COVID-19 inpatient mortality in Brazil from 2020 to 2022: a cross-sectional overview study based on secondary data.

BACKGROUND: In Brazil, the COVID-19 pandemic found the universal and public Unified Health System (SUS) with problems accumulated over time, due, among other reasons, to low investments, and disparities in resource distribution. The preparedness and response of the healthcare system, involving the SUS and a private sector, was affected by large socioeconomic and healthcare access inequities. This work was aimed at offering an overview of COVID-19 inpatient mortality during the pandemic in Brazil, exploring factors associated with its variations and, specifically, differences across public, private (for-profit) and philanthropic (private non-profit) inpatient healthcare units, providers, and non-providers of services to the SUS. METHODS: This cross-sectional study used public secondary data. The main data source was the SIVEP-Gripe, which comprises data on severe acute respiratory illness records prospectively collected. We also employed the National Record of Health Establishments, the SUS' Hospitalization Information System and municipalities' data from IBGE. We considered adult COVID-19 hospitalizations registered in SIVEP-Gripe from February 2020 to December 2022 in inpatient healthcare units with a minimum of 100 cases in the period. Data analyses explored the occurrence of inpatient mortality, employing general linear mixed models to identify the effects of patients', health care processes', healthcare units' and municipalities' characteristics on it. RESULTS: About 70% of the COVID-19 hospitalizations in Brazil were covered by the SUS, which attended the more vulnerable population groups and had worse inpatient mortality. In general, non-SUS private and philanthropic hospitals, mostly reimbursed by healthcare insurance plans accessible for more privileged socioeconomic classes, presented the best outcomes. Southern Brazil had the best performance among the macro-regions. Black and indigenous individuals, residents of lower HDI municipalities, and those hospitalized out of their residence city presented higher odds of inpatient mortality. Moreover, adjusted inpatient mortality rates were higher in the pandemic peak moments and were significantly reduced after COVID-19 vaccination reaching a reasonable coverage, from July 2021. CONCLUSIONS: COVID-19 exposed socioeconomic and healthcare inequalities and the importance and weaknesses of SUS in Brazil. This work indicates the need to revert the disinvestment in the universal public system, a fundamental policy for reduction of inequities in the country.

Patterns of hospital utilization in the Unified Health System in six Brazilian capitals: comparison between the year before and the first six first months of the COVID-19 pandemic.

OBJECTIVE: To analyze the temporal evolution of the pattern of hospital use in the context of the COVID-19 pandemic in Brazil. METHODS: This retrospective observational study compared hospital use and mortality in the Brazilian Unified Health System (SUS) in the first six months of the COVID-19 pandemic with the year before the onset of the pandemic in six Brazilian capitals (São Paulo, Rio de Janeiro, Manaus, Fortaleza, Recife, and Brasilia). It was based on secondary administrative data from the SUS Hospital Information System (SIH), focusing on the number of hospitalizations per fortnight, age, and gender of patients, hospital length of stay, and the proportions of surgical, elective, with the use of ICU, and resulting in death hospitalizations. It also compared the number of hospitalizations and mortality related to frequent diagnostic groups. RESULTS: A significant drop was identified in the number of hospitalizations as of March 2020, with the first peak of COVID-19 hospitalizations in five capitals recorded in May 2020. In the six capitals, we observed significant reductions in the mean number of hospitalizations per fortnight from the beginning of the pandemic. We also identified an increase in the mean age of the patients and the proportion of male patients. The proportion of surgical and elective hospitalizations dropped significantly in all capitals, while the proportion of hospitalizations with ICU use increased significantly. Significant increases in-hospital mortality were also recorded in the six capitals with the pandemic, including or excluding COVID-19 hospitalizations from the comparison. CONCLUSION: The pandemic caused changes in the pattern of use and hospital indicators in the first six months in the cities considered, evidencing the need for attention to diseases with a hospital production altered by the COVID-19 course and health system performance problems in the face of challenges.

Challenges to the improvement of obstetric care in maternity hospitals of a large Brazilian city: an exploratory qualitative approach on contextual issues.

