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Introducción: En Medicina Intensiva y Emergencias se requiere el desarrollo de competencias gerenciales y su evaluación para garantizar una atención de excelencia al paciente grave. Es pertinente un acercamiento teórico a los antecedentes y fundamentos que sustentan dicha afirmación. Objetivo: Determinar los fundamentos teóricos sobre la evaluación de competencias profesionales gerenciales en Medicina Intensiva y Emergencias. Métodos: Investigación cualitativa en la que se realizó la revisión de artículos entre 2000 y 2023, con un 90 por ciento de los últimos cinco años. Las bases de datos consultadas fueron Medline, Scopus y Google académico. Conclusiones: Los fundamentos teóricos parten de las definiciones y el surgimiento del término competencias, sus clasificaciones y descripción de los elementos que la conforman, donde resalta la importancia de la interrelación entre ellos; lo expuesto permitió visualizar la capacidad de desaprender como aspecto esencial y novedoso. La gerencia y su estrecha relación con el desempeño de los intensivistas los define como gerentes asistenciales, lo que representa un aporte teórico y evidencia la importancia del desarrollo de competencias gerenciales en dicha especialidad. Es vital el diseño de estándares como referentes para lograr la evaluación de competencias gerenciales en la práctica asistencial, si se persigue la excelencia en los servicios de atención al paciente grave(AU)

Introduction: In intensive care and emergency medicine, the development of managerial competences and their assessment is required to ensure excellence in the care of critically-ill patients. A theoretical approach to the antecedents and foundations supporting such assertion is pertinent. Objective: To determine the theoretical foundations on the assessment of professional managerial competences in intensive care and emergency medicine. Methods: A qualitative research was carried out through the review of articles from 2000 to 2023, with 90 percent belonging to the latest five years. The consulted databases were Medline, Scopus and Google Scholar. Conclusions: The theoretical foundations start from the definitions and the emergence of the term competences, its classifications and the description of the elements that make it up, highlighting the importance of the interrelation among them; the above allowed visualizing the ability to unlearn as an essential and novel aspect. Management and its close relationship with the performance of intensive care specialists defines them as care managers, which represents a theoretical contribution and evidences the importance of the development of managerial competences in this specialty. It is vital to design standards as a reference for the assessment of managerial competences in the healthcare practice, if excellence is to be pursued in the care of critically-ill patients(AU)

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This paper studies the effect on hospital service prices of a health system reform that allows managed selective contracting and regulation as a means for efficiency and price competition. Cross-sectional data about prices and market structure were analysed from a pool of 20 markets which includes 15 million Colombians. A multilevel regression method comparing three different market settings was performed. The analysis evaluates the effects of insurer choice, hospital quality and market characteristics using