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Our study evaluates the liquidation effect of a health insurer from a subsidized scheme, with the largest number of members in Colombia, on restrictions to future access to user care. Based on the information regarding complaints and judicial claims about healthcare, the effect of this government decision is estimated using a dynamic econometric model of differences in differences. Our results suggest that the liquidation of the Health-Promoting Entity (EPS, its acronym in Spanish) CAPRECOM has a negative effect, specifically, it led to an increase of 0.32 and 0.21 in complaints rates per 1,000 members in the receiving EPSs during the first and second quarters after the intervention, respectively. However, this effect does not persist over time and becomes diluted in the following quarters. There is no evidence of a relationship between the magnitude of the effect and the EPSs performance ranking. Additionally, we do not find significant effects on judicial claims. Our results are important concerning the design and implementation of public policies for EPSs liquidation. We demonstrate the necessity of implementing actions to incorporate guidelines and strategic plans during the transition period. Such actions would enable safeguarding the right to health for the affected population in a liquidation insurer case.

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A growing body of scholarship examines the varying impact of legal status and race on accessing healthcare. However, a notable gap persists in comprehending the supplementary mechanisms that hinder immigrants' pathway to seek care. Drawing on ethnographic observations in various clinical settings and in-depth interviews with 28 healthcare professionals and 12 documented Haitian immigrants in a city in Upstate New York, between 2019 and 2021, I demonstrate the tension between the conceptualization and implementation of inclusive care practices by healthcare providers. I argue that the mere expansion and adoption of inclusive discourse among providers do not inherently ensure equity and the removal of barriers to healthcare access. This work contributes to the social study of medicine and race and ethnic studies by introducing the innovative concept of "immigrant-blind." Through this concept, the research sheds light on how providers' conceptualization of inclusivity proclaims medical encounters to be devoid of stratifications and rationalizes their practices which mask the profound impact of immigration status and immigration on immigrant health. Furthermore, these practices reinforce existing divisions within care settings and medical encounters, where immigration laws and enforcement practices operate and further exacerbate stratifications. By examining providers' uninformed implementation of culturally competent care practices, the findings reveal that providers stigmatize and essentialize immigrants during medical encounters. This highlights the imperative for a more nuanced and informed approach to healthcare provision, where genuine inclusivity is upheld, and barriers to access are dismantled to foster equitable and dignified healthcare experiences for all.

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Resumo O gênero é uma categoria social diretamente ligada à determinação da saúde, mas tem sido frequentemente limitado às categorias de masculino e feminino, invisibilizando demandas importantes de identidades que fogem ao binarismo, como no caso de identidade transgênero (travestis e transexuais). A teoria do estresse de minorias de gênero categoriza fatores de estresse e resiliência relevantes para explicar como as vivências ligadas ao gênero impactam de maneira desproporcional pessoas transgênero, especialmente em desfechos de saúde mental. Nesse contexto, este estudo analisa a relação entre acesso e uso de serviços de saúde e os fatores de estresse e resiliência de travestis e mulheres transexuais no interior do nordeste brasileiro. Foi conduzida uma pesquisa qualitativa em saúde: dados foram coletados por meio de entrevistas semiestruturadas com cinco mulheres trans adultas, residentes da região do Cariri, Ceará. Observou-se homogeneidade no acesso à saúde, mas todas as entrevistadas enfrentaram situações de estresse durante a utilização. Identificaram-se fatores de resiliência que levam essa população a buscar cuidados de saúde fora do sistema de saúde, devido a suas dificuldades de uso. Portanto, evidencia-se a necessidade de discutir a amplitude e o progresso do processo transexualizador e a capacidade de aplicação da Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais e Transgêneros no âmbito do Sistema Único de Saúde no interior do nordeste brasileiro.

Abstract Gender is a social category directly linked to health determination, but it has often been constrained to the categories of male and female, obscuring significant demands from identities that go beyond this binary framework, such as transgender identities (travestis and transsexuals). Gender minority stress is a theory that categorizes stress and resilience factors relevant to explaining how gender experiences disproportionately impact transgender individuals, particularly in mental health outcomes. Given this context, this study examines the relations between user access and use of health services and the stress and resilience factors of travestis and transgender women in northeastern Brazil. A qualitative health research was conducted with data collected by means of semi-structured interviews with five adult trans women residing in the Cariri region, Ceará state. Health access was homogeneous, yet all interviewees faced stress-inducing situations during service use. Resilience factors were identified, leading this population to seek healthcare outside the state system due to use challenges. These findings highlight the need to discuss the breadth and progress of gender affirming care and the applicability of the National Policy of Comprehensive Healthcare for LGBT individuals within the Brazilian National Health System in northeastern Brazil.

