O fim da extensão das patentes e as Parcerias para Desenvolvimento Produtivo: reflexos no acesso a medicamentos no Brasil / The end of patent extensions and the Productive Development Partnerships: effects on access to medicines in Brazil

Resumo A covid-19 jogou luz sobre o impacto negativo da propriedade intelectual na saúde e deu nova relevância à Ação Direta de Inconstitucionalidade 5529/DF, que, acatada pelo Supremo Tribunal Federal em 2021, culminou na extinção da extensão automática de patentes no Brasil. Este estudo busca analisar o efeito do julgamento histórico da ADI 5529/DF sobre pedidos de patente e as patentes de interesse das Parcerias para Desenvolvimento Produtivo (PDP). Trata-se de um estudo com base em uma pesquisa documental de análise do andamento, até 31 de dezembro de 2020, de 90 pedidos de patente relacionados a 15 medicamentos objetos de PDP. Nos sites do Instituto Nacional de Propriedade Industrial, do Ministério da Saúde, da Anvisa e da Câmara de Regulação do Mercado de Medicamentos, foram pesquisadas variáveis para comparar o cenário patentário dos medicamentos com o das PDP. De 88 pedidos válidos, 28 patentes foram concedidas, das quais dezessete foram estendidas para mais de vinte anos (média de 24 anos e nove meses). A decisão do STF resultou em mais de 68 anos de monopólio perdidos, potencialmente desanuviando alternativas para a produção de genéricos no país. Neste momento de retomada das PDP, estratégias para a superação de barreiras patentárias deveriam ser incorporadas à política.

Abstract The COVID-19 pandemic has shed light on the negative impact of intellectual property on health and has given new relevance to the Direct Action of Unconstitutionality 5529/DF, which was ruled by the Supreme Court in 2021, resulting in the extinction of automatic patent extensions in Brazil. This documentary case study analyzes the effects of the judicial decision on patent applications and patents of interest for Productive Development Partnerships (PDP), investigating the progress of 90 patent applications related to 15 PDPs drugs of interest until Decembre 31, 2020. Variables for comparing the drug patent scenario with that of the PDPs were researched on the websites of the National Institute of Industrial Property, the Ministry of Health, ANVISA, and the Brazilian Medicines Market Regulation Chamber. Of 88 valid applications, 28 patents were granted, 17 of which had been extended to more than 20 years (24 years and 09 months average). The court decision resulted in a loss of over 68 years of monopoly, potentially opening alternatives for generic production. This resumption of the PDP policy should incorporate strategies to overcome patent barriers.

Association between hospitalizations for sensitive conditions and quality of primary care.

OBJECTIVE: To analyze the association between municipal rates of ambulatory care sensitive conditions (ACSC) hospitalization and the quality of primary health care (PHC), socioeconomic, and demographic variables and those related to local characteristics of the health system from 2010 to 2019. METHOD: Ecological time series study in Brazilian municipalities analyzing the correlation of ACSC hospitalization rates with PHC quality measured by the three cycles of the Primary Care Access and Program for improving primary care access and quality (PMAQ-AB). The study included municipalities whose teams participated in 80% or more of at least two PMAQ-AB cycles. The correlation between standardized ACSC hospitalization rates and PHC quality and other variables was analyzed. Spearman's test was used between the response variable and numerical explanatory variables. Generalized equations estimation was used as a multivariate model associating ACSC hospitalization rates with the other variables over the years. RESULTS: A total of 3,500 municipalities were included in the models. The quality of PHC (PMAQ-AB score) showed an inverse association with the variation in ACSC hospitalization rates. Hospitalization rates fell by -2% per year every ten-point increase in the PMAQ-AB score, adjusted by the remaining variables. A one-unit increase in the beds per 1,000 inhabitants variable had an impact of approximately +6.4% on ACSC hospitalization rates. Regarding population size, larger municipalities had lower ACSC hospitalization rates. Increased PHC coverage and lower socioeconomic inequality were also associated with the reduction in hospitalizations. CONCLUSIONS: The reduction in ACSC hospitalization rates over time was associated with an increase in the quality of PHC. It was also associated with a reduction in the number of hospital beds and municipalities with better socioeconomic indicators.

Use of Telehealth Resources in Primary Care and Its Association with Facing the COVID-19 Pandemic in Minas Gerais, Brazil.

