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Objective: The Brazilian remote rurality has been classified more reliably only recently, according to demographic density, proportion of urban population, and accessibility to urban centers. It comprises 5.8% of the municipalities, in nearly half of the states, with a population of 3,524,597 (1.85%). Remote rural localities (RRL) have reduced political/economic power, facing greater distances and barriers. Most health strategies are developed with the urban space in mind. We aim to understand how RRL are positioned concerning efficiency/effectiveness in health, compared to other urban-rural typologies of Brazilian localities, focusing on Primary Health Care (PHC), and its organizational models. Methods: We evaluated the efficiency and effectiveness of the organizational models using the health production model, from 2010-2019, gradually deepening the immersion into the RRL reality. We analyzed the human and financial resources dimensions, emphasizing teams, the results of PHC actions, and health levels. We used the fixed effects model and data envelopment analysis, cross-sectioned by intersectional inequities. We compared the Brazilian states with and without RRL, Brazilian municipalities according to rural-urban typologies, and RRL clusters. Results: Brazilian RRL states show superior resource/health efficiency through services utilization according to health needs. The remote rural typology demonstrated greater efficiency and effectiveness in health than the other typologies in the RRL states. The organizational models with the Family Health Strategy (FHS) teams and the Community Health Worker (CHW) visits played a key role, together with local per capita health expenditures and intergovernmental transfers. Thus, financial resources and health professionals are essential to achieve efficient/effective results in health services. Among the RRL, the Amazon region clusters stand out, denoting the importance of riverine and fluvial health teams, the proportion of diagnostic/treatment units in addition to the proportion of illiteracy and adolescent mothers along with the inequity of reaching high levels of schooling between gender/ethnicity. Conclusion: Hopefully, these elements might contribute to gains in efficiency and effectiveness, prioritizing the allocation of financial/human resources, mobile FHS teams, availability of local diagnosis/treatment, and basic sanitation. Finally, one should aim for equity of gender/ethnicity in income and education and, above all, of place, perceived in its entirety.

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Background: During the COVID-19 pandemic, children faced a disproportionate burden of malnutrition and poor health outcomes. Nurturing care interventions (NCIs) including actions toward good health, adequate nutrition, responsive care, opportunities for early learning, and security and safety are critical for promoting equity. Due to the need for evidence-based responses and preparedness, we analyzed adaptations in NCIs' implementation strategies during COVID-19 according to the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS). Method: We conducted a global scoping review including peer-reviewed and non-peer-reviewed literature. The databases searched were PubMed, Embase, Scopus, BVS, Scielo, and Web of Science. This search was complemented by an extensive examination of relevant websites and an additional internet search via Google Scholar. We extracted and analyzed the data following the seven modules of the FRAME-IS. Results: Out of 20 records, 27 NCI were identified across Africa (n = 3), Asia (n = 7), Europe (n = 3), North America (n = 11), Oceania (n = 1), and South America (n = 2). NCIs adapted their content (e.g., adding elements), evaluation (e.g., conducting needs assessment), training (e.g., using experts), and context (e.g., setting-shifting from in-person to remote, and population-expanding interventions' reach). Adaptation goals were to increase acceptability (n = 9, 32.1%), adoption (n = 5, 17.8%), appropriateness (n = 10, 35.7%), feasibility (n = 25, 89.3%), penetration (n = 15, 53.6%), sustainability (n = 23, 82.1%), and fidelity (n = 1, 3.7%). The rationale to adapt varied from sociopolitical (n = 6, 21.4%), organizational (n = 13, 46.4%), implementer (n = 11, 39.3%), practitioner (n = 15, 53.6%), and recipient (n = 11, 39.3%). A quarter were reactive planned adaptations and 75.0% were unplanned modifications. Decisions were led by program leaders (n = 21, 75.0%), funders (n = 9, 32.1%), partners (n = 3, 10.7%), researchers (n = 1, 3.6%), and practitioners (n = 3, 10.7%). Adaptations were widespread from unit (e.g., hospital) (n = 1, 3.6%), organization (n = 4, 14.3%), and community system (e.g., countrywide) (n = 14, 50.0%). Conclusion: The results from our global scoping review show that it is possible for NCIs to continue and even improve their delivery despite the global crisis, suggesting that remote delivery is feasible and can work as an alternative when in lockdown. Strategic planning taking advantage of existing structures and partnerships may have allowed NCI adaptations to be sustainable as well as facilitated replication within the organization network system.

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We aim to conduct a comparative analysis of the implementation of PHC in nine South American countries. Three dimensions were highlighted from documentary sources: political commitment, leadership, and governance; care model; and engagement of communities and other stakeholders. The results indicate a formal commitment that places PHC at the center of efforts to achieve universal access. The following can be observed: revitalization processes in public subsystems, based on guaranteeing preventive, promotional, curative and rehabilitation actions; PHC as gatekeeper; emphasis on family and community; assigned population and territory; multidisciplinary teams; and, in some cases, the accent on interculturality expressed in the concept of "buen vivir" (good living). The PHC revitalization processes were affected by political changes. Between progress and setbacks, the segmentation of coverage was not overcome. The current moment seeks to recover more inclusive and broad public policies in the context of the return of the progressive and democratic fields. The dissemination of country experiences can contribute to the development of a comprehensive, integrated, and quality approach to PHC in the Region.

El objetivo es realizar un análisis comparativo de la implementación de la APS en nueve países de Suramérica. A partir de fuentes documentales fueron destacadas tres dimensiones: compromiso político, liderazgo y gobernanza; modelo de atención; involucramiento de comunidades y otros actores. Los resultados indican la existencia de compromiso formal que localiza la APS en el centro de los esfuerzos para lograr el acceso universal. Se observan procesos de revitalización en los subsistemas públicos, basados en la garantía de acciones preventivas, promocionales, de cura y rehabilitación; puerta de entrada; enfoque familiar y comunitario; población y territorio adscriptos; equipos multiprofesionales, y, en algunos casos, énfasis en la interculturalidad expresada en la concepción de "buen vivir". Los procesos de revitalización de la APS fueron afectados por cambios políticos. Entre avances y retrocesos, no se logró superar la segmentación de cobertura. El momento actual es de rescate de políticas públicas más inclusivas y amplias, en el contexto de recomposición de los campos progresistas y democráticos. Difundir experiencias de los países puede contribuir para el desarrollo de un enfoque de APS integral, integrada y de calidad en la Región.

