Dissertations / Theses on the topic '200310 Primary care'

This study aims at analyzing Turkish health policy from a Primary Health Care perspective as pronounced in Alma-Ata, 1978. The Alma-Ata Declaration has long been regarded as a watershed in the health field and 134 countries, including Turkey, have endorsed the Declaration showing their support for the views expressed in the Document. However, although the international community gave its full support, in practice, different interpretations and implementation of the principles have emerged. Turkey, one of the countries where health has rarely occupied the agenda, has been undergoing radical reforms since the mid 1980s with the ultimate aim of achieving Health for all by the Year 2000 through Primary Health Care. There is full commitment at the national policy-making level to endorse policies coherent with the principles of Alma-Ata. However, not all policies adopted seem to be consonant with what was declared in Alma-Ata requiring a detailed analysis of the policies suggested and implemented. In the light of this, the aims of the study are: (1) to analyze Turkish health policy since the 1960s from a Primary Health Care perspective with the aim of exploring the Turkish response to Alma-Ata; (2) to explore the perceptions of Turkish health policy-makers about Primary Health Care and related issues; (3) to discuss the prospects for Primary Health Care in Turkey. Basic principles of the Primary Health Care approach as declared in Alma-Ata have been taken as a guideline in analyzing Turkish health policy and the perceptions of the Turkish health policy-makers. These principles and their implementation, or the way they are perceived, have guided the research in answering the question ''what are the prospects for Primary Health Care in Turkey?" The nature of the research, based on document analysis and semi-structured interviews, has necessitated a qualitative stance. It was concluded that the Turkish version of Primary Health Care differs from the Declaration in a number of ways. A number of possible reasons for this have been offered. The perceptions of the policy-makers on certain issues that are closely related with the Approach, inter alia, has been found as one of the most possible explanations behind the current situation and a need to alter the ascendant approach towards health issues in general has been emphasized.

Assignment (MPA)--University of Stellenbosch, 2002.
ENGLISH ABSTRACT: Primary Health Care (PHC) approach is currently receiving tremendous attention worldwide as a mechanism to ensure effective and efficient public health services. The concept has evolved from the Alma Ata conference (1978). Since then many countries began to reorient their health services to achieve the goals of availability, accessibility and affordability of health care for all citizens and a number of management issues came to the forefront. Therefore, the provision of comprehensive PHC services is the key aspect to improving health services. A district health system has been identified as an ideal model for comprehensive PHC services to all the citizens in South Africa. Public health services in the Cape Metropolitan Area are characterised by functional fragmentation. Two public authorities render Primary Health Care services, namely the: Provincial Administration of the Western Cape through CHSO, and the Municipal Health Department. The fragmented nature of the public health services, which result in poor coordination of service delivery between the two health authorities, compromises the quality of service delivery. Historically, PHC services in the Cape Metropolitan Area - and indeed in the whole South Africa - have developed in a skewed manner. This work is an attempt at conceptualising the implications and consequences of this skewed health development. South Africa is presently undergoing fundamental reform, which has brought the PHC into disarray of fundamental change. Since the South African health care system is a highly complex institution, attempts have been made to critically analyse those aspects and features of inequality, inaccessibility, and inequity. Among these is the historical and present development of Cape Metropolitan Area health care and the structural features it assumed with the passing of time, trends and characteristics. In order to examine the theory in practice, the evolvement of PHC in the Cape Metropolitan Area will be analysed. The analysis highlights how different political formations have affected the development of PHC services and points out obstacles and limitations throughout the process, which had to be dealt with. Transformation of the existing health services, based on the principles of PHC, requires the redressing the imbalances of the past. Therefore, the integration of the two health authorities into one entity would best achieve the principles of district health system and will ensure comprehensive PRe.
AFRIKAANSE OPSOMMING: Die Primêre Gesondheidsorg benadering geniet tans wereldwyd erkenning as 'n meganisme om doeltreffende openbare gesondheidsdienslewering te versker. Die konsep, wat ontwikkel en gegroei het uit die Alma Ata-konferensie van 1978, is reeds deur verskeie regerings ge-implementeer ten einde die doelwitte van beskikbaarheid, toeganklikheid en bekostigbaarheid van gesondheidsorg vir alle landsburgers te verseker. Die voorsiening van omvattende Primêre Gesondheidsorgdienste word erken as 'n noodsaaklike middelom gesondheidsorg te verbeter. Die Distrikgesondheid-stelsel is geidentifiseer as 'n ideale model vir die implementering van omvattende Primêre Gesondheidsorgdienste in Suid Afrika. Publieke Gesondheidsdienste in die Kaapse Metropolitaanse-gebied word gekenmerk deur die feit dat dit funksioneel gefragmenteer is. Twee publieke owerhede, te wete die Provinsiale Administrasie van die Wes Kaap en die Kaapse Stadsraad lewer Primêre Gesondheidsorgdienste, wat aanleiding gee tot swak koordinering met die gevolg dat dienslewering daaronder ly. Primêre Gesondheidsdienste in die Kaapse Metropolitaansegebied, soos in die res van Suid Afrika, het op 'n onlogiese, skewe manier ontwikkel Hierdie werk is 'n poging om die gevolge en implikasies van die onlogiese, skewe gesondheids-ontwikkeling te konseptualiseer. Daar is gepoog om die uiters gekompliseerde gesondheidsdiens-stelsel in Suid Afrika krities te analiseer met spesifieke verwysing na die kenmenrke van ongelykheid, ontoeganklikheid en onbillikheid. Dit sluit die historiese en huidige ontwikkeling van gesondheidsorg in die Kaapse Metropolitaanse gebied en die strukturele kenmerke in wat deur die loop van jare as gevolg van verskeie invloede en neigings sigbar geraak het. Die ontwikkeling van Primêre Gesondheidsorg in die Kaapse Metropolitaanse-gebied word ge-analiseer ten einde bogenoemde teorie in die praktyk te bevestig. Die analise beklemtoon die invloed van verskillende politieke rolspelers op ,die ontwikkeling van Primêre Gesondheidsorgdienste en bevestig die struikelblokke en beperkings wat deurentyd opgeduik het. Transformasie van gesondheidsdienste soos dit tans daaruit sien, gegrond op die beginsels van Primêre Gesondheidsorg, vereis dat die ongelykhede van die verlede aangespreek word. Die integrasie van die twee gesondheidsdiensowerhede sal die beginsels van die Gesondheidsdistrik-stelsel verwesenlik, wat daartoe sal aanleiding gee dat omvattende Primêre Gesondheidsorg 'n werklikheid word.

Background Opioids are the most potent analgesics available and their treatment is well established in cancer and acute pain. However, their long-term use in non-cancer pain is worrisome due to insufficient evidence on long-term effectiveness and safety. Population-based research examining the utilisation of opioids in non-cancer pain patients in UK primary care remains limited and little information exists on patients receiving long-term therapy. Aims This thesis aimed to examine the demographics, clinical traits, prescribing patterns and healthcare use of non-cancer pain patients prescribed strong opioids in primary care, with a focus on long-term strong opioid use. Methods The thesis was a retrospective observational study using the Clinical Practice Research Datalink. Prescription data of four strong opioids (morphine, buprenorphine, fentanyl and oxycodone) issued between 2000-2010 to adults (aged ≥18 years) without cancer diagnosis 12 months within the date of first prescription use were included. The annual prevalence and incidence of non-cancer pain patients prescribed strong opioids over the 11 years were initially assessed using joinpoint regression analysis, and the users' demographic and clinical characteristics were explored descriptively. The numbers of prescriptions per patients, total number of days of drug supply, and total oral morphine equivalent daily dose (OMED) were subsequently calculated annually and compared between long-term (>90 days/year) and short-term (≤90 days/year) users. Multivariate linear regression modelling with generalized estimating equations was consecutively used to identify baseline and time-varying covariates linked to long-term strong opioid use. Lastly, long-term strong opioid users' primary and secondary healthcare use was quantified using CPRDs' data link with Hospital Episode Statistics (HES), and the nature of hospital admissions and patient-level factors of influence were determined by multivariate regression data analysis. Results A total of 135,941 non-cancer pain patients (63.34% female, mean age 66.34±17.98 years) were prescribed strong opioids and were included in the analysis. The incidence of long-term prescribing (>90 days) continued to increase by 16.96% per year (95%CI: 13.70%, 20.30%, p < 0.001) from 3.60 (95%CI: 3.38, 3.82) per 10,000 person-years in 2001 to 12.75 (95%CI: 12.41, 13.10) per 10,000 person-years in 2010. The mean number of pain diagnoses amongst long-term users was 3.00±2.16, with back pain, abdominal pain and osteoarthritis presenting the most common diagnostic disorders, and the mean number of co-morbidities was 2.04±1.70. Depression and anxiety were prevalent in 50.02% and 22.13% of long-term users, respectively. The mean daily oral morphine equivalent dose (OMED) of long-term users (95.88±109.03 mg/day/year) was almost twice that of short-term users (54.80±54.55mg/day/year). Over a quarter (26.01%) of long-term users received high oral morphine equivalent daily dose and their mean annual OMED was 221.19±148.07mg/day and mean annual days' supply was 277.05±84.55 days. Forty-one percent of long-term users had one or more all cause in-patient admissions during the study period, and a rising trend of admission spells was noted annually by 28.16% (95% CI: 26.40, 29.90, p < 0.001). Musculoskeletal pain disorders were the main cause of hospital admissions and re-admissions. Factors associated with hospitalisation included; greater GP visits per year (>3 consultations/year), >120mg morphine equivalent daily dose (aRR: 1.37; 95%CI: 1.27, 1.49) and co-prescriptions of psychoactive medications, including antidepressants (aRR: 1.07; 95%CI: 1.00, 1.14), benzodiazepines (aRR: 1.17; 95%CI: 1.09, 1.26) and non-benzodiazepines (aRR: 1.15; 95%CI: 1.05, 1.27). Conclusions Prescribing of strong opioids over the 11 years was characterized by a shift towards long-term prescribing. Primary care non-cancer pain patients exposed to strong opioids long-term were typified by multiple pain and co-morbid illnesses that included common psychiatric disorders, which suggest complex, and vulnerable, high-risk patients that are susceptible to negative health consequences. The thesis has identified several covariates linked to strong opioid-utilisation and healthcare use, which exemplifies key findings that can be used to inform clinical decision-making, targeted management interventions and monitoring of non-cancer pain patients treated with strong opioids long-term.

