The effect of primary care policy changes on hospitalisation for ambulatory care sensitive conditions: notes from Brazil.

OBJECTIVES: The aim of this study was to assess the effect of the Primary Health Care Reform and the impact of recent national policy changes on the trend in hospitalisation rates for Ambulatory Conditions Sensitive to Primary Care (ACSC) in the city of Rio de Janeiro, Brazil. STUDY DESIGN: Ecological study with data from the Brazilian National Health Information System. METHODS: This study performed an interrupted time-series analysis, comparing three different time periods related to important changes in primary care policies in Brazil: Baseline (2008-2009); Primary Health Care Reform (RCAPS) (2010-2017); and National Primary Health Care Policy (PNAB) (2018-2019). Data included total monthly admissions for ACSC and rates for 19 groups of causes for hospitalisation. RESULTS: There was a non-significant increasing trend in ACSC hospital admissions between January 2008 and December 2009 (ß = 4.01, 95% confidence interval [CI] -12.14 to 20.15). The Primary Health Care Reform (RCAPS), which commenced in January 2010, resulted in a significant reduction in ACSC hospital admission trends during this time period (ß = -7.97, 95% CI -9.78 to -6.16). Change in the PNAB did not change the declining ACSC hospital admission trend but it did reduce the rate of decline. In addition, the coefficient was no longer significant (ß = -1.93, 95% CI -2.46 to 0.59), suggesting that monitoring of the historical series for a long time may show a reversal of the downward trend in some months. The most consistent change in ACSC hospital admission trend occurred between baseline and the RCAPS (ß slope = -0.143, P < 0.001) and the level between the RCAPS period and the new PNAB (ß step = 7.00, P = 0.008). Trends and differences in the time periods vary in the different ACSC hospitalisation-cause groups. CONCLUSION: Changes in public health policies impact ACSC hospitalisation rates, which can thus be used as an indicator for monitoring primary health care. We also recommend analysing admission rates by the individual ACSC hospitalisation-cause groups.

Critical perspective of social participation in health surveillance / Vigilância civil em saúde, estudos de população e participação popular

Many barriers impede the defense of health equity, especially those that hinder social participation in health. In the mid-1990s, Victor Valla proposed incorporating the population's participation into health surveillance through Paulo Freire's popular education. This counterpoint to traditional surveillance practices, then called civil health surveillance, is added to the expanded concept of health, and has a strong connection with the critical perspective of epidemiology to understand the dialectical relationship between social classes and their lived spaces. The practice of civil surveillance aims to overcome essential gaps left by traditional methods of public health investigation. It includes a lack of attention to socio-cultural contexts, the construction of risk located only in the individual, and the representation of public health agendas that privilege and pathologize certain behaviors. In this sense, this paper discusses concept of civil health surveillance, the locus of discussion of population studies in the reification of the role of the contextual effect in explaining the social production of health and the incorporation of popular participation in health surveillance as an element of social transformation. The deepening of this discussion allows a participatory construction of new health models focused on the effective reduction of health inequities and, consequently, the effective universalization of the right to health.

Muitas barreiras impedem a defesa da equidade na saúde, especialmente aquelas que dificultam a participação popular. Em meados dos anos 90, Victor Valla propõe a incorporação da participação da população à prática da vigilância em saúde, por meio da educação popular de Paulo Freire. Este contraponto às práticas tradicionais da vigilância, nomeadas vigilância civil da saúde, se somam à concepção ampliada de saúde, e possuem forte ligação com a perspectiva crítica da epidemiologia enquanto meio de compreender a relação dialética entre classes sociais e seus espaços vividos. A prática da vigilância civil pretende superar lacunas importantes deixadas pelos métodos tradicionais de investigação em saúde pública, como falta de atenção aos contextos socioculturais, a construção do risco localizada somente no indivíduo e a representação de agendas de saúde pública que privilegiam e patologizam certos comportamentos.  Neste sentido, o presente trabalho debate o conceito de vigilância civil da saúde, o locus de discussão dos estudos de população na reificação do papel do efeito contextual para a explicação da produção social da saúde e a incorporação da participação popular à vigilância em saúde como elemento de transformação social. O aprofundamento desta discussão, no limite, permite uma construção participativa de novos modelos de saúde focados na redução efetiva das iniquidades em saúde e, consequentemente, universalização efetiva do direito à saúde.