Migration and health right: Probabilistic estimate of the factors that impact on health right of the migrant population, Peru 2019-2021.

The study aims to identify factors associated with the violation of the right to health of the regular migrant population with respect to the nonmigrant population in Peru during the period 2019-2021, based on the complaints of health services users. It is a three-year cross-sectional and retrospective study on a total population of 122,505 complainants to the National Superintendency of Health (SUSALUD). The types of health rights used were those established in Peruvian Law No. 29414. An unordered multinomial probability model was used to estimate the probability of belonging to five types of violated rights based on the regular migrant and nonmigrant population, and the exogenous variables that affect this probability. The individual significance tests of the model, the tests for combining categories and the test of independence of irrelevant alternatives by means of the Wald and Hausman-McFadden tests were previously taken. The results indicated an increase in complaints from regular migrants of 5.6% in the 2019-2021 period unlike nonmigrants who had a decrease of 12.2%. The greatest probability that health rights of regular migrants are violated refers to access to information and the right to care and recovery, where their probability of violation is 27.7% and 25.4%, respectively (p-v < 0.05, CI = 95%). Likewise, health rights are more likely to be violated if they are women; if they are adults (41 years old on average); if they do not possess any type of health insurance; if they use Peruvian Ministry of Health (MINSA) services; and if they are located in metropolitan cities, such as Lima and Callao.

[Patterns of social behavior among informal workers during extreme events: lessons from social life during the Covid-19 pandemic in Lima, Peru.] / Patrones de conducta social de trabajadores informales durante eventos extremos: lecciones de la vida social durante la pandemia de covid-19 en Lima, Perú.

This study analyzes changes in social life during the pandemic and the early stages of the post-pandemic period within a population characterized by high levels of informality in Lima, particularly the textile district of Gamarra, encompassing 89,123 people. A qualitative approach was adopted, based on 62 semi-structured interviews with garment manufacturers, in-store traders, and street vendors. Two distinct moments could be identified: a) experiences confronting the shock induced by the Covid-19 pandemic; and b) experiences of reconfiguring work and daily life, alongside strategies adopted by the population. In conclusion, the study suggests that some elements of daily life acquired during the Covid-19 pandemic may carry over into the future, inducing society to place greater emphasis on preventive measures against emerging risks, including behaviors related to hygiene and health, fostering closer family ties, increased utilization of digitalization and hybrid work models, and the cultivation of enhanced social capital.

El estudio analiza los cambios en la vida social durante la pandemia y en la inicial pospandemia, en una población de alta informalidad en Lima, en la zona textil de Gamarra, que involucra a 89.123 personas. Es una investigación cualitativa, basada en 62 entrevistas semiestructuradas a confeccionistas, comerciantes de tienda y vendedores/as ambulantes. El estudio identifica dos momentos: a) las experiencias de recepción del shock por la pandemia de covid-19, y b) las experiencias de reprocesamiento del trabajo y la vida cotidiana y las salidas encontradas por la población. Se concluye que el futuro podría tener elementos adquiridos de la vida cotidiana con el covid-19, hacia una sociedad más preventiva ante los riesgos emergentes, en particular, conductas más higienistas y consideradas con la salud, más cercanas a la familia, con un uso mayor de la digitalización y trabajo híbrido, con más capital social.

Resilient health systems for already resilient countries? Pandemic discourses in the post-COVID-19 era. / ¿Sistemas de salud resilientes para países ya resilientes? Los discursos de la pandemia en la era post COVID-19.

This study aimed to reconstruct and analyze the discourses of the pandemic in the post-COVID-19 era. The methodology was based on a critical review of the scientific literature on the pandemic, selecting 80 non-biomedical, clinical, or pharmacological articles published in journals indexed in Scopus or Web of Science from a sample of the 500 most cited scientific articles on the pandemic in Google Scholar. The theoretical approach was based on the debates on predictability, unpredictability, determination, and indeterminacy in the health and social sciences. As a result, six theses on the pandemic were identified and analyzed: a) the thesis of the unpredictability of pandemics; b) the thesis of pandemic denial; c) the thesis of the pandemic as a failure in predictability systems; d) the thesis of the prevention of catastrophic events with timely interventions; e) the thesis of the structural postponement of predictive care by non-developed countries; and f) the environmentalist-health thesis, of foreseeing a critical phase for the planet and humanity. We concluded on the limits of resilience as the center in preparing Latin American health systems in the post-pandemic.