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BACKGROUND: Delays in preventative service uptake are increasing in the UK. Universal, comprehensive monthly outreach by Community Health and Wellbeing Workers (CHW), who are integrated at the GP practice and local authority, offer a promising alternative to general public health campaigns as it personalises health promotion and prevention of disease holistically at the household level. We sought to test the ability of this model, which is based on the Brazilian Family Health Strategy, to increase prevention uptake in the UK. METHODS: Analysis of primary care patient records for 662 households that were allocated to five CHWWs from July 2021. Primary outcome was the Composite Referral Completion Indicator (CRCI), a measure of how many health promotion activities were received by members of a household relative to the ones that they were eligible for during the period July 2021-April 2022. The CRCI was compared between the intervention group (those who had received at least one visit) and the control group (allocated households that were yet to receive a visit). A secondary outcome was the number of GP visits in the intervention and control groups during the study period and compared to a year prior. RESULTS: Intervention and control groups were largely comparable in terms of household occupancy and service eligibilities. A total of 2251 patients in 662 corresponding households were allocated to 5 CHWs and 160 households had received at least one visit during the intervention period. The remaining households were included in the control group. Overall service uptake was 40% higher in the intervention group compared to control group (CRCI: 0.21 ± 0.15 and 0.15 ± 0.19 respectively). Likelihood of immunisation uptake specifically was 47% higher and cancer screening and NHS Health Checks was 82% higher. The average number of GP consultations per household decreased by 7.4% in the intervention group over the first 10 months of the pilot compared to the 10 months preceding its start, compared with a 0.6% decrease in the control group. CONCLUSIONS: Despite the short study period these are promising findings in this deprived, traditionally hard to reach community and demonstrates potential for the Brazilian community health worker model to be impactful in the UK. Further analysis is needed to examine if this approach can reduce health inequalities and increase cost effectiveness of health promotion approaches.

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Consensus has been reached that symptoms of depression can begin as early as preschool. Nevertheless, only few studies have associated environmental (malnutrition) and social factors (poverty condition, access to health systems, etc.) to the onset of depression in preschoolers. The aim of this study was to explore possible associations between malnutrition (underweight, overweight/obesity), poverty status (home quality, overcrowding), access to healthcare systems and the presence of depressive symptoms in the preschoolers of a semi-rural community. In total, 695 children between 3 and 6 years from the municipality of Chiconcuac, Mexico were evaluated for symptoms of depression with the Preschool Depression Scale for Teachers (ESDM 3-6). Additionally, they were assessed for nutritional status and divided into three groups (low weight, normal weight, overweight/obesity), and their parents were asked to fill out a social demographic questionnaire. Malnutrition status OR = 2.702, 95% CI [1.771-4.145]; UW OR = 4.768, 95% CI [2.570-8.795] and OW/OB OR = 1.959, 95% CI [1.175-3.324]; poverty condition per se OR = 1.779, 95% CI [0.9911-2.630]; housing quality OR = 2.020, 95% CI [0.9606-2.659] and overcrowding = 1.619, 95% CI [0.8989-4.433] were associated to a greater risk for children to show depressive symptoms (DS). Access to healthcare was negatively related with the risk of presenting DS (OR = 0.660, 95% CI [0.3130 to 1.360]). Social and environmental factors such as malnutrition, home quality and overcrowding may increase the risk of presenting DS as soon as in preschool.

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Background: Unmet need is a metric used to assess the performance of health care systems throughout the world. One of the primary objectives of the Brazilian health care system is to identify ways to improve the health outcomes of all citizens. To accomplish this challenging goal, the health care system in Brazil will need to identify and eliminate barriers and provide timely and adequate access to health care services to all. Methods: This study assessed the performance of the Brazilian health care system by focusing on the unmet need for health care services and medications. We evaluated the Brazilian National Health Survey data collected in 2013 and 2019 to determine the magnitude of socioeconomic-related inequalities associated with unmet health care needs. Primary contributing factors were identified via decomposition analysis of the calculated concentration indices (CInds). Findings: Despite the availability of universal health care, 3.8% and 7.5% of the population in Brazil reported unmet needs for health care services and medications, respectively in the 2019 survey. Although the overall unmet need for medications remained unchanged between 2013 and 2019, CInd analysis revealed significant pro-poor inequalities with respect to unmet needs for both health care services and medications. The overall magnitude of these inequalities was higher in the poorer regions of the country. The use of private health insurance as well as individual health and socioeconomic status contributed significantly to the inequalities associated with unmet needs for health care services and medication throughout Brazil. Interpretations: Policy interventions should focus on improving access to health care services, extending coverage to include pharmaceuticals, and targeting both financial and non-financial barriers to obtaining care, particularly those experienced by the poor and vulnerable populations in Brazil. Funding: None.

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SLE increases disease burden in those affected with it, and that is particularly the case in low- and middle-income countries. The 2019 Addressing Lupus Pillar of Health Advancement project is a multiphase initiative whose objective is to recognize, hierarchize and establish approaches for diligent SLE research, care and access to healthcare. Lack of access to high-cost medications that have been shown to be efficacious in the short term and that potentially reduce damage in SLE is a complex issue. In this review, we highlight opportunities and plans of action to diminish costs and improve access to therapies, which should be recognized and executed, preferably within regional strategies with multiple stakeholders (including supranational organizations, governments, the pharmaceutical industry, medical societies and the general population) connected with and grounded in structured and clear cost-effectiveness analysis.