BACKGROUND: Maternal morbidity and mortality are still serious public health concerns in Brazil, and access to quality obstetric care is one critical point of this problem. Despite efforts, obstetric care quality problems and sub-optimal/poor outcomes persist. The study aimed to identify contextual elements that would potentially affect the implementation of an obstetric care quality improvement intervention. METHODS: A qualitative study was conducted in three public maternity hospitals of a large Brazilian city, with high annual volume of births and buy-in from high-level managers. Individual interviews with doctors and nurses were conducted from July to October 2015. Semi-structured interviews sought to explore teamwork, coordination and communication, and leadership, being open to capture other contextual elements that could emerge. Interviews were recorded and transcribed, and the categories of analysis were identified and updated based on the constant comparative method. RESULTS: Twenty-seven interviews were carried out. Extra-organizational context concerning the dependence of the maternity hospitals on primary care units, responsible for antenatal care, and on other healthcare organizations' services emerged from interviews, but the main findings of the study centered on intra-organizational context with potential to affect healthcare quality and actions for its improvement, including material resources, work organization design, teamwork, coordination and communication, professional responsibility vis-à-vis the patient, and leadership. A major issue was the divergence of physicians' and nurses' perspectives on care quality, which in turn negatively affected their capacity to work together. CONCLUSION: Overall, the findings suggest that care on the maternity hospitals was fragmented and lacked continuity, putting at risk the quality. Redesigning work organization, promoting conditions for multi-professional teamwork, better communication and coordination, improving more systemic accountability/lines of authority, and investing in team members' technical competence, and fitness of organizational structures and processes are all imbricated actions that may contribute to obstetric care quality improvement.

Geographical variation in demand, utilization, and outcomes of hospital services for COVID-19 in Brazil: A descriptive serial cross-sectional study.

OBJECTIVE: To analyze the geographical variation in the provision of health services, namely in demand, patterns of utilization, and effectiveness in the Brazilian Health Regions in four different periods of the COVID-19 pandemic, from February 2020 to March 2021. METHODS: Descriptive serial cross-sectional study based on secondary data on COVID-19 hospitalizations from SIVEP-Gripe, a public and open-access database of Severe Acute Respiratory Illness records collected by the Brazilian Ministry of Health, and COVID-19 case notification data from Brasil.io, a repository of public data. Fifty-six epidemiological weeks were split into four periods. The following variables were considered for each Brazilian Health Region, per period: number of hospitalizations, hospitalizations per 100,000 inhabitants, hospitalizations per 100 new cases notified in the Health Region, percentage of hospitalizations with ICU use, percentages of hospitalizations with invasive and non-invasive ventilatory support, percentage of hospitalizations resulting in death and percentage of hospitalizations with ICU use resulting in death. Descriptive statistics of the variables were obtained across all 450 Health Regions in Brazil over the four defined pandemic periods. Maps were generated to capture the spatiotemporal variation and trends during the first year of the COVID-19 pandemic in Brazil. RESULTS: There was great variation in how COVID-19 hospitalizations grew and spread among Health Regions, with higher numbers between June and August 2020, and, especially, from mid-December 2020 to March 2021. The variation pattern in the proportion of ICU use in the hospitalizations across the Health Regions was broad, with no intensive care provision in large areas in the North, Northeast, and Midwest. The proportions of hospitalizations and hospitalizations with ICU use resulting in deaths were remarkably high, reaching medians of 34.0% and 62.0% across Health Regions, respectively. CONCLUSION: The Heath Regions in Brazil are highly diverse, showing broad disparities in the capacity to respond to the demands imposed by COVID-19, services provided, use and outcomes.

[Contributions from the Critical Success Factors model to analysis of the management of Product Development Partnerships in a government laboratory]. / Contribuições do modelo Fatores Críticos de Sucesso para análise da gestão de Parcerias para o Desenvolvimento Produtivo de um laboratório oficial.

Product Development Partnerships (PDP) are one of the measures used by the Brazilian government to incentivize innovation policy, to expand the population's access to strategic medicines, and to reduce the country's technological dependence by strengthening the national pharmaceutical manufacturing base. The study aimed to identify the Critical Success Factors (FCS in Portuguese) for the implementation of these partnerships, using as the reference one of the largest Brazilian government pharmaceutical laboratories. FCS are seen as key areas in which the results must be satisfactory in order to ensure successful performance in the organization or project. The methodological strategies included literature review, analysis of internal documents, and semi-structured interviews with key actors. We analyzed the partnerships approved for this public laboratory from 2009 to May 2018. The study enabled a critical view of the phases in a PDP and identification of specific critical factors for this type of project. The findings reveal persistent organizational challenges for increasing the executability of partnerships, which can serve as a reference for other government laboratories that have PDP agreements under way or that intend to submit proposals for them.

A Parceria para o Desenvolvimento Produtivo (PDP) é uma das medidas usada pelo Estado brasileiro para incentivar a política de inovação, ampliar o acesso da população a medicamentos estratégicos e reduzir a dependência tecnológica do país, por meio do fortalecimento da base produtiva nacional de medicamentos. O trabalho procurou identificar os Fatores Críticos de Sucesso (FCS) para a implantação dessas parcerias, tendo como referência as PDPs de um dos maiores laboratórios farmacêuticos oficiais do país. FCS são compreendidos como áreas-chave nas quais os resultados devem ser satisfatórios para assegurar um desempenho de sucesso para a organização ou projeto. Como estratégias metodológicas, além da revisão bibliográfica e análise de documentos internos, foram realizadas entrevistas semiestruturadas com atores-chave. Foram consideradas as parcerias aprovadas para o laboratório no período de 2009 a maio de 2018. O estudo permitiu uma visão crítica sobre as fases do processo de uma PDP e a identificação de fatores críticos específicos para esse tipo de projeto. Os resultados encontrados demonstram existir desafios organizacionais a serem superados para o aumento da executabilidade das parcerias, e podem servir de referência para outros laboratórios oficiais que tenham acordos de PDPs em andamento ou que pretendam apresentar propostas.