El objetivo fue reconstruir y analizar los discursos de la pandemia en la era post-COVID-19. La metodología se basó en una revisión crítica de la literatura científica sobre la pandemia, seleccionándose entre una muestra de los 500 artículos científicos más citados en Google Scholar sobre la pandemia, a 80 artículos de carácter no biomédico, clínico o farmacológico, publicados en revistas indexadas en Scopus o Web of Science. El abordaje teórico se basó en los debates sobre predictibilidad e impredecibilidad, determinación e indeterminación, en las ciencias de la salud y ciencias sociales. Como resultado se identificaron y analizaron seis tesis sobre la pandemia: a) la tesis de la impredecibilidad de las pandemias; b) la tesis negacionista de la pandemia; c) la tesis de la pandemia como falla en los sistemas de predictibilidad; d) la tesis de la prevención de eventos catastróficos con intervenciones puntuales; e) la tesis de la postergación estructural de la atención de predicciones por los países no desarrollados; y f) la tesis ecologista-sanitaria, de previsión de una fase crítica para el planeta y la humanidad. Se concluyó sobre los límites de la resiliencia como centro en la preparación de los sistemas de salud de Latinoamérica en la post-pandemia.

¿Sistemas de salud resilientes para países ya resilientes? Los discursos de la pandemia en la era post COVID-19 / Resilient health systems for already resilient countries? Pandemic discourses in the post-COVID-19 era

Resumen El objetivo fue reconstruir y analizar los discursos de la pandemia en la era post-COVID-19. La metodología se basó en una revisión crítica de la literatura científica sobre la pandemia, seleccionándose entre una muestra de los 500 artículos científicos más citados en Google Scholar sobre la pandemia, a 80 artículos de carácter no biomédico, clínico o farmacológico, publicados en revistas indexadas en Scopus o Web of Science. El abordaje teórico se basó en los debates sobre predictibilidad e impredecibilidad, determinación e indeterminación, en las ciencias de la salud y ciencias sociales. Como resultado se identificaron y analizaron seis tesis sobre la pandemia: a) la tesis de la impredecibilidad de las pandemias; b) la tesis negacionista de la pandemia; c) la tesis de la pandemia como falla en los sistemas de predictibilidad; d) la tesis de la prevención de eventos catastróficos con intervenciones puntuales; e) la tesis de la postergación estructural de la atención de predicciones por los países no desarrollados; y f) la tesis ecologista-sanitaria, de previsión de una fase crítica para el planeta y la humanidad. Se concluyó sobre los límites de la resiliencia como centro en la preparación de los sistemas de salud de Latinoamérica en la post-pandemia.

Abstract This study aimed to reconstruct and analyze the discourses of the pandemic in the post-COVID-19 era. The methodology was based on a critical review of the scientific literature on the pandemic, selecting 80 non-biomedical, clinical, or pharmacological articles published in journals indexed in Scopus or Web of Science from a sample of the 500 most cited scientific articles on the pandemic in Google Scholar. The theoretical approach was based on the debates on predictability, unpredictability, determination, and indeterminacy in the health and social sciences. As a result, six theses on the pandemic were identified and analyzed: a) the thesis of the unpredictability of pandemics; b) the thesis of pandemic denial; c) the thesis of the pandemic as a failure in predictability systems; d) the thesis of the prevention of catastrophic events with timely interventions; e) the thesis of the structural postponement of predictive care by non-developed countries; and f) the environmentalist-health thesis, of foreseeing a critical phase for the planet and humanity. We concluded on the limits of resilience as the center in preparing Latin American health systems in the post-pandemic.

Efectividad de la cuarentena durante la primera y segunda ola de COVID-19: un estudio de corte transversal y temporal