Introduction: Use of telehealth (TH) resources increased dramatically during the COVID-19 pandemic. This study set out to examine associations between the level of integration of TH resources and the level of Primary Health Care (PHC) structuring to deal with the COVID-19 pandemic in the State of Minas Gerais, Brazil. Methods: This work was a cross-sectional study conducted through the application of a semistructured questionnaire to a sample of 260 PHC Teams working in the state of Minas Gerais, Brazil, from September to December 2020. This study was approved by the Research Ethics Committee and logged under report number 44.294.637. Results: Two variables were created - Level of the PHC structuring to deal with the COVID-19 pandemic and Level of TH structuring. Variables were grouped into five categories (poor to excellent). Associations between variables were examined using the Tukey's test for multiple comparisons and the Spearman correlation coefficient. Variables associated with socioeconomic dimensions (human development index and Gini index) and health care were also analyzed. Levels of TH structuring in PHC ranged from poor (43%) to regular (40%) in most cases. Most PHC teams had regular (56%) or good (37%) levels of PHC structuring to deal with the pandemic. The greater the availability and use of TH resources at a given unit, the better the structure to face COVID-19 (0.45 - p < 0.001). Conclusion: PHC was structured to tackle the pandemic. However, there is a lot to be done before TH resources are effectively incorporated into PHC. Whenever incorporated, TH resources contributed to a more robust response to the COVID-19 pandemic.

Association between hospitalizations for sensitive conditions and quality of primary care / Associação entre internações por condições sensíveis e qualidade da atenção primária

ABSTRACT OBJECTIVE To analyze the association between municipal rates of ambulatory care sensitive conditions (ACSC) hospitalization and the quality of primary health care (PHC), socioeconomic, and demographic variables and those related to local characteristics of the health system from 2010 to 2019. METHOD Ecological time series study in Brazilian municipalities analyzing the correlation of ACSC hospitalization rates with PHC quality measured by the three cycles of the Primary Care Access and Program for improving primary care access and quality (PMAQ-AB). The study included municipalities whose teams participated in 80% or more of at least two PMAQ-AB cycles. The correlation between standardized ACSC hospitalization rates and PHC quality and other variables was analyzed. Spearman's test was used between the response variable and numerical explanatory variables. Generalized equations estimation was used as a multivariate model associating ACSC hospitalization rates with the other variables over the years. RESULTS A total of 3,500 municipalities were included in the models. The quality of PHC (PMAQ-AB score) showed an inverse association with the variation in ACSC hospitalization rates. Hospitalization rates fell by -2% per year every ten-point increase in the PMAQ-AB score, adjusted by the remaining variables. A one-unit increase in the beds per 1,000 inhabitants variable had an impact of approximately +6.4% on ACSC hospitalization rates. Regarding population size, larger municipalities had lower ACSC hospitalization rates. Increased PHC coverage and lower socioeconomic inequality were also associated with the reduction in hospitalizations. CONCLUSIONS The reduction in ACSC hospitalization rates over time was associated with an increase in the quality of PHC. It was also associated with a reduction in the number of hospital beds and municipalities with better socioeconomic indicators.

RESUMO OBJETIVO Analisar a associação entre taxas municipais de internações por condições sensíveis à atenção primária (ICSAP), com a qualidade da atenção primária à saúde (APS), variáveis socioeconômicas, demográficas e relacionadas a características locais do sistema de saúde, de 2010 a 2019. MÉTODOS Estudo ecológico de séries temporais nos municípios brasileiros analisando a correlação das taxas de ICSAP, com a qualidade da APS medida pelos três ciclos do Programa de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ-AB). Foram incluídos municípios que participaram com 80% ou mais de suas equipes em, ao menos, dois ciclos do PMAQ-AB. Foi analisada a correlação entre as taxas de ICSAP padronizadas com a qualidade da APS e demais variáveis. Empregou-se o teste de Spearman entre a variável resposta e as variáveis explicativas numéricas. Foi usado o generalized equations estimating como modelo multivariado associando as taxas de ICSAP e as demais variáveis ao longo dos anos. RESULTADOS Foram incluídos 3.500 municípios nos modelos. A qualidade da APS (nota do PMAQ-AB) apresentou associação inversa com a variação das taxas de ICSAP. As taxas de internação tiveram queda de -2% ao ano a cada aumento de dez pontos na nota do PMAQ-AB, ajustado pelas demais variáveis. O aumento de uma unidade na variável leitos por mil habitantes impactou em uma elevação de aproximadamente +6,4% nas taxas de ICSAP. Quanto ao porte populacional, municípios maiores tiveram menores taxas de ICSAP. Também se associaram à redução das internações o aumento da cobertura da APS e a menor desigualdade socioeconômica. CONCLUSÕES A redução das taxas de ICSAP ao longo do tempo mostrou-se associada com o aumento da qualidade da APS. Além disso, esteve associada com diminuição do número de leitos hospitalares e a municípios com melhores indicadores socioeconômicos.

[Quality of prehospital fixed components of the Brazilian Emergency and Urgent Care Network: a study based on data from PMAQ-AB and PNASS]. / Qualidade dos componentes pré-hospitalares fixos da Rede de Urgência e Emergência no Brasil: um estudo a partir de dados do PMAQ-AB e PNASS.