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During the COVID-19 pandemic, populations living further away from urban centers faced immense difficulties accessing health services. This study aims to analyze how Brazilian remote rural municipalities faced the COVID-19 pandemic based on their political, structural, and organizational response to access to healthcare. A qualitative study of multiple cases was conducted with thematic and deductive content analysis of 51 interviews conducted with managers and healthcare professionals in 16 remote rural municipalities in the states of Rondônia, Mato Grosso, Tocantins, Piauí, Minas Gerais, and Amazonas. With their socio-spatial dynamics and long distances to reference centers, the remote rural municipalities responded to the demands of the pandemic but did not have their needs met promptly. They preserved communication with the population, reorganized the local system centered on primary health care (PHC), and changed the functioning of healthcare units, exceeding the limits of their responsibilities to provide the necessary care and awaiting referral to other levels of complexity. They faced a shortage of services, gaps in assistance in the regional network, and inadequate healthcare transport. The pandemic reiterated PHC's difficulties in coordinating care, exposing care gaps in reference regions. The equitable and resolute provision of the local health system in the remote rural municipalities implies inter-federative articulation in formulating and implementing public policies to ensure the right to health.

Na pandemia de COVID-19, as populações que vivem mais afastadas dos centros urbanos enfrentaram imensas dificuldades no acesso aos serviços de saúde. O objetivo deste estudo é analisar como os municípios rurais remotos brasileiros enfrentaram a pandemia de COVID-19, tendo como base sua resposta política, estrutural e organizativa ao acesso à saúde. Trata-se de estudo qualitativo de casos múltiplos com a análise de conteúdo temática e dedutiva de 51 entrevistas conduzidas com gestores e profissionais de saúde em 16 municípios rurais remotos dos estados de Rondônia, Mato Grosso, Tocantins, Piauí, Minas Gerais e Amazonas. Com dinâmicas socioespaciais próprias, grandes distâncias até os centros de referência, os municípios rurais remotos responderam às demandas da pandemia, mas não tiveram suas necessidades atendidas oportunamente. Preservaram a comunicação com a população, reorganizaram o sistema local centrado na atenção primária à saúde (APS), alteraram o funcionamento das unidades de saúde, ultrapassando os limites de suas atribuições para prestar o cuidado necessário e aguardar o encaminhamento aos demais níveis de complexidade. Enfrentaram a escassez de serviços, as lacunas assistenciais da rede regional e o transporte sanitário inadequado. A pandemia reiterou as dificuldades da APS em coordenar o cuidado e expôs os vazios assistenciais nas regiões de referência. A provisão equitativa e resolutiva do sistema local de saúde nos municípios rurais remotos implica na articulação interfederativa à formulação e implementação de políticas públicas de modo a assegurar o direito à saúde.

En la pandemia de COVID-19, las poblaciones que viven más alejadas de los centros urbanos enfrentaron inmensas dificultades para acceder a los servicios de salud. El objetivo de este estudio es analizar cómo los municipios rurales remotos de Brasil enfrentaron la pandemia de COVID-19, a partir de su respuesta política, estructural y organizativa al acceso a la salud. Se realizó el estudio cualitativo de casos múltiple con el análisis de contenido temático y deductivo de 51 entrevistas realizadas con gestores y profesionales de la salud en 16 municipios rurales remotos de los estados de Rondônia, Mato Grosso, Tocantins, Piauí, Minas Gerais y Amazonas. Con dinámicas socioespaciales propias y alejados de los centros de referencia, los municipios rurales remotos respondieron a las demandas de la pandemia, pero no se atendieron sus necesidades de manera oportuna. Preservaron la comunicación con la población, reorganizaron el sistema local centrado en la atención primaria de salud (APS), modificaron el funcionamiento de las unidades de salud, superando los límites de sus atribuciones para proporcionar la atención necesaria, y esperar la derivación a los demás niveles de complejidad. Enfrentaron la falta de servicios, las lagunas asistenciales de la red regional y el transporte sanitario inadecuado. La pandemia reafirmó las dificultades de la APS para coordinar la atención y expuso las lagunas asistenciales en las regiones de referencia. La provisión equitativa y resolutiva del sistema de salud local en los municipios rurales remotos implica en la articulación interfederativa para elaborar e implementar políticas públicas para asegurar el derecho a la salud.

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Resumo: Na pandemia de COVID-19, as populações que vivem mais afastadas dos centros urbanos enfrentaram imensas dificuldades no acesso aos serviços de saúde. O objetivo deste estudo é analisar como os municípios rurais remotos brasileiros enfrentaram a pandemia de COVID-19, tendo como base sua resposta política, estrutural e organizativa ao acesso à saúde. Trata-se de estudo qualitativo de casos múltiplos com a análise de conteúdo temática e dedutiva de 51 entrevistas conduzidas com gestores e profissionais de saúde em 16 municípios rurais remotos dos estados de Rondônia, Mato Grosso, Tocantins, Piauí, Minas Gerais e Amazonas. Com dinâmicas socioespaciais próprias, grandes distâncias até os centros de referência, os municípios rurais remotos responderam às demandas da pandemia, mas não tiveram suas necessidades atendidas oportunamente. Preservaram a comunicação com a população, reorganizaram o sistema local centrado na atenção primária à saúde (APS), alteraram o funcionamento das unidades de saúde, ultrapassando os limites de suas atribuições para prestar o cuidado necessário e aguardar o encaminhamento aos demais níveis de complexidade. Enfrentaram a escassez de serviços, as lacunas assistenciais da rede regional e o transporte sanitário inadequado. A pandemia reiterou as dificuldades da APS em coordenar o cuidado e expôs os vazios assistenciais nas regiões de referência. A provisão equitativa e resolutiva do sistema local de saúde nos municípios rurais remotos implica na articulação interfederativa à formulação e implementação de políticas públicas de modo a assegurar o direito à saúde.

Abstract: During the COVID-19 pandemic, populations living further away from urban centers faced immense difficulties accessing health services. This study aims to analyze how Brazilian remote rural municipalities faced the COVID-19 pandemic based on their political, structural, and organizational response to access to healthcare. A qualitative study of multiple cases was conducted with thematic and deductive content analysis of 51 interviews conducted with managers and healthcare professionals in 16 remote rural municipalities in the states of Rondônia, Mato Grosso, Tocantins, Piauí, Minas Gerais, and Amazonas. With their socio-spatial dynamics and long distances to reference centers, the remote rural municipalities responded to the demands of the pandemic but did not have their needs met promptly. They preserved communication with the population, reorganized the local system centered on primary health care (PHC), and changed the functioning of healthcare units, exceeding the limits of their responsibilities to provide the necessary care and awaiting referral to other levels of complexity. They faced a shortage of services, gaps in assistance in the regional network, and inadequate healthcare transport. The pandemic reiterated PHC's difficulties in coordinating care, exposing care gaps in reference regions. The equitable and resolute provision of the local health system in the remote rural municipalities implies inter-federative articulation in formulating and implementing public policies to ensure the right to health.

