Challenges for the Brazilian State from the COVID-19 pandemic: the case of paradiplomacy in the state of Maranhão. / Desafios do Estado brasileiro diante da pandemia de COVID-19: o caso da paradiplomacia maranhense.

As the COVID-19 pandemic has spread worldwide in 2020, populations, authorities, and local and global health governance institutions have been affected differently. Global Health Diplomacy and "paradiplomacy" have become relevant instruments and arenas for the challenges raised by the pandemic, especially for non-State or subnational actors. This Essay analyzes the case of the Brazilian state of Maranhão during the pandemic, which used a "wartime operation" to purchase more than a hundred mechanical ventilators on the international market, over the Federal Government's head, at a moment of fierce international competition for medical supplies and equipment. The Essay examines the principal aspects, contexts, reasons, factors, actors, and actions that contextualize the operation conducted by the state of Maranhão as an activity in paradiplomacy and Global Health Diplomacy by a subnational government in Brazil. We analyzed these concepts in light of the literature on the topic and studied the action by Maranhão based on cross-analysis of data from documents, statements, and news coverage. We conclude that the case of Maranhão illustrates the capacity of subnational bodies to respond to global emergencies, mainly in contexts of inefficacy or absence of the Federal executive, legitimizing independent action aimed at saving lives.

À medida que a pandemia de COVID-19 se espalhou pelo mundo em 2020, populações, autoridades e instituições locais e globais de governança em saúde foram atingidas de maneira distinta. A chamada Diplomacia em Saúde Global e a "paradiplomacia" tornaram-se instrumentos e arenas de relevância diante dos desafios trazidos pela pandemia, sobretudo para atores não estatais ou subnacionais. Este Ensaio analisa o caso do Estado do Maranhão, Brasil, no contexto da pandemia, que, por meio de uma "operação de guerra", comprou no mercado internacional mais de cem respiradores à revelia do Governo Federal, em um momento de acirrada competição internacional por materiais e equipamentos médicos. O Ensaio investiga os principais aspectos, contextos, razões, fatores, atores e ações que contextualizam a operação realizada pelo Estado do Maranhão, como uma atividade paradiplomática e de Diplomacia em Saúde Global de um ente subnacional no Brasil. Analisamos os conceitos citados à luz da literatura sobre o tema e estudamos a atuação do Maranhão a partir do cruzamento de dados de documentos, pronunciamentos e notícias. Concluímos que o caso maranhense ilustra a capacidade de entes locais responderem às emergências de cunho global, principalmente em contextos de ineficácia ou ausência do executivo federal, legitimando ações independentes que visem à proteção da vida.

A medida que la pandemia de COVID-19 se extendió por el mundo en 2020, poblaciones, autoridades e instituciones locales y globales de gobernanza en salud se vieron afectadas de manera distinta. La llamada Diplomacia en Salud Global y la "paradiplomacia" se convirtieron en instrumentos y campos de relevancia ante los desafíos presentados por la pandemia, sobre todo para actores no estatales o entes subnacionales. Este Ensayo analiza el caso del Estado de Maranhão, Brasil, en el contexto de la pandemia, el cual mediante una "operación de guerra", compró en el mercado internacional más de cien respiradores, aun a pesar del Gobierno Federal, en un momento de acérrima competición internacional por materiales y equipamientos médicos. El Ensayo investiga los principales aspectos, contextos, razones, factores, actores y acciones que contextualizan la operación realizada por el Estado de Maranhão como una actividad paradiplomática y de Diplomacia en Salud Global de un ente subnacional en Brasil. Analizamos los conceptos citados a la luz de la literatura sobre el tema y estudiamos la actuación de Maranhão, a partir del cruce de datos de documentos, pronunciamientos y noticias. Concluimos que el caso marañense ilustra la capacidad de entes locales en responder a las emergencias de cuño global, principalmente en contextos de ineficacia o ausencia del ejecutivo federal, legitimando acciones independientes que visen la protección a la vida.

The impact of economic recessions on health workers: a systematic review and best-fit framework synthesis of the evidence from the last 50 years.

Economic crises carry a substantial impact on population health and health systems, but little is known on how these transmit to health workers (HWs). Addressing such a gap is timely as HWs are pivotal resources, particularly during pandemics or the ensuing recessions. Drawing from the empirical literature, we aimed to provide a framework for understanding the impact of recessions on HWs and their reactions. We use a systematic review and best-fit framework synthesis approach to identify the relevant qualitative, quantitative and mixed-methods evidence, and refine an a priori, theory-based conceptual framework. Eight relevant databases were searched, and four reviewers employed to independently review full texts, extract data and appraise the quality of the evidence retrieved. A total of 57 peer-reviewed publications were included, referring to six economic recessions. The 2010-15 Great Recession in Europe was the subject of most (52%) of the papers. Our consolidated framework suggests that recessions transmit to HWs through three channels: (1) an increase in the demand for services; (2) the impacts of austerity measures; and (3) changes in the health labour market. Some of the evidence appeared specific to the context of crises; demand for health services and employment increased during economic recessions in North America and Oceania, but stagnated or declined in Europe in connection with the austerity measures adopted. Burn-out, lay-offs, migration and multiple jobholding were the reactions observed in Europe, but job opportunities never dwindled for physicians during recessions in North America, with nurses re-entering labour markets during such crises. Loss of motivation, absenteeism and abuse of health systems were documented during recessions in low-income countries. Although the impacts of recessions may vary across economic events, health systems, labour markets and policy responses, our review and framework provide an evidence base for policies to mitigate the effects on HWs.