The organization and management of integrated health systems is complex and challenging. As a strategy to improve the quality and access to urgent services, the Brazilian Ministry of Health implemented the Emergency and Urgent Care Network (RUE), comprised of care facilities with different technological levels. Assess the quality of prehospital fixed components of the RUE in health macroregions. A cross-sectional study using data from the Brazilian National Health Services Evaluation Program (PNASS) and the Brazilian National Program for Improvement of Access and Quality of Basic Care (PMAQ-AB) was carried out. A typology was built for the quality of the emergency care units (UPAs) and the first visit by health macroregion, correlating it with socioeconomic variables. A cluster analysis was performed. In total, 280 UPAs, 21,182 basic health units (UBSs), and 27,335 family health teams from 74 health macroregions were evaluated. The general indicator of the quality of the components presented an average of 0.687 (reference score: 1.00). UPA quality (0.61) was positively influenced by the indicators Pharmacy support and Immediate emergency and urgent care, with worse results in Contract management, Planning and organization, and Organizational model. In primary healthcare (PHC) quality (0.78), the dimensions with better evaluations were Articulation with the network, Reception and procedures, unlike Exams and medications. Health macroregions were allocated to three clusters. Cluster 3 obtained a much higher overall average score (0.81) than the others (0.64 and 0.63). A lower quality of PHC was observed in Cluster 1, which showed the highest level of social vulnerability.

A organização e gestão de sistemas de saúde integrados são complexas e desafiadoras. Como estratégia para melhoria da qualidade e do acesso aos serviços de urgência, o Ministério da Saúde adotou a implantação da Rede de Urgência e Emergência (RUE), composta por pontos de atenção de diferentes densidades tecnológicas. O objetivo foi avaliar a qualidade dos componentes pré-hospitalares fixos da RUE em macrorregiões de saúde. Foi realizado estudo transversal utilizando dados do Programa Nacional de Avaliação dos Serviços de Saúde (PNASS) e do Programa de Melhoria da Qualidade da Atenção Básica (PMAQ-AB). Foi construída uma tipologia da qualidade das unidades de pronto atendimento (UPAs) e do acolhimento, por macrorregião de saúde, correlacionando-as com variáveis socioeconômicas. Foi realizada uma análise de clusters. Foram avaliadas 280 UPAs, 21.182 unidades básicas de saúde (UBS) e 27.335 equipes de saúde da família (EqSF) de 74 macrorregiões de saúde. O indicador geral da qualidade dos componentes apresentou média 0,687 em 1,00. A qualidade da UPA (0,61) foi positivamente influenciada pelos indicadores Assistência farmacêutica e Atenção imediata à urgência e emergência, com piores resultados em Gestão de contratos, Planejamento e organização e Modelo organizacional. Na qualidade da atenção primária à saúde (APS) (0,78), as dimensões mais bem avaliadas foram Articulação com a rede, Acolhimento e procedimentos, ao contrário de Exames e medicamentos. As macrorregiões de saúde foram alocadas em três clusters. O Cluster 3 obteve nota média geral (0,81) bem superior aos demais (0,64 e 0,63). Observou-se qualidade inferior da APS no Cluster 1, aquele com maior vulnerabilidade social.

La organización y la gestión de los sistemas de salud integrados es compleja y desafiante. Como estrategia para mejorar la calidad y el acceso a los servicios de urgencia, el Ministerio de Salud brasileño adoptó la implementación de la Red de Urgencia y Emergencia (RUE), compuesta por puntos de atención de diferentes densidades tecnológicas. Evaluar la calidad de los componentes prehospitalarios fijos de RUE en las macrorregiones de salud. Se llevó a cabo un estudio transversal utilizando datos del Programa de Evaluación de los Servicios Nacionales de Salud (PNASS) y del Programa Nacional de Mejoría de Acceso y Calidad de la Atención Básica (PMAQ-AB). Fue construida una tipología de la calidad de las unidades de atención de urgencias (UPAs) y de la recepción por macrorregión de salud, correlacionándolas con variables socioeconómicas. Se realizó un análisis de grupos. Evaluadas 280 UPAs, 21.182 servicios de salud básicos (UBSs) y 27.335 equipos de salud familiares de 74 macrorregiones de salud. El indicador general de la calidad de los componentes promedió mostró una media de 0,687 sobre 1,00. En la calidad de las UPAs (0,61) influyeron positivamente los indicadores Asistencia farmacéutica y Atención inmediata de urgencias y emergencias, con peores resultados en Gestión de contratos, Planificación y organización y Modelo organizativo. En la calidad de la atención primaria en salud (APS) (0,78) las dimensiones mejor evaluadas fueron la Coordinación con la red, la Recepción y los procedimientos, frente a los Exámenes y la medicación. Las macrorregiones de salud se asignaron en tres grupos. El Grupo 3 obtuvo nota media general (0,81) muy superior a los demás (0,64 y 0,63). Se observó una calidad inferior de la APS en el Grupo 1, aquel con mayor vulnerabilidad social.

Admissions due to ambulatory care-sensitive conditions (ACSC): an analysis based on socio-demographic characteristics, Brazil and regions, 2010 to 2019.