Resumen: En la pandemia de COVID-19, las poblaciones que viven más alejadas de los centros urbanos enfrentaron inmensas dificultades para acceder a los servicios de salud. El objetivo de este estudio es analizar cómo los municipios rurales remotos de Brasil enfrentaron la pandemia de COVID-19, a partir de su respuesta política, estructural y organizativa al acceso a la salud. Se realizó el estudio cualitativo de casos múltiple con el análisis de contenido temático y deductivo de 51 entrevistas realizadas con gestores y profesionales de la salud en 16 municipios rurales remotos de los estados de Rondônia, Mato Grosso, Tocantins, Piauí, Minas Gerais y Amazonas. Con dinámicas socioespaciales propias y alejados de los centros de referencia, los municipios rurales remotos respondieron a las demandas de la pandemia, pero no se atendieron sus necesidades de manera oportuna. Preservaron la comunicación con la población, reorganizaron el sistema local centrado en la atención primaria de salud (APS), modificaron el funcionamiento de las unidades de salud, superando los límites de sus atribuciones para proporcionar la atención necesaria, y esperar la derivación a los demás niveles de complejidad. Enfrentaron la falta de servicios, las lagunas asistenciales de la red regional y el transporte sanitario inadecuado. La pandemia reafirmó las dificultades de la APS para coordinar la atención y expuso las lagunas asistenciales en las regiones de referencia. La provisión equitativa y resolutiva del sistema de salud local en los municipios rurales remotos implica en la articulación interfederativa para elaborar e implementar políticas públicas para asegurar el derecho a la salud.

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Resumen El objetivo es realizar un análisis comparativo de la implementación de la APS en nueve países de Suramérica. A partir de fuentes documentales fueron destacadas tres dimensiones: compromiso político, liderazgo y gobernanza; modelo de atención; involucramiento de comunidades y otros actores. Los resultados indican la existencia de compromiso formal que localiza la APS en el centro de los esfuerzos para lograr el acceso universal. Se observan procesos de revitalización en los subsistemas públicos, basados en la garantía de acciones preventivas, promocionales, de cura y rehabilitación; puerta de entrada; enfoque familiar y comunitario; población y territorio adscriptos; equipos multiprofesionales, y, en algunos casos, énfasis en la interculturalidad expresada en la concepción de "buen vivir". Los procesos de revitalización de la APS fueron afectados por cambios políticos. Entre avances y retrocesos, no se logró superar la segmentación de cobertura. El momento actual es de rescate de políticas públicas más inclusivas y amplias, en el contexto de recomposición de los campos progresistas y democráticos. Difundir experiencias de los países puede contribuir para el desarrollo de un enfoque de APS integral, integrada y de calidad en la Región.

Abstract We aim to conduct a comparative analysis of the implementation of PHC in nine South American countries. Three dimensions were highlighted from documentary sources: political commitment, leadership, and governance; care model; and engagement of communities and other stakeholders. The results indicate a formal commitment that places PHC at the center of efforts to achieve universal access. The following can be observed: revitalization processes in public subsystems, based on guaranteeing preventive, promotional, curative and rehabilitation actions; PHC as gatekeeper; emphasis on family and community; assigned population and territory; multidisciplinary teams; and, in some cases, the accent on interculturality expressed in the concept of "buen vivir" (good living). The PHC revitalization processes were affected by political changes. Between progress and setbacks, the segmentation of coverage was not overcome. The current moment seeks to recover more inclusive and broad public policies in the context of the return of the progressive and democratic fields. The dissemination of country experiences can contribute to the development of a comprehensive, integrated, and quality approach to PHC in the Region.

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Objectives: Brazil's PHC wide coverage has a potential role in the fight against COVID, especially in less developed regions. PHC should deal with COVID-19 treatment; health surveillance; continuity of care; and social support. This article aims to analyze PHC performance profiles during the pandemic, in these axes, comparing the five Brazilian macro-regions. Methods: A cross-sectional survey study was carried out, using stratified probability sampling of PHC facilities (PHCF). A Composite Index was created, the Covid PHC Index (CPI). Factor analysis revealed that collective actions contrastingly behaved to individual actions. We verified differences in the distributions of CPI components between macro-regions and their associations with structural indicators. Results: Nine hundred and seven PHCF participated in the survey. The CPI and its axes did not exceed 70, with the highest value in surveillance (70) and the lowest in social support (59). The Individual dimension scored higher in the South, whereas the Collective dimension scored higher in the Northeast region. PHCF with the highest CPI belong to municipalities with lower HDI, GDP per capita, population, number of hospitals, and ICU beds. Conclusion: The observed profiles, individually and collectively-oriented, convey disputes on Brazilian health policies since 2016, and regional structural inequalities.

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INTRODUCTION: The COVID-19 pandemic has emerged as one of the greatest challenges to societies, world health systems and science in the past century, making it imperative to restructure care networks. Therefore, it is essential to discuss the role and initiatives of primary health care (PHC) to deal with it. However, regarding the response to the pandemic, including the current global effort against COVID-19, the nuances of the rural/remote PHC context in the pandemic is barely visible. Rural and remote communities have differentiated health risks, such as socioeconomic disadvantages, difficulties in mobility and access to health services, in addition to linguistic and cultural barriers. This scoping review aimed to analyze the set of individual and collective initiatives and innovations developed to face the COVID-19 pandemic, within the PHC scope, in rural and remote areas. METHODS: A scoping review methodology was applied to peer-reviewed articles. Eight databases were searched to identify scientific articles published in English, Spanish and Portuguese, initially from January 2020 to July 2021, complemented by a rapid review of articles published from January 2022 to April 2023. The main focus sought in the literature was the set of initiatives and innovations carried out within the PHC scope in rural and remote locations during the pandemic, as well as the comparison with pre-pandemic situations and between different countries. The bibliographic information of each search result was imported into Rayyan (Intelligent Systematic Review), followed by the screening and eligibility stages, performed independently by two reviewers, with a third reviewer being accessed in case of conflicts. RESULTS: This review included 54 studies, with publications mostly from Australia, Canada, the US and India. The main PHC initiatives were related to access; to the roles of community health workers and health surveillance; and to the importance of placing, retaining and valuing human resources in health. Cultural, equity and vulnerability issues occupy a major place among the initiatives. Regarding the innovations, telehealth and customized communication are highlighted. From an organizational point of view, rural and remote locations showed enormous flexibility to deal with the pandemic and to improve intersectoral activities at the local level. The description of rurality and remoteness is practically coincident with that of the specific populations, present in geographic areas of difficult sociospatial and cultural access. Rarely, there is an index to measure rurality, or its description deals with the need to overcome distances and obstacles. CONCLUSION: The findings highlight and summarize knowledge about initiatives and innovations developed to face the COVID-19 pandemic, within the PHC scope in rural and remote areas in the world. This review has identified collective, clinical, intersectoral and, mainly, organizational health initiatives. An articulation between different government levels would be paramount in evaluating the implementation of policies and protocols in rural and remote locations for future sanitary crises. Innovations and lessons learned are equally relevant in strengthening health services and systems. This issue calls for considerable further exploration by new reviews and empirical research that seek evidence to assess the sustainability and effectiveness of the implemented measures to face post-pandemic difficulties and other adversities.