Reinventing Privatization: A Political Economic Analysis of the Social Health Organizations in Brazil.

The Brazilian state apparatus was reformed throughout the 1990s, influenced by New Public Management (NPM). NPM was embodied in the health care sector by the creation of Social Health Organizations (Organizações Sociais de Saúde or OSS), private non-profit entities to provide welfare services. We performed a systematic review of the literature outlining the origins and role of OSS in Brazil. Our selected articles (peer-reviewed) cover the origins/performance of OSS and their services provision between 1998 and 2018, in English or Portuguese. Databases used were Lilacs, Bireme, Medline, Pubmed, and SciELO. We identified 4,732 articles applying a pre-defined set of descriptors, from which we selected 49 for analysis. The main findings reveal that NPM is the central theme of most articles about OSS in Brazil (n = 26). There is evidence corroborating our hypothesis that transferring management of public health care services to private non-profit organizations is a softer version of privatization as, although financing is kept public, the rationale and ethos of OSS services institutionally and operationally mimic the private sector. The practical consequence is that attainment of health care in Brazil ends up being neither fully commodified (based on ability to pay) nor fulfilled as a citizen's right following its national constitution.

Education in the Mais Médicos program: the gap between proposals and implementation / A dimensão da formação no Programa Mais Médicos: hiato entre propostas e implementação

Abstract: Introduction: The scarcity and inequalities in the geographical distribution of physicians challenge the consolidation of the right to health and create migratory flows that increase health inequities. Due to their complex and multidimensional characteristics, they demand multisectoral political approaches, considering several factors related to the availability and area of ​​practice of medical doctors, as well as the social vulnerability of local populations. Objective: This study aimed at analysing results of the "Mais Médicos" (More Doctors) Program Educational Axis in Brazil. Methodology: A documental research was conducted, highlighting the location and the public or private nature of new undergraduate medical school vacancies between the years 2013 until 2017, which were then compared to the goals and strategies outlined in the official Program documents. Results: The Educational Axis reached important milestones despite the resistance of some institutional actors. The Program extended its undergraduate vacancies by 7696 places, 22.48% of that in public institutions and 77.52% in private ones. Vacancy distribution prioritized cities in rural areas of Brazil, at the same instance bringing forward significant regulatory changes for undergraduate medical courses. However, political disputes with representatives of medical societies and stakeholders interested in favouring the private educational and healthcare sectors surface in the official discourses and documents. These factors weakened the program normative body, creating a hiatus between its core objectives and respective implementation. Evidence related to the concentration of vacancies in the Southeast regions allow the maintenance of a known unequal workforce distribution, despite a proportionally bigger increase in the Midwest, North and Northeast regions. Conclusion: The predominance of vacancies in private institutions and the weakening of the new undergraduate courses monitoring instruments can compromise changes in the graduate students' profiles, which are necessary for the fixation of physicians in strategic geographic areas to promote Primary Healthcare.

Resumo: Introdução: A carência e as desigualdades na distribuição geográfica de médicos desafiam a consolidação do direito à saúde e criam fluxos migratórios que acirram iniquidades em saúde. Devido ao seu caráter complexo e multidimensional, demandam abordagens políticas multissetoriais, considerando vários fatores relativos à disponibilidade e à área de atuação de médicos, bem como à vulnerabilidade social das populações consideradas. Objetivo: Este estudo teve como objetivo analisar os resultados do eixo Formação do Programa Mais Médicos no Brasil. Métodos: Realizou-se uma pesquisa documental, especificamente relativa à localização e à natureza pública ou privada das novas vagas de graduação em Medicina, no período de 2013 a 2017, em que se confrontaram os resultados obtidos com as metas e estratégias pactuadas nos documentos oficiais do programa. Resultados: O eixo Formação alcançou resultados importantes, apesar da resistência de alguns atores institucionais. O programa expandiu em 7.696 vagas de graduação, sendo 22,48% em instituições públicas e 77,52% em instituições privadas. A distribuição das novas vagas priorizou cidades do interior do Brasil e aprovou mudanças regulatórias importantes para os cursos de Medicina. No entanto, as disputas políticas com atores sociais representativos da classe médica e aqueles interessados no favorecimento do setor privado na educação e assistência à saúde ficaram expressas nos discursos e documentos oficiais. Tais aspectos fragilizaram o corpo normativo do programa e criaram um hiato entre os seus objetivos e a implementação. Evidências referentes à concentração de vagas no Sudeste do país favorecem a manutenção das desigualdades, a despeito de um crescimento proporcionalmente maior nas Regiões Centro-Oeste, Nordeste e Norte. Conclusão: A prevalência de vagas em instituições privadas e a fragilização de instrumentos de monitoramento dos novos cursos podem comprometer a mudança no perfil dos egressos, necessária para a fixação de médicos em áreas estratégicas e na atenção primária à saúde.