OBJECTIVE: To analyze the temporal trend of hospital admissions due to Ambulatory Care-Sensitive Conditions (ACSC) in Brazil per sex, region, cause and age group, from 2010 to 2019. METHODS: This is an ecological study based on the temporal trend of ACSC rates. Standardized rates were analyzed in a simple linear regression and a generalized linear model (GLM) Gamma. The percentage change was also checked over three periods: 2010-2014, 2015-2019 and 2010-2019. RESULTS: There was a reduction in hospital admission rates between 2010 and 2019 for Brazil: 124.3/10,000 inhab. to 88.2/10,000 inhab. among women (-29.0%) and 119.0/10,000 inhab. to 88.2/10,000 inhab. (-25.9%) among men in all regions. The decrease was more prominent between 2010-2014 (-17.7%) and (-17.8%) than between 2015-2019 (-.2%) and (-5.9%) for females and males, respectively. The milder decline in the period from 2015 to 2019 was more noticeable among age groups 0-4y and 5-19y in all regions. As for the causes, most ICD-10 diseases had a downward trend, the more expressive ones being gastroenteritis (-60%); however, an increase was seen in cerebrovascular diseases among women (11.2%) and men (17.1%), and angina (15% %) and skin infections (56.1%) among men. CONCLUSION: There was a significant drop in ACSC rates in the period analyzed, especially for age groups 0-4y and 5-19y. The rates had a milder drop from 2015 to 2019, a period of austerity and economic crisis.

Fractured lives in fractured cities: Towards a critical understanding of urban violence in the context of market-driven urban restructuring processes in Bogotá and Rio de Janeiro.

Based on a comparative case study on two neighborhoods in Bogota and Rio de Janeiro (2017-2019) and a comprehensive literature review, this article proposes a critical Public Health approach to urban violence and makes a case for understanding the phenomenon in the context of market-driven urban territorial restructuring processes that assume specific qualities in cities of the Global South. The case studies are based on focus groups and semi-structured interviews with residents, specialists and community leaders. It is argued that urban violence is a key public health challenge, particularly in Latin America, given its dimensions and its impact on the populations' life and health. In this regard it configures "fractured lives" in what urban scholars have termed "fractured cities" - essentially unequal and polarized cities that are not merely sites of urban violence but, as we argue in this article, fundamentally shape urban violence, its qualities, dynamics and dimensions. The study is informed by a unique theoretical articulation between Latin American Social Medicine and Collective Health, critical (Latin American) geographical theory and authoritarian neoliberalism literature and shows how urban violence is directly implied in the territorial making and un-making of the cities, driven by commodification as well as both legal and illegal capitalist market logics, that include but are not limited to drug trade. The cases reflect the violence implied in permanent threats of eviction and displacement, "necropolitical" police/military interventions and what is described as a silent imposition of a "slow death" on infrastructure, the neighborhood and ultimately also its residents, which "fracture" the lives of significant parts of the urban population, produce "ill-being" and bring about health consequences that are rarely considered in relation to urban violence.

Admissions due to ambulatory care-sensitive conditions (ACSC): an analysis based on socio-demographic characteristics, Brazil and regions, 2010 to 2019 / Internações por condições sensíveis à atenção primária (ICSAP): uma análise segundo características sociodemográficas, Brasil e regiões, 2010 a 2019

ABSTRACT: Objective: To analyze the temporal trend of hospital admissions due to Ambulatory Care-Sensitive Conditions (ACSC) in Brazil per sex, region, cause and age group, from 2010 to 2019. Methods: This is an ecological study based on the temporal trend of ACSC rates. Standardized rates were analyzed in a simple linear regression and a generalized linear model (GLM) Gamma. The percentage change was also checked over three periods: 2010-2014, 2015-2019 and 2010-2019. Results: There was a reduction in hospital admission rates between 2010 and 2019 for Brazil: 124.3/10,000 inhab. to 88.2/10,000 inhab. among women (-29.0%) and 119.0/10,000 inhab. to 88.2/10,000 inhab. (-25.9%) among men in all regions. The decrease was more prominent between 2010-2014 (-17.7%) and (-17.8%) than between 2015-2019 (-.2%) and (-5.9%) for females and males, respectively. The milder decline in the period from 2015 to 2019 was more noticeable among age groups 0-4y and 5-19y in all regions. As for the causes, most ICD-10 diseases had a downward trend, the more expressive ones being gastroenteritis (-60%); however, an increase was seen in cerebrovascular diseases among women (11.2%) and men (17.1%), and angina (15% %) and skin infections (56.1%) among men. Conclusion: There was a significant drop in ACSC rates in the period analyzed, especially for age groups 0-4y and 5-19y. The rates had a milder drop from 2015 to 2019, a period of austerity and economic crisis.