Las Alianzas para el Desarrollo Productivo (PDP por sus siglas en portugués) es una de las medidas usadas por el estado brasileño para incentivar la política de innovación, ampliar el acceso de la población a medicamentos estratégicos y reducir la dependencia tecnológica del país, a través del fortalecimiento de la base productiva nacional de medicamentos. El trabajo buscó identificar los Factores Críticos de Éxito (FCS por sus siglas en portugués) para la implementación de esas colaboraciones, teniendo como referencia las PDPs de uno de los mayores laboratorios farmacéuticos oficiales del país. Los FCS se entienden como las áreas-clave en las que los resultados deben ser satisfactorios para asegurar un desempeño de éxito para la organización o proyecto. Como estrategias metodológicas, además de la revisión bibliográfica y análisis de documentos internos, se realizaron entrevistas semiestructuradas con actores-clave. Se consideraron las colaboraciones aprobadas para el laboratorio durante el período de 2009 a mayo de 2018. El estudio permitió una visión crítica sobre las fases del proceso de una PDP y la identificación de factores críticos específicos para ese tipo de proyecto. Los resultados encontrados demuestran que existen desafíos organizativos que deben superarse para que aumente la posibilidad de ejecución de colaboraciones y puedan servir de referencia para otros laboratorios oficiales que tengan acuerdos de PDPs en transcurso o que pretendan presentar propuestas.

COVID-19 hospitalizations in Brazil's Unified Health System (SUS).

OBJECTIVE: To study the profile of hospitalizations due to COVID-19 in the Unified Health System (SUS) in Brazil and to identify factors associated with in-hospital mortality related to the disease. METHODS: Cross-sectional study, based on secondary data on COVID-19 hospitalizations that occurred in the SUS between late February through June. Patients aged 18 years or older with primary or secondary diagnoses indicative of COVID-19 were included. Bivariate analyses were performed and generalized linear mixed models (GLMM) were estimated with random effects intercept. The modeling followed three steps, including: attributes of the patients; elements of the care process; and characteristics of the hospital and place of hospitalization. RESULTS: 89,405 hospitalizations were observed, of which 24.4% resulted in death. COVID-19 patients hospitalized in the SUS were predominantly male (56.5%) with a mean age of 58.9 years. The length of stay ranged from less than 24 hours to 114 days, with a mean of 6.9 (±6.5) days. Of the total number of hospitalizations, 22.6% reported ICU use. The odds on in-hospital death were 16.8% higher among men than among women and increased with age. Black individuals had a higher likelihood of death. The behavior of the Charlson and Elixhauser indices was consistent with the hypothesis of a higher risk of death among patients with comorbidities, and obesity had an independent effect on increasing this risk. Some states, such as Amazonas and Rio de Janeiro, had a higher risk of in-hospital death from COVID-19. The odds on in-hospital death were 72.1% higher in municipalities with at least 100,000 inhabitants, though being hospitalized in the municipality of residence was a protective factor. CONCLUSION: There was broad variation in COVID-19 in-hospital mortality in the SUS, associated with demographic and clinical factors, social inequality, and differences in the structure of services and quality of health care.

Production of knowledge on policy, planning, and management in Journal Ciência & Saúde Coletiva. / Produção de conhecimento em política, planejamento e gestão na Revista Ciência & Saúde Coletiva.

The area of Policy, Planning and Health Management (PPG) express the intersection between research, intervention and political action. The article analyzes the dynamics of knowledge production about PPG in the Journal Ciência & Saúde Coletiva (C&SC) from 1996 to 2019. The study articulates a bibliometric and qualitative approach to explore the profile of articles in three dimensions: thematic, methodological and authorship/institutional partnerships. 1680 PPG manuscripts were identified, corresponding to 28.3% of the total publications. Thematic analysis showed a strong influence of the context and the implementation of Unified Health System (SUS). Qualitative empirical studies predominated, followed by quantitative and quanti-qualitative studies. The combination of methodological procedures was frequent, with bibliographic review and interviews being the most cited. The average number of authors per article and national institutional partnerships increased. As most articles were published in Portuguese, the challenge of internationalization persists. The PPG area stands out in the Journal C&SC and in the production of scientific knowledge relevant to SUS.