How the 'plates' of a health system can shift, change and adjust during economic recessions: A qualitative interview study of public and private health providers in Brazil's São Paulo and Maranhão states.

BACKGROUND: Economic recessions carry an impact on population health and access to care; less is known on how health systems adapt to the conditions brought by a downturn. This particularly matters now that the COVID-19 epidemic is putting health systems under stress. Brazil is one of the world's most affected countries, and its health system was already experiencing the aftermath of the 2015 recession. METHODS: Between 2018 and 2019 we conducted 46 semi-structured interviews with health practitioners, managers and policy-makers to explore the impact of the 2015 recession on public and private providers in prosperous (São Paulo) and impoverished (Maranhão) states in Brazil. Thematic analysis was employed to identify drivers and consequences of system adaptation and coping strategies. Nvivo software was used to aid data collection and analysis. We followed the Standards for Reporting Qualitative Research to provide an account of the findings. RESULTS: We found the concept of 'health sector crisis' to be politically charged among healthcare providers in São Paulo and Maranhão. Contrary to expectations, the public sector was reported to have found ways to compensate for diminishing federal funding, having outsourced services and adopted flexible-if insecure-working arrangements. Following a drop in employment and health plans, private health insurance companies have streamlined their offer, at times at the expenses of coverage. Low-cost walk-in clinics were hit hard by the recession, but were also credited for having moved to cater for higher-income customers in Maranhão. CONCLUSIONS: The 'plates' of a health system may shift and adjust in unexpected ways in response to recessions, and some of these changes might outlast the crisis. As low-income countries enter post-COVID economic recessions, it will be important to monitor the adjustments taking place in health systems, to ensure that past gains in access to care and job security are not eroded.

FOREIGN POLICY, DIPLOMACY AND GLOBAL HEALTH IN PANDEMIC TIMES: BRAZIL IN THE CONTERFLOW OF HISTORY / POLÍTICA EXTERNA Y DIPLOMACIA DE SALUD GLOBAL EM TIEMPOS DE PANDEMIA: BRASIL EN CONTRAMANO DE LA DA HISTORIA / POLÍTICA EXTERNA E DIPLOMACIA DA SAÚDE GLOBAL EM TEMPOS DE PANDEMIA: O BRASIL NA CONTRAMÃO DA HISTÓRIA

This article analyses the international performance of Brazil related to the new coronavirus pandemic, taking into consideration the strategic role of foreign policy and the historic Brazilian diplomatic participation in multilateral forums, including global health. It analyzes how Brazilian foreign policy is responding to the main domestic and international challenges related to fighting the pandemic and the country's economic recovery, highlighting its social consequences. We start from the hypothesis that Brazil is acting far below the requirements and far below the country's prohibitions and diplomatic tradition. We conclude that beyond the detrimental effect on the international scene of global health governance, when denying science through systematic action and policies, the Brazilian government is responsible for exposing the population to avoidable deaths.

Este artículo analiza el desempeño internacional de Brasil  la pandemia debido al nuevo coronavirus, teniendo en cuenta el papel estratégico de la política exterior; las relaciones internacionales de Brasil y la tradición diplomática brasileña en foros multilaterales e en la salud mundial. Analiza se cómo la política exterior brasileña está respondiendo a los principales desafíos nacionales e internacionales relacionados a la pandemia y los resultados de esta acción. Comienza con la hipótesis de que Brasil está actuando abajo de las necesidades y por debajo de las capacidades y la tradición diplomática del país. Concluimos que el efecto nocivo en el escenario internacional de la gobernanza mundial de la salud, al negar la ciencia a través de acciones y políticas sistemáticas, el gobierno brasileño es responsable de exponer a la población a muertes prevenibles.

O artigo analisa a atuação internacional do Brasil durante uma pandemia por novo coronavírus, considerando o papel estratégico da política externa, uma tradição diplomática brasileira nos fóruns multilaterais e na área da saúde global. Analise como a política externa brasileira está respondendo aos principais desafios domésticos e internacionais relacionados ao combate à pandemia e quais são os resultados práticos dessa atuação. Parte-se da hipótese de que o Brasil está atuando abaixo das exigências e das habilidades e tradição diplomática do país. Conclui que, para além do efeito prejudicial no cenário de governança global da saúde, para negar uma ciência por meio de ações e políticas sistemáticas, o governo brasileiro é responsável por exportar uma população a mortes evitáveis.

An ecological study of publicly funded elective hip arthroplasties in Brazil and Scotland: do access inequalities reinforce the inverse care law?