This study was designed to explore organizational change in primary health care, specifically the introduction of Local Health Groups which were meant to create radical change at local level across Wales. The aim was to gain a better understanding of the factors that influence the formation and development of organizations receptive to change. The specific questions included: firstly, what structural and organizational changes were made for the promotion and development of Local Health Groups Secondly, what leadership behaviours did the selected health professionals apply to their roles as Chairmen, in terms of building organizations capable of change and development And thirdly, what lessons can be learned for leadership and organisational reform, and policy implementation at local level for the future The policy decision to devolve decision-making in health care to primary care professionals at local level provided the opportunity to conduct a prospective study. A case study approach was selected to explore the experiences of all 22 Local Health Groups, through the reported experiences of the Chairmen as the lead figures responsible for forming and developing the new organizations. Data were collected using three waves of face-to-face interviews, supplemented with Minutes of Board Meetings tracing the study period: April 1999 to October 2001. Some limited observation of key events was also carried out. The study was conducted at a time of considerable turbulence in the health system in Wales. Firstly, it appears from this study that the structural changes made to implement the new policy were inadequate to that task. But some Chairmen appeared to exercise specific skills that enabled them to manage the consequent uncertainty in the system more comfortably than others. In addition, key leadership behaviours appeared to influence the development of change promoting organizations. These included strategic vision: the ability of the lead figures to articulate an attractive vision of the future, and persuade others to pursue it. Secondly, the ability to forge constructive working relationships with a wide variety of stakeholder organizations proved to be pivotal. Thirdly, the ability to identify key features of the organization and build on them to create unique organizational identities and services emerged as a key leadership behaviour in this context.

Campos, S. S. L. HansenÃase no MunicÃpio de Sobral, CearÃ: AnÃlise EpidemiolÃgica e Operacional das AÃÃes de EliminaÃÃo no PerÃodo de 1997 a 2003. Fortaleza-Cearà 2005. DissertaÃÃo de Mestrado em SaÃde PÃblica [Epidemiologia] â Departamento de SaÃde ComunitÃria â Faculdade de Medicina â Universidade Federal do CearÃ. O cenÃrio polÃtico dos Ãltimos 20 anos vem permitindo grandes discussÃes e avanÃos no sentido da descentralizaÃÃo das aÃÃes na atenÃÃo bÃsica. A implementaÃÃo das aÃÃes de controle da hansenÃase no sistema pÃblico brasileiro mantÃm-se como um desafio constante, ainda presente no sÃculo XXI. Nesse contexto, o Programa de SaÃde da FamÃlia vem representando a estratÃgia para a reorientaÃÃo e reestruturaÃÃo do sistema Ãnico de saÃde. O presente estudo tem como objetivo principal descrever, do ponto de vista epidemiolÃgico, os fatores que influenciaram o processo de integraÃÃo das aÃÃes de controle da hansenÃase na atenÃÃo bÃsica no MunicÃpio de Sobral de 1997 a 2003. Tomou-se como base Sobral uma vez que representa um dos municÃpios cearenses considerados prioritÃrios, alÃm de ser um exemplo de sucesso do desenvolvimento da atenÃÃo bÃsica à saÃde. Foi reconstruÃdo o processo de eliminaÃÃo das aÃÃes de controle da hansenÃase na atenÃÃo bÃsica do MunicÃpio de Sobral a partir da descriÃÃo histÃrica no perÃodo de 1997 a 2003. A anÃlise dos indicadores epidemiolÃgicos e operacionais essenciais preconizados pelo Programa Nacional de EliminaÃÃo da HansenÃase no perÃodo de estudo permitiu o reconhecimento de altos coeficientes de detecÃÃo, principalmente em 2003. AlÃm disso, importantes inconsistÃncias relativas à anÃlise mais detalhada de variÃveis como idade, formas clÃnicas e classificaÃÃo operacional em 2003 sinalizam para a possibilidade de inadequaÃÃo diagnÃstica. Por fim, procedeu-se à contextualizaÃÃo do processo de descentralizaÃÃo das aÃÃes de controle da hansenÃase no MunicÃpio de Sobral relacionando-o aos indicadores epidemiolÃgicos no perÃodo. Ressalta-se nesse estudo a potencialidade do desenvolvimento da atenÃÃo integral aos pacientes com hansenÃase na atenÃÃo bÃsica, com efetivo envolvimento e controle dos movimentos sociais. Inclui-se nessa anÃlise a necessidade de se avaliar e monitorar o cenÃrio epidemiolÃgico mesmo em situaÃÃes em que se pressupostamente observa sucesso das aÃÃes de controle, como foi o caso do MunicÃpio de Sobral.
Campos, S. S. L. Leprosy in the Municipality of Sobral, State of CearÃ: Epidemiological and Operational Analysis of Elimination Measures from 1997 to 2003. Fortaleza-Cearà 2005. Dissertation of Master Degree in Public Health [Epidemiology] - Department of Community Health - School of Medicine - Federal University of CearÃ. In the last 20 years, Brazilian health policy has been provoking fruitful discussions on the decentralization of the primary health care system. Even in the 21st century, the implementation of leprosy control measures on the public health level has been an ongoing challenge. In this context, the Family Health Program is a strategy for the reorientation and restructuring of the unified health system. This study has the objective to describe the epidemiologic factors that influenced the process of integration of leprosy control measures in the primary health care system in the Municipality of Sobral from 1997 to 2003. Sobral has been selected, as it represents one of the prioritized Municipalities for leprosy control in Cearà and as it is an example of successful implementation of an effective primary health care system. The process of leprosy elimination in the primary health care of Sobral was analyzed based on a retrospective description in the period from 1997 to 2003. The analysis of the epidemiological and operational indicators favored by the National Program of Leprosy Elimination, revealed high detection rates, mainly in 2003. Besides, considerable inconsistencies in age, clinical forms and operational classification indicate the possibility of diagnostic errors. Finally, in this study the process of integration of leprosy control measures in the Municipality of Sobral has been related to the epidemiological indicators. The possibility to develop integrated health care for leprosy patients in the primary health care system with effective involvement and control of community associations and other nongovernmental organizations is emphasized. The need to evaluate and monitor the epidemiology of leprosy, even in situations in which control measures seem to be successful, as it is the case with Sobral, is also discussed.