A área de Políticas, Planejamento e Gestão em Saúde (PPG) é um dos pilares do campo da Saúde Coletiva, expressando a interseção entre pesquisa, intervenção e ação política. O artigo analisa a dinâmica da produção de conhecimento em PPG, na revista Ciência & Saúde Coletiva (C&SC), de 1996 a 2019, articulando abordagem bibliométrica e qualitativa para caracterizar três dimensões: temática, metodológica e autoria/parcerias institucionais. Identificaram-se 1.680 manuscritos, correspondendo a 28,3% do total de publicações da revista no período. A análise temática mostrou influência do contexto e da trajetória de implantação do Sistema Único de Saúde (SUS). Destacaram-se estudos empíricos qualitativos, seguidos dos quantitativos e dos com outros desenhos. A combinação de procedimentos metodológicos foi frequente, sendo mais citadas a revisão bibliográfica e entrevistas/questionários. A maioria dos artigos foi publicada em português e, apesar do aumento das publicações em inglês no final do período, parcerias com autores de outros países foram raras, persistindo o desafio da internacionalização. Conclui-se que a área de PPG se destaca na revista C&SC, periódico que expressa o vigor do campo da Saúde Coletiva na produção de conhecimento científico relevante para o SUS e para a saúde da população.

Access and effectiveness inpatient care indicators and economic crisis: analysis based on the Brazilian Unified Health System data, Brazil and Southern Brazil states, 2009-2018. / Indicadores hospitalares de acesso e efetividade e crise econômica: análise baseada nos dados do Sistema Único de Saúde, Brasil e estados da região Sudeste, 2009-2018.

In the context of crisis and resource constraints, it is reasonable to assume the deteriorated weaknesses of the Unified Health System (SUS), such as regional inequalities, underfinancing, and care quality issues. This study explored the application of easily comprehensible and calculated access and effectiveness indicators that could reflect the hospital network crisis. Five indicators extracted from the Hospital Information System, related to Brazil and states of the Southeastern region, were analyzed in the 2009-2018 period: hospitalizations resulting in death; surgical hospitalizations resulting in death; elective surgeries in the total of surgical hospitalizations; hip prostheses in the senior population; and angioplasties in the population aged 20 years and over. Statistical control charts were used to compare indicators between states, before and from 2014. In Brazil, overall hospital deaths had a slight increase while surgical deaths declined; elective surgeries and hipprosthesis also decreased. In Southeastern Brazil, Rio de Janeiro was the worst performer, especially the decrease of the elective surgeries. The results illustrate the potential of indicators to monitor crisis effects on hospital care.

No contexto de crise e restrições de recursos é razoável supor o agravamento de fragilidades do Sistema Único de Saúde (SUS), como desigualdades regionais, subfinanciamento e problemas na qualidade do cuidado. Este estudo explorou a aplicação de indicadores de acesso e efetividade, facilmente compreensíveis e calculados, passíveis de refletir a crise na rede hospitalar. Cinco indicadores extraídos do Sistema de Informações Hospitalares, relativos ao Brasil e a estados da Região Sudeste, foram analisados no período de 2009-2018: internações resultantes em morte; internações cirúrgicas resultantes em morte; cirurgias eletivas no total das internações cirúrgicas; próteses de quadril na população de idosos; e angioplastias na população de 20 anos ou mais. Utilizaram-se gráficos de controle estatístico para a comparação dos indicadores entre estados, antes e a partir de 2014. No Brasil, as mortes hospitalares tiveram um leve crescimento enquanto que as mortes cirúrgicas uma queda; as cirurgias eletivas e próteses de quadril também diminuíram. No Sudeste, o Rio de Janeiro apresentou os piores resultados, em especial a queda de cirurgias eletivas. Os resultados ilustram o potencial dos indicadores para monitorar efeitos da crise sobre o cuidado hospitalar.

[On the crisis: meanings and perspectives. Interview with Marco Américo Lucchesi]. / Sobre crise: significados e perspectivas. Entrevista com Marco Américo Lucchesi.

In this interview, Marco Américo Lucchesi, Tenured Professor of Comparative Literature at the Federal University of Rio de Janeiro (UFRJ), visiting professor of the Oswaldo Cruz Foundation (Fiocruz), and member and president of the Brazilian Academy of Letters, outlines his perception of the current crisis and the impact on the consolidation of Brazilian democracy. Based on his experiences as a critic and intellectual, he comments on the attacks on culture and the production of knowledge that we have witnessed in Brazil. He reminds us that no democracy is a fully-fledged ontological reality and highlights the role of schools and universities in mobilizing citizenship and spreading republican values. He highlights some achievements that are expressed by the presence of Indians and African Brazilians in universities. Acknowledging the call for help inherent in every crisis, he calls upon us to revive the dream and courage and advocates the suspension of distinctions in favor of forming a front of democracy and solidarity. These are analyses and convocations that are based, at all times, on a firm confidence in the power and capacity of resilience of culture.