RESUMO: Objetivo: Analisar a tendência temporal das internações por condições sensíveis à atenção primária (ICSAP) no Brasil, por sexo, regiões, causas e faixas etárias, no período de 2010 a 2019. Métodos: Trata-se de estudo ecológico baseado na tendência temporal das taxas de ICSAP. Foram analisadas as taxas padronizadas segundo regressão linear simples e modelo linear generalizado (MLG) gama. Observou-se também a variação percentual em três períodos: 2010-2014, 2015-2019 e 2010-2019. Resultados: Ocorreu redução nas taxas de internação entre 2010 e 2019 para Brasil: 124,3/10.000 hab. para 88,2/10.000 hab. em mulheres (-29,0%) e 119,0/10.000 hab. para 88,2/10.000 hab. (-25,9%) em homens, em todas as regiões. A queda foi maior entre 2010 e 2014 (-17,7% e -17,8%) do que entre 2015 e 2019 (-9,2% e -5,9%) — valores para sexo feminino e masculino, respectivamente. Esse declínio menor no período de 2015 a 2019 foi mais perceptível entre as faixas de zero a quatro anos e de cinco a 19 anos em todas as regiões. Quanto às causas, foi verificada redução para maioria dos códigos da Classificação Internacional de Doenças (CID-10), mais expressiva para gastroenterites (-60%), entretanto tiveram aumento doenças cerebrovasculares entre mulheres (11,2%) e homens (17,1%) e angina (15%%) e infecções da pele (56,1%) entre homens. Conclusão: Ocorreu importante queda das taxas de ICSAP no período analisado, especialmente para as faixas etárias de zero a quatro e de cinco a 19. As taxas tiveram menor queda entre 2015 e 2019, período de austeridade e crise econômica.

Revisiting the social determinants of health agenda from the global South.

In an effort to provide an overview of the conceptual debates shaping the mobilisation around social determinants of health and health inequities and challenge the apparent consensus for equity in health, this essay compares two of the most influential approaches in the field: the WHO Commission on Social Determinants of Health approach (CSDH), strongly influenced by European Social Medicine, and the Latin American Social Medicine and Collective Health (LASM-CH) 'Social determination of the health-disease process' approach, hitherto largely invisibilized. It is argued that the debates shaping the equity in health agenda do not merely reflect conceptual differences, but essentially different ethical-political proposals that define the way health inequities are understood and proposed to be transformed. While the health equity agenda probably also gained momentum due to the broad political alliance it managed to consolidate, it is necessary to make differences explicit as this allows for an increase in the breadth and specificity of the debate, facilitating the recognition of contextually relevant proposals towards the reduction of health inequities.

El territorio como categoría fundamental para el campo de la salud pública / Territory as an essential category in public health sciences

RESUMO Este ensayo hace una aproximación conceptual a la categoría 'territorio', vinculándola como categoría de análisis fundamental en salud pública. Se hizo una revisión de fuentes academicas en donde la geografía, las ciencias sociales y la salud se interrelacionan para reconocer como se concibe el territorio dentro del campo de la salud. La primera parte del texto aborda el territorio como ámbito de expresión del bienestar y malestar de la sociedad a partir de tres casos de configuración territorial. En la segunda parte se propone una discusión sobre la influencia/el papel el territorio en el campo de la investigación salud pública; lo que permite concluir que en el territorio se dan los procesos de producción y reproducción social, que constituyen la base de la determinación social de la salud-enfermedad-muerte.

ABSTRACT This essay seeks to conceptually approach the category of 'territory', assuming it as an essential research category in public health sciences. The first part addresses the territory as a marker of wellbeing and ill-being of society in relation to three cases of territorial configuration: territories of extractivist accumulation; urban territories of sacrifice and territories of life. In the second part of the essay, territory is discussed as a research category in public health.

Capacidades de investigación sobre determinantes sociales de la salud en Brasil, Colombia y México / Research capacities on social determinants of health in Brazil, Colombia and Mexico / Capacidades de investigação sobre determinantes sociais da saúde no Brasil, Colômbia e México

RESUMEN Objetivo: analizar las capacidades de investigación sobre determinantes sociales y determinación social de los procesos saludenfermedad (DSS) en Brasil, Colombia y México con base en los sistemas nacionales de ciencia, tecnología e innovación (SNCTI) y la producción científica sobre DSS (2005-2012) de cada país. Metodología: se realiza un estudio exploratorio a partir de revisión de literatura, consulta de plataformas nacionales de cada SNCTI, entrevistas y foros de consulta, contemplando las siguientes categorías de estudio para analizar las capacidades de: 1. Producción científica, formación de investigadores y políticas relativas a capacidades de investigación; 2. Redes de colaboración; 3. Infraestructura para la investigación y 4. Producción y apropiación social del conocimiento. Resultados y Discusión: la investigación sobre DSS se divulga principalmente en revistas científicas de circulación nacional, en Brasil y Colombia, mientras que en México se publica principalmente en revistas extranjeras. Los tres países cuentan con SNCTI consolidados, sin embargo, son escasos los montos de financiamiento para investigación sobre DSS. Conclusiones: es necesario articular acciones de fortalecimiento de capacidades de investigación, fortaleciendo redes y posicionando los DSS en agendas estratégicas.