ZIEL: Ermittlung der Stichtagsprävalenz von Insomnie und anderen Schlafstörungen in deutschen Allgemeinarztpraxen sowie Bestimmung hausärztlicher Erkennensraten. METHODIK: Bundesweite Zufallsauswahl von 539 Arztpraxen. Charakterisierung der Arzt- und Praxismerkmale mittels initialer Vorstudie. Darauf folgend eine Stichtagsbefragung aller Hausarzt-Patienten mittels Schlaffragebogen (PSQI) und klinischen Fragen (N = 19155 Fälle) sowie klinisch-ärztliche Beurteilung durch den behandelnden Artz mittels CGI und Fragebogen. ERGEBNISSE: 1. Trotz nur moderater Kompetenzeinschätzungen hinsichtlich Diagnose und Therapie behandeln Hausärzte Insomnien und andere Schlafstörungen vorwiegend selbst, auch wenn diese einen hohen Behandlungsaufwand erfordern. 2. Die Stichprobe kann als typisch für die Hausarzt-Klientel angesehen werden. 3. Schlafstörungen sind der dritthäufigste Konsultationsanlass. Nahezu jeder zweite Patient berichtete, in den vergangenen 2 Wochen unter Schlafbeschwerden gelitten zu haben, 26,5% erfüllten aufgrund der subjektiven Angaben die Studienkriterien (DSM-IV) für Insomnie. 4. Auch die Ärzte beurteilten 46,4% aller ihrer Patienten mittels CGI zumindest als Grenzfälle einer Schlafstörung, 85,6% wurden als chronisch eingeordnet. Die ärtzlich beurteilte Insomnieprävalenz betrug 25,9%, die anderer Schlafstörungen 13,7%. 5. Nur 54,3% aller Insomniepatienten wurden auch als solche vom Hausarzt diagnostiziert. DISKUSSION: Die Studie liefert erstmals bundesrepräsentative, differenzierte epidemiologische Daten zu der Prävalenz, dem Schweregrad, den Einschränkungen und den Verlaufsmustern von Insomnien und Schlafstörungen. Die außerordentlich große Häufigkeit und die zum Teil markanten Defizite hinsichtlich Erkennen und Diagnostik in der primärärztlichen Versorgungen werden diskutiert
AIM: To estimate the point prevalence of insomnia, recognition and prescription behavior in primary care. METHODS: Nationwide sample of 539 primary care settings along with their characterization (stage 1). Standardized assessment of all attenders (N = 19.155 patients) on the NISAS target day using a sleep questionnaire (PSQI) and additional questions to cover psychosocial and additional clinical variables. All patients were evaluated by the primary care doctors using a standardized clinical appraisal questionnaire, including a CGI-rating. RESULTS: Prevalence insomnia according to DSM-IV was 26.5%. Recognition of presence of any clinically significant sleep disorder was 72%, recognition of insomnia was poor 54.3%. 85.6% of insomnia patients were rated as chronic. Close to 50% of all insomnia cases did not receive a specific insomnia therapy. Herbals, followed by hypnotics and sedatives and antidepressants were the three most frequent treatments applied, psychotherapy was only seldomly indicated. DISCUSSION: NISAS provides for the first time nationally representative estimates of interventions for insomnia in primary care. The relatively low treatment rates and the high proportion of chronic patients receiving longterm prescription of benzodiazepines seem to be critical. Priorities for future agenda to improve this situation are discussed

Trata-se de estudo qualitativo desenvolvido por meio de análise de discurso cujo objetivo foi analisar a discursividade dos gestores em diferentes níveis de gestão sobre transferência da política do tratamento diretamente observado (TDO) no controle da tuberculose. Para isto, esta análise parte do contexto de decisão macropolítico para o contexto micropolítico tendo como cenário local o município de Ribeirão Preto-SP, considerado prioritário para o controle da doença. Foram entrevistados quatro sujeitos-gestores envolvidos com a política do TDO nas instâncias estadual, regional, municipal e no nível intermediário entre a regional e o município, mediante aceite de termo de compromisso. Os dados foram coletados no período de agosto a dezembro de 2013, as entrevistas foram audiogravadas, transcritas, respeitando-a na sua íntegra. O corpus da pesquisa foi composto por recortes, formação discursiva e marcas linguísticas, quais foram selecionados dos discursos dos sujeitos. A análise ocorreu mediante a fundamentação teórico-metodológica da Análise de Discurso (AD) de matriz francesa, que se sustenta sobre três vertentes teóricas: o Materialismo Histórico, a Linguística e a Psicanálise. Este tipo de análise não visa uma análise exaustiva horizontal ou de toda extensão do objeto de pesquisa, por entender que este não se esgota e que um discurso institui-se sempre em relação aos outros. Busca-se apoiar na exaustividade vertical com o intuito de contemplar o objetivo do trabalho e da temática abordada. Os dados foram organizados sob o eixo da temática da transferência de políticas e da temática da TB os quais apontaram para diferentes efeitos de sentido durante a transferência da política do TDO como o silenciamento, apagamento, polifonia, polissemia e contradição durante o processo de transferência desta política nos diferentes níveis de gestão, que passou gradativamente pelo processo de transferência autoritária para a transferência voluntária da maior instancia política para a menor. Destaca-se que no município este processo ocorreu de forma incompleta visto que não houve a superação do paradigma da desconcentração das ações de TB para a Atenção Primária em Saúde (APS)
This qualitative study was conducted using discourse analysis, the objective of which was analyzed the reports of different level managers regarding policy transfer of Directly Observed Treatment (DOT) in the control of tuberculosis. This analysis starts with the context of macro-political decisions in the micro-political context and the local setting was the city of Ribeirão Preto, SP, Brazil, considered a priority in the control of the disease. Four managers involved with the DOT policy at the state, regional, and city levels and another manager in the intermediate level between region and city were interviewed after signing consent forms. Data were collected from August to December 2013. The interviews were recorded, transcribed, respecting it in its entirety. The study\'s corpus was composed of excerpts, discursive formations and linguistics marks, which were selected from the participants\' reports according to the guiding question. Analysis was based on the French theoretical-methodological framework of Discourse Analysis, which in turn is grounded on three theoretical aspects: the Historical Materialism, Linguistics and Psychoanalysis. An exhaustive horizontal analysis, or an analysis that encompasses the entire extent of the research\'s object, is not intended in this type of analysis because the topic is not exhausted and discourses are always instituted in relation to others. The objective is to be supported in vertical exhaustiveness to contemplate the objective of the study and the topic under study. Data were organized under policy transfer\' and tuberculosis\' thematic axis, which indicate different effects of meanings during DOT policy transfer, such as muting, blanking, polyphony, polysemy, and contradictions during this policy transfer process at the different levels of management, which gradually moved from an authoritative transfer to a voluntary transfer, from a higher political instance to a lower one. Nonetheless, this process was not completed in the city because the paradigm decentralizing TB actions from Primary Health Care (PHC) was not overcome

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FAPEMIG - Fundação de Amparo à Pesquisa do Estado de Minas Gerais
A necessidade de se avaliar as políticas de saúde implementadas para a estruturação da atenção primária em todo o território nacional levou o Ministério da Saúde a institucionalizar indicadores de avaliação já utilizados em diversos países, entre eles, as Internações por Condições Sensíveis à Atenção Primária (ICSAP). Objetivo: Avaliar a atenção primária no Estado de Minas Gerais entre 2000 e 2011, com o uso do indicador ICSAP. Métodos: Trata-se de um estudo ecológico dos municípios mineiros, utilizando dados do Sistema de Informação Hospitalar, Sistema de Informação Ambulatorial, Departamento de Informática do Sistema Único Brasileiro, Censos 2000-2010 e dados do Instituto Brasileiro de Geografia e Estatística. A dimensão espacial correspondeu ao estado de Minas Gerais e a dimensão temporal teve como limites os anos de 2000 e 2011. Ambas foram submetidas a três recortes, para que a análise das ICSAP fossem realizadas sob diferentes perspectivas. Utilizou-se os municípios mineiros como unidades de análise, agregando-os por Regionais de Saúde (RS). Analisou-se as taxas de ICSAP quanto à permanência hospitalar, proporção de óbitos e relação com a cobertura pela Saúde da Família. Foram comparados os anos de 2000 e 2010. Posteriormente os municípios foram analisados no triênio 2009-2011, utilizando-se a análise das internações por infecções de rins e trato urinário sensíveis à atenção primária (IRTU-CSAP) em indivíduos enrte 40 e 59 anos, agregando-os por RS, porte populacional e cobertura pela saúde da família. As IRTU-CSAP foram analisadas, por sexo, quanto à permanência hospitalar, proporção de óbitos e os gastos com as internações. Por fim, analisou-se as causas mais freqüentes de ICSAP por sexo e faixa etária no município de Juiz de Fora, comparando-se os quadriênios 2002-2005 e 2006-2009. Para as análises estatísticas foram utilizados o Teste t para dados pareados, Anova seguida do teste post hoc de Scheffe e Dunnett T3 e correlação de pearson. Resultados: As taxas gerais de ICSAP no estado diminuíram entre 2000 e 2010, mas não foram observadas correlação com a expansão da Estratégia de Saúde da Família. As RS que apresentaram maiores taxas foram as de Ubá e Leopoldina. As causas mais freqüentes das hospitalizações foram a Insuficiência Cardíaca e as Gastroenterites. Algumas causas apresentaram aumento das taxas, a exemplo das Infecções de Rim e Trato Urinário, tornando-se a terceira causa mais freqüente no estado, em 2010. A permanência hospitalar e a proporção de óbitos por ICSAP aumentaram no estado. Juiz de Fora se destacou por ser sede de uma das 7 duas únicas RS que apresentaram elevação das taxas de ICSAP no estado. Conclusão: As iniciativas governamentais, como a expansão da Estratégia de Saúde da Família e a Regionalização da Saúde, não foram efetivas para a diminuição das internações por condições sensíveis à atenção primária em Minas Gerais. As características dos municípios influenciaram de formas distintas no comportamento das taxas, permanência hospitalar e proporção de óbitos por ICSAP. Evidencia-se aumento das desigualdades entre algumas Regionais de Saúde, o que alerta para a necessidade de se priorizar a estruturação da atenção primária em regiões do estado onde as internações potencialmente evitáveis permanecem mais elevadas.
The need to evaluate the health policies implemented for the structuring of primary care nationwide prompted the Ministry of Health to institutionalize assessment indicators already in use in several countries, including the indicator Hospitalizations for Primary Health Care Sensitive Conditions (HPHSC). Objective: To evaluate the primary care in the State of Minas Gerais, between 2000 and 2011, using the indicator HSPHC. Methods: This is an ecological study of Minas Gerais municipalities, using data from the Hospital Informations System, Ambulatory Information System, Computing Department of System Unique of Healph, and 2000- 2010 Census data from the Brazilian Institute of Geography and Statistics. The spatial dimension corresponded to the state of Minas Gerais and the temporal dimension was limited to the years between 2000 and 2011. Both were subjected to three selections, so that an analysis of HPHSC were performed under different views. Used the Minas Gerais municipalities as units of analysis, aggregating them by Regionals Health (RH). HPHSC rates were analyzed regarding to hospital stay, proportion of deaths and the relation with coverage by Family Health. The years between 2000 and 2010 were compared. Subsequently, the cities were analyzed in the three-years period 2009-2011, using the analysis of hospitalizations for infections of the kidneys and urinary tract sensitive to primary health (IKUT-PH) in individuals from 40 to 59 years, aggregated by RH, population size and coverage by family health. The IKUT-PH were analyzed by sex, regarding to hospital stay, number of deaths and costs of hospitalizations. Finally, were analyzed the most frequent causes of HPHSC by sex and age in the city of Juiz de Fora, comparing the four-years periods 2002-2005 and 2006-2009. For statistical analyzes we used the t test for paired data, ANOVA followed by post hoc Dunnett T3 and Scheffe test and correlation of Pearson. Results: Overall rates of HPHSC in the state declined between 2000 and 2010, but were not verified any correlations with the expansion on the Family Health Strategy. The RH showed that the highest rates were in Ubá and Leopoldina. The most frequent causes of hospitalization were heart failure and gastroenteritis. Some causes had higher rates, such as infections of the Kidney and Urinary Tract, making it the third most frequent cause in the state in 2010. The hospital stay and the proportion of deaths for HPHSC increased in the state. Juiz de Fora is highlighted as home to one of only two RH in which the HPHSC rate increased in the State. Conclusion: The governmental actions, such as the expansion of the Family Health Strategy and the Health Regionalization, were not efective on decreasing the HPHSC in Minas Gerais. The characteristics of the municipalities affected in different ways in the behavior of rates, hospital stay and proportion of deaths by HPHSC. It is evidenced an increase in inequalities among the Regionals Health, what warns to the need of structuring the primary care in some regions of the State where the hospitalization due to potentially avoidable causes remains high.