OBJECTIVES: To compare elective hip arthroplasty rates funded by the public sector in Brazil and Scotland. DESIGN: Ecological study, 2009-13, of crude and directly standardised rates of elective primary hip arthroplasty rates (per 100,000) funded by the public sector at national and regional level for age (30 + years) and gender in Brazil and Scotland. SETTING: National Health Service Scotland and Unified Health System in Brazil. PARTICIPANTS: Over 30 s who had undergone an elective hip arthroplasty funded by the public sector. MAIN OUTCOME MEASURES: Publicly funded standardised elective hip arthroplasty rates in Brazil and Scotland. RESULTS: Between 2009 and 2013, there was a seven-fold difference in treatment rates between Brazil and Scotland, and an eight-fold regional difference in Brazil; Brazil (7.8-8.3/100,000, increase of 0.5 per 100,000, 95% confidence interval (CI) (0.3, 0.7) from 2009/10 to 2012/13) and Scotland (from 61.1 to 57.7/100,000, decrease of 3.4 per 100,000, 95% confidence interval (1.4, 5.8) per 100,000); a two-fold difference in number of public beds per head of population (Brazil 158.3/100,000 vs. Scotland 305.1/100,000) and general medical workforce (Brazil 198.8/100,000 vs. Scotland 327.4/100,000); numbers of orthopaedic surgeons per head of population in the two countries were similar in 2013 (Brazil 5.2/100,000 vs. Scotland 4.3/100,000). CONCLUSION: Although the 'inverse care law' is seen in both countries, access to publicly funded hip arthroplasties in Brazil is worse than in Scotland; the distribution of specialists and higher treatment rates in Brazil is highly skewed towards wealthier areas, perpetuating historical regional inequalities.

CHALLENGES OF THE BRAZILIAN STATE POSED BY THE COVID-19 PANDEMIC: THE CASE OF PARADIPLOMACY FROM MARANHAO STATE / DESAFÍOS DEL ESTADO BRASILEÑO FRENTE A LA PANDEMIA PELA COVID-19: EL CASO DE LA PARADIPLOMACIA MARANHENSE / DESAFIOS DO ESTADO BRASILEIRO FRENTE À PANDEMIA PELA COVID-19: O CASO DA PARADIPLOMACIA MARANHENSE

Alongside the current Covid19 pandemic spreading around the world, the odd 'war operation' set up by the Maranhão state government in Brazil, allowing the purchase of medical respirators through an 'alternative' trade route, is the trigger for this essay. Why a federalist state needs to seek alternative trade routes leading to international diplomatic protagonism? There is incipient evidence concerning the Brazilian challenges to deal with the new Corona virus in the field of global health; we analyse the trade actions of Maranhão state government, the news published in the media and reports of international organizations to clarify our guiding question. Three main factors can be pointed as explanatory factors: the negationist speech of the presidency of the republic of Brazil despite scientific evidence, which has been harming public health responses to the pandemic; diplomatic tensions and setbacks with Brazil's largest trading partner for the trade of medicines, equipment and medical-hospital materials in Brazil; the problematic relations between Brazil and international bodies of Global Health Governance after the election of Jair Bolsonaro.

A medida que la pandemia actual se extiende por todo el mundo, la "operación de guerra" establecida por el gobierno de Maranhão para comprar respiradores a través de una ruta "alternativa" se presenta como el desencadenante de esta prueba. La pregunta que nos mueve es entender por qué una entidad subnacional hace esfuerzos en la búsqueda de su inserción internacional. Aunque la evidencia con respecto a los desafíos brasileños para lidiar con el nuevo coronavirus en el campo de la Salud Global aún es incipiente, desde el desempeño internacional del Gobierno de Maranhão, las noticias publicadas en los medios y los informes de organizaciones internacionales señalan tres elementos considerados esenciales para esto. análisis: el discurso negacionista de la Presidencia de la República de Brasil, que ha estado boicoteando la confrontación de la pandemia a pesar de la evidencia científica; tensiones diplomáticas y contratiempos con el mayor socio comercial de Brasil para medicamentos, equipos y material médico-hospitalario en Brasil; y los obstáculos en las relaciones entre Brasil y los organismos internacionales de Global Health Governance.

À medida que a atual pandemia se espalha pelo mundo, a 'operação de guerra' montada pelo governo maranhense para a compra de respiradores por meio de uma rota 'alternativa' apresenta-se como o disparador deste ensaio. A questão que nos move é entender por que um ente subnacional empenha esforços na busca da sua inserção internacional. Embora as evidências a respeito dos desafios brasileiros para lidar com o novo coronavírus no campo da Saúde Global sejam ainda incipientes, a partir da atuação internacional do Governo do Maranhão, notícias divulgadas na mídia e relatórios de organizações internacionais apontam para três elementos considerados fundamentais para esta análise: o discurso negacionista da Presidência da República do Brasil, que vem boicotando o enfrentamento da pandemia a despeito das evidências científicas; as tensões e os retrocessos diplomáticos com o maior parceiro comercial de medicamentos, equipamentos e materiais médico-hospitalares do Brasil; e os entraves nas relações entre o Brasil e os organismos internacionais de Governança Global da Saúde.