Introducción. La principal estrategia para enfrentar la pandemia del COVID-19 fue la cuarentena. Cierta literatura admite su utilidad; en cambio otra resalta los perjuicios y riesgos que conlleva la aplicación de esta medida. Objetivo. Utilizando cortes semanales y mensuales de defunciones de la primera y segunda ola del COVID-19, se evaluó la utilidad de la cuarentena en Perú en términos de adherencia y efectividad a nivel provincial. Métodos. Tomando como dependiente el número de casos de fallecidos en cada provincia se estimó el efecto de la movilidad según distintos tipos de lugares y otras covariables sobre la variable de interés. Se utilizó información del Centro Nacional de Epidemiología, Prevención y Control de Enfermedades del Ministerio de Salud (CDC - MINSA); la Plataforma Nacional de Datos Abiertos (PCM - MINSA); la data de la Superintendencia Nacional de Salud (SUSALUD); e información agregada de Google Analytics. Para estimar la efectividad se construyó un modelo de efectos fijos. Resultados. En la estimación mensual, durante la primera y segunda ola de COVID-19, las covariables y la mayoría de las tendencias de la movilidad de las personas resultaron significativas. En la segunda ola la movilidad en parques, supermercados y farmacias perdieron relevancia. En la estimación semanal solo la disponibilidad de oxígeno no fue relevante en la segunda ola; las demás variables independientes sí lo fueron. Conclusiones. La estrategia sanitaria de la cuarentena, tanto en la estimación mensual como en la semanal, no tuvo la efectividad esperada, aunque lograra adherencia en su cumplimiento.

Introduction. The main strategy to face the COVID-19 pandemic was quarantine. Some literature admits its usefulness; on the other hand, other literature emphasizes the harm and risks involved in the application of this measure. Objective. Using weekly and monthly cut-offs of deaths from the first and second waves of COVID-19, the usefulness of quarantine in Peru was evaluated in terms of adherence and effectiveness at the provincial level. Methods. Taking as dependent the number of cases of deaths in each province, the effect of mobility according to different types of places and other covariates on the variable of interest was estimated. Information from the National Center for Epidemiology, Prevention and Disease Control of the Ministry of Health (CDC - MINSA); the National Open Data Platform (PCM - MINSA); data from the National Superintendence of Health (SUSALUD); and aggregate information from Google Analytics were used. A fixed effects model was constructed to estimate effectiveness. Results. In the monthly estimation, during the first and second waves of COVID-19, the covariates and most of the trends in people's mobility were significant. In the second wave, mobility in parks, supermarkets and pharmacies lost relevance. In the weekly estimation only oxygen availability was not relevant in the second wave; the other independent variables were. Conclusions. The health strategy of quarantine, both in the monthly and weekly estimation, did not have the expected effectiveness, although it achieved adherence.

Patrones de conducta social de trabajadores informales durante eventos extremos: lecciones de la vida social durante la pandemia de covid-19 en Lima, Perú / Patterns of social behavior among informal workers during extreme events: lessons from social life during the Covid-19 pandemic in Lima, Peru

RESUMEN El estudio analiza los cambios en la vida social durante la pandemia y en la inicial pospandemia, en una población de alta informalidad en Lima, en la zona textil de Gamarra, que involucra a 89.123 personas. Es una investigación cualitativa, basada en 62 entrevistas semiestructuradas a confeccionistas, comerciantes de tienda y vendedores/as ambulantes. El estudio identifica dos momentos: a) las experiencias de recepción del shock por la pandemia de covid-19, y b) las experiencias de reprocesamiento del trabajo y la vida cotidiana y las salidas encontradas por la población. Se concluye que el futuro podría tener elementos adquiridos de la vida cotidiana con el covid-19, hacia una sociedad más preventiva ante los riesgos emergentes, en particular, conductas más higienistas y consideradas con la salud, más cercanas a la familia, con un uso mayor de la digitalización y trabajo híbrido, con más capital social.

ABSTRACT This study analyzes changes in social life during the pandemic and the early stages of the post-pandemic period within a population characterized by high levels of informality in Lima, particularly the textile district of Gamarra, encompassing 89,123 people. A qualitative approach was adopted, based on 62 semi-structured interviews with garment manufacturers, in-store traders, and street vendors. Two distinct moments could be identified: a) experiences confronting the shock induced by the Covid-19 pandemic; and b) experiences of reconfiguring work and daily life, alongside strategies adopted by the population. In conclusion, the study suggests that some elements of daily life acquired during the Covid-19 pandemic may carry over into the future, inducing society to place greater emphasis on preventive measures against emerging risks, including behaviors related to hygiene and health, fostering closer family ties, increased utilization of digitalization and hybrid work models, and the cultivation of enhanced social capital.

Factors Associated With the Health and Economic Effects of the COVID-19 Pandemic in the Peruvian Textile Sector, 2020-2021.