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The adequate fight against pandemics requires effective coordination between primary health care (PHC) and health surveillance, guaranteed attention to acute and chronic demands, and a bond with the community dimension in the scope of basic health units (UBS, acronym in Portuguese). This study aims to contrast two extreme standards of PHC performance in the fight against COVID-19 in Brazil, comparing them with the profiles of the corresponding municipalities and characteristics of the organization of services. Based on the results of a cross-sectional national survey with a representative sample of UBSs, we created a synthetic index to evaluate how PHC performs against COVID-19 called CPI, composed of axes of health surveillance and social support (collective dimension) and of COVID-19 care and continuity of care (individual dimension). Of the 907 surveyed UBSs, 120 were selected, half of which had the highest indexes (complete standard) and the other half, the lowest ones (restricted standard). The municipalities of the UBSs with a complete standard are predominantly rural, have low Municipal Health Development Index (MHDI), high Family Health Strategy (FHS) coverage, and stand out in the collective dimension, whereas the UBSs in urban municipalities with this same standard have high MHDI, low FHS coverage, and an emphasis on the individual dimension. In the restricted standard, we highlight community health workers' reduced work in the territory. In the Brazilian Northeast, UBSs with complete standard predominate, whereas, in its Southeast, UBSs with restricted standard predominate. The study poses questions that refer to the role and organization of PHC in the health care network under situations that require prompt response to health issues and indicates the greater potential capacity of the FHS program in such situations.

O enfrentamento adequado de pandemias requer forte articulação entre atenção primária à saúde (APS) e vigilância em saúde, atenção garantida às demandas agudas e crônicas e vinculação com a dimensão comunitária no âmbito das unidades básicas de saúde (UBS). O objetivo deste artigo é contrastar dois padrões extremos de desempenho da APS no enfrentamento da COVID-19 no Brasil, cotejando-os com os perfis dos respectivos municípios e características da organização dos serviços. A partir dos resultados de inquérito nacional transversal com amostra representativa das UBS, foi criado um índice sintético de desempenho da APS em relação à COVID-19, denominado CPI, composto pelos eixos de vigilância e apoio social (dimensão coletiva) e de atendimento ao paciente com COVID-19 e continuidade do cuidado (dimensão individual). Das 907 UBS pesquisadas, foram selecionadas 120, sendo a metade com os maiores índices encontrados (padrão completo) e a outra com os menores (padrão restrito). Os municípios das UBS com padrão completo são preponderantemente rurais, com baixo Índice de Desenvolvimento Humano Municipal (IDHM), alta cobertura da Estratégia Saúde da Família (ESF) e destacam-se na dimensão coletiva, enquanto as UBS nesse mesmo padrão situadas em municípios urbanos apresentam alto IDHM, baixa cobertura de ESF, com ênfase na dimensão individual. No padrão restrito, destaca-se a reduzida atuação de agentes comunitários de saúde no território. Na Região Nordeste, predominam UBS com padrão completo, enquanto na Sudeste preponderam UBS com padrão restrito. O estudo apresenta questões que remetem ao papel e à organização da APS na rede de cuidados em situações que requerem pronta resposta aos agravos de saúde e indica maior capacidade potencial da ESF em tais situações.

El enfrentamiento adecuado de las pandemias requiere una fuerte articulación entre atención primaria de salud (APS) y la vigilancia en salud, una atención garantizada a las demandas agudas y crónicas y la vinculación con la dimensión comunitaria en el ámbito de las unidades básicas de salud (UBS). El objetivo de este artículo es contrastar dos patrones extremos de desempeño de la APS en el enfrentamiento del COVID-19 en Brasil, comparándolos con los perfiles de los respectivos municipios y características de la organización de los servicios. A partir de los resultados de una encuesta nacional transversal con una muestra representativa de las UBS fue creado un índice sintético de desempeño de la APS frente al COVID-19, denominado CPI, compuesto por los ejes de vigilancia y apoyo social (dimensión colectiva) y de atención al COVID-19 y continuidad de la atención (dimensión individual). De las 907 UBS investigadas, se seleccionaron 120, siendo la mitad con los índices más grandes encontrados (estándar completo) y la otra con los más bajos (estándar estricto). Los municipios de las UBS con estándar completo son preponderantemente rurales, con bajo índice de desarrollo humano municipal (IDHM), alta cobertura de la Estrategia Salud de la Familia (ESF) y se destacan en la dimensión colectiva, mientras que las UBS en este mismo estándar situadas en municipios urbanos presentan alto IDHM, baja cobertura de ESF, con énfasis en la dimensión individual. En el estándar estricto, se destaca la reducida actuación de los agentes comunitarios de salud en el territorio. En la región Nordeste predominan las UBS con estándar completo, mientras que en el Sureste predominan las UBS con un estándar estricto. El estudio aporta cuestiones que remiten al papel y organización de la APS en la red de atención en situaciones que requieren respuesta rápida a los problemas de salud e indica una mayor capacidad potencial de la ESF en tales situaciones.

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RESUMO A epidemiologia, apesar de suas origens sócio-históricas, tornou-se hegemonicamente individual, linear, com clivagens entre os hemisférios norte e sul, entre método e teoria crítica, de onde emerge a necessidade de uma epidemiologia voltada à emancipação humana. O objetivo deste artigo é avaliar de que forma a epidemiologia contra-hegemônica tem contribuído para práticas efetivas de emancipação humana na saúde pública nos diferentes níveis de justiça. Realizou-se revisão integrativa, com busca nas bases de dados PubMed, BVS, Assia, Embase e SA e análise temática e cross-case. Diante de lentes ajustadas à epidemiologia crítica, reconstituímos os tensionamentos entre as diferentes formas de emancipações política e humana, nos níveis de justiça cognitiva, socioambiental e de saúde. O primeiro nível, cognitivo, é atravessado pela razão de mundo e pelo pensamento abissal e envolve os demais. O nível socioambiental foi ancorado no metabolismo socionatural-histórico e o de saúde, angustia-se entre o bem viver e as lutas fragmentadas pelos direitos à saúde universal, frente à espoliação do setor. No enfrentamento ao modelo de acumulação de capital, devemos valorizar a interculturalidade e a subjetividade. Evidenciou-se que a 'Epistemologia do Sul' remete a um pensamento descolonizador, orientando metodologias capazes de potencializar descobertas bem como desmistificar as relações sociais.