Desafios do Estado brasileiro diante da pandemia de COVID-19: o caso da paradiplomacia maranhense / Desafíos del Estado brasileño frente a la pandemia por la COVID-19: el caso de la paradiplomacia marañense / Challenges for the Brazilian State from the COVID-19 pandemic: the case of paradiplomacy in the state of Maranhão

Resumo: À medida que a pandemia de COVID-19 se espalhou pelo mundo em 2020, populações, autoridades e instituições locais e globais de governança em saúde foram atingidas de maneira distinta. A chamada Diplomacia em Saúde Global e a "paradiplomacia" tornaram-se instrumentos e arenas de relevância diante dos desafios trazidos pela pandemia, sobretudo para atores não estatais ou subnacionais. Este Ensaio analisa o caso do Estado do Maranhão, Brasil, no contexto da pandemia, que, por meio de uma "operação de guerra", comprou no mercado internacional mais de cem respiradores à revelia do Governo Federal, em um momento de acirrada competição internacional por materiais e equipamentos médicos. O Ensaio investiga os principais aspectos, contextos, razões, fatores, atores e ações que contextualizam a operação realizada pelo Estado do Maranhão, como uma atividade paradiplomática e de Diplomacia em Saúde Global de um ente subnacional no Brasil. Analisamos os conceitos citados à luz da literatura sobre o tema e estudamos a atuação do Maranhão a partir do cruzamento de dados de documentos, pronunciamentos e notícias. Concluímos que o caso maranhense ilustra a capacidade de entes locais responderem às emergências de cunho global, principalmente em contextos de ineficácia ou ausência do executivo federal, legitimando ações independentes que visem à proteção da vida.

Resumen: A medida que la pandemia de COVID-19 se extendió por el mundo en 2020, poblaciones, autoridades e instituciones locales y globales de gobernanza en salud se vieron afectadas de manera distinta. La llamada Diplomacia en Salud Global y la "paradiplomacia" se convirtieron en instrumentos y campos de relevancia ante los desafíos presentados por la pandemia, sobre todo para actores no estatales o entes subnacionales. Este Ensayo analiza el caso del Estado de Maranhão, Brasil, en el contexto de la pandemia, el cual mediante una "operación de guerra", compró en el mercado internacional más de cien respiradores, aun a pesar del Gobierno Federal, en un momento de acérrima competición internacional por materiales y equipamientos médicos. El Ensayo investiga los principales aspectos, contextos, razones, factores, actores y acciones que contextualizan la operación realizada por el Estado de Maranhão como una actividad paradiplomática y de Diplomacia en Salud Global de un ente subnacional en Brasil. Analizamos los conceptos citados a la luz de la literatura sobre el tema y estudiamos la actuación de Maranhão, a partir del cruce de datos de documentos, pronunciamientos y noticias. Concluimos que el caso marañense ilustra la capacidad de entes locales en responder a las emergencias de cuño global, principalmente en contextos de ineficacia o ausencia del ejecutivo federal, legitimando acciones independientes que visen la protección a la vida.

Abstract: As the COVID-19 pandemic has spread worldwide in 2020, populations, authorities, and local and global health governance institutions have been affected differently. Global Health Diplomacy and "paradiplomacy" have become relevant instruments and arenas for the challenges raised by the pandemic, especially for non-State or subnational actors. This Essay analyzes the case of the Brazilian state of Maranhão during the pandemic, which used a "wartime operation" to purchase more than a hundred mechanical ventilators on the international market, over the Federal Government's head, at a moment of fierce international competition for medical supplies and equipment. The Essay examines the principal aspects, contexts, reasons, factors, actors, and actions that contextualize the operation conducted by the state of Maranhão as an activity in paradiplomacy and Global Health Diplomacy by a subnational government in Brazil. We analyzed these concepts in light of the literature on the topic and studied the action by Maranhão based on cross-analysis of data from documents, statements, and news coverage. We conclude that the case of Maranhão illustrates the capacity of subnational bodies to respond to global emergencies, mainly in contexts of inefficacy or absence of the Federal executive, legitimizing independent action aimed at saving lives.

Impact of economic recessions on healthcare workers and their crises' responses: study protocol for a systematic review of the qualitative and quantitative evidence for the development of an evidence-based conceptual framework.

INTRODUCTION: During economic recessions, health professionals face reduced income and labour opportunities, hard conditions often exacerbated by governments' policy responses to crises. Growing evidence points to non-negligible effects on national health workforces and health systems-decrease in motivation, burnout, migration-arising from the combination of crisis-related factors. However, no theoretical conceptualisation currently exists framing the impacts recessions have on human resources for health (HRH), or on their reactions. METHODS AND ANALYSIS: This paper lays out a protocol for a systematic review of the existing qualitative, quantitative and mixed-method evidence on the economic recessions and HRH; results from the review will be used to develop a conceptual framework linking existing theories on recessions, austerity measures, health systems and population health, with a view of informing future health policies. Eight relevant databases within the health, health systems, multidisciplinary and economic literature will be searched, complemented by secondary searches and experts' input. Eligible studies will present primary quantitative or qualitative evidence on HRH impacts, or original secondary analyses. We will cover the 1970-2019 period-the modern age of global economic recessions-and full texts in English, Spanish, Italian, French, Portuguese or Greek. Two reviewers will independently assess, perform data extraction and conduct quality appraisal of the texts identified. A 'best-fit' framework synthesis will be applied to summarise the findings, using an a priori, theoretically driven framework. That preliminary framework was built by the research team to inform the searches, and will be appraised by external experts. ETHICS AND DISSEMINATION: In addition to peer-reviewed publications, the new framework will be presented in global health systems research conferences and inform regional policy dialogue workshops in Latin America on economic recessions and health systems. PROSPERO REGISTRATION NUMBER: CRD42019134165.