The article identifies the factors associated with the health and economic effects of the COVID-19 pandemic on people working in the textile industry of Lima, Peru, during 2021. The study was conducted in Peru's largest textile emporium, so-called Gamarra. The study design is observational and cross-sectional, with two models with two temporal samples for the first and second waves of the COVID-19 pandemic. The first model measures the chance of getting sick from COVID-19. The second model measures the economic impact by the variations in incomes. Inferential statistics are employed, using the chi-square test. The p-value (p < 0.05) is evaluated to decide the statistical significance of the variables. Of 820 workers included, 48% work in street trading, 45% are ≤ 35 years of age and 15% are foreign migrants. Logistic regression analysis for the first model reveals an association between infection by a family member, people breaking quarantine, foreign nationality, not having hygienic services and having a chronic disease, with the highest probability of COVID-19 infection. Regarding economic impact, an association is found between educational level, being ≥45 years of age and infection of a family member, with a greater probability of variation in income.

The importance of confidence, complacency, and convenience for influenza vaccination among key risk groups in large urban areas of Peru.

Influenza vaccination has been available under Peru's national immunization program since 2008, but vaccination coverage has decreased lately. Surveys and focus groups were conducted among four risk groups (pregnant women, mothers of children aged <6 years, adults with risk factors, and adults aged ≥65 years) to identify factors affecting influenza vaccine hesitancy in Peru. The 3Cs model (Confidence, Complacency, and Convenience) was used as a conceptual framework for the study. Most pregnant women and mothers of young children (70.0%), but less than half (46.3%) of older adults and adults with risk factors were vaccinated against influenza. Vaccine confidence and complacency were positively associated with educational level. Complacency was the most deficient of the 3Cs. Pregnant women and mothers were the most informed and least complacent among risk groups. Focus groups revealed the misconceptions behind the high level of complacency observed, including the perception of influenza risk and the role assigned to vaccination in preventing the disease. Interviews with officials identified that most strategies are directed to vaccination availability and hence to convenience, with opportunities for strategies to improve vaccination uptake and community engagement. The results highlight the importance of implementing in Peru communication strategies to increase perceptions of vaccine safety and effectiveness thus improving confidence and reducing complacency. The establishment of explicit incentives should also be considered to increase vaccination uptake, particularly to health personnel.

Influenza vaccination hesitancy in five countries of South America. Confidence, complacency and convenience as determinants of immunization rates.

INTRODUCTION: Influenza morbidity and mortality are significant in the countries of South America, yet influenza vaccination is as low as 56.7% among pregnant women, reaching 76.7% of adults with chronic diseases. This article measures the relative values for the vaccination hesitancy indicators of confidence, complacency and convenience by risk-groups in urban areas of five countries of South America with contrasting vaccination rates, analyzing their association with sociodemographic variables and self-reported immunization status. METHODS: An exit survey was applied to 640 individuals per country in Brazil, Chile, Paraguay, Peru and Uruguay, distributed equally across risk groups of older adults, adults with risk factors, children ≤6 and pregnant women. Indicators were constructed for vaccine confidence, complacency and convenience. Analysis of variance and multiple logistic analysis was undertaken. RESULTS: Adults with risk factors are somewhat more confident of the influenza vaccine yet also more complacent. Convenience is higher for mothers of minors. Children and older adults report higher levels of vaccination. The 3Cs are more different across countries than across risk groups, with values for Chile higher for confidence and those for Uruguay the lowest. Complacency is lower in Brazil and higher in Uruguay. Results suggest that confidence and complacency affect vaccination rates across risk groups and countries. CONCLUSIONS: Influenza vaccine confidence, complacency and convenience have to be bolstered to improve effective coverage across all risk groups in the urban areas of the countries studied. The role played by country contextual and national vaccination programs has to be further researched in relation to effective coverage of influenza vaccine.

Health policy and systems research publications in Latin America warrant the launching of a new specialised regional journal.

