widely recognized in the Argentine courts, however only those who have the ability to access the justice system are able to fully enjoy that right. Therefore traditionally excluded groups, who for different reasons have not been able to make their demands heard in a judicial court, do not benefit from the recognition gained up to this point in the different judicial resolutions. Taking into account these institutionalized unequal practices, this article suggests a model for understanding the right to health truly as a right. A distinction is made between the right to health as a rule (understood as the minimum or essential core of that right) and the right to health as a principle (understood as the periphery of the right). In this way, it is shown how considering the right to health as both a rule and as a principle could offer greater equality in recognition of that right for disadvantaged groups that lack access to the justice system.