Na entrevista, Marco Américo Lucchesi, professor Titular de Literatura Comparada da Universidade Federal do Rio de Janeiro (UFRJ), professor convidado da Fundação Oswaldo Cruz (Fiocruz), membro e presidente da Academia Brasileira de Letras, apresenta sua percepção da crise atual e do impacto sobre a consolidação da democracia brasileira. Com base em suas experiências como intelectual crítico e atuante, comenta os ataques que assistimos, no Brasil, à cultura e à produção de conhecimento. Ao mesmo tempo, lembra que nenhuma democracia se configura como uma realidade ontológica terminada e ressalta o papel das escolas e universidades na mobilização da cidadania e na difusão de valores republicanos. Frente à constatação de que vivemos uma profunda mudança de registro cultural, aponta algumas conquistas que se expressam, por exemplo, pela presença de índios e negros nas universidades. Reconhecendo o pedido de socorro imerso em todas as crises,convoca-nos a reavivar o sonho e a coragem, combustíveis da utopia, e defende a suspensão das distinções em favor da formação de uma frente democrática e solidária. São análises e convocações que se pautam, o tempo todo, numa firme confiança na potência e na capacidade de resistência da cultura.

[An analysis of managed care provided by charitable hospitals in Brazil]. / Uma análise das operadoras de planos próprios de saúde dos hospitais filantrópicos no Brasil.

This article describes charitable hospitals in Brazil that provide managed care and the health management organizations themselves, considering the level of autonomy by the latter in relation to the hospitals and their degree of management development, based on a nationwide study. A random sample of individual hospitals was drawn from the hospital groups. After refusals and replacements, the final sample consisted of 112 individual hospitals and 10 hospital groups. The charitable hospitals' managed care plans do no operate precisely according to the overall Brazilian health plan market, in which most of the managed care is situated in insurance companies, group medicine, and medical cooperatives. Rather than operating as typical plans, they function "inside the organization or hospital itself", almost always with a limited management infrastructure and with little autonomy in relation to the organizations harboring them. Individual plans were more common than collective products, unlike the rest of the market, which may also result from the limited management capacity of these arrangements.

[Clinical guidelines and other practices for improving quality of care by health plans from the perspective of their operators in Brazil]. / Diretrizes clínicas e outras práticas voltadas para a melhoria da qualidade assistencial em operadoras de planos de saúde sob a perspectiva dos seus dirigentes, no Brasil.

This study aimed to characterize the implementation of clinical guidelines and other instruments and practices for health care quality improvement among health plan operators in Brazil. It was a national cross-sectional descriptive study, initially considering 1,573 health plan operators registered in the National Agency for Supplementary Health Care. The sample design was complex, stratified by macro-region, market segment, and number of beneficiaries. Ninety health plan operators agreed to participate and were interviewed. To obtain estimates for the universe of health plan operators, a sample expansion factor attributed per stratum was considered. Only 32.3% of the health plan operators implemented clinical guidelines, with important variation across regions and market segments. Clinical governance practices are still in the very initial stages. Challenges are presented with regard to health care incorporation as a dimension of management within health care organizations, including health plan operators. Initiatives to improve quality of care need to be integrated and conducted at the organizational level.

[Utilization of clinical guidelines by health plan operators in the Brazilian health system]. / Utilização de diretrizes clínicas em cardiologia na saúde suplementar no Brasil.

BACKGROUND: The objective of this study is to present cardiovascular results of a national study about the implementation of clinical guidelines and other instruments and practices for clinical care management among health plan operators in Brasil. METHODS: This was a cross-sectional study based on a representative sample of the 1,573 Brazilian health plan operators, stratified by macro region and market segment. Each stratum was subdivided in take-all and take-some strata by Hedlin's method, with equiprobability selection in each take-some stratum. The resulting sample size was of 90 health plan operators who were interviewed using a structured questionnaire. The study had a descriptive nature and, to obtain estimates for percents and total number of health plan operators relative to a population size of N=1572., sample weights were taken into account. RESULTS: Of the health plan operators, 61.2% considered that the implementation of clinical guidelines should be conducted by administrative and regulatory government organizations, involving a partnership with health plan operators, health service providers and medical societies. It was shown that only 32.3% of the health plan operators in the country enforce clinical guidelines. With regard to cardiovascular disease, the reported utilization of guidelines was one of the highest among all diseases analyzed. The percentages for acute myocardial infarction (87%), congestive heart failure (85%) and the use of invasive procedures (81.1%) were higher than for arterial hypertension (74.1%) and cerebrovascular disease (72.2%). CONCLUSION: This study indicated the incipient utilization of clinical guidelines among health plan operators in the Brazilian health system. In general, the cardiovascular area showed one of the highest rates of utilization reported in the study.