ZIEL: Ermittlung der Stichtagsprävalenz von Insomnie und anderen Schlafstörungen in deutschen Allgemeinarztpraxen sowie Bestimmung hausärztlicher Erkennensraten. METHODIK: Bundesweite Zufallsauswahl von 539 Arztpraxen. Charakterisierung der Arzt- und Praxismerkmale mittels initialer Vorstudie. Darauf folgend eine Stichtagsbefragung aller Hausarzt-Patienten mittels Schlaffragebogen (PSQI) und klinischen Fragen (N = 19155 Fälle) sowie klinisch-ärztliche Beurteilung durch den behandelnden Artz mittels CGI und Fragebogen. ERGEBNISSE: 1. Trotz nur moderater Kompetenzeinschätzungen hinsichtlich Diagnose und Therapie behandeln Hausärzte Insomnien und andere Schlafstörungen vorwiegend selbst, auch wenn diese einen hohen Behandlungsaufwand erfordern. 2. Die Stichprobe kann als typisch für die Hausarzt-Klientel angesehen werden. 3. Schlafstörungen sind der dritthäufigste Konsultationsanlass. Nahezu jeder zweite Patient berichtete, in den vergangenen 2 Wochen unter Schlafbeschwerden gelitten zu haben, 26,5% erfüllten aufgrund der subjektiven Angaben die Studienkriterien (DSM-IV) für Insomnie. 4. Auch die Ärzte beurteilten 46,4% aller ihrer Patienten mittels CGI zumindest als Grenzfälle einer Schlafstörung, 85,6% wurden als chronisch eingeordnet. Die ärtzlich beurteilte Insomnieprävalenz betrug 25,9%, die anderer Schlafstörungen 13,7%. 5. Nur 54,3% aller Insomniepatienten wurden auch als solche vom Hausarzt diagnostiziert. DISKUSSION: Die Studie liefert erstmals bundesrepräsentative, differenzierte epidemiologische Daten zu der Prävalenz, dem Schweregrad, den Einschränkungen und den Verlaufsmustern von Insomnien und Schlafstörungen. Die außerordentlich große Häufigkeit und die zum Teil markanten Defizite hinsichtlich Erkennen und Diagnostik in der primärärztlichen Versorgungen werden diskutiert.
AIM: To estimate the point prevalence of insomnia, recognition and prescription behavior in primary care. METHODS: Nationwide sample of 539 primary care settings along with their characterization (stage 1). Standardized assessment of all attenders (N = 19.155 patients) on the NISAS target day using a sleep questionnaire (PSQI) and additional questions to cover psychosocial and additional clinical variables. All patients were evaluated by the primary care doctors using a standardized clinical appraisal questionnaire, including a CGI-rating. RESULTS: Prevalence insomnia according to DSM-IV was 26.5%. Recognition of presence of any clinically significant sleep disorder was 72%, recognition of insomnia was poor 54.3%. 85.6% of insomnia patients were rated as chronic. Close to 50% of all insomnia cases did not receive a specific insomnia therapy. Herbals, followed by hypnotics and sedatives and antidepressants were the three most frequent treatments applied, psychotherapy was only seldomly indicated. DISCUSSION: NISAS provides for the first time nationally representative estimates of interventions for insomnia in primary care. The relatively low treatment rates and the high proportion of chronic patients receiving longterm prescription of benzodiazepines seem to be critical. Priorities for future agenda to improve this situation are discussed.

O Estado de São Paulo concentra grande número de cirurgiões-dentistas, mas a desigualdade social e de renda presentes e as diferenças na distribuição dos profissionais pelas suas regiões não colabora para a equidade na oferta e no acesso aos serviços odontológicos da Atenção Básica. Este estudo ecológico teve como objetivo descrever a relação entre indicadores de experiência da cárie dentária, desenvolvimento social, oferta e acesso aos serviços odontológicos, no período de 2000 a 2006, analisados segundo a área de abrangência dos Departamentos Regionais de Saúde do Estado de São Paulo (DRS). Foram utilizados indicadores obtidos a partir da revisão de documentos e consultas aos bancos de dados da Fundação Sistema Estadual de Análise de Dados (SEADE), do Departamento de Informática do SUS (DATASUS), do Instituto de Pesquisa Econômica Aplicada (IPEA), Instituto Brasileiro de Geografia e Estatística (IBGE) e da Secretaria de Estado da Saúde de São Paulo (SES-SP). As informações reunidas foram o indicador CPO-D (12 anos), Índice Desenvolvimento Humano dos municípios paulistas (IDHM), o número de cirurgiões-dentistas (CD) registrados no CRO-SP, o número de CD atuantes na área de saúde municipal e os Indicadores do Pacto da Atenção Básica 2006 para a saúde bucal. Os dados foram organizados em mapas, utilizando-se análise de distribuição espacial, o que permitiu a observação visual de suas relações. Os menores valores do CPO-D foram encontrados em DRS (DRS I, DRS IV) que possuem maiores indicadores de desenvolvimento humano. Na região de baixo IDHM (DRS XII) foi observada menor relação de CD registrados no CRO-SP, no serviço público e menor oferta e acesso aos serviços básicos de saúde bucal. DRS localizados em regiões de melhor IDH-M e mais populosos (DRS I, DRS IV, DRS VII) também demonstram certa dificuldade na oferta e acesso a esses serviços. A oferta foi maior nos DRS localizados ao norte do Estado e de menor tamanho populacional. Tanto em DRS de baixo como alto IDH-M a ação escovação dental supervisionada foi ofertada, mas com baixa cobertura. O percentual de procedimentos odontológicos especializados em relação às ações odontológicas individuais foi maior nos DRS localizados em regiões de alto IDH e naqueles que possuem Centro de Especialidades Odontológicas (CEO) instalados. A experiência de cárie dentária no Estado de São Paulo, no período de 2000 a 2006, mostrou correlação significativa com o indicador de desenvolvimento humano. A melhoria dos indicadores da saúde bucal depende de políticas abrangentes, direcionadas para o desenvolvimento humano e, também, de ações estratégicas voltadas para as populações de regiões que apresentam baixos indicadores socioeconômicos.
The State of Sao Paulo has a high concentration of dental surgeons, but the social and financial inequality presented there and the difference in the distribution of professionals throughout the region do not collaborate for equity in the offering and access to the odontological services in Primary Health Care. The aim of this ecological study was to describe the relationship between the indicators of dental caries experience, social development and offer and access to odontological services, during the period of 2000 to 2006, analyzed according to the areas covered by the Regional Health Departments of the State of Sao Paulo (DRS). Indicators were used from a review of documents and from consultation of the data base of the Foundation of the State System of Data Analysis (SEADE), of the Informatics Department of SUS (DATASUS), of the Institute of Economic and Applied Research (IPEA), of the Brazilian Institute of Geography and Statistics (IBGE) and of the State Health Secretary of Sao Paulo (SES-SP). The information gathered was, the Indicator CPOD (12 years), Human Development Index of the municipalities of Sao Paulo (IDHM), the number of dental surgeons (CD) registered at the Regional Council of Odontology of the State of Sao Paulo (CRO-SP), the number of CD in the area of health in the municipality and the Basic Care Indicators Pact 2006 for oral health. The data were organized in maps, using the analysis of spatial distribution, which allowed visual observation of its relationships. The lowest values of CPO-D were found in DRS (DRS I, DRS IV) that had higher indicators of human development. In the region of low IDH-M (DRS XII), lower numbers of CDs registered at the CROSP, within the public service and less offers and access to the basic services of oral health were observed. DRS located in the regions with better IDH-M and with higher populations (DRS I, DRS IV, DRS VII) also showed some difficulties in the offering of and access to these services. The offer was greater at DRS located in the north of the State and with smaller population sizes. Even at the DRS with low IDHM, as with higher, the supervised action of tooth brushing was offered, but with low cover. The percentage of specialized odontological procedures in relation to individual odontological actions was greater at the DRS located in the regions of high IDH and at the ones that have a Center of Odontological Specialties (CEO). The experience of dental caries in the State of Sao Paulo, during the period of 2000 to 2006, showed significant correlation to the indicator of human development. The improvement on oral healths indicators depends on comprehensive policies, having as target the human development and also strategic actions to the populations from regions that present low socioeconomic indicators.