International Trade and Health Care in Brazil: An Unpredicted Tale Threatening Health Care Entitlement?

The General Agreement on Trade in Services (GATS), established in 1994, has been a key element of market liberalization of health care services. Brazil had the provision of health care services partially protected from international competition until 2015, when a constitutional change opened the national health care market to international provision. We performed a retrospective and prospective policy analysis based on a systematic policy document review, general literature review, and secondary data analysis mapping, describing and analyzing the international trade agreements signed by Brazil with the World Trade Organization (WTO) and the available legislation relevant to health care services. The provision of health care services was not included in the WTO commitments signed by Brazil during the analyzed period (1994-2018). Financing of private health insurance was part of the agreement since 1994. There was a mild liberalization of the private health insurance sector, while provision of health care services was forbidden to foreign investors until 2015. The mode 3 of GATS presents the greatest potential impact as it exposes health care provision to international competition. The international liberalization of the provision of health care services in Brazil is now legal and an observable consequence of the pressure to gradually lift trade barriers in the health and health care sector.

"Liberalizing" the English National Health Service: background and risks to healthcare entitlement. / A "liberalização" do Serviço Nacional de Saúde da Inglaterra: trajetória e riscos para o direito à saúde.

The recent reform of the English National Health Service (NHS) through the Health and Social Care Act of 2012 introduced important changes in the organization, management, and provision of public health services in England. This study aims to analyze the NHS reforms in the historical context of predominance of neoliberal theories since 1980 and to discuss the "liberalization" of the NHS. The study identifies and analyzes three phases: (i) gradual ideological and theoretical substitution (1979-1990) - transition from professional and health logic to management and commercial logic; (ii) bureaucracy and incipient market (1991-2004) - structuring of the bureaucracy focused on administration of the internal market and expansion of pro-market measures; and (iii) opening to the market, fragmentation, and discontinuity of services (2005-2012) - weakening of the territorial health model and consolidation of health as an open market for public and private providers. This gradual but constant liberalization has closed services and restricted access, jeopardizing the system's comprehensiveness, equity, and universal healthcare entitlement in the NHS.

Nurses' performance on primary care in the National Health Service in England.

OBJECTIVE: To analyze the expansion of nursing roles in primary care in the English National Health Service and the implications for professional practice. METHOD: qualitative research in case study format, held in London, England, in six primary care units. Data were obtained through interviews with nine nurses. After the thematic data analysis, two units emerged: the nurses' performance characteristics and effects of the expansion of nursing roles. RESULTS: expansion of nurses' roles: consultation, diagnosis and drug therapy, case management and monitoring of chronic conditions. Repercussions: for the user, there was improved access, communication and comprehensive care, increased duration of consultations, resulting in greater adherence; for nurses, there was the expansion of professional skills, knowledge and professional recognition; to the health care system, it resulted in cost savings. CONCLUSION: benefits in expanding nursing roles, were visible, contributing to primary care quality.

Atuação do enfermeiro na Atenção Primária no Serviço Nacional de Saúde da Inglaterra / Actuación del enfermero en la Atención Primaria en el Servicio Nacional de Salud de Inglaterra / Nurses' performance on primary care in the National Health Service in England

RESUMO Objetivo: analisar a ampliação das funções do enfermeiro na atenção primária no Serviço Nacional de Saúde inglês e as repercussões para a prática profissional. Método: pesquisa qualitativa em formato estudo de caso, realizada em Londres, Inglaterra, em seis unidades de atenção primária. Dados obtidos por meio de entrevista com nove enfermeiros. Feita análise temática de dados, emergiram duas unidades: características da atuação do enfermeiro e repercussões da ampliação de funções do enfermeiro. Resultados: funções ampliadas do enfermeiro: consultas, diagnóstico e terapêutica medicamentosa, gestão de casos e acompanhamento de condições crônicas. Repercussões: para o usuário, melhorou o acesso, a comunicação e o cuidado integral, aumentou o tempo de duração das consultas, resultando em maior adesão terapêutica; para o enfermeiro, houve a ampliação da competência profissional, do conhecimento e do reconhecimento profissional; para o sistema de saúde, acarretou na redução de custos. Conclusão: sobressaíram-se benefícios na ampliação de funções do enfermeiro, contribuindo para atenção primária de qualidade.

RESUMEN Objetivo: analizar la ampliación de las funciones del enfermero en la atención primaria en el Servicio Nacional de Salud inglés y las repercusiones para la práctica profesional. Método: investigación cualitativa en formato estudio de caso, realizada en Londres, Inglaterra, en seis unidades de atención primaria. Datos obtenidos por medio de entrevista con nueve enfermeros. Hecho el análisis temático de los datos, surgieron dos unidades: características de la actuación del enfermero y repercusiones de la ampliación de funciones del enfermero. Resultados: funciones ampliadas del enfermero: consultas, diagnóstico y terapêutica medicamentosa, gestión de casos y acompanamiento de condiciones crónicas. Repercusiones: para el usuario, mejoró el acceso, la comunicación y el cuidado integral, aumentó el tiempo de duración de las consultas, resultando en mayor adherencia terapêutica; para el enfermero, se dio la ampliación de la competencia profesional, del conocimiento y del reconocimiento profesional; para el sistema de salud, llevando para la reducción de costos. Conclusión: se sobresalieron los beneficios en la ampliación de funciones del enfermero, contribuyendo para la atención primaria de calidad.