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ABSTRACT OBJECTIVE To analyze the access of women to the public health system network to childbirth care, highlighting the barriers related to the "availability and accommodation" dimension in a health macroregion of Pernambuco. METHODS Ecological study, conducted based on hospital birth records from the Hospital Information System of the Brazilian Unified Health System (SUS), and information from the state's Hospital Beds Regulation Center, about women residing in health macroregion II, in 2018. Displacements were reviewed considering the geographic distance between the municipality of residence and that of the childbirth; estimated time of displacement of pregnant women; ratio of shifts blocked for admission of pregnant women for delivery; and the reason for unavailability. RESULTS In 2018, health macroregion II performed 84% of usual risk childbirths, and 46.9% of high-risk childbirths. The remaining high-risk childbirths (51.1%) occurred in macroregion I, especially in Recife. The reference maternity for high-risk childbirths in that macroregion had 30.4% of the days of day shifts and 38.9% of the night shifts blocked for admission of childbirths; the main reason was the difficulty in maintaining the full team in service. CONCLUSIONS Women residing in the health macroregion II of Pernambuco face great barriers of access in search of hospital care for childbirth, traveling great distances even when pregnant women of usual risk, leading to pilgrimage in search of this care. There is difficulty regarding availability and accommodation in high-risk services and obstetric emergencies, with shortage of physical and human resources. The obstetric care network in macroregion II of Pernambuco is not structured to ensure equitable access to care for pregnant women at the time of childbirth. This highlights the need for restructuring this healthcare services pursuant to what is recommended by the Cegonha Network.

RESUMO OBJETIVO Analisar o acesso de mulheres atendidas na rede pública aos serviços de atenção ao parto, destacando-se as barreiras relacionadas à dimensão "disponibilidade e acomodação" em uma macrorregião de saúde de Pernambuco. MÉTODOS Estudo ecológico, realizado a partir dos registros de partos hospitalares do Sistema de Informação Hospitalar e de informações da Central de Regulação de Leitos do estado sobre mulheres residentes na macrorregião de saúde II, em 2018. Analisou-se os deslocamentos, considerando a distância geográfica entre o município de residência e o de ocorrência do parto, o tempo estimado do deslocamento das gestantes, a proporção de plantões bloqueados para admissão das gestantes para o parto e o motivo da indisponibilidade. RESULTADOS Em 2018, a macrorregião de saúde II realizou 84% dos partos de risco habitual e 46,9% de alto risco. Os demais partos de alto risco (51,1%) ocorreram na macrorregião I, sobretudo no Recife. A maternidade de referência para partos de alto risco dessa macrorregião teve 30,4% dos dias de plantões diurnos bloqueados para admissão de partos e 38,9% dos noturnos; o principal motivo foi a dificuldade em manter a equipe completa no serviço. CONCLUSÕES Mulheres residentes na macrorregião de saúde II de Pernambuco enfrentam grandes barreiras de acesso em busca de atendimento hospitalar para o parto, percorrendo grandes distâncias, mesmo quando gestantes de risco habitual, levando à peregrinação em busca dessa assistência. Há dificuldade de disponibilidade e acomodação nos serviços de alto risco e de emergências obstétricas, com insuficiente capacidade física e de recursos humanos. A rede de atenção obstétrica na macrorregião II de Pernambuco não está estruturada para garantir um acesso equânime à assistência das gestantes no momento do parto, o que evidencia a necessidade de sua reestruturação em aproximação ao preconizado pela Rede Cegonha.

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RESUMEN El desarrollo político-económico que ha tenido Chile durante las últimas décadas ha permitido la evolución de su institucionalidad sanitaria, donde se ha mejorado la cobertura, gestión e infraestructura hospitalaria. La organización de la política sanitaria es altamente centralizada y estructurada desde el Estado, ello ha permitido implementar con rapidez diversos programas. La participación, por otro lado, se mantiene dentro de los espacios que la institucionalidad permite, sin embargo, existe una permanente presión de grupos no gubernamentales que piden una gobernanza diferente. Se desea, por lo tanto, pasar de una reactividad participativa en materias sanitarias a una proactividad permanente, aunque ello requiere de una permanente conversación entre el Estado y la ciudadanía. En el artículo se analiza el sistema sanitario chileno y cómo se relaciona con la participación ciudadana subsecuente, evidenciando los elementos, que bajo la realidad social actual, necesitan de un cambio para satisfacer adecuadamente a la población.

ABSTRACT The political-economic development that Chile has had in recent decades has allowed the evolution of its health institutions, where hospital coverage, management, and infrastructure have been improved. The health policy organization is highly centralized and structured by the State, and this has allowed the rapid implementation of several programs. On the other hand, participation is maintained within the spaces allowed by institutionality. However, there is permanent pressure from non-governmental groups asking for different governance. Therefore, moving from a participatory reactivity in health matters to permanent proactivity is desired, although this requires a constant dialogue between the State and citizens. This paper analyzes the Chilean health system and how it relates to subsequent citizen participation, highlighting the elements that, under the current social reality, require a change to satisfy the population adequately.