O câncer colorretal (CCR) é o quarto tipo mais incidente mundialmente e a taxa de mortalidade ocupa a terceira posição. Apresenta desenvolvimento lento e bom prognóstico quando diagnosticado em estadio inicial. Apesar de ser um câncer que pode ter rastreamento populacional, as políticas públicas não têm conseguido estabelecer estratégicas efetivas de prevenção e diagnóstico precoce. Este estudo teve como objetivo geral caracterizar o perfil epidemiológico da coorte dos pacientes diagnosticados com CCR, atendidos no Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP), no período de janeiro de 2000 a dezembro de 2010. Estudo de coorte retrospectivo, longitudinal, baseado em dados secundários do Registro Hospitalar de Câncer (RHC) do HCFMRP-USP. As análises foram realizadas com o auxílio do Programa Excel 2010 da Microsoft e o Software R 3.0.1. Para análise da sobrevida, foi utilizado o método não paramétrico de Kaplan-Meier e para as associações foi aplicado o teste de Fisher e Qui-quadrado. Estudo aprovado pelo Comitê de Ética da Escola de Enfermagem de Ribeirão Preto- USP, nº 224.448/2012, Resolução CNS 466/2012. A população foi composta por 926 pacientes e os resultados evidenciaram prevalência do sexo masculino, com idade de 70 anos ou mais, 38,9% analfabetos/baixa escolaridade, 54,2% foram diagnosticados com o estadio III e IV e a localização predominante do tumor foi cólon e reto. O tempo médio entre a primeira consulta e o diagnóstico foi de 19,8 dias e entre o diagnóstico e o tratamento, foi de 27,8 dias. Observou-se igual sobrevida para homens e mulheres, sendo que o tempo médio entre o início do tratamento e a ocorrência do óbito foi de 626,3 dias. Conclui-se que há necessidade de investir na prevenção primária do CCR, com ações que minimizem os fatores de riscos conhecidos e na prevenção secundária com testes efetivos, como a pesquisa de sangue oculto nas fezes. Destaca-se ainda a urgente necessidade de políticas públicas mais direcionadas e investimento na educação permanente dos profissionais de saúde, principalmente o enfermeiro, que tem papel primordial na geração de conhecimento para esta população
Colorectal cancer (CCR) is the fourth most incident cancer worldwide and is the third leading cause of cancer-related deaths. It develops slowly and has a good prognosis when identified in early stages. Even though it can be screened in the population, public policies have not established effective preventive measures or early diagnosis strategies. This study\'s general objective was to characterize the epidemiological profile of a cohort of patients diagnosed with CCR cared for by the Hospital das Clinicas at University of São Paulo at Ribeirão Preto, Medical School (HCFMRP-USP) from January 2000 to December 2010. This longitudinal, retrospective cohort was based on secondary data from the Cancer Hospital Record from HCFMRP-USP. Analyses were performed using Excel 2010, Microsoft and R software 3.0.1. For the analysis of survival, Kaplan-Meier non-parametric method was used and the Fisher\'s test and Chi-square were used for associations. The study was approved by the Institutional Review Board at the College of Nursing at Ribeirão Preto, USP according to CNS Resolution 466/2012 (No. 224,448/2012). The population was composed of 926 patients and the results show a prevalence of 70 years old or older males, 38.9% were illiterate or had low level of education, 54.2% were diagnosed at stages III and IV, while the predominant sites were colon and rectum. The average time between the first consultation and diagnosis was 19.8 days and 27.8 days between diagnosis and treatment. Equal survival rates were observed for both men and women while the average time between the beginning of treatment and death was 626.3 days. There is a need to invest in CCR primary prevention with actions that minimize known risks and secondary prevention with effective tests such as fecal occult blood test. We also highlight the urgent need of public policies focused on this condition and investment on the permanent education of healthcare professionals, especially nurses who play an essential role in transmitting knowledge to this population

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The aim of this study is to identify changing tendencies in health systems in Argentina, Paraguay and Uruguay, especially related to basic care organization. Such changes arise from the hypothesis that these ones are related to the altering in the situational policy occurred in each one of these countries since 2000. This topic comes from the understanding that, in these countries, after elections during this period were victorious the parties with social and democratic tendencies, which would likely provoke changes in their ideological models of ruling. Such ones are possibly reflected in the national guidelines of health policies, inverting the former situation, in other words, the implementation of health systems of more focalized origin with the reduction of universal health right. It is reflected upon this that it has been happening alterations in the foundations of the health system, through incremental reformulations, derived from the process of reformulation occurred in the 1990‟s. The aim of this study is to produce knowledge which can contribute to the analysis about alterations in the access to actions and health services and the formulations of programs and specific universal integrated and regionalized public policies in favor of articulation and harmonization of health policies in the MERCOSUR. The studies, which have as an object health policies in the mentioned countries, derived, mainly, from the interest in strengthening regional policies due to the MERCOSUR institution and the social aspects contained in the deal of its initial formulation. Thus, it is intended to contribute in the current debate about the ethic foundations of public policies for strengthening regional policies. For data collecting it has been used several resources: governmental programs, official memos since 1990, governmental guidelines in search of dealing with the problematic in studies and scientific papers about this topic, published in the indexed journals. The documents which gave subsidies to the analysis were only those of public domain since the elements favor and express the constructions of consensus related to national health policies. The systematized data were analyzed from the content analysis technique, allowing to uncover the changes occurred in health policies after national elections of different party ideas from those former presidents. It has been removed from the collected material, the party ideals about health system, pointing out as it would happen before and how it is being carried out at the moment. Historical processes of each country have been taken into account, because these were molded and influenced by their history. It is observed that this study object is a snip of the Project The implementation of the SIS Program FRONTIERS and Health Pact - perspectives for implementing the health right to foreigner users in the southern border sponsored by CNPq Conselho Nacional de Desenvolvimento Tecnológico and supported by CONASEMS Conselho Nacional de Secretários Municipais de Saúde and coordinated by Professor Vera Maria Ribeiro Nogueira and initiated in 2009
Este estudo tem como objetivo identificar as mudanças nos sistemas de saúde, na Argentina, Paraguai e Uruguai, especialmente no que se refere à organização da atenção básica. Parte da hipótese que as mudanças referidas estão relacionadas às alterações no quadro político ocorrido em cada um destes, a partir dos anos 2000. Esta abordagem decorre do entendimento que, nestes países, após as eleições deste período, foram vitoriosos os partidos de tendência social-democrata, o que possivelmente levaria a alterações em seus modelos ideológicos de governar. Tal, possivelmente, se refletiria nas diretrizes nacionais de políticas de saúde, revertendo a situação anterior, ou seja, a implantação de sistemas de saúde de cunho mais focalista com a redução do direito universal à saúde. Resgata-se assim que vêm ocorrendo alterações nos fundamentos do sistema de saúde, através de reformas incrementais, derivadas do processo de reformas ocorridas na década de 1990. Com este estudo pretende-se produzir conhecimentos que favoreçam a análise sobre alterações no acesso às ações e aos serviços de saúde e a formulação de programas e políticas públicas específicas, universais, integrais e regionalizadas, favorecendo a articulação e harmonização das políticas de saúde no nos países vizinhos. Os estudos que tem como objeto as políticas de saúde nos países citados decorrem, em grande parte, do interesse em fortalecer as políticas regionais devido a instituição do MERCOSUL e os aspectos sociais contidos no pacto de sua formulação inicial. Com isso pretende contribuir para o debate atual acerca dos fundamentos éticos das políticas públicas fortalecendo as políticas regionais. Para a coleta de dados utilizamos fontes diversificadas: os programas de governo, os relatórios oficiais a partir de 1990, as diretrizes governamentais buscando cercar a problemática em estudo e trabalhos científicos desenvolvidos sobre o tema, publicados em periódicos indexados. Os documentos que subsidiaram a análise foram unicamente os de domínio público visto que favorecem e expressam a construção de consensos relacionados às políticas nacionais de saúde. Os dados sistematizados foram analisados a partir da técnica de análise de conteúdo, permitindo desvelar as mudanças ocorridas nas políticas de saúde após as eleições de governos presidenciais de idéias partidárias diferentes das que estavam na presidência anteriormente. Foram retirados do material coletado, os ideais partidários sobre a sistematização da saúde, apontando como acontecia antes e como está sendo realizada neste momento. Levaram-se em conta os processos históricos de cada país, pois estes foram moldados e influenciados pela sua história. Observa-se que este objeto de estudo é um recorte do Projeto A implementação do Programa SIS FRONTEIRAS e do Pacto pela Saúde perspectivas para a ampliação do direito à saúde aos usuários estrangeiros na Fronteira Arco Sul , financiado pelo CNPq Conselho Nacional de Desenvolvimento Tecnológico e apoiado pelo CONASEMS - Conselho Nacional de Secretários Municipais de Saúde e coordenado pela Professora Vera Maria Ribeiro Nogueira e iniciado em 2009