ABSTRACT Epidemiology, despite its socio-historical origins, has become hegemonically individual and linear, with the north-southern hemispheres divide, methodology and critical theory, which calls for a human emancipation oriented epidemiology. The aim of this article is to assess how critical epidemiology has contributed to effective human emancipation practices in public health, at different justice levels. An Integrative review was performed, with searches in PubMed, VHL, ASSIA, EMBASE and SA databases and thematic and cross-case analysis. Elaborating through critical counter-hegemonic epidemiology adjusted lens, we reconstitute the tension between different modes of human and political emancipations, at the levels of cognitive, socio-environmental and health justice. The cognitive level is crossed by the 'way of the world' and the 'abyssal' thinking and involves the other levels. The socio-environmental level was anchored in the historical socio-natural metabolism and that of health, anguishes between well-being and the fragmented struggles for universal health rights, as opposed to the spoliation of the sector. In confronting the capital accumulation model, it's essential to value interculturality and subjectivity We found evidence that the 'Epistemology of the South' points out to a decolonizing thought-oriented methodology, capable of enhancing discoveries and demystifying social relations.

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O enfrentamento adequado de pandemias requer forte articulação entre atenção primária à saúde (APS) e vigilância em saúde, atenção garantida às demandas agudas e crônicas e vinculação com a dimensão comunitária no âmbito das unidades básicas de saúde (UBS). O objetivo deste artigo é contrastar dois padrões extremos de desempenho da APS no enfrentamento da COVID-19 no Brasil, cotejando-os com os perfis dos respectivos municípios e características da organização dos serviços. A partir dos resultados de inquérito nacional transversal com amostra representativa das UBS, foi criado um índice sintético de desempenho da APS em relação à COVID-19, denominado CPI, composto pelos eixos de vigilância e apoio social (dimensão coletiva) e de atendimento ao paciente com COVID-19 e continuidade do cuidado (dimensão individual). Das 907 UBS pesquisadas, foram selecionadas 120, sendo a metade com os maiores índices encontrados (padrão completo) e a outra com os menores (padrão restrito). Os municípios das UBS com padrão completo são preponderantemente rurais, com baixo Índice de Desenvolvimento Humano Municipal (IDHM), alta cobertura da Estratégia Saúde da Família (ESF) e destacam-se na dimensão coletiva, enquanto as UBS nesse mesmo padrão situadas em municípios urbanos apresentam alto IDHM, baixa cobertura de ESF, com ênfase na dimensão individual. No padrão restrito, destaca-se a reduzida atuação de agentes comunitários de saúde no território. Na Região Nordeste, predominam UBS com padrão completo, enquanto na Sudeste preponderam UBS com padrão restrito. O estudo apresenta questões que remetem ao papel e à organização da APS na rede de cuidados em situações que requerem pronta resposta aos agravos de saúde e indica maior capacidade potencial da ESF em tais situações.

El enfrentamiento adecuado de las pandemias requiere una fuerte articulación entre atención primaria de salud (APS) y la vigilancia en salud, una atención garantizada a las demandas agudas y crónicas y la vinculación con la dimensión comunitaria en el ámbito de las unidades básicas de salud (UBS). El objetivo de este artículo es contrastar dos patrones extremos de desempeño de la APS en el enfrentamiento del COVID-19 en Brasil, comparándolos con los perfiles de los respectivos municipios y características de la organización de los servicios. A partir de los resultados de una encuesta nacional transversal con una muestra representativa de las UBS fue creado un índice sintético de desempeño de la APS frente al COVID-19, denominado CPI, compuesto por los ejes de vigilancia y apoyo social (dimensión colectiva) y de atención al COVID-19 y continuidad de la atención (dimensión individual). De las 907 UBS investigadas, se seleccionaron 120, siendo la mitad con los índices más grandes encontrados (estándar completo) y la otra con los más bajos (estándar estricto). Los municipios de las UBS con estándar completo son preponderantemente rurales, con bajo índice de desarrollo humano municipal (IDHM), alta cobertura de la Estrategia Salud de la Familia (ESF) y se destacan en la dimensión colectiva, mientras que las UBS en este mismo estándar situadas en municipios urbanos presentan alto IDHM, baja cobertura de ESF, con énfasis en la dimensión individual. En el estándar estricto, se destaca la reducida actuación de los agentes comunitarios de salud en el territorio. En la región Nordeste predominan las UBS con estándar completo, mientras que en el Sureste predominan las UBS con un estándar estricto. El estudio aporta cuestiones que remiten al papel y organización de la APS en la red de atención en situaciones que requieren respuesta rápida a los problemas de salud e indica una mayor capacidad potencial de la ESF en tales situaciones.

The adequate fight against pandemics requires effective coordination between primary health care (PHC) and health surveillance, guaranteed attention to acute and chronic demands, and a bond with the community dimension in the scope of basic health units (UBS, acronym in Portuguese). This study aims to contrast two extreme standards of PHC performance in the fight against COVID-19 in Brazil, comparing them with the profiles of the corresponding municipalities and characteristics of the organization of services. Based on the results of a cross-sectional national survey with a representative sample of UBSs, we created a synthetic index to evaluate how PHC performs against COVID-19 called CPI, composed of axes of health surveillance and social support (collective dimension) and of COVID-19 care and continuity of care (individual dimension). Of the 907 surveyed UBSs, 120 were selected, half of which had the highest indexes (complete standard) and the other half, the lowest ones (restricted standard). The municipalities of the UBSs with a complete standard are predominantly rural, have low Municipal Health Development Index (MHDI), high Family Health Strategy (FHS) coverage, and stand out in the collective dimension, whereas the UBSs in urban municipalities with this same standard have high MHDI, low FHS coverage, and an emphasis on the individual dimension. In the restricted standard, we highlight community health workers' reduced work in the territory. In the Brazilian Northeast, UBSs with complete standard predominate, whereas, in its Southeast, UBSs with restricted standard predominate. The study poses questions that refer to the role and organization of PHC in the health care network under situations that require prompt response to health issues and indicates the greater potential capacity of the FHS program in such situations.