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O Sistema Único de Saúde (SUS) e suas políticas são regidos por princípios norteadores, porém, o acesso universal não é garantia do atendimento das demandas de todos. As políticas públicas voltadas aos LGBT foram criadas para combater o preconceito, a discriminação e a exclusão. Em 2011, foi instituída a Política Nacional de Saúde Integral LGBT (PNSI LGBT) entretanto, a carência de informações sobre a implementação desta no Rio de Janeiro-RJ evidencia as dificuldades de atender essa população. Esta Tese objetivou analisar o processo de implementação e os conflitos éticos envolvidos da PNSI LGBT, no município do Rio de Janeiro, através da perspectiva do acesso aos serviços de saúde. Realizou-se uma revisão sistemática da literatura e abordagem metodológica qualitativa por meio de entrevistas semiestruturadas com gestores, profissionais de saúde e usuários LGBT. As entrevistas foram gravadas e os dados analisados numa perspectiva hermenêutica dialética. A revisão da literatura ressaltou as demandas específicas de saúde LGBT, e os desafios que a PNSI LGBT enfrenta para sua plena implementação, além de ainda ser pouco explorada. As narrativas foram agrupadas em quatro categorias abordando as questões de vínculo; percepções a respeito da orientação sexual e identidade de gênero; demandas para a atenção integral à saúde LGBT; e as questões éticas sobre justiça, igualdade e equidade no acesso à saúde LGBT. As entrevistas demonstraram como os gestores, profissionais de saúde e usuários percebem o acesso à saúde da população LGBT, e o quanto a PNSI LGBT ainda é pouco conhecida. Percebeu-se a ausência de desdobramentos práticos para a implementação da PNSI LGBT por parte do poder público, uma dubiedade dos entrevistados em reconhecer discursos discriminatórios, ou mesmo a importância da identificação da orientação sexual e da identidade de gênero no acesso à saúde, o que acarreta a invisibilização das demandas LGBT. As narrativas apontaram para um atendimento aparentemente não discriminatório, embora reconheçam que o preconceito não atinge todos da mesma forma. Houve a percepção de que as pessoas LGBT são previamente identificadas pelos profissionais de saúde como portadores do vírus HIV, sendo um estigma infelizmente ainda persistente. Evidenciou-se nas narrativas conflitos éticos relacionados à garantia do direito à saúde; da igualdade no acesso e no atendimento; e da equidade, reconhecendo que a saúde deve ser ofertada na medida das necessidades das pessoas, respeitando sua diversidade. A PNSI LGBT foi percebida no que compete ao eixo do acesso à saúde, entretanto ela ainda necessita de estratégias que promovam desdobramentos práticos para sua plena implementação, capazes de promover e garantir o direito à saúde, rompendo a perspectiva equivocada de que a igualdade universal no acesso seria suficiente e sinônimo de equidade.

The Unified Health System (SUS) and its policies are governed by guiding principles, however, universal access is not a guarantee of meeting everyone's demands. Public policies aimed at LGBT were created to combat prejudice, discrimination and exclusion. In 2011, the National Policy on Comprehensive Health of LGBT (PNSI LGBT) was instituted, however, the lack of information about its implementation in Rio de Janeiro-RJ highlights the difficulties of serving this population. This Thesis aimed to analyze the implementation process and the ethical conflicts involved in the PNSI LGBT, in the city of Rio de Janeiro, through the perspective of access to health services. A systematic review of the literature and qualitative methodological approach was carried out through semi-structured interviews with managers, health professionals and LGBT users. The interviews were recorded and the data analyzed in a dialectic hermeneutic perspective. The literature review highlighted the specific demands of LGBT health, and the challenges that the PNSI LGBT faces for its full implementation, in addition to being still little explored. The narratives were grouped into four categories addressing bonding issues; perceptions regarding sexual orientation and gender identity; demands for comprehensive care for LGBT health; and ethical questions about justice, equality and equity in LGBT healthcare access. The interviews showed how managers, health professionals and users perceive access to health care for the LGBT population, and how little is known about the PNSI LGBT. It was noticed the absence of practical developments for the implementation of the PNSI LGBT by the public power, a dubiousness of the interviewees in recognizing discriminatory discourses, or even the importance of identifying sexual orientation and gender identity in access to health, which leads to the invisibility of LGBT demands. The narratives pointed to an apparently non-discriminatory service, although they recognize that prejudice does not affect everyone in the same way. There was a perception that LGBT people are previously identified by health professionals as having the HIV virus, which is unfortunately still a persistent stigma. It was evident in the narratives ethical conflicts related to the guarantee of the right to health; equality in access and care; and equity, recognizing that health should be offered according to people's needs, respecting their diversity. The PNSI LGBT was perceived in terms of the axis of access to health, however it still needs strategies that promote practical developments for its full implementation, capable of promoting and guaranteeing the right to health, breaking with the mistaken perspective that universal equality in the access would be sufficient and synonymous with equity.