ABSTRACT Objective: to analyze the research capacities on social determinants and social determination of the health-disease process (SDH) in Brazil, Colombia and Mexico based on the characteristics of the National Systems of Science, Technology and Innovation (SNCTI) and the scientific production on SDH between 2005 and 2012. Methodology: an exploratory study was conducted. Data were obtained from literature reviews, the national platforms for each SNCTI, interviews and forums. The following categories of study were taken into account when analyzing capabilities: 1. Scientific production, training of researchers and policies concerning research capabilities. 2. Collaborative networks; 3. Infrastructure for research and 4. Production and social appropriation of knowledge. Results and discussion: research on SDH is primarily published in scientific journals. In Brazil and Colombia, findings are primarily published in national journals, while the majority of research on SDH from Mexico is published in international journals. All three countries have solid SNCTI. However, funding for research on SDH is scarce. Conclusion: it is necessary to coordinate actions to strengthen the capacities for research on SDH in order to strengthen networks and position SDH on strategic agendas.

RESUMO Objetivo: analisar as capacidades de investigação sobre determinantes sociais e determinação social dos processos saúdedoença (DSS) no Brasil, Colômbia e México com base nos sistemas nacionais de ciência, tecnologia e inovação (SNCTI) e a produção científica sobre DSS (2005-2012) de cada país. Metodologia: Se realiza um estudo exploratório a partir da revisão de literatura, consulta de plataformas nacionais de cada SNCTI, entrevistas e foros de consulta, contemplando as seguintes categorias de estudo para analisar as capacidades: 1. Produção científica, formação de investigadores e políticas relativas a capacidades de investigação; 2. Redes de colaboração; 3. Infraestrutura para a investigação e 4. Produção e apropriação social do conhecimento. Resultados e discussão: A investigação sobre DSS se divulga principalmente em revistas científicas de circulação nacional, em Brasil e Colômbia, entanto que no México se publica principalmente em revistas estrangeiras. Os três países contam com SNCTI consolidados, mas, são escassos os montantes de financiamento para investigação sobre DSS. Conclusão: È necessário articular ações de fortalecimento de capacidades de investigação, fortalecendo redes e posicionando os DSS em agendas estratégicas.

Measuring health inequities in low and middle income countries for the development of observatories on inequities and social determinants of health.

BACKGROUND: Almost seven years after the publication of the final report of the World Health Organization's Commission on Social Determinants of Health (CSDH), its third recommendation has not been attended to properly. Measuring health inequities (HI) within countries and globally, in order to develop and evaluate evidence-based policies and actions aimed at the social determinants of health (SDH), is still a pending task in most low and middle income countries (LMIC) in the Latin American region. In this paper we discuss methodological and conceptual issues to measure HI in LMIC and suggest a three-stage methodology for the creation of observatories on health inequities (OHI) and social determinants of health, based on the experience of the Brazilian Observatory on Health Inequities (BOHI) that has been successfully operating since 2010 at the Fundação Oswaldo Cruz (FIOCRUZ). METHODS: A three-stage methodology for the creation of an OHI was developed based on a literature review on the following topics: SDH, HI measurement, and the process of setting-up of health observatories; followed by semi-structured interviews with key informants from the BOHI. We describe the three stages and discuss the replicability of this methodology in other Latin American countries. We also carried out a search of suitable national information systems to feed an OHI in Mexico, along with an outline of the institutional infrastructure to sustain it. RESULTS: When implementing the methodology for an OHI in LMIC such as Mexico, we found that having strong infrastructure of information systems for measuring HI is required, but not sufficient to build an OHI. Adequate funding and intersectoral network collaborations lead by a group of experts is a requirement for the consolidation and sustainability of an OHI in LMIC. CONCLUSION: According to the described methodology, and the available information systems on health, the creation of an OHI in LMIC, particularly in Mexico, is plausible in the near future. However, institutional support (in academic, financial, and policymaking terms) is essential to materialize such needed instance, thus locally contributing to attain health equity.

Uma análise crítica da abordagem dos Determinantes Sociais da Saúde a partir da medicina social e saúde coletiva latino-americana / A critical analysis of the social determinants of health approach from the perspective of the latin american social medicine and collective health

O enfoque dos Determinantes Sociais da Saúde tem tido ampla difusão e foi aparentemente bem acolhido globalmente. Este artigo assume uma visão crítica desse enfoque, buscando sistematizar as críticas principalmente provenientes de debates no interior da medicina social e saúde coletiva latino-americana, que se articularam ao redor da diferenciação entre Determinantes Sociais da Saúde e a determinação social dos processos saúde-doença. Pretendemos examinar estas diferenças para problematizar a aparente unanimidade retórica em prol da equidade. Ainda que a abordagem dos Determinantes Sociais da Saúde marque um enorme avanço na mobilização pela equidade em saúde, em nossa avaliação ela não consegue ser mais do que um avanço incompleto.