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Resumo A pandemia ressaltou novos e antigos riscos à saúde que demandam ações sanitárias e formas de apoio social. Este artigo analisou o conhecimento dos profissionais de saúde de UBSs sobre iniciativas da sociedade e dos serviços de saúde, articulados ou separadamente na promoção de saúde e apoio social a grupos vulneráveis. Partiu-se da revisão teórica sobre o conceito e sua aplicação e da análise de dados empíricos do estudo multidimensional "Desafios à APS no enfrentamento da COVID-19", de desenho transversal, com amostra representativa das UBSs brasileiras, em nível nacional e regional. Gerou-se escore a partir de variáveis selecionadas e agregadas e estimou-se proporções de ações selecionadas e IC (95%), no Brasil e suas regiões. Ações a partir das UBSs e da população mostraram-se heterogêneas entre as regiões, sendo significativamente mais frequentes na região NE e em municípios não urbanos e de menor IDH, associando-se às ações desenvolvidas no território pelos ACS. Identificaram-se desafios, lacunas e necessidade de novas investigações; amplificação da magnitude e escopo de ações intra/intersetoriais; fortalecimento de laços entre diferentes atores e reversão dos efeitos da pandemia que aprofundaram desigualdades e iniquidades em saúde.

Abstract The pandemic highlighted new and old health risks that require health actions and social support. This study analyzed the knowledge of health professionals working in primary health care centers (PHCCs) regarding civil society and health service separately or along with health promotion and social support initiatives targeting vulnerable groups. The article begins by discussing the concept of social support and then goes on to present an analysis of empirical data from the multidimensional cross-sectional study "Challenges facing primary health care in the response to COVID-19 in the SUS", conducted using a nationally representative sample of PHCCs. Scores were calculated for selected and aggregated variables, and we calculated percentages for selected actions together with 95% confidence intervals at national and regional level. The percentage of PHCCs that supported actions and where the local community developed initiatives in the catchment area varied across regions, with rates being significantly higher in the Northeast and in non-urban municipalities with low MHDI, which was associated with actions developed in the catchment area by community health workers. The findings reveal several gaps and challenges, including the need to amplify the magnitude and scope of intra and intersectoral actions, strengthen ties between different actors, reverse the effects of the pandemic on health inequities and promote further research.

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Health equity is cross sectioned by the reproduction of social relations of gender, ethnicity and power. The purpose of this article is to assess how intersectional health equity determines societal health levels, in a local efficiency analysis within Brazil's Unified Health System (SUS), among Sao Paulo state municipalities. Fixed Panel Effects Model and Data Envelopment Analysis techniques were applied, according to resources, health production and intersectoral dimensions. The effect variables considered were expectation of life at birth and infant mortality rates, in 2000 and 2010, according to local health regions (HR) and regionalized healthcare networks (RRAS). Inequity was assessed both socioeconomically and culturally (income, education, ethnicity and gender). Both methods demonstrated that localities with higher inequities (income and education, gender and ethnicity oriented), associated or not to vulnerability (young and low-income families, in subnormal urban agglomerations), were the least efficient. Health production contributes too little to health levels, especially at the local level, which is highly correlated to the intersectoral dimension. Intersectional health equity, reinforced in its intertwining with ethnicity, gender and social position, is essential in order to achieve adequate societal health levels, beyond health access or sanitary and clinical efficacy.

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This paper examines the evolution of Brazil's Family Health Strategy coverage from the findings of the 2013 and 2019 National Health Survey censuses. Indicators included Family Health Clinic coverage of residents and households, frequency of visits by Community Health Workers, and usual source of care, all stratified by rural and urban areas, Brazilian regions, states, education of the household head, and income quintile. In 2019, 60.0% of households were enrolled in a Family Health Clinic, and population coverage was 62.6%. Coverage was higher in rural than in urban areas in the Northeast and South regions. Between 2013 and 2019, coverage increased by 11.6%, while monthly health worker visits decreased. Coverage was highest among the most vulnerable population, as defined by the household head education level or by the family income. Availability of usual source of care was highest among those enrolled in a Family Health Clinic. The 2019 National Health Survey findings confirm that Brazil's Family Health Strategy continues to be an equitable policy and the main SUS' Primary Health Care model. However, recent changes in the national policy guidance, which are weakening the community approach and the priority given to the Family Health Strategy Program, may jeopardize those gains.

O artigo analisa a evolução da cobertura da Estratégia de Saúde da Família (ESF), a partir dos resultados dos inquéritos populacionais das Pesquisas Nacionais de Saúde (PNS) de 2013 e 2019. Foram calculados indicadores de cobertura de moradores e domicílios por Unidade de Saúde da Família (USF), frequência da visita de Agente Comunitário de Saúde (ACS), serviço de procura regular e tipo de serviço buscado; estratificados por área rural e urbana, grandes regiões, unidades da federação, escolaridade do responsável pelo domicílio e quintis de renda. Em 2019, 60,0% dos domicílios estavam cadastrados em USF e a cobertura de moradores era 62,6%. A cobertura é superior na área rural e nas regiões Nordeste e Sul. Entre 2013 e 2019, observa-se aumento de cobertura em 11,6% e redução na visita mensal do ACS. A cobertura é mais elevada entre a população mais vulnerável, considerada escolaridade do responsável pelo domicílio ou renda familiar. A disponibilidade de serviço de procura regular é maior entre cadastrados na USF. Os resultados da PNS 2019 reiteram que a ESF permaneceu como política equitativa e principal modelo de APS no SUS. No entanto, as recentes mudanças na condução da política nacional, que enfraquecem o enfoque comunitário e a prioridade da ESF, podem ameaçar tais avanços.

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Resumo O artigo analisa a evolução da cobertura da Estratégia de Saúde da Família (ESF), a partir dos resultados dos inquéritos populacionais das Pesquisas Nacionais de Saúde (PNS) de 2013 e 2019. Foram calculados indicadores de cobertura de moradores e domicílios por Unidade de Saúde da Família (USF), frequência da visita de Agente Comunitário de Saúde (ACS), serviço de procura regular e tipo de serviço buscado; estratificados por área rural e urbana, grandes regiões, unidades da federação, escolaridade do responsável pelo domicílio e quintis de renda. Em 2019, 60,0% dos domicílios estavam cadastrados em USF e a cobertura de moradores era 62,6%. A cobertura é superior na área rural e nas regiões Nordeste e Sul. Entre 2013 e 2019, observa-se aumento de cobertura em 11,6% e redução na visita mensal do ACS. A cobertura é mais elevada entre a população mais vulnerável, considerada escolaridade do responsável pelo domicílio ou renda familiar. A disponibilidade de serviço de procura regular é maior entre cadastrados na USF. Os resultados da PNS 2019 reiteram que a ESF permaneceu como política equitativa e principal modelo de APS no SUS. No entanto, as recentes mudanças na condução da política nacional, que enfraquecem o enfoque comunitário e a prioridade da ESF, podem ameaçar tais avanços.