ABSTRACT Objective: To analyze the expansion of nursing roles in primary care in the English National Health Service and the implications for professional practice. Method: qualitative research in case study format, held in London, England, in six primary care units. Data were obtained through interviews with nine nurses. After the thematic data analysis, two units emerged: the nurses' performance characteristics and effects of the expansion of nursing roles. Results: expansion of nurses' roles: consultation, diagnosis and drug therapy, case management and monitoring of chronic conditions. Repercussions: for the user, there was improved access, communication and comprehensive care, increased duration of consultations, resulting in greater adherence; for nurses, there was the expansion of professional skills, knowledge and professional recognition; to the health care system, it resulted in cost savings. Conclusion: benefits in expanding nursing roles, were visible, contributing to primary care quality.

A "liberalização" do Serviço Nacional de Saúde da Inglaterra: trajetória e riscos para o direito à saúde / La "liberalización" del Servicio Nacional de Salud de la Inglaterra: trayectoria y riesgos para el derecho a la salud / "Liberalizing" the English National Health Service: background and risks to healthcare entitlement

Resumo: A recente reforma do Serviço Nacional de Saúde (NHS) inglês por meio do Health and Social Care Act de 2012 introduziu mudanças importantes na organização, gestão e prestação de serviços públicos de saúde na Inglaterra. O objetivo deste estudo é analisar as reformas do NHS no contexto histórico de predomínio de teorias neoliberais desde 1980 e discutir o processo de "liberalização" do NHS. São identificados e analisados três momentos: (i) gradativa substituição ideológica e teórica (1979-1990) - transição da lógica profissional e sanitária para uma lógica gerencial/comercial; (ii) burocracia e mercado incipiente (1991-2004) - estruturação de burocracia voltada à administração do mercado interno e expansão de medidas pró-mercado; e (iii) abertura ao mercado, fragmentação e descontinuidade de serviços (2005-2012) - fragilização do modelo de saúde territorial e consolidação da saúde como um mercado aberto a prestadores públicos e privados. Esse processo gradual e constante de liberalização vem levando ao fechamento de serviços e à restrição do acesso, comprometendo a integralidade, a equidade e o direito universal à saúde no NHS.

Resumen: La reciente reforma del Servicio Nacional de Salud (NHS) inglés a través de la Health and Social Care Act de 2012 introdujo cambios importantes en la organización, gestión y prestación de los servicios de salud pública en Inglaterra. El objetivo de este estudio es analizar las reformas del NHS en el contexto histórico del predominio de las teorías neoliberales desde 1980 y discutir el proceso de "liberalización" del NHS. Fueron identificados y se analizaron tres momentos: (i) sustitución gradual ideológica y teórica (1979-1990) -transición de la lógica profesional y de salud para una lógica de gestión/negocio; (ii) la burocracia y el mercado incipiente (1991-2004) -estructuración de la burocracia dedicada a la gestión del mercado interior y la expansión de las medidas pro-mercado; y (iii) la apertura del mercado, la fragmentación y la discontinuidad de los servicios (2005-2012) -fragilización del modelo de salud territorial y consolidación de la salud como un mercado abierto para los proveedores públicos y privados. Este proceso gradual y constante de la liberalización ha provocado el cierre de los servicios y la restricción del acceso, comprometiendo la integridad, justicia y derecho universal a la salud en el NHS.

Abstract: The recent reform of the English National Health Service (NHS) through the Health and Social Care Act of 2012 introduced important changes in the organization, management, and provision of public health services in England. This study aims to analyze the NHS reforms in the historical context of predominance of neoliberal theories since 1980 and to discuss the "liberalization" of the NHS. The study identifies and analyzes three phases: (i) gradual ideological and theoretical substitution (1979-1990) - transition from professional and health logic to management and commercial logic; (ii) bureaucracy and incipient market (1991-2004) - structuring of the bureaucracy focused on administration of the internal market and expansion of pro-market measures; and (iii) opening to the market, fragmentation, and discontinuity of services (2005-2012) - weakening of the territorial health model and consolidation of health as an open market for public and private providers. This gradual but constant liberalization has closed services and restricted access, jeopardizing the system's comprehensiveness, equity, and universal healthcare entitlement in the NHS.

A abertura da saúde nacional ao capital estrangeiro: efeitos do mercado global no Brasil / The opening of the national healthcare market to Foreign Direct Investment: effects of the global market in Brazil

A saúde é um direito constitucional no Brasil. Este ensaio debate a abertura do mercado da saúde, em seu subsistema privado, ao investimento estrangeiro (Foreign Direct Investment), sancionada pelo governo brasileiro (Lei 13.097/2015). Busca evidências na literatura que demonstrem experiências semelhantes em outros países, assim como contextualiza o mercado da saúde nacional na conjuntura global de investimento em serviços. Tal lei, carecendo de mecanismos regulatórios e de discussões prévias nas instâncias de controle social, falhará na promoção de maior competitividade entre provedores e acarretará, como consequência de longo termo, a inviabilidade do subsistema público de saúde nacional.

