Gobernanza y economía política de las políticas de APS en América Latina

Primary health care as a tool to promote equity and sustainability; a review of Latin American and Caribbean literature

Primary health care (PHC) has increased in global relevance as it has been demonstrated to be a useful strategy to promote community access to health services. Multilateral organizations and national governments have reached a consensus regarding the basic principles of PHC, but the application of these varies from country to country due to the particularities of local health systems.This article aims to review and summarize PHC strategies and the configuration of health networks in Latin American and Caribbean countries.The review was carried out using keywords in at least 9 databases. Papers in languages other than English, Portuguese, and Spanish were excluded, while non-refereed articles and regional gray literature were incorporated. As a result, 1,146 papers were identified. After three instances of analysis, 142 articles were selected for this investigation. Data were analyzed according to an analysis by theme.The evidence collected on health reforms in the region reflects the need to intensify care strategies supported by PHC and care networks. These must be resilient to changes in the population's needs and must be able to adapt to contexts of epidemiological accumulation.

Stewardship and governance: structuring dimensions for Implementation Primary Health Care Policies in Paraguay, 2008-2017

This study analyzes the conduction patterns of implementing Primary Health Care (PHC) in Paraguay in three government periods (2008-2012, 2012-2013 and 2013-2017) and three management levels (national, regional and local). This is a qualitative study based on grounded theory. A priori categories on PHC stewardship and governance in Paraguay were analyzed. An open-ended questionnaire was applied to a sample of social, political and technical stakeholders: ministers, coordinators, managers, consultants, and international organizations' experts. Data were processed combining the use of Atlas Ti software and sorting findings in a structured Excel matrix. Gaps in leadership, regulatory mechanisms, technical capacities for health planning and management and financial implementation methods have affected PHC continuous expansion and strengthening process. The findings show limitations and possibilities for the implementation of this health policy in Paraguay, evidencing the need for greater qualification of management and political stability in its conduction.

Analysis of the enablers of capacities to produce primary health care-based reforms in Latin America: a multiple case study

BACKGROUND

Primary health care (PHC)-based reforms have had different results in Latin America. Little attention has been paid to the enablers of collective action capacities required to produce a comprehensive PHC approach.

OBJECTIVE

To analyse the enablers of collective action capacities to transform health systems towards a comprehensive PHC approach in Latin American PHC-based reforms.

METHODS

We conducted a longitudinal, retrospective case study of three municipal PHC-based reforms in Bolivia and Argentina. We used multiple data sources and methodologies: document review; interviews with policymakers, managers and practitioners; and household and services surveys. We used temporal bracketing to analyse how the dynamic of interaction between the institutional reform process and the collective action characteristics enabled or hindered the enablers of collective action capacities required to produce the envisioned changes.

RESULTS

The institutional structuring dynamics and collective action capacities were different in each case. In Cochabamba, there was an 'interrupted' structuring process that achieved the establishment of a primary level with a selective PHC approach. In Vicente López, there was a 'path-dependency' structuring process that permitted the consolidation of a 'primary care' approach, but with limited influence in hospitals. In Rosario, there was a 'dialectic' structuring process that favoured the development of the capacities needed to consolidate a comprehensive PHC approach that permeates the entire system.

CONCLUSION

The institutional change processes achieved the development of a primary health care level with different degrees of consolidation and system-wide influence given how the characteristics of each collective action enabled or hindered the 'structuring' processes.

Comparing the performance of the public, social security and private health subsystems in Argentina by core dimensions of primary health care

BACKGROUND

Most Latin American health systems are comprised of public (PubS), social security (SSS) and private (PrS) subsystems. These subsystems coexist, causing health care fragmentation and population segmentation.

OBJECTIVE

To estimate the extent of subsystem cross-coverage in a geographically bounded population (Rosario city) and to compare the subsystems' performance on primary health care (PHC) dimensions.

METHODS

Through a cross-sectional, interviewer-administered survey to a representative sample (n = 822) of the Rosario population, we measured the percentage of cross-coverage (people with usual source of care in one subsystem but also covered by another subsystem) and the health services' performance by core PHC dimensions, as reported by each subsystem's usual users. We compared the subsystems' performance using chi-square analysis and one-way analysis of variance testing. We analyzed whether the observed differences were coherent with the predominant institutional and organizational features of each subsystem.

RESULTS

Overall, 39.3% of the population was affiliated with the PubS, 44.8% with the SSS and 15.9% with the PrS. Cross-coverage was reported by 40.6% of respondents. The performance of the PubS was weak on accessibility but strong on person-and-community-oriented care, the opposite of the PrS. The SSS combined the strengths of the other two subsystems.

CONCLUSION

Rosario's health system has a high percentage of cross-coverage, contributing to issues of fragmentation, segmentation, financial inequity and inefficiency. The overall performance of the SSS was better than that of the PrS and PubS, though each subsystem had a particular performance pattern with areas of strength and weakness that were consistent with their institutional and organizational profiles.

Escolas Técnicas do SUS (ETSUS) no Brasil: regulação da integração ensino serviço e sustentabilidade administrativa

O objetivo deste artigo foi discutir a sustentabilidade administrativa das Escolas Técnicas do SUS (ETSUS) a partir do princípio da integração ensino serviço, que traz uma nova dimensão do trabalho na saúde ainda não regulada pela administração pública brasileira. Trata-se de uma pesquisa qualitativa, por meio de um estudo de caso. A pesquisa foi realizada por meio de questionário semiestruturado junto aos gestores das ETSUS, abordando aspectos institucionais, administrativos e de gestão do trabalho. O universo amostral foi de 6 ETSUS pertencentes à Rede de Escolas Técnicas do SUS (RET-SUS). As ETSUS apresentaram gestão e planejamento centralizados e execução descentralizada de sua atividade fim, em sua maioria sem autonomia administrativa e altamente dependente de financiamento do governo federal. Segundo os gestores das escolas, a falta de regulação da atividade docente por servidor público fragiliza a gestão das ETSUS. Estas instituições apresentam problemas de gestão relacionados à integração ensino serviço, que precisa ser regulamentada para conferir sustentabilidade às escolas e evitar contradições com a legislação brasileira.