Abstract This paper examines the evolution of Brazil's Family Health Strategy coverage from the findings of the 2013 and 2019 National Health Survey censuses. Indicators included Family Health Clinic coverage of residents and households, frequency of visits by Community Health Workers, and usual source of care, all stratified by rural and urban areas, Brazilian regions, states, education of the household head, and income quintile. In 2019, 60.0% of households were enrolled in a Family Health Clinic, and population coverage was 62.6%. Coverage was higher in rural than in urban areas in the Northeast and South regions. Between 2013 and 2019, coverage increased by 11.6%, while monthly health worker visits decreased. Coverage was highest among the most vulnerable population, as defined by the household head education level or by the family income. Availability of usual source of care was highest among those enrolled in a Family Health Clinic. The 2019 National Health Survey findings confirm that Brazil's Family Health Strategy continues to be an equitable policy and the main SUS' Primary Health Care model. However, recent changes in the national policy guidance, which are weakening the community approach and the priority given to the Family Health Strategy Program, may jeopardize those gains.

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BACKGROUND: Health equity, although addressed in several publications dealing with health efficiency analysis, is not easily translated into the operationalization of variables, mainly due to technical difficulties. Some studies provide evidence that it does not influence health outcomes; others demonstrate that its effect is an indirect one, with the hegemony of material living conditions over its social connotation. The aim of this article is to evaluate the role of health equity in determining health outcomes, in an international comparative analysis of the effectiveness and efficiency of health systems. METHOD: Fixed Effects Model Panel and Data Envelopment Analysis, a dynamic and network model, in addition to comparative analysis between methods and health impacts. The effect variables considered in the study were life expectancy at birth and infant mortality, in 2010 and 2015, according to the sociocultural regions of the selected countries. Inequity was assessed both economically and socially. The following dimensions were considered: physical and financial resources, health production (access, coverage and prevention) and intersectoral variables: demographic, socioeconomic, governance and health risks. RESULTS: Both methods demonstrated that countries with higher inequity levels (regarding income, education and health dimensions), associated or not with poverty, are the least efficient, not reaching the potential for effective health outcomes. The outcome life expectancy at birth exhibited, in the final model, the following variables: social inequity and per capita health expenditure. The outcome infant mortality comprehended the level of education variable, in association with the following healthcare variabels: care seeking due to diarrhea in children under five, births attended by skilled health professionals and the reduction in the incidence of HIV. CONCLUSION: The dissociation between the distribution of health outcomes and the overall level of health of the population characterizes a devastating political choice for society, as it is associated with high levels of segregation, disrespect and violence from within. Countries should prioritize health equity, adding value to its resources, since health inequties affect society altogether, generating mistrust and reduced social cohesion.

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A literatura internacional e nacional tem demonstrado uma série de discordâncias nas mensurações de eficiência de sistemas de saúde, principalmente no que se refere à equidade em saúde e sua relação com a efetividade, que foi a base deste estudo. Os próprios conceitos são abrangentes e de difícil apreensão, enquanto que as metodologias utilizadas são diversas. O objetivo deste trabalho é analisar e buscar os melhores modelos para a comparação intertemporal de eficiência dos sistemas de saúde, em âmbito internacional e local, especificamente entre os municípios paulistas, tendo como norte a equidade. Para tanto, buscouse a análise da produção de saúde, com variáveis que pudessem refletir extensivamente os seus estágios, desde recursos (financeiros, humanos, materiais, tecnológicos e de governança) até atividades e produtos intermediários (acesso, cobertura e prevenção) e resultados finais (expectativa de vida ao nascer e mortalidade infantil), com variáveis ambientais avaliadas transversalmente. A metodologia empregada foi a análise envoltória de dados (DEA) em rede intertemporal, estratificada por níveis de equidade em saúde, com folgas (modelo aditivo - SBM), além de regressão para dados em painel (efeitos fixos), precedida de revisão integrativa. As variáveis remanescentes nos modelos finais, tanto em nível global quanto local, foram aquelas relacionadas às iniquidades socioeconômicas e culturais (incluindo saúde em nível global; renda e educação de modo interseccional, em nível local) e às vulnerabilidades (desembolsos diretos, em nível global; famílias jovens, de baixa renda, em aglomerados urbanos subnormais, em nível local). Na análise global, a variável expectativa de vida ao nascer foi determinada por baixa iniquidade e altos gastos em saúde per capita. A variável mortalidade infantil associou-se a piores níveis de educação e de busca por atenção à saúde decorrente de diarreia em crianças, aos partos não realizados por profissionais qualificados e à alta incidência de HIV. Na análise local, a produção de saúde pouco explicou os níveis de saúde, estando altamente correlacionados à dimensão intersetorial e de recursos. Neste nível, a variável expectativa de vida ao nascer associou-se à baixa iniquidade de renda e vulnerabilidade, alta renda média per capita, baixa proporção de mães adolescentes, saneamento adequado, baixas taxas de analfabetismo e desemprego, e altas taxas de envelhecimento. A variável mortalidade infantil associou-se à alta iniquidade de renda do trabalho e por etnia, alta proporção de crianças fora da escola, baixas taxas de envelhecimento e altas taxas de desemprego e analfabetismo. O mais marcante é como que a eficiência é tanto maior, quanto menores as iniquidades, conforme os mapas de iniquidades do nível de educação por gênero e etnia, do índice de Theil geral e do trabalho. A dissociação entre a distribuição dos resultados em saúde e o nível geral de saúde da população caracteriza uma escolha política desastrosa para a sociedade, pois associa-se ao incremento dos níveis de segregação, desrespeito e violência em seu interior. A equidade em saúde interseccional, reforçada em seus entrelaçamentos com etnia, gênero e posição social, é essencial para o alcance de bons resultados finais para a sociedade, para além do acesso e da eficácia clínica e sanitária.