BACKGROUND: Scientific journals play a critical role in research validation and dissemination and are increasingly vocal about the identification of research priorities and the targeting of research results to key audiences. No new journals specialising in health policy and systems research (HPSR) and focusing in the developing world or in a specific developing world region have been established since the early 1980s. This paper compares the growth of publications on HPSR across Latin America and the world and explores the potential, feasibility and challenges of innovative publication strategies. METHODS: A bibliometric analysis was undertaken using HPSR MeSH terms with journals indexed in Medline. A survey was undertaken among 2500 authors publishing on HPSR in Latin America (LA) through an online survey, with a 13.1% response rate. Aggregate indicators were constructed and validated, and two-way ANOVA tests were performed on key variables. RESULTS: HPSR publications on LA observed an average annual growth of 27.5% from the years 2000 to 2018, as against 11.4% worldwide and yet a lag on papers published per capita. A total of 48 journals with an Impact Factor publish HPSR on LA, of which 5 non-specialised journals are published in the region and are ranked in the bottom quintile of Impact Factor. While the majority of HPSR papers worldwide is published in specialised HPSR journals, in LA this is the minority. Very few researchers from LA sit in the Editorial Board of international journals. Researchers highly support strengthening quality HPSR publications through publishing in open access, on-line journals with a focus on the LA region and with peer reviewers specialized on the region. Researchers would support a new open access journal specializing in the LA region and in HPSR, publishing in English. Open access up-front costs and disincentives while waiting for an Impact Factor can be overcome. CONCLUSION: Researchers publishing on HPSR in LA widely support the launching of a new specialised journal for the region with a vigorous editorial policy focusing on regional and country priorities. Strategies should be in place to support English-language publishing and to develop a community of practice around the publication process. In the first years, special issues should be promoted through a priority-setting process to attract prominent authors, develop the audience and attain an Impact Factor.

Redistribution of salary or professional recognition? The difficult construction of a profession, the Peruvian nursing / Redistribuição de salário ou reconhecimento profissional? A difícil construção de uma profissão, a enfermagem peruana

Abstract The study presents the current profile of Peruvian nursing, its professional construction and its dilemmas, emphasizing its socio-cultural features. To this end, an extensive literature was reviewed, interviewing nurses in key positions and analyzing secondary source data. This study keeps its distance from other studies on health care professions as a workforce, to analyze the low social legitimacy of the nursing profession despite being the great operator of health care services in Peru. This resulting psychological overload, additionally to the work overload is reflected in job dissatisfaction, stress, burnout, intention of changing careers, and a strong desire to migrate. As a result, Peruvian nursing has opted for three alternatives: a) resilience, which means to adapt to this unfavorable situation; b) abandoning the profession, or leaving the country; and c) reaction, which gathers all manifestations of the profession against abandonment, informality, and mediocrity. In conclusion, the biggest challenge of professions given low social value is the recognition and not only the salary redistribution. This significant challenge for Peruvian nursing does not mainly relate to legal professionalization, but professionalism, which must result in greater legitimacy and autonomy.

Resumo O estudo apresenta o perfil atual da enfermagem peruana, sua construção profissional e seus dilemas, enfatizando suas características socioculturais. Para tanto, foi realizada extensa revisão de literatura, entrevistas com profissionais de enfermagem em posições-chave e análise de dados de fontes secundárias. O estudo distancia-se dos estudos das profissões da saúde como força de trabalho, a fim de analisar a baixa legitimidade social da profissão de enfermagem, apesar de ser a grande operadora de serviços no Peru. Isso produz uma sobrecarga psicológica, que se soma à sobrecarga de trabalho e se reflete em insatisfação no trabalho, estresse, burnout, desejo de mudar de carreira ou migrar. Diante disso, a enfermagem peruana optou por três saídas: a) resiliência, que representa adaptação; b) abandono, ou saída do país ou profissão; e c) a reação, que agrupa todas as manifestações contra o abandono à informalização e à mediocrização. Conclui-se que as profissões de baixo valor social têm como desafio central o reconhecimento profissional e não apenas a redistribuição salarial. Esse desafio central da enfermagem peruana não está centralmente ligado à sua profissionalização legal, mas ao seu profissionalismo, que trará maior legitimidade e autonomia.

Redistribution of salary or professional recognition? The difficult construction of a profession, the Peruvian nursing.

The study presents the current profile of Peruvian nursing, its professional construction and its dilemmas, emphasizing its socio-cultural features. To this end, an extensive literature was reviewed, interviewing nurses in key positions and analyzing secondary source data. This study keeps its distance from other studies on health care professions as a workforce, to analyze the low social legitimacy of the nursing profession despite being the great operator of health care services in Peru. This resulting psychological overload, additionally to the work overload is reflected in job dissatisfaction, stress, burnout, intention of changing careers, and a strong desire to migrate. As a result, Peruvian nursing has opted for three alternatives: a) resilience, which means to adapt to this unfavorable situation; b) abandoning the profession, or leaving the country; and c) reaction, which gathers all manifestations of the profession against abandonment, informality, and mediocrity. In conclusion, the biggest challenge of professions given low social value is the recognition and not only the salary redistribution. This significant challenge for Peruvian nursing does not mainly relate to legal professionalization, but professionalism, which must result in greater legitimacy and autonomy.