O objetivo deste estudo epidemiológico e retrospectivo foi analisar o Programa de Prevenção e Controle da Tuberculose na jurisdição sanitária de Tlalnepantla, México 2000-2002). A partir de uma revisão de fontes secundárias (prontuários médicos), os dados foram coletados por meio de um formulário e complementados com os dados obtidos através de entrevistas com trabalhadores de saúde que atuam no programa. A informação foi processada e analisada utilizando os programas Epi-Info versão 6.0, SPSS versão 10.0, Microsoft Word e o Microsoft Excel para tabulação e apresentação dos dados. As variáveis foram: qualidade da informação, dados sóciodemográficos, aspectos relacionados ao diagnóstico, tratamento, referência de casos, relação entre a notificação dos casos e a existência de um laboratório nos serviços de saúde, relação entre a distância das unidades e a Direção Sanitária da jurisdição, relação entre os casos notificados e a incidência esperada e observada dos casos de TB no período de estudo. Os principais resultados foram: qualidade dos registros: ótima 23%, boa 34%, regular 4% e deficiente 39%. Foram encontrados 75 casos notificados no período, 95% dos quais encontravam-se acima de 15 anos; houve uma relação 1:1 homem-mulher, com predomínio do estado civil “casado”. Observou-se baixa escolaridade em 50% dos casos. 5 das 18 unidades detectaram 57% dos casos. Foi diagnosticado Tuberculose Pulmonar em 65% dos casos e Extrapulmonar em 35%. Constatou-se a associação estatística entre a existência de laboratório nas unidades e o número de casos notificados em cada uma delas (p=0.003). Do total de casos, 60% foram detectados nos níveis secundário e terciário de assistência; 46% foram diagnosticados por baciloscopia; 61% iniciaram tratamento posterior ao diagnóstico dentro do período de um dia até um ano; 60% não tinham registro sobre a data de alta do programa; 50% não tinham data de término do tratamento e 77% foram registrados como tratamento supervisionado. Os 75 casos encontrados corresponderam a apenas 24%do total estimado para o tamanho da população. Conclui-se que os prontuários médicos têm uma importante margem de erro e não acompanham as normas vigentes. Não existe participação da população atendida no PPCT e, conseqüentemente, os princípios da Atenção Primária à Saúde não são cumpridos. Existe pouca busca e detecção dos casos em nível de assistência primária. Apesar dos esforços realizados, estas atividades continuam sendo centralizados em nível de atenção terciária.
This epidemiological and retrospective study aimed to analyze the Tuberculosis Prevention and Control Program in the health jurisdiction of Tlalnepantla, Mexico (2000-2002). Starting from a review of secondary sources (medical files), data were collected by means of a form and complemented with the data obtained through interviews with health workers who work in the program. The information was processed and analyzed using Epi-info version 6.0 program, SPSS version 10.0, Microsoft Word and Microsoft Excel for data tabulation and presentation. The variables were: information quality, sociodemographic data, diagnosis-related aspects, treatment, reference of cases, relationship between notification of cases and existence of laboratories at the health service, relation between distance from the units to the Health Direction of the jurisdiction, relation between the notified cases and the prospective and observed incidence of TB cases in the study period. The main results were: the quality of registration was: very good (23%), good (34%), regular (4%) and faulty (39%). 75 notified cases were found in the period, 95% of which were over 15 years old; there was a 1:1 relationship between men and women; the most frequent civil status was “married”. Low educational levels were observed in 50% of the cases. Five of the eighteen units detected 57% of the cases. Pulmonary Tuberculosis was responsible for 65% and Extrapulmonary Tuberculosis for 35% of the notified cases. A statistical association was found between the existence of lab units and the number of notified cases in each of them (p=0.003). 60% of all cases were detected at the secondary and tertiary care levels; 46% were detected through bacilloscopy; 61% started treatment after one day up to one year; no records of the data of discharge from the program were found in 60%; 50% did not mention the end date of the treatment and 77% were registered as supervised treatment. The 75 detected cases corresponded to a mere 24% of the total number of cases estimated in accordance with the population size. It was concluded that the medical files contain an important margin of error and do not attend to official standards. The population attended at the PPCT does not participate and, consequently, the principles of Primary Health Care are not complied with. Little TB case search and detection occurs at the primary care level. In spite of these efforts, these activities are still centralized at the tertiary care level.

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The aim of this study was to analyze rates of hospitalization due to primary care-sensitive cardiovascular conditions. This ecological study on 237 municipalities in the state of Goiás, Central-West Brazil, between 2000 and 2008, used data from the Hospital Information System and the Primary Care Information System. The hospitalization rates were calculated as the ratio between the number of hospitalizations due to cardiovascular conditions and the population over the age of 40 years. The data were evaluated over the three-year periods A (2000-2002), B (2003-2005) and C (2006-2008), according to sex, age group, population size, whether the individual belonged to the metropolitan region, healthcare macroregion, distance from the state capital, living conditions index and coverage within the Family Health Strategy. The potential population coverage of the Family Health Strategy was calculated in accordance with Ministry of Health guidelines. The variability of the rates was evaluated using the t test and ANOVA. A total of 253,254 hospitalizations (17.2%) occurred due to primary care-sensitive cardiovascular conditions. The hospitalization rates diminished between the three-year periods: A (213.5, SD = 104.6), B (199.7, SD = 96.3) and C (150.2, SD = 76.1), with differences from A to C and from B to C (p < 0.001). Municipal population size did not influence the behavior of the rates. Municipalities near the state capital and those in the metropolitan area presented higher rates (p < 0.001). At all percentiles of the Life and Health Conditions Index, there were decreases in the rates (p < 0.001), except at percentile 1. Decreases were also observed in all the macroregions except for the northeastern region of the state. The reduction in rates was independent of the Family Health Strategy coverage. The rates of hospitalization due to primary care-sensitive cardiovascular conditions decreased in these municipalities, independent of the Family Health Strategy coverage.
O obejtivo desse estudo foi analisar taxas de hospitalização por condições cardiovasculares sensíveis à atenção primária. Estudo ecológico com 237 municípios do Estado de Goiás, de 2000 a 2008, utilizando dados do Sistema de Informação Hospitalar e Sistema de Informação da Atenção Básica. As taxas de hospitalização foram calculadas pela proporção entre o número de hospitalizações por condições cardiovasculares e a população acima de 40 anos. Foram avaliadas em triênios: A (2000-2002), B (2003-2005) e C (2006-2008), segundo sexo, faixa etária, porte populacional, pertencimento à região metropolitana, macrorregião de saúde, distância da capital, Índice de Condições de Vida e Saúde e cobertura de Estratégia Saúde da Família. A cobertura populacional potencial da Saúde da Família foi calculada conforme diretrizes do Ministério da Saúde. A variabilidade das taxas foi avaliada segundo teste t e ANOVA. Ocorreram 253.254 internações (17,2% do total) por condições cardiovasculares sensíveis à atenção primária. As taxas de hospitalização diminuíram entre os triênios: A (213,5, dp = 104,6), B (199,7, dp = 96,3) e C (150,2, dp = 76,1), com diferença entre os períodos A-C e B-C (p < 0,001). Porte populacional municipal não influenciou o comportamento das taxas. Municípios próximos à capital e aqueles da região metropolitana apresentaram maiores taxas (p < 0,001). Em todos os percentis do Índice de Condições de Vida e Saúde, houve redução das taxas (p < 0,001), exceto no percentil 1. Redução foi também observada em todas as macrorregiões, exceto na região nordeste do estado. A redução das taxas ocorreu independentemente da cobertura da Saúde da Família. As taxas de hospitalização por condições cardiovasculares sensíveis à atenção primária diminuíram nesses municípios, independentemente da cobertura da Saúde da Família.