El Sistema Único de Salud (SUS) y sus políticas se rigen por principios rectores, pero el acceso universal no es garantía de atender las demandas de todos. Las políticas públicas dirigidas a LGBT se crearon para combatir los prejuicios, la discriminación y la exclusión. En 2011, se instituyó la Política Nacional de Salud Integral de LGBT (PNSI LGBT) todavía, la falta de información sobre su implementación en Rio de Janeiro-RJ destaca las dificultades para atender a esta población. Esta Tesis tuvo como objetivo analizar el proceso de implementación y los conflictos éticos involucrados en la PNSI LGBT, en la ciudad de Rio de Janeiro, a través de la perspectiva del acceso a los servicios de salud. Se realizó una revisión sistemática de la literatura y enfoque metodológico cualitativo a través de entrevistas semiestructuradas a directivos, profesionales de la salud y usuarios LGBT. Las entrevistas fueron grabadas y los datos analizados en una perspectiva hermenéutica dialéctica. La revisión de la literatura destacó las demandas específicas de la salud LGBT y los desafíos que enfrenta la PNSI LGBT para su plena implementación, además de ser aún poco explorada. Las narraciones se agruparon en cuatro categorías que abordan cuestiones de vinculación; percepciones sobre orientación sexual e identidad de género; demandas de atención integral a la salud LGBT; y cuestiones éticas sobre la justicia, la igualdad y la equidad en el acceso a la salud LGBT. Las entrevistas mostraron cómo los gestores, profesionales de salud y usuarios perciben el acceso a la salud de la población LGBT, y lo poco que se sabe sobre la PNSI LGBT. Se percibió la ausencia de desarrollos prácticos para la implementación de la PNSI LGBT por parte del poder público, un recelo de los entrevistados en reconocer discursos discriminatorios, o incluso la importancia de identificar la orientación sexual y la identidad de género en el acceso a la salud, lo que conduce a la invisibilidad de las demandas LGBT. Las narrativas apuntaron a un servicio aparentemente no discriminatorio, aunque reconocen que los prejuicios no afectan a todos de la misma manera. Existía la percepción de que los profesionales de la salud identificaban previamente a las personas LGBT como portadoras del VIH, lo que sigue siendo un estigma persistente. Se evidenció en las narrativas conflictos éticos relacionados con la garantía del derecho a la salud; igualdad en el acceso y la atención; y equidad, reconociendo que la salud debe ser ofrecida de acuerdo a las necesidades de las personas, respetando su diversidad. La PNSI LGBT fue percibida en términos del eje del acceso a la salud, aunque necesita estrategias que promuevan desarrollos prácticos para su plena implementación, capaces de promover y garantizar el derecho a la salud, rompiendo con la perspectiva equivocada de que la igualdad universal en el acceso sería suficiente y sinónimo de equidad.

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OBJECTIVES: To compare elective hip arthroplasty rates funded by the public sector in Brazil and Scotland. DESIGN: Ecological study, 2009-13, of crude and directly standardised rates of elective primary hip arthroplasty rates (per 100,000) funded by the public sector at national and regional level for age (30 + years) and gender in Brazil and Scotland. SETTING: National Health Service Scotland and Unified Health System in Brazil. PARTICIPANTS: Over 30 s who had undergone an elective hip arthroplasty funded by the public sector. MAIN OUTCOME MEASURES: Publicly funded standardised elective hip arthroplasty rates in Brazil and Scotland. RESULTS: Between 2009 and 2013, there was a seven-fold difference in treatment rates between Brazil and Scotland, and an eight-fold regional difference in Brazil; Brazil (7.8-8.3/100,000, increase of 0.5 per 100,000, 95% confidence interval (CI) (0.3, 0.7) from 2009/10 to 2012/13) and Scotland (from 61.1 to 57.7/100,000, decrease of 3.4 per 100,000, 95% confidence interval (1.4, 5.8) per 100,000); a two-fold difference in number of public beds per head of population (Brazil 158.3/100,000 vs. Scotland 305.1/100,000) and general medical workforce (Brazil 198.8/100,000 vs. Scotland 327.4/100,000); numbers of orthopaedic surgeons per head of population in the two countries were similar in 2013 (Brazil 5.2/100,000 vs. Scotland 4.3/100,000). CONCLUSION: Although the 'inverse care law' is seen in both countries, access to publicly funded hip arthroplasties in Brazil is worse than in Scotland; the distribution of specialists and higher treatment rates in Brazil is highly skewed towards wealthier areas, perpetuating historical regional inequalities.

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Objective: identify constraints of patients with acute febrile syndrome to institutional care services access, emphasizing the identification of communication barriers. Method: this is a descriptive study that involves qualitative research techniques including malaria care service patients as well as assistance and administrative personnel of El Bagre town in Antioquia, Colombia in 2016. Semi-structured individual surveys, interviews and focus groups were used. Results: users listed difficulties including transportation, insufficient number of appointments and absence of personnel to access healthcare. Communication difficulties were related to the information provided in the paperwork and documents filled out to attend healthcare facilities, scarce information about diagnostic, control, and adherence to antimalarial treatment; additionally some patients did not use Spanish to communicate in oral or write form. Conclusion: the creation of health models based on structural transformations that encompass the needs of Healthcare System actors and communities is a must, which allows the establishment of foundations for a multicultural society project

Objetivo: Identificar limitaciones de los pacientes con síndrome febril agudo para acceder a los servicios de atención institucional, con énfasis en la identificación de barreras de comunicación.Método: Estudio descriptivo que involucra técnicas de investigación cualitativa con pacientes de los servicios de atención de la malaria y con personal asistencial y administrativo del municipio de El Bagre Antioquia, Colombia en el 2016. Se aplicaron encuestas semiestructuradas individuales, entrevistas y grupos focales. Los usuarios señalaron dificultades con el transporte, insuficiente número de citas y falta de personal para acceder a la atención. Resultados: Las dificultades de comunicación se relacionaron con la información suministrada sobre trámites y documentación para asistir a los puestos de salud, poca información sobre el diagnóstico, control y adherencia al tratamiento antimalárico y el no uso de algunos pacientes del español para comunicarse en forma verbal o escrita. Conclusiones: Esto exige crear modelos de salud basados en transformaciones estructurales que abarquen las necesidades de los actores del sistema de salud y las comunidades, permitiendo establecer las bases para un proyecto multicultural de sociedad.