Carrera sanitaria en el Perú: fundamentos técnicos para su desarrollo / Health career in Peru: technical foundation for development

La presente publicación sistematiza la experiencia acumulada en el campo laboral en salud, formulando las bases para la construcción de la carrera sanitaria en el Perú, contribuyendo a generar debates, movilizar opiniones y promover decisiones entre los actores del campo de recursos humanos en nuestro país.

Carrera sanitaria en el Perú. Fundamentos técnicos para su desarrollo / Health career in Peru. Technical foundation for development

La presente publicación sistematiza la experiencia acumulada en el campo laboral en salud, formulando las bases para la construcción de la carrera sanitaria en el Perú, contribuyendo a generar debates, movilizar opiniones y promover decisiones entre los actores del campo de recursos humanos en nuestro país(AU)

Situación de los campos clínicos en el Perú. Análisis y propuestas de acreditación de campos de práctica en la formación en salud / Status of clinical fields in Peru. Analysis and proposals for accreditation of fields of practice in health education

La presente publicación condensa el informe final del estudio sobre los campos de práctica profesional de salud, una propuesta de estándares de acreditación y mecanismos para su operacionalización(AU)

Situación y desafíos en el campo de los recursos humanos en el área Andina en los albores de los 2000 / Situation an challenges in the field of human resources on health in the Andean area on the 2000 initial

El artículo presenta una revisión de la situación actual y desafíos de los recursos humanos en salud en cinco países andinos: Bolivia, Colombia, Ecuador, Perú y Venezuela. El artículo reseña transversalmente los problemas comunes al área andina, sobre la base de los estudios por países compendiados en el capítulo Inicial del informe, no publicado aquí. El estudio se hizo entre agosto y noviembre del año 2000 en base a fuentes secundarias y consultas a expertos en el tema en los cinco países andinos. Se concluye que en los países andinos hay un tránsito muy inicial a la nueva situación de los recursos humanos defínida por los postulados de las reformas sectoriales, diferenciándose tres situaciones sobre recursos humanos: a) situación de fíexibilización laboral avanzada y en medio de un cambio sistémico (Colombia); b) situación inversa, de países con una muy lenta asimilación de los cambios reformistas, persistencia del modelo previo y fuerte resistencia gremial a los cambios (Ecuador, Bolivia y Venezuela); y c) situación sui generis de fragmentación del régimen laboral, retroceso de los nombramientos e incremento de las contrataciones, ingreso con fuerza del modelo gerencial y presencia gremial médica importante con incidencia en el campo de recursos humanos.(AU)

Situación y desafíos en el campo de los recursos humanos en el área Andina en los albores de los 2000 / Situation an challenges in the field of human resources on health in the Andean area on the 2000 initial

El artículo presenta una revisión de la situación actual y desafíos de los recursos humanos en salud en cinco países andinos: Bolivia, Colombia, Ecuador, Perú y Venezuela. El artículo reseña transversalmente los problemas comunes al área andina, sobre la base de los estudios por países compendiados en el capítulo Inicial del informe, no publicado aquí. El estudio se hizo entre agosto y noviembre del año 2000 en base a fuentes secundarias y consultas a expertos en el tema en los cinco países andinos. Se concluye que en los países andinos hay un tránsito muy inicial a la nueva situación de los recursos humanos defínida por los postulados de las reformas sectoriales, diferenciándose tres situaciones sobre recursos humanos: a) situación de fíexibilización laboral avanzada y en medio de un cambio sistémico (Colombia); b) situación inversa, de países con una muy lenta asimilación de los cambios reformistas, persistencia del modelo previo y fuerte resistencia gremial a los cambios (Ecuador, Bolivia y Venezuela); y c) situación sui generis de fragmentación del régimen laboral, retroceso de los nombramientos e incremento de las contrataciones, ingreso con fuerza del modelo gerencial y presencia gremial médica importante con incidencia en el campo de recursos humanos.