Both international and national literature have shown major disagreements in measuring health system efficiency, especially concerning health equity and its relationship with system effectiveness, which was the basis of this project. The concepts vary widely and are hard to grasp, while applied methodologies are diverse. The aim of this study is to analyse and seek the best models that apply, in order to compare intertemporal health system efficiency, at both global and local levels, the latter among Sao Paulo municipalities, directed to equity. To achieve this goal, the health production process was studied thoroughly, with variables that could reflect all of its stages, from inputs (financial, human, material, technological and governance resources), activities and intermediate products (access, coverage and prevention) to outcomes (life expectancy at birth and infant mortality rates), cross-sectioned by environmental variables. The methodological approach chosen was Data Envelopment Analysis (DEA), stratified according to equity levels, slack-based intertemporal network model (additive model - SBM), besides panel data regression analysis (fixed effects model), preceded by an integrative review of the literature. Both methods, in global and local levels, demonstrated that localities with higher inequities (including health at the global level; income and education, gender and ethnicity oriented at the local level), associated or not to vulnerability (out-of-pocket payments at the global level; young and low-income families, in subnormal urban agglomerations at the local level) were the least efficient. At the global level, the outcome life expectancy at birth determinants were lower inequity and higher health expenditure per capita. Infant mortality rates associated with lower education levels and careseeking for diarrhea in children under five, births attended by non skilled health personnel and higher incidence of HIV. At the local level, health production hardly explained the health levels, which are highly correlated to the intersectoral and resources dimensions. At this level, life expectancy at birth determinants were lower income inequity and social vulnerability, lower proportions of teenage mothers, adequate sanitation, along with aging, literacy and employment rates. Infant mortality rates associated with income inequity from work and by ethnicity, with higher proportions of children out of school, lower levels of aging, and higher unemployment and illiteracy rates. Most strikingly, efficiency revealed to be higher in those localities with lower inequities, according to the inequity maps generated for gender and ethnicity inequities in education and for income distribution (Theil index-general and work-related). The dissociation between the distribution of health outcomes and the overall population level of health characterizes a devastating political choice for society, as it is associated with increases in the levels of segregation, disrespect and violence from within. Intersectional health equity, reinforced in its intertwining with ethnicity, gender and social position, is essential in order to achieve adequate societal health levels, beyond health access or sanitary and clinical efficacy.

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Resumo Nas últimas décadas, o sistema capitalista, transformado por meio de crises mais agressivas e globais, tem submetido a sociedade à austeridade fiscal e tensionado a garantia dos direitos à saúde, como imposição para ampliar a eficiência e efetividade dos sistemas de saúde. A equidade em saúde, por outro lado, opera como fator protetor em relação aos efeitos nocivos da austeridade sobre a saúde da população. O objetivo deste artigo é analisar o efeito da crise financeira global quanto à valorização da equidade em saúde frente à efetividade nas comparações internacionais de eficiência dos sistemas de saúde na literatura científica. Realizada revisão integrativa, com busca nas bases de dados PubMed e BVS, de 2008-18, com análise cross-case. O equilíbrio entre equidade e efetividade deve ser buscado desde o financiamento até os resultados em saúde, de modo eficiente, como forma de fortalecimento dos sistemas de saúde. A escolha entre alteridade ou austeridade deve ser feita de forma explícita e transparente, com resiliência dos valores societais e princípios de universalidade, integralidade e equidade.

Abstract In recent decades, the global and aggressive crises-transformed capitalist system has subjected society to fiscal austerity and strained the assurance of its right to health, as an imposition to increase health systems efficiency and effectiveness. Health equity, on the other hand, provides protection against the harmful effects of austerity on population health The aim of this article is to analyse the effect of the global financial crisis on how health equity is considered against effectiveness in international comparisons of health systems efficiency in the scientific literature. Integrative review, based on PubMed and VHL databases searches, 2008-18, and cross-case analysis. The balance between equity and effectiveness must be sought from health financing to results, in an efficient way, as a means to strengthening health systems. The choice between alterity or austerity must be made explicitly and transparently, with resilience of societal values and the principles of universality, integrality and equity.

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In recent decades, the global and aggressive crises-transformed capitalist system has subjected society to fiscal austerity and strained the assurance of its right to health, as an imposition to increase health systems efficiency and effectiveness. Health equity, on the other hand, provides protection against the harmful effects of austerity on population health The aim of this article is to analyse the effect of the global financial crisis on how health equity is considered against effectiveness in international comparisons of health systems efficiency in the scientific literature. Integrative review, based on PubMed and VHL databases searches, 2008-18, and cross-case analysis. The balance between equity and effectiveness must be sought from health financing to results, in an efficient way, as a means to strengthening health systems. The choice between alterity or austerity must be made explicitly and transparently, with resilience of societal values and the principles of universality, integrality and equity.

Nas últimas décadas, o sistema capitalista, transformado por meio de crises mais agressivas e globais, tem submetido a sociedade à austeridade fiscal e tensionado a garantia dos direitos à saúde, como imposição para ampliar a eficiência e efetividade dos sistemas de saúde. A equidade em saúde, por outro lado, opera como fator protetor em relação aos efeitos nocivos da austeridade sobre a saúde da população. O objetivo deste artigo é analisar o efeito da crise financeira global quanto à valorização da equidade em saúde frente à efetividade nas comparações internacionais de eficiência dos sistemas de saúde na literatura científica. Realizada revisão integrativa, com busca nas bases de dados PubMed e BVS, de 2008-18, com análise cross-case. O equilíbrio entre equidade e efetividade deve ser buscado desde o financiamento até os resultados em saúde, de modo eficiente, como forma de fortalecimento dos sistemas de saúde. A escolha entre alteridade ou austeridade deve ser feita de forma explícita e transparente, com resiliência dos valores societais e princípios de universalidade, integralidade e equidade.

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OBJECTIVE: To evaluate the quality of life during the first three years of training and identify its association with sociodemographicoccupational characteristics, leisure time and health habits. METHOD: A cross-sectional study with a random sample of 128 residents stratified by year of training was conducted. The Medical Outcome Study -short form 36 was administered. Mann-Whitney tests were carried out to compare percentile distributions of the eight quality of life domains, according to sociodemographic variables, and a multiple linear regression analysis was performed, followed by a validity checking for the resulting models. RESULTS: The physical component presented higher quality of life medians than the mental component. Comparisons between the three years showed that in almost all domains the quality of life scores of the second year residents were higher than the first year residents (p < 0.01). The mental component scores remained high for third year residents (p < 0.01). Predictors of higher quality of life were: second or third year of residency, satisfaction with the training program, sufficient time for leisure, and care of critical patients for less than 30 hours per week. CONCLUSION: The mental component of quality of life was the most impaired component, indicating the importance of caring for residents' mental health, especially during their first year and when they are overloaded with critical patients.

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