[Philanthropic hospitals and the operation of provider-owned health plans in Brazil]. / Hospitais filantrópicos e a operação de planos de saúde próprios no Brasil.

OBJECTIVE: To describe the management performance of philanthropic hospitals that operate their own health plans, in comparison with philanthropic hospitals as a whole in Brazil. METHODS: The managerial structures of philanthropic hospitals that operated their own health plans were compared with those seen in a representative group from the philanthropic hospital sector, in six dimensions: management and planning, economics and finance, human resources, technical services, logistics services and information technology. Data from a random sample of 69 hospitals within the philanthropic hospital sector and 94 philanthropic hospitals that operate their own health plans were evaluated. In both cases, only the hospitals with less than 599 beds were included. RESULTS: The results identified for the hospitals that operate their own health plans were more positive in all the managerial dimensions compared. In particular, the economics and finance and information technology dimensions were highlighted, for which more than 50% of the hospitals that operated their own health plans presented almost all the conditions considered. CONCLUSIONS: The philanthropic hospital sector is important in providing services to the Brazilian Health System (SUS). The challenges in maintaining and developing these hospitals impose the need to find alternatives. Stimulation of a public-private partnership in this segment, by means of operating provider-owned health plans or providing services to other health plans that work together with SUS, is a field that deserves more in-depth analysis.

Improvement Science: conceptual and theoretical foundations for its application to healthcare quality improvement.

The development and study of healthcare quality improvement interventions have been reshaped, moving from more intuitive approaches, dominated by biomedical vision and premised on easy transferability, to gradually acknowledge the need for more planning and systematization, with greater incorporation of the social sciences and enhancement of the role of context. Improvement Science has been established, with a conceptual and methodological framework for such studies. Considering the incipient of the debate and scientific production on Improvement Science in Brazil, this article aims to expound its principal conceptual and theoretical fundamentals, focusing on three central themes: the linkage of different disciplines; recognition of the role of context; and the theoretical basis for the design, implementation, and evaluation of interventions. Resumo: O desenvolvimento e estudo de intervenções para a melhoria do cuidado de saúde tem ganhado novo contorno, movendo-se das abordagens mais intuitivas, com domínio da visão biomédica e assentadas no pressuposto de fácil transferibilidade, para gradativamente reconhecer a necessidade de mais planejamento e sistematização, com maior incorporação das ciências sociais e valorização do papel do contexto. A Ciência da Melhoria do Cuidado de Saúde vem se estabelecendo, propiciando referencial conceitual e metodológico para tais estudos. Considerando a incipiência do debate e produção sobre Ciência da Melhoria do Cuidado de Saúde no Brasil, este artigo objetiva discorrer sobre as principais bases conceituais e teóricas que a sustentam, com foco em três temas centrais: a articulação de diferentes disciplinas; o reconhecimento do papel do contexto; e o embasamento teórico para o desenho, implementação e avaliação das intervenções.

Expressões da precarização do trabalho nas regras do jogo: Organizações Sociais na Atenção Primária do município do Rio / Expressions of precarious working conditions in the rules of the game: Social Organizations in Primary Care in the municipality of Rio

RESUMO Objetivou-se analisar as relações de trabalho no âmbito da Atenção Primária (AP) operada pelas Organizações Sociais (OSs) no município do Rio de Janeiro no período de 2009 a 2019. Foram utilizadas contribuições do neoinstitucionalismo histórico para analisar as regras formais das relações de trabalho e sua relação com a precarização a partir dos documentos elaborados pelas instâncias legislativa, executiva e prestadora de serviços. Foram consideradas as modalidades de contratação; contribuições previdenciárias ou trabalhistas; modalidades de recrutamento e seleção; representação dos trabalhadores; plano de cargos, salários e benefícios; remuneração; escopo de práticas e composição das equipes. Destacaram-se como expressões da precarização as incertezas na garantia de direitos trabalhistas, a insegurança quanto ao futuro profissional, a sobrecarga de trabalho, entre outros. O estudo da trajetória da política de AP no período considerado permitiu reconstruir argumentos, dimensões legislativas e regulamentares, bem como as inflexões e a evolução da política. As regras do jogo contidas nas normativas expressam a flexibilização e a precarização do trabalho na AP do município, colocando em questão a sustentabilidade dos serviços baseados no modelo das OSs.

ABSTRACT The objective was to analyze the labor relations in the scope of Primary Care operated by Social Organizations in the city of Rio de Janeiro in the period from 2009 to 2019. The contributions of historical neoinstitutionalism were used to analyze the formal rules of labor relations and their relationship with precarious working conditions based on documents prepared by the legislative, executive and service providers. The following hiring modalities were considered: social security or labor contributions; recruitment and selection modalities; worker representation; job, salary and benefits plan; remuneration; scope of practices and team composition. The uncertainties in guaranteeing labor rights, insecurity about the professional future, work overload, among others, stood out as expressions of precarious working conditions. The study of the trajectory of Primary Care policy in the considered period reconstructs arguments, legislative and regulatory dimensions, as well as the inflections and evolution of the policy. The rules of the game contained in the regulations express the flexibility and precarious working conditions in Primary Care in the municipality, calling into question the sustainability of services based on the model of Social Organizations.