Health is a constitutional right in Brazil. This essay debates the opening of the healthcare market, in its private subsystem, to foreign investment (Foreign Direct Investment), sanctioned by the Brazilian government (Law 13097/2015). It searches for evidence in the literature which demonstrate similar experiences in other countries, as well as contextualises the national healthcare market in the global services investment setting. This Law, lacking regulatory mechanisms and previous discussions in social control instances, will fail in the promotion of greater competition among providers and will entail, as a long term consequence, the unviability of the national public health subsystem.

Democracia e conquista: saúde mental como política pública municipal / Democracy and achievement: mental health as a municipal public policy

A Reforma Psiquiátrica brasileira é parte integrante da construção da democracia no Brasil e a Constituição Nacional de 1988 marca a descentralização política e financeira em direção aos municípios da federação. A pesquisa é qualitativa e objetiva analisar o processo democrático de construção, implantação e a aplicabilidade de uma Lei Municipal de Saúde Mental frente às contradições do processo social de reforma psiquiátrica brasileiro. Metodologia: triangulação de dados entre entrevistas com gestores (2), trabalhadores (5) e usuários (2) envolvidos com a política de saúde mental do município; observações registradas em diário de campo (18 horas em 6 turnos alternados); e análise de documentos públicos. Análise dos dados: pela característica da hipótese, optou-se pelo referencial materialista histórico e dialético, dividindo a análise em duas etapas cronológicas - de 1989 a 1996 (promulgação da legislação municipal) e de 1996 a 2007 (implantação dos serviços). Conclusões: a legislação municipal reformista de saúde mental é necessária enquanto garantia legal de direitos, mas a mesma possui sentido apenas se agregada à história que a produziu; é preciso aproximar-se da condição humana inerente às produções sociais para reproduzir nos novos trabalhadores de saúde o sentido da existência de movimentos sociais como a reforma psiquiátrica.

The Brazilian psychiatric reform is part of the construction of Brazil's democracy and the National Constitution of 1988 subscribes the politic and financial decentralization towards the nation's municipalities. This study reveals the country's democratization consequences in a Brazilian city in addition to the political characteristics of the psychiatric reform between 1989 until 2009. It is a qualitative research and aimed to analyze the democratic process of construction, implementation and applicability of a Municipal Law of Mental Health facing the contradictions of the Brazilian psychiatric reform processes, testing the hypothesis of necessity of a reformist mental health law at the municipal level. Methodology: interviews with managers (2), health workers (5) and users (2) involved with the mental health municipal policy; observations registered on a journal (18 hours divided in 6 alternate shifts); analysis of public domain documents. Data analysis: because of the hypothesis characteristics, the theoretical framework of historical and dialectical materialism was used in two chronological stages - from 1989 until 1996 (publication of the municipal law) and from 1996 until 2007 (implementation of services). Conclusions: the reformist municipal mental health law is necessary as a legal warrantee of rights, however, it only has meaning if summed to the history that has produced it; it is necessary to approach the inherent human condition of the social production to reproduce on the new health workers the meaning of existence of social movements such as the psychiatric reform.

Humanização e loucura, em busca do humano que dialoga saúde / Humanization and madness, in search of the Human who dialogues health

Investindo na necessária relação teórica entre as Políticas de Humanização e de Saúde Mental do sistema de saúde brasileiro, o presente artigo defende, através do diálogo teórico entre ambas, a ideia de que as propostas expressas em tais políticas são respostas coerentes às principais contradições do intrincado sistema público de saúde nacional. Neste intento são apresentadas: as bases teóricas das citadas políticas ministeriais; suas relações com a sociedade que as demandou enquanto políticas públicas; e, finalmente, a maneira como a conjunção de ambas fornece contribuições essenciais à continuidade do Sistema Único de Saúde (SUS). A metodologia ensaística foi utilizada, de acordo com bibliografia metodológica atualizada, relacionando autores e suas contribuições com o objetivo de defender o ponto de vista dos autores do artigo. Conclui-se que o incentivo público à protagonização da sociedade contraria a lógica biologicista dos cursos de formação de profissionais de saúde e horizontaliza as relações humanas do SUS, fortificando-o e dando-lhe razão essencial de existência à sociedade brasileira.

Investing in the necessary theoretical relationship between Humanization and Mental Health Policies of the Brazilian health system, this paper argues, through the theoretical dialogue between them, the idea that the proposals set forth in such policies are coherent answers to the main contradictions of the intricate national public health system. So are presented: the theoretical basis of the aforementioned ministerial policies; their relations with the society demanded as public policy; and finally, how the combination of both provide essential contributions to the continuity of the Unified Health System (SUS). The essay methodology was used, according to updated methodological bibliography, listing authors and their contributions in order to defend the views of the authors. We conclude that the public encouragement of protagonizsm of society undermines the logic of biological training courses for health professionals and flattens human relations within the SUS, fortifying it and giving it essential reason for existence to the Brazilian society.