Este estudo trata da formulação da política de formação do agente comunitário de saúde (ACS), buscando compreender as disputas que então se travaram, a partir dos processos políticos relativos à gestão da educação e do trabalho do ACS, implementados no período compreendido entre o início de 2003 e meados de 2005. Para tal fim, foram analisados os documentos debatidos nessa formulação, no intervalo de tempo compreendido entre março de 2003 e julho de 2004, o qual se revelou um período intenso de produção conceitual em torno dessa política. Nos documentos analisados, revelaram-se posições acerca do perfil social do ACS e do trabalho que este deve realizar, articuladas a concepções de ensino e formação em saúde, que disputaram o conteúdo e a forma que a política de formação desses trabalhadores deveria assumir. Tais disputas guardam relação também com o modo como esta função se instituiu no SUS e as contradições geradas desde então; ao mesmo tempo, as posições conflitantes apontam para distintos projetos de saúde, educação e trabalho. Esse processo resultou na publicação do Referencial Curricular para Curso Técnico de Agente Comunitário de Saúde, que consolidou a proposta de formação técnica, mas cuja implementação não tem se dado integralmente, configurando a prevalência de uma qualificação inicial, conforme determina a legislação que orienta o exercício da profissão de ACS. Entretanto, a dissertação indica que o processo não se esgotou, sendo a atual política de formação dos ACS objeto de disputas e demandas, tanto pela sua conservação, quanto pela sua transformação.
This study focuses on the community health agent (from now on, CHA) education policy formulation, aimed at understanding the disputes that occurred within the political processes relative to CHAs education and work management, implemented in the period between the beginning of 2003 and the middle of 2005. To that end, the documents debated in this formulation were analyzed in the time frame between March 2003 and July 2004, which revealed to be an intense conceptual production period about this policy. In the documents analyzed, positions about the CHAs social profile and the work that he/she has to do turned out to be articulated to teaching and health training conceptions, which disputed both the content and the format that the formation policy of these workers should assume. Such debates also bear relation to the way this function has been instituted in SUS (Brazilian Public Health System) and the contradictions generated ever since; at the same time, the conflicting positions point out to distinct health, education and work projects. This process resulted in the publication of the Curricular Referential for the Community Health Agent Technician Course, which consolidated the technical education proposal, but whose implementation has not been complete, figuring the prevalence of an initial qualification, as determined by the legislation on CHA profession. However, the dissertation indicates that the subject has not been exhausted, as the current CHA education policy is an object of dispute and demand for its conservation as well as for its transformation.

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The modern connection between the basic attention to health and sanitation had the beginning with the Declaration of Alma Ata in 1978, when the proposal to establish local health services focusing on the real needs of the population had as one of its elementary actions the drinking-water supply and sewage collection and treatment. Thirty four years later the review of the literature demonstrates that the sanitation and health had been more theorized than actually combined to promote improvement in the health conditions of populations around the world. Considering these facts, the motivation to produce this study has been found, which is: knowing and researching its interfaces, its associations and how they contribute to the health of the population in the cities of Espírito Santo. To perform the study objectives, the methodology has been used was the statistical analysis of a variable dependent on health and sanitation indicators, on secondary data, referring to the State s municipalities in 2001, 2006 and 2011. The literature review indicates that in recent years the parasitic and infectious diseases caused by the lack of sanitation are decreasing in areas where interventions in primary health care can be found, making them good indicators in planning and monitoring of health services. The results indicated a strong connection between primary health care and the provision of water supply and sewage collection by collective network, over the variable rate of diarrhea in children under two years old, in 2001, 2006 and 2011 in the municipalities in Espírito Santo. The analysis indicate that, in areas where the teams of community health agents work and the family health strategy, good results in controlling diarrhea are presented in all years of the study. And these outcomes are increased when associated to more coverage of public water supply systems and sanitation. This complement confirms the requirement for greater investments in the actions planned and performed on a intersectorial way by the municipal public administrations
A moderna relação entre a atenção básica à saúde e o saneamento básico tem sua certidão de nascimento lavrada na Declaração de Alma Ata em 1978, quando a proposta de instituir serviços locais de saúde centrados nas necessidades reais da população trazia como suas ações essenciais elementares o abastecimento de água potável e a coleta e tratamento de esgoto sanitário. Passados 34 anos a revisão da literatura nos revela que a relação entre saneamento e saúde foi mais teorizada do que de fato conjugada para promover melhorias nas condições de saúde das populações mundo a fora. Daí a motivação do presente estudo: conhecer suas interfaces, suas associações e como estas contribuem para a saúde da população nos municípios capixabas. Para cumprir os objetivos a metodologia empregada consistiu na análise estatística de uma variável dependente e de indicadores de saúde e saneamento, utilizando dados secundários de fontes oficiais dos municípios capixabas nos anos de 2001, 2006 e 2011. A revisão bibliográfica aponta que nos últimos anos as doenças infecciosas e parasitarias causadas pela falta de saneamento básico estão diminuindo nos territórios onde encontramos intervenções de Atenção Primária à Saúde, tornando-as bons indicadores no planejamento das ações de saúde. Os resultados mostraram forte relação entre a Atenção Primária à Saúde e a oferta de abastecimento de água potável e da coleta de esgoto por rede coletiva, sobre a variável taxa de diarréia em menores de 2 anos, nos anos de 2001, 2006 e 2011 nos municípios capixabas. A análise mostra que, em áreas de atuação de equipes de Agentes Comunitários de Saúde e da estratégia de Saúde da Família, bons resultados no controle de diarréias são apresentados em todos os anos do estudo, sendo potencializados quando consorciados por maiores coberturas dos sistemas públicos de abastecimento de água e esgotamento sanitário. Esta complementaridade confirma a necessidade de maiores investimentos em ações planejadas e executadas de forma intersetorial pelas gestões públicas municipais

O Brasil possui um sistema de saúde com cobertura universal (Sistema Único de Saúde- SUS) defendendo a saúde como um direito de todos os cidadãos e dever do estado. Apesar deste sistema público universal, o sistema de saúde brasileiro é composto por um mix público-privado que favorece cobertura duplicada aos serviços de saúde para a parcela da população com posse de plano privado de saúde. Um quarto dos brasileiros possui plano privado de saúde e, portanto, tem acesso duplicado aos serviços de saúde. A posse de plano privado de saúde e o uso dos serviços médicos e odontológicos precisam ser analisados neste contexto. Os objetivos desta tese são analisar as tendências no uso dos serviços de saúde médicos e odontológicos e verificar sua relação com a posse de planos privados de saúde. Os resultados desta tese estão organizados em dois manuscritos. O primeiro manuscrito “The relationship between private health plans and use of dental and medical health services among Brazilians: a cross-sectional study, 2008” teve por objetivo descrever o uso de serviços de saúde médico e odontológico de acordo com o tipo de serviço utilizado (público, privado ou por plano privado de saúde) e analisar o efeito do cadastro na Estratégia de Saúde da Família (ESF). Neste estudo foram analisados 391.868 indivíduos provenientes do banco da Pesquisa Nacional de Amostra Domiciliar (PNAD) de 2008. Como esperado, indivíduos sem plano privado de saúde utilizaram mais o serviço público, enquanto aqueles com plano utilizaram mais os serviços do seu plano. Ainda, os indivíduos com plano privado de saúde tendem a utilizar mais os serviços de saúde. Por outro lado, estar cadastrado em ESF aumenta o uso do serviço público e reduz o uso do privado e do plano entre os indivíduos sem plano e aumenta a chance de usar qualquer serviço entre aqueles que têm plano. Assim, políticas para a expansão da ESF devem ser incentivadas e a posse de plano privado precisa ser monitorada e regulada para evitar gastos desnecessários em saúde e o aumento das iniqüidades no acesso, principalmente em países com sistema universal de saúde. O segundo manuscrito “Tendências no uso de serviços de saúde médicos e odontológicos e a relação com nível educacional e posse de plano privado de saúde no Brasil, 1998 a 2013” teve como objetivo analisar as tendências no uso de serviços de saúde médico e odontológicos por adultos no Brasil entre 1998 e 2013 em relação à posse de planos privados de saúde e nível educacional. Foram analisados 760.678 indivíduos oriundos dos bancos de dados nacionais da PNAD de 1998, 2003, 2008 e da Pesquisa Nacional de Saúde de 2013. Adultos (18 a 59 anos) com posse de plano privado de saúde apresentaram chance maior de usar os serviços de saúde comparados àqueles sem plano em todos os anos analisados. No entanto, houve tendência de diminuição do uso dos serviços médicos entre indivíduos com posse de plano privado de 1998 para 2013. Em relação ao uso dos serviços odontológicos, o declínio foi observado de 2003 para 2013. O percentual de adultos com plano privado para assistência médica diminuiu de 24,9% para 22,2%, enquanto a tendência de posse de plano exclusivamente odontológico aumentou de 1,0% para 6,3% de 1998 para 2013. Tendência de aumento no uso de serviços de saúde, médico e odontológico, entre adultos sem plano privado de saúde também foi verificada. Acompanhar as tendências na posse de planos privados e no uso dos serviços, bem como avaliar o estado de saúde e o tipo de serviço utilizado (público, pagamento direto do bolso ou através do plano) são necessários para auxiliar o estado na regulação dos planos e evitar o aumento das iniquidades no acesso e uso dos serviços entre os cidadãos.
Brazil has a health care system with universal coverage (Unified Health System, or SUS) advocating health as a right to all citizens and a duty of the state. Despite this universal public system, the Brazilian health system is composed of a public-private mix that favors doubled coverage for part of the population with private health plan. About a quarter of Brazilians has private health insurance and therefore has duplicate access to health services. The private health plan possession and the use of medical and dental services need to be analyzed in this context. The objectives of this thesis are to analyze trends in possession of private health plans and verify their relation to the use of medical and dental health services. The results this thesis is organized in two manuscripts. The first manuscript "The relationship between private health plans and use of dental and medical health services among Brazilians: a cross-sectional study, 2008" aimed to describe the use of medical and dental health services according to the type of service used (public, private or private health plan) and assess the effect of being registered in the Family Health Strategy (ESF). This study analyzed 391,868 individuals from the 2008 National Household Survey (PNAD). As expected, individuals without private health plan used more public health services, while those with private health plan tend to use more their plan. Overall, those with private health plan tend to use more the health services. On the other hand, being registered in ESF increased the use of public service and reduced the use of private service among individuals without private health plan, and increased the chance to use any service among those with plan. Thus, policies for expanding ESF should be encouraged and private health plans need to be monitored and regulated to avoid unnecessary expenses on health and increasing inequities in access, especially in countries with universal health systems. The second manuscript " Trends in use of dental and medical services and its association with education and having private health plan in Brazil, 1998 to 2013" aimed to analyze trends in use of medical and dental health services among Brazilian adults between 1998 and 2013 in relation to private health plans and educational level. The sample included 760,678 individuals from the PNAD in the years 1998, 2003, 2008 and the National Health Survey in 2013. Adults (18-59 year-old) with private health plan were more likely to use health services compared to those without a plan in every years analyzed. However, there was a trend of decrease in the use of medical services among adults with private health plan from 1998 to 2013. In relation to the use of dental services, a decrease was observed from 2003 to 2013. The percentage of individuals with medical plans has decreased from 24.9% to 22.2%, while the trend in exclusively dental private plan has increased from 1.0% to 6.3% from 1998 to 2013. Trend the increase to use health services between adults without private health plan was found in medical and dental service. Monitoring trends in the private health plan possession, and health services use, and to assess the health conditions and the type of service used (public, private out-of-pocket or through the plan) are important for the state regulation and to avoid increasing inequities in access and use of health services among citizens.