This article seeks to critically analyze the Social Determinants of Health approach and proposes a synthesis of the critique that has shaped the debate and particularly found expression in the differentiation between SDH and the Latin American Social Medicine and Collective Health 'social determination of the health-disease processes' approach. Reexamining the apparent rhetoric unanimity that defined the agenda of the mobilization around the Social Determinants of Health, we seek to address the differences between these approaches and conclude that the Social Determinants of Health approach marks an important but incomplete advance in the mobilization towards the reduction of health inequities.

Mapping of capacities for research on health and its social determinants in Brazil.

This article describes tendencies in research on social determinants of health (SDH) and health inequities in Brazil (2005-2012) and maps research system structures to analyze capacities for research on health and its social determinants. Brazil has a strong national research system and counts on a wealth of research in the field of SDH drawing on a long tradition of research and political commitment in this area. While innovative strategies seeking to strengthen the links between research, policy and practice have been developed, the impact of SDH research continues to be largely restricted to the academic community with notable but still insufficient repercussions on public policy and the social determinants of health inequities. SDH research in Brazil will therefore need to become even more responsive to social urgencies and better attuned to political processes, enhancing its capacity to influence strategic policy decisions affecting health inequities and mobilize strategic agendas for health equity.

Mapping of capacities for research on health and its social determinants in Brazil / Mapeamento da produção e das estruturas de pesquisa sobre determinantes sociais da saúde no Brasil / Mapeo de capacidades para la investigación sobre determinantes sociales de la salud en Brasil

This article describes tendencies in research on social determinants of health (SDH) and health inequities in Brazil (2005-2012) and maps research system structures to analyze capacities for research on health and its social determinants. Brazil has a strong national research system and counts on a wealth of research in the field of SDH drawing on a long tradition of research and political commitment in this area. While innovative strategies seeking to strengthen the links between research, policy and practice have been developed, the impact of SDH research continues to be largely restricted to the academic community with notable but still insufficient repercussions on public policy and the social determinants of health inequities. SDH research in Brazil will therefore need to become even more responsive to social urgencies and better attuned to political processes, enhancing its capacity to influence strategic policy decisions affecting health inequities and mobilize strategic agendas for health equity.

Este artigo descreve as tendências na produção de pesquisa sobre os determinantes sociais da saúde (DSS) no Brasil (2005-2012) e mapeia as estruturas do sistema de pesquisa sobre saúde e seus determinantes sociais. O país tem um sólido sistema nacional de pesquisa e conta com uma rica produção sobre DSS e suas iniquidades ancoradas em uma longa tradição de pesquisa e compromisso político nesse campo. Apesar das estratégias inovadoras que buscam fortalecer os vínculos entre pesquisa, políticas e práticas, o impacto da investigação sobre DSS continua a ser em grande parte restrito à comunidade acadêmica, com repercussões notáveis, mas ainda insuficientes sobre a política pública e os determinantes sociais das iniquidades em saúde. Portanto, a pesquisa sobre DSS no Brasil necessita tornar-se ainda mais sensível às urgências sociais e desenvolver uma melhor sintonia com os processos políticos, aumentando a sua capacidade de influenciar decisões estratégicas que possam afetar as iniquidades em saúde e mobilizar agendas para a promoção da equidade.

Este artículo pretende analizar las capacidades de investigación sobre determinantes sociales de la salud (DSS) en Brasil, mapeando instituciones y grupos de investigación, así como las principales tendencias temáticas y dimensiones cuantitativas de la producción científica brasileña en este área (2005-2012). Brasil posee un sistema nacional de investigación en salud bien consolidado y la producción científica sobre la temática es amplia. Se han logrado ampliar los nexos entre la producción científica y la política pública en el campo de los DSS, estableciendo un compromiso político estable en torno a este tema. Sin embargo, cabe notar que la investigación sobre DSS continua teniendo poco impacto sobre políticas públicas y los determinantes sociales de las inequidades en salud. La investigación sobre DSS en Brasil, por lo tanto, necesita ser más sensible a las urgencias sociales y adaptarse mejor a los procesos políticos, aumentando su capacidad influencia en las decisiones políticas que afectan las inequidades en salud, además de movilizar agendas estratégicas para la equidad en salud.