Contribuições do modelo Fatores Críticos de Sucesso para análise da gestão de Parcerias para o Desenvolvimento Produtivo de um laboratório oficial / Contributions from the Critical Success Factors model to analysis of the management of Product Development Partnerships in a government laboratory / Contribuciones del modelo de Factores Críticos de Éxito para el análisis de la gestión de Alianzas para el Desarrollo Productivo de un laboratorio oficial

Resumo: A Parceria para o Desenvolvimento Produtivo (PDP) é uma das medidas usada pelo Estado brasileiro para incentivar a política de inovação, ampliar o acesso da população a medicamentos estratégicos e reduzir a dependência tecnológica do país, por meio do fortalecimento da base produtiva nacional de medicamentos. O trabalho procurou identificar os Fatores Críticos de Sucesso (FCS) para a implantação dessas parcerias, tendo como referência as PDPs de um dos maiores laboratórios farmacêuticos oficiais do país. FCS são compreendidos como áreas-chave nas quais os resultados devem ser satisfatórios para assegurar um desempenho de sucesso para a organização ou projeto. Como estratégias metodológicas, além da revisão bibliográfica e análise de documentos internos, foram realizadas entrevistas semiestruturadas com atores-chave. Foram consideradas as parcerias aprovadas para o laboratório no período de 2009 a maio de 2018. O estudo permitiu uma visão crítica sobre as fases do processo de uma PDP e a identificação de fatores críticos específicos para esse tipo de projeto. Os resultados encontrados demonstram existir desafios organizacionais a serem superados para o aumento da executabilidade das parcerias, e podem servir de referência para outros laboratórios oficiais que tenham acordos de PDPs em andamento ou que pretendam apresentar propostas.

Abstract: Product Development Partnerships (PDP) are one of the measures used by the Brazilian government to incentivize innovation policy, to expand the population's access to strategic medicines, and to reduce the country's technological dependence by strengthening the national pharmaceutical manufacturing base. The study aimed to identify the Critical Success Factors (FCS in Portuguese) for the implementation of these partnerships, using as the reference one of the largest Brazilian government pharmaceutical laboratories. FCS are seen as key areas in which the results must be satisfactory in order to ensure successful performance in the organization or project. The methodological strategies included literature review, analysis of internal documents, and semi-structured interviews with key actors. We analyzed the partnerships approved for this public laboratory from 2009 to May 2018. The study enabled a critical view of the phases in a PDP and identification of specific critical factors for this type of project. The findings reveal persistent organizational challenges for increasing the executability of partnerships, which can serve as a reference for other government laboratories that have PDP agreements under way or that intend to submit proposals for them.

Resumen: Las Alianzas para el Desarrollo Productivo (PDP por sus siglas en portugués) es una de las medidas usadas por el estado brasileño para incentivar la política de innovación, ampliar el acceso de la población a medicamentos estratégicos y reducir la dependencia tecnológica del país, a través del fortalecimiento de la base productiva nacional de medicamentos. El trabajo buscó identificar los Factores Críticos de Éxito (FCS por sus siglas en portugués) para la implementación de esas colaboraciones, teniendo como referencia las PDPs de uno de los mayores laboratorios farmacéuticos oficiales del país. Los FCS se entienden como las áreas-clave en las que los resultados deben ser satisfactorios para asegurar un desempeño de éxito para la organización o proyecto. Como estrategias metodológicas, además de la revisión bibliográfica y análisis de documentos internos, se realizaron entrevistas semiestructuradas con actores-clave. Se consideraron las colaboraciones aprobadas para el laboratorio durante el período de 2009 a mayo de 2018. El estudio permitió una visión crítica sobre las fases del proceso de una PDP y la identificación de factores críticos específicos para ese tipo de proyecto. Los resultados encontrados demuestran que existen desafíos organizativos que deben superarse para que aumente la posibilidad de ejecución de colaboraciones y puedan servir de referencia para otros laboratorios oficiales que tengan acuerdos de PDPs en transcurso o que pretendan presentar propuestas.

[Evaluation of the Food and Nutrition Surveillance System (SISVAN) in food and nutritional management services in the State of Minas Gerais, Brazil]. / Avaliação do SISVAN na gestão de ações de alimentação e nutrição em Minas Gerais, Brasil.