Objetivo: Identificar limitações dos pacientes com síndrome febril agudo para aceder aos serviços de atenção institucional, com ênfase na identificação de barreiras de comunicação. Método: Estudo descritivo que involucra técnicas de pesquisa qualitativa com pacientes dos serviços de atenção da malária e com equipe assistencial e administrativo do município do Bagre Antioquia, Colômbia no 2016. Fizeram-se enquetes semiestruturadas individuais, entrevistas e grupos focais. Os usuários sinalaram dificuldades com o transporte, insuficiente número de horas marcadas e falta de pessoal para aceder à atenção. Resultados: As dificuldades de comunicação se relacionaram com a informação subministrada sobre trâmites e documentação para chegar aos SUS (Sistema Único de Saúde), pouca informação sobre o diagnóstico, controle e aderência ao tratamento antimalárico e o não uso de alguns pacientes do espanhol para comunicar-se em forma verbal ou escrita. Conclusões: Isto exige criar modelos de saúde baseados em transformações estruturais que abarquem as necessidades dos atores do sistema de saúde e as comunidades, permitindo estabelecer as bases para um projeto multicultural de sociedade.

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O catador de materiais recicláveis é excluído pelo tipo de atividade que realiza, em condições inadequadas e sem reconhecimento social. O objetivo desta pesquisa foi compreender o processo saúde-doença-cuidado de pessoas que trabalham com reciclagem para auxiliar na formação de estratégias de acolhimento dessa população na Atenção Primária. Trata-se de um estudo exploratório descritivo de base qualitativa, tendo sido realizadas oito entrevistas com trabalhadores da reciclagem e análise hermenêutica gadameriana. A análise evidenciou três grandes núcleos argumentais: cotidiano do trabalho, riscos ocupacionais e relação com os serviços de saúde. A reciclagem para muitos trabalhadores é uma última opção de sobrevivência dentro das regras sociais do mundo do trabalho; e a possibilidade de trabalhar, apesar de todas as suas dificuldades, esforços e sobrecargas, é vista como uma forma digna de sobrevivência e valorizada como um dos maiores bens de suas vidas.(AU)

Recycling collectors are excluded for the activity they perform (in inadequate conditions and with no social recognition). The objective of this research was to understand the health-disease-care process of people who work with recycling to help build strategies to welcome this population in Primary healthcare. It was an exploratory, descriptive, and qualitative study where eight interviews were conducted with recycling workers. The analysis was conducted based on Gadamer's hermeneutics. The analysis evidenced three large argumentative nuclei: work routine, occupational risks, and health service relation. For most workers, recycling is their last resort to survive in the social rules of the occupational world, despite all its difficulties, efforts, and burdens. It is considered a dignified way of survival and valued as one of the greatest assets in their lives: the possibility to work.(AU)

El recogedor de materiales reciclables es excluido por el tipo de actividad que realiza, en condiciones inadecuadas y sin reconocimiento social. El objetivo de este estudio fue entender el proceso salud-enfermedad-cuidado de personas que trabajan con reciclaje para auxiliar en la formación de estrategias de acogida de esta población en la Atención Primaria. Estudio exploratorio descriptivo de base cualitativa, habiéndose realizado ocho entrevistas con trabajadores del reciclaje y un análisis utilizando la hermenéutica gadameriana. El análisis mostró tres grandes núcleos argumentales: cotidiano del trabajo, riesgos ocupacionales y relación con los servicios de salud. Para muchos trabajadores, el reciclaje, es una última opción de supervivencia dentro de las reglas sociales del mundo del trabajo y, a pesar de todas sus dificultades, esfuerzos y sobrecargas, es vista como una forma digna de supervivencia y valorizada como uno de los mayores bienes de sus vidas: la posibilidad de trabajar.(AU)

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O objetivo da presente pesquisa foi conhecer os usuários vinculados às 12 Unidades Básicas de Saúde (UBS) que se consultaram em uma Unidade de Pronto Atendimento (UPA) e receberam classificação de risco pouco urgente, em um munícípio brasileiro de grande porte, em 2017. Trata-se de uma pesquisa de abordagem quantitativa que utilizou dados secundários do serviço. Foram identificados 3.584 usuários que atenderam aos critérios do estudo. Estes representaram 7% do total de usuários dessa UPA que tiveram a mesma classificação. A maioria dos usuários possuía entre 41 e 65 anos (36,3%), principalmente mulheres (62.3%), e preferiram ser atendidos em dias e horários em que as UBSs estavam fechadas. Houve relação positiva entre o número de indivíduos cadastrados em cada UBS e a demanda de consultas pouco urgentes para adultos na UPA; além disso, a faixa etária relacionou-se com o horário de busca do atendimento. Os principais sintomas observados foram: cefaleia; dispneia; e dor abdominal, lombar e de garganta.(AU)

The objective of this study was to know the users of 12 Primary Care Units (UBSs) who went to an Emergency Care Unit (UPA) and were classified as least urgent in a Brazilian large city in 2017. The quantitative approach research used secondary data of the service. A total of 3,584 users met the study's criteria. They represent 7% of the total users of this UPA who had the same classification. Most of the users were 41 to 65 years old (36.3%), mostly women (62.3%), and preferred days and times the UBSs were closed. There was a positive correlation between the number of individuals registered in each UBS and the demand for least urgent appointments for adults at UPA, and the age range was related to the time they sought the service. The main symptoms observed were: headache, dyspnea, abdominal and back pain, and sore throat.(AU)