Notas para uma reinterpretação crítica dos processos de determinação social das iniquidades étnico-raciais em saúde / Notes for a critical reinterpretation of the processes of social determination of ethnic and racial inequities in health

Esta dissertação, em forma de ensaio, pretende problematizar as interpretações e abordagens dominantes das iniquidades étnico-raciais em saúde e objetiva propor reflexões para uma reinterpretação dos processos de determinação social das iniquidades étnico-raciais em saúde desde a perspectiva da Medicina Social e Saúde Coletiva Latinoamericana (MS-SC) e da “inflexão descolonial” do Grupo Modernidade/Colonialidade (Grupo M/C). Partimos do pressuposto de que os processos envolvidos na configuração das iniquidades étnico-raciais em saúde continuam pouco reconhecíveis nas abordagens dominantes no campo da saúde pública e epidemiologia, principalmente como consequência de interpretações reducionistas dos processos de determinação social da saúde-doença e ainda como consequência do silenciamento sistemático de reinterpretações contra hegemônicas, cujas interpretações permitiriam reconhecer as manifestações dos processos de subordinação social e desumanização, que se engendram no contexto da acumulação capitalista e da concentração de poder que caracteriza o sistema-mundo capitalista/colonial, nos processos saúde-doença.O presente ensaio encontra-se dividido em três capítulos. No primeiro capítulo abordamos o que é sistematicamente excluído das interpretações dominantes das iniquidades étnico-raciais (em saúde): os processos de subalternização das populações não-brancas e o racismo. No segundo capítulo objetivamos problematizar as bases epistemológicas das interpretações dominantes, abordando o modelo de racionalidade dominante e a epistemologia epidemiológica. No terceiro capítulo buscamos exemplificar e detalhar a crítica articulada nos dois primeiros capítulos, analisando a abordagem dos Determinantes Sociais da Saúde (DSS), que assumiu centralidade nos debates ao redor das iniquidades sociais em saúde nos últimos anos.

This dissertation, written as an essay, seeks to critically review dominant approaches and interpretations of ethnic and racial inequities in health and further aims to develop notes toward a reinterpretation of the processes of social determination of ethnic and racial inequities in health from the perspective of the Latin American Social Medicine and Collective Health movement and the Modernity/Coloniality research program. We argue that the processes involved in shaping ethnic and racial inequities in health remain poorly recognizable in dominant approaches in the field of public health and epidemiology. From our perspective, this is primarily a result of reductionist interpretations of the processes of social determination in health and also a consequence of the systematic invisibilization of contrahegemonic reinterpretations, which have articulated the health-disease processes and particularly the social determination of (etnic and racial) health inequities with processes of oppression, marginalization and exploitation, engendered in the context of the consolidation of capitalist accumulation structures along the lines of class, gender and etnic/racial priviledge and subordination.This essay is divided in three chapters. In the first chapter we discuss what is systematically excluded from dominant interpretations of ethnic and racial inequities (in health), particularly the processes of oppression, marginalization and exploitation defining the subordination of non-white populations in capitalist modernity and structural racism. In the second chapter we aim to critically review the epistemological foundations of dominant interpretations in public health and epidemiology and argue that the hegemonic model of rationality and specifically epidemiological epistemology, forges and reproduces reductionist interpretations. In the third chapter we seek to illustrate and detail this critique, analyzing the WHO Social Determinants of Health approach, which has dominanted the debates on health inequities during the last couple of years.

¿Determinación social o determinantes sociales?: Diferencias conceptuales e implicaciones praxiológicas / Conceptual differences and praxiological implications concerning social determination or social determinants

Las diferencias entre la determinación social y los determinantes sociales de la salud no son sólo conceptuales, son también ético-políticas. Conllevan rutas y apuestas divergentes, explicaciones distintas sobre la causalidad y el riesgo en salud con implicaciones esenciales en las relaciones de poder, en la concepción de la ética y en la comprensión del proceso salud enfermedad. El propósito de este texto es advertir las implicaciones praxiológicas de los enfoques de la epidemiología social latinoamericana y la anglosajona y, nutrir el debate entre la determinación social y los determinantes sociales de la salud. Para ello primero sitúa la construcción socio-histórico de estos enfoques, luego analiza sus diferencias con base en criterios de valoración epistemológica, metodológica y ontológica y finaliza con una breve consideración acerca de las implicaciones prácticas que conllevan estas diferencias.

The differences between the social determination of health approach adopted by the Latin-American Social Medicine and Collective Health movement and the WHO's social determinants of health approach are not merely conceptual but involve ethical and political considerations. Different notions of causality and risk are implied in the aforementioned approaches and shape how concepts regarding health-illness and health inequity are understood and how they may be confronted. This article attempts to clarify the praxiological implications of such approaches and contextualise the approaches' socio-historical construction, address epistemological, methodological and ontological differences and propose some considerations regarding the praxiological implications.

[Conceptual differences and praxiological implications concerning social determination or social determinants]. / ¿Determinación social o determinantes sociales?: Diferencias conceptuales e implicaciones praxiológicas.

The differences between the social determination of health approach adopted by the Latin-American Social Medicine and Collective Health movement and the WHO's social determinants of health approach are not merely conceptual but involve ethical and political considerations. Different notions of causality and risk are implied in the aforementioned approaches and shape how concepts regarding health-illness and health inequity are understood and how they may be confronted. This article attempts to clarify the praxiological implications of such approaches and contextualise the approaches' socio-historical construction, address epistemological, methodological and ontological differences and propose some considerations regarding the praxiological implications.