The scope of this article is to evaluate the SISVAN as a tool for planning, management and evaluation of food and nutrition actions in primary healthcare in the Unified Health System (SUS). It involved a cross-sectional study composed of a stratified random sample of the municipalities in the State of Minas Gerais. The subjects of the research were municipal officials of SISVAN who filled out a structured questionnaire. Descriptive analysis of the data was performed with the construction of simple and bivariate tables. It was observed that those responsible for SISVAN, collect (50%) and input (55%) weight, height, and food consumption data; whereas 53%, 59% and 71% do not analyze and do not recommend or perform nutrition actions, respectively. This being the case, most of those responsible do not use the information for planning, management and evaluation of food and nutrition traits. The findings show that the SISVAN is not used to its full potential; the data generated have not been used for planning, management and evaluation of nutrition services in primary healthcare in the SUS.

Produção de conhecimento em política, planejamento e gestão na Revista Ciência & Saúde Coletiva / Production of knowledge on policy, planning, and management in Journal Ciência & Saúde Coletiva

Resumo A área de Políticas, Planejamento e Gestão em Saúde (PPG) é um dos pilares do campo da Saúde Coletiva, expressando a interseção entre pesquisa, intervenção e ação política. O artigo analisa a dinâmica da produção de conhecimento em PPG, na revista Ciência & Saúde Coletiva (C&SC), de 1996 a 2019, articulando abordagem bibliométrica e qualitativa para caracterizar três dimensões: temática, metodológica e autoria/parcerias institucionais. Identificaram-se 1.680 manuscritos, correspondendo a 28,3% do total de publicações da revista no período. A análise temática mostrou influência do contexto e da trajetória de implantação do Sistema Único de Saúde (SUS). Destacaram-se estudos empíricos qualitativos, seguidos dos quantitativos e dos com outros desenhos. A combinação de procedimentos metodológicos foi frequente, sendo mais citadas a revisão bibliográfica e entrevistas/questionários. A maioria dos artigos foi publicada em português e, apesar do aumento das publicações em inglês no final do período, parcerias com autores de outros países foram raras, persistindo o desafio da internacionalização. Conclui-se que a área de PPG se destaca na revista C&SC, periódico que expressa o vigor do campo da Saúde Coletiva na produção de conhecimento científico relevante para o SUS e para a saúde da população.

Abstract The area of Policy, Planning and Health Management (PPG) express the intersection between research, intervention and political action. The article analyzes the dynamics of knowledge production about PPG in the Journal Ciência & Saúde Coletiva (C&SC) from 1996 to 2019. The study articulates a bibliometric and qualitative approach to explore the profile of articles in three dimensions: thematic, methodological and authorship/institutional partnerships. 1680 PPG manuscripts were identified, corresponding to 28.3% of the total publications. Thematic analysis showed a strong influence of the context and the implementation of Unified Health System (SUS). Qualitative empirical studies predominated, followed by quantitative and quanti-qualitative studies. The combination of methodological procedures was frequent, with bibliographic review and interviews being the most cited. The average number of authors per article and national institutional partnerships increased. As most articles were published in Portuguese, the challenge of internationalization persists. The PPG area stands out in the Journal C&SC and in the production of scientific knowledge relevant to SUS.

[Management characteristics in charity hospitals in Brazil]. / Caracterização gerencial dos hospitais filantrópicos no Brasil.

This paper presents the management characteristics of charity hospitals in Brazil, based on data from a national survey developed in 2001. The sample accounted for the random inclusion of 66 Brazilian Unified Health System (SUS) inpatient care providers with less than 599 beds and all 26 hospitals with at least 599 beds. It also included 10 institutions assumed as non-providers of services to the SUS. The analyses are descriptive, focusing on the classification of the hospitals according to their managerial development level, as well as selected issues regarding the utilization of specific managerial technologies, human resources, technical services, and services contracting. Distinct managerial levels were identified, but it is important to note that 83% of the SUS providers with less than 599 beds were classified as having incipient management. The authors discuss implications of the findings for inpatient care policies, considering the importance of charity hospitals for the Brazilian Health System.

[Regulation of radiotherapy and chemotherapy services by health plan organizations in Brazil]. / Regulação dos serviços de radioterapia e quimioterapia pelas operadoras de planos de saúde no Brasil.

This paper characterizes regulatory procedures applied by private health plan operators on their outpatient radiotherapy and chemotherapy services, especially via contracts, and outlines the health care providers' perception on regulation. The study relied on primary data, taking into consideration 638 hospitals and outpatient health care units with the services in question. A stratified random sample was selected, resulting in the inclusion of 54 units that are representative of the population, excluding hospitals that only provide radiotherapy. Private chemotherapy services are largely funded by health insurance plans (75.0%), while radiotherapy services are predominantly covered by the public health system (49.0%). Contracts are not applied by third part payers, in their potential, as regulatory and health care coordination instruments. The mechanisms of regulation applied by third part payers are centered on services use control and administrative aspects. It is recognized the need of adjustments for a health care quality focus, and contracts may contribute in this sense.