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Este estudo analisa a atenção primária na política nacional de saúde brasileira no período de 2003 a 2008, a partir da compreensão da inserção dessa política na nova agenda federal que se inicia com a ascensão de Lula à presidência da república. A metodologia do estudo se baseou no marco teórico do institucionalismo histórico e no conceito de path-dependence, compreendendo uma diversidade de estratégias, tais como: realização de revisão bibliográfica; análise documental; análise de bases de dadossecundários; análise orçamentária e realização de sete entrevistas com atores-chave. A pesquisa identificou elementos de continuidade e mudança na condução federal da política nacional de atenção primária à saúde (APS) no governo Lula. Dentre as estratégiasfederais prioritárias no âmbito da APS, identificou-se a ênfase no Programa de Saúde da Família (PSF), que permanece ao longo de todo o período analisado. Entretanto, observou-se no período de 2003 a 2005 a presença de visões distintas em relação ao modelo de atenção básica e a inserção do PSF, enquanto no período seguinte, 2006 a 2008, houve a reafirmação deste programa como a estratégia prioritária de organização da APS no país. A inovação mais expressiva pode ser atribuída à criação dos Núcleos de Apoio à Saúde da Família. No que concerne ao modelo de intervenção do gestor federal nesta política específica, destaca-se o papel residual de execução direta das ações e serviços de saúde,fragilidades no que diz respeito ao planejamento e ênfase na regulação e no papel de financiador de programas e políticas. Em todo o período analisado a formulação da política de APS no âmbito nacional foi amplamente compartilhada com os diferentes atores nos espaçosformais de pactuação e deliberação.
Avanços ocorreram no que diz respeito à APS no governo Lula. Foi possível observar além de elementos de continuidade, mudanças incrementais e algumas inovações importantes, tais como a ampliação da cobertura e do escopo das ações no âmbito da atenção primária à saúde, ainda que desafios antigos não tenham sido superados.
This study examines the primary care in the Brazilian national health policy between 2003 and 2008, from the understanding of the integration agenda of the new federal policy that begins with the rise of Lula to the presidency of the republic. The methodology of the study was based on the theoretical framework of historical institutionalism and the concept of path-dependence, including a variety of strategies, such as: completion of literature review, document analysis, analysis of secondary databases, budget analysis and execution of seven interviews with key actors. The study identified elements of continuity and change in the conduct of the federal policy of primary health care (PHC) in the Lula government. Among the strategies under the federal priority APS, identified to focus on the Family Health Program (FHP), which remains throughout the period analyzed. However, it was observed between 2003 and 2005 the presence of different views on the model of primary care and integration of the FHP, while the following period, from 2006 to 2008, there was the reaffirmation of this program as a strategic priority for the organization of the PHC in the country. The most significant innovation can be attributed to the creation of Centers of Support for Family Health (NASF). Regarding the model of the authorizing federal intervention in this specific policy, there is the role of residual direct implementation of activities and health services, weaknesses in regard to planning and emphasis on the role of regulation and funding of programs and policies. Throughout the period analyzed the formulation of policy at the national PHC was widely shared with all actors in the areas of agreement and formal approval. Progress occurred in respect of APS in the Lula government. It was observed in addition to elements of continuity, incremental changes and some important innovations, such as expansion of coverage and scope of actions within the primary health care, though not old challenges have been overcome.

This thesis examines hospitalizations for ambulatory care sensitive conditions among persons with an intellectual disability living in Manitoba from 1999 to 2003. Hospitalizations for ambulatory care sensitive conditions are considered an indicator of access to, and the quality of, primary care. Intellectual disability can be defined as a disability originating before age 18 characterized by significant limitations both in intellectual functioning and in adaptive behaviour as expressed in conceptual, social, and practical adaptive skills. Between 1 and 3% of the population has an intellectual disability. This thesis addressed three objectives: 1) To identify ambulatory care sensitive conditions that are applicable to persons with an intellectual disability; 2) To compare hospitalization rates for ambulatory care sensitive conditions between persons with and without an intellectual disability in Manitoba; 3) To identify factors associated with hospitalizations for ambulatory care sensitive conditions among adults with an intellectual disability living in Manitoba. An online survey of primary care providers with experience working with persons with an intellectual disability found consensus on fifteen ambulatory care sensitive conditions applicable to persons with an intellectual disability. Large discrepancies in hospitalization rates for these conditions were found between persons with and without an intellectual disability. Controlling for age, year, sex, and region, persons with an intellectual disability were 6 times more likely to be hospitalized for an ambulatory care sensitive condition. Future research should investigate reasons for the large discrepancy in rates between persons with and without an intellectual disability. Among adults with an intellectual disability, living in a rural area (odds ratio 1.3; 95% CI=1.0, 1.8), living in an area with a high proportion of First Nations people (odds ratio 2.3; 95% CI=1.3, 4.1), and experiencing higher levels of comorbidity (odds ratio 25.2; 95% CI=11.9, 53.0) were all associated with a higher likelihood of being hospitalized for an ambulatory care sensitive condition. Dwelling in higher income areas had a protective effect (odds ratio 0.56; CI=0.37, 0.85). The results suggest that addressing the socioeconomic problems of poorer areas and specifically areas densely populated by First Nations people would likely have an impact on hospitalizations for ACS conditions for persons with an intellectual disability.

碩士
亞洲大學
健康管理研究所
94
Health service which provide by primary health care is accepted as the model for delivering basic health to people base upon house hold as small unit of community. Cross sectional study using data taken from third wave of Indonesia Family Life Survey (IFLS) in 2000, this study examined to understand determinant of Indonesian Primary Health Care (especially Community Health Center or Puskesmas) utilization among Indonesian people. Objective: To assess the effects of health need, enabling factors, and predisposing factors and to assess determinant on Community Health Center (Puskesmas) utilization by Indonesian people. Study Design: Logistic regression and Poisson regression analysis is use to estimate the qualitative determinant of Community Health Center (Puskesmas) utilization with cross-sectional data. Data: Data will be taken from third wave of Indonesia Family Life Survey (IFLS) in 2000. This survey comprises totally 10,435 house holds, 43,649 individuals, representing 13 provinces and approximately 83 % of Indonesian population. Result: The needs for care, enabling (income, employment, health insurance, travel time and cost, waiting time) and predisposing factors (age, gender, education, residence and region) were associated with primary health care utilization. Overall, 35 % of Indonesian respondents entered the primary health care in the past 4 weeks, making an average of 1.39 visits. Conclusions: Access to primary health care for Indonesian remains a major problem, significantly affected by structural and predisposing factors. Policy solutions that address the health service needs of the improving health services and community participation will largely benefit for Indonesian.