Conocer a los usuarios vinculados a 12 Unidades Básicas de Salud (UBS), que se consultaron en una Unidad de Urgencias (UPA, por sus siglas en portugués) y recibieron clasificación de riesgo poco urgente en un municipio brasileño de grande porte en 2017. Estudio de abordaje cuantitativo, utilizó datos secundarios del servicio. Se identificaron 3.584 usuarios que atendieron los criterios del estudio. Ellos representaron el 7% del total de usuarios de esta UPA que tuvieron la misma clasificación. La mayoría de los usuarios tenía entre 41 y 65 años (36,3%), principalmente mujeres (62,3%) y prefirieron días y horarios en que las UBS estaban cerradas. Hubo una relación positiva entre el número de individuos registrados en cada UBS y la demanda de consultas poco urgentes para adultos en la UPA y el rango de edad se relacionó con el horario de búsqueda de la atención. Los principales síntomas observados fueron: cefalea, disnea, dolor abdominal, lumbar y de garganta.(AU)

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A migração venezuelana é uma problemática da atualidade que se intensificou em Roraima, acarretando demandas nos serviços públicos de saúde. O objetivo do presente estudo foi analisar o impacto da migração na assistência em um hospital de referência de Roraima. Consiste em um trabalho qualitativo que utilizou vinte entrevistas semiestruturadas com os profissionais do hospital. Percebe-se que não houve o incremento de quantitativo profissional e do aporte de insumos; planejamento prévio; ou melhorias na infraestrutura para se adequar à nova realidade. Muitos imigrantes vivem em situação de vulnerabilidade social e as diferenças culturais e comportamentais são elementos que dificultam a assistência em saúde. A imigração impacta negativamente na assistência, contudo, apenas potencializando os problemas crônicos já existentes desse hospital.(AU)

The Venezuelan migration is a current issue that has intensified in Roraima, Brazil, overburdening public health services. The proposal of this estudy was to analyze the impact of migration in healthcare in a reference hospital of Roraima, Brazil. It was a qualitative research comprised comprised of twenty semistructured interviews with professionals who work at the hospital. We noticed there was no change in the number of professionals, in the supply of input, in planning, and in infrastructure improvements to adapt to this new reality. Many migrants live in social vulnerability situation, and cultural and behavioral differences hinder the provision of healthcare. Therefore, migration negatively impacts healthcare, but it only intensifies chronic issues that already exist in that hospital.(AU)

La migración venezolana es una problemática de la actualidad que se intensificó en el Estado de Roraima, causando demandas en los servicios públicos de salud. La investigación tuvo como objetivo analizar el impacto de la migración en la asistencia en un hospital de referencia de Roraima, Brasil. Consiste en un trabajo cualitativo, por medio de veinte entrevistas semiestructuradas con los profesionales del hospital. Se percibe que no hubo el aumento de cuantitativo profesional, ni de la aportación de insumos, ni planificación previa o mejoras en la infraestructura para adecuarse a la nueva realidad. Muchos emigrantes viven en situación de vulnerabilidad social y las diferencias culturales y comportamentales son elementos que dificultan la asistencia de la salud. Por lo tanto, la migración causa un impacto negativo en la asistencia, aunque potencializando los problemas crónicos ya existentes en el hospital.(AU)

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OBJECTIVE: Chagas disease affects over six million people, but less than 1% are diagnosed and treated. Complicated diagnostic processes are a major barrier. Colombia's previous diagnostic algorithm, using in-house tests, was difficult to scale up, creating significant access barriers for patients. A new algorithm using commercially manufactured immunoassays would potentially improve access, but these tests' performance in Colombian patients with Chagas disease is not well known. METHODS: We assessed seven commercially available assays. Samples (n=501), 93.8% originating from Colombia, were characterized as positive or negative based on standard procedure at the National Reference Laboratory. Performance characteristics were calculated for individual assays and hypothetical test pairings, then compared to the existing algorithm. RESULTS: Five of seven assays exhibited sensitivity >98% while six showed specificity >97%. A total antigen ELISA paired with a recombinant assay provided similar performance to the current diagnostic process. Six of six assays tested proved capable of detecting different Trypanosoma cruzi genetic lineages. CONCLUSIONS: The study indicated that several commercial assays accurately detect T. cruzi infection in Colombian patients. A simplified testing process with two commercial assays could perform comparably to the previous process, reducing cost and accessibility barriers and facilitating national scale-up.

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Résumé Cet article analyse la prise en charge de la pauvreté à l'hôpital public. Il prend l'exemple des Permanences d'accès aux soins de santé (PASS), structure hospitalière qui prend en charge des personnes connaissant des difficultés d'accès aux soins dans le système de santé français. Il s'appuie sur une enquête empirique issue d'un travail de thèse en sociologie. L'enquête mêle observations participantes et entretiens semi-directifs (n=49) et a été réalisée dans 16 PASS différentes. Sur un plan théorique, l'article met en miroir les travaux sur les métamorphoses de la question sociale et une perspective biopolitique d'inspiration foucaldienne. La prise en charge des populations en marge du système de santé par une institution publique (l'hôpital) est considérée comme agissant dans des domaines qui dépassent le strict traitement de la maladie pour entrer dans ceux de la régulation sociale, la protection de la santé publique ou la réalisation de droits humains. Dans le cas des PASS, l'article montre la construction d'une biopolitique de la migration autour d'un bricolage compliqué qui mêle citoyenneté, politiques économiques, politiques de santé publique et accès aux soins. Le mode d'exercice du pouvoir se caractérise par un gouvernement par le bas qui est réalisé par les professionnels de terrain lors des interactions avec les patients et met en scène une économie morale basée sur des représentations de ce qui est bon et mauvais pour la société.

Abstract This article analyses how the modern public hospital handles poverty. To do so it goes from the example of the hospital-based Departments for access to healthcare (Permanences d'accès aux soins de santé - PASS), that is specialized in taking care of patients experiencing difficulties to access healthcare in the French healthcare system. The article relies on an empirical study achieved as part of a PhD work in sociology. The study combines participant observations and interviews (n=49) which have been conducted in 16 different PASS. On a theoretical level, the paper mirrors the work on the metamorphosis of the social question and a biopolitics perspective inspired by Foucault. In this perspective the way the public hospital takes care of individuals situated at the margin of the healthcare system is thought as entering in the areas of social regulation, protection of the public health or realization of human right. In the case of PASS, the article shows the construction of a biopolicy of migration that is a cobbling together of citizenship, economic policies, public health and access to healthcare. The form of power is characterized by a government from the bottom which is realized by street-level healthcare professionals during interaction with the patients and based on a moral economy depicting representations of what is good and bad for the society.

Resumo Este artigo analisa o acesso de pessoas de baixa renda a hospitais públicos. Tomamos como exemplos os Permanences d'Accès aux Soins de Santé (PASS), ou Centros de Acesso à Saúde, estrutura hospitalar que atende pessoas que têm dificuldades para acessar o sistema de saúde francês. Baseada em uma investigação empírica, resultado de uma tese em sociologia, esta investigação junta observações de participantes e entrevistas semidiretivas realizadas em 16 PASS diferentes. Em um plano teórico, o artigo espelha os trabalhos sobre as metamorfoses da questão social e uma perspectiva biopolítica de inspiração foucaultiana. O atendimento de populações à margem do sistema de saúde por uma instituição pública (hospital) é considerada agindo em áreas que sobrepassam o estrito tratamento de doença para entrar em áreas de regulação social, proteção da saúde pública ou a realização de direitos humanos. No caso dos PASS, o artigo mostra a construção de uma biopolítica de migração ao redor de uma montagem complicada que mistura cidadania, políticas econômicas, políticas de saúde pública e acesso à saúde. A maneira de exercer o poder se caracteriza por um governo de base realizado por profissionais de campo em interações com os pacientes e colocando em cena uma economia moral baseada em representações do que é bom ou ruim para a sociedade.

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BACKGROUND: Reducing maternal mortality is a top priority in Latin American countries. Despite the progress in maternal mortality reduction, Brazil and Colombia still lag behind countries at similar levels of development. METHODS: Using data from the Demographic Health Survey, this study quantified and compared, by means of concentration indices, the socioeconomic-related inequity in access to four key maternal health interventions in Brazil and Colombia. Decomposition analysis of the concentration index was used for two indicators - skilled attendance at birth and postnatal care in Brazil. RESULTS: Coverage levels of the four key maternal health interventions were similar in the two countries. More specifically, we found that coverage of some of the interventions (e.g. ante-natal care and skilled birth assistance) was higher than 90% in both countries. Nevertheless, the concentration index analysis pointed to significant pro-rich inequities in access in all four key interventions in both countries. Interestingly, the analysis showed that Colombia fared slightly better than Brazil in terms of equity in access of the interventions studied. Finally, the decomposition analysis for the presence of a skilled attendant at birth and postnatal care in Brazil underlined the significance of regional disparities, wealth inequalities, inequalities in access to private hospitals, and inequalities in access to private health insurance. CONCLUSIONS: There are persistent pro-rich inequities in access to four maternal health interventions in both Brazil and Colombia. The decomposition analysis conducted on Brazilian data suggests the existence of disparities in system capacity and quality of care between the private and the public health services, resulting in inequities of access to maternal health services.

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Neoliberal reforms lead to deep changes in healthcare systems around the world, on account of their emphasis on free market rather than the right to health. People with disabilities can be particularly disadvantaged by such reforms, due to their increased healthcare needs and lower socioeconomic status. In this article, we analyse the impacts of neoliberal reforms on access to healthcare for disabled people. This article is based on a critical analytical review of the literature and on two case studies, Chile and Greece. Chile was among the first countries to introduce neoliberal reforms in the health sector, which led to health inequalities and stratification of healthcare services. Greece is one of the most recent examples of countries that have carried out extensive changes in healthcare, which have resulted in a deterioration of the quality of healthcare services. Through a review of the policies performed in these two countries, we propose that the pathways that affect access to healthcare for disabled people include: a) Policies directly or indirectly targeting healthcare, affecting the entire population, including disabled people; and b) Policies affecting socioeconomic determinants, directly or indirectly targeting disabled people, and indirectly impacting access to healthcare. The power differentials produced through neoliberal policies that focus on economic rather than human rights indicators, can lead to a category of disempowered people, whose health needs are subordinated to the markets. The effects of this range from catastrophic out-of-pocket payments to compromised access to healthcare. Neoliberal reforms can be seen as a form of structural violence, disproportionately affecting the most vulnerable parts of the population - such as people with disabilities - and curtailing access to basic rights, such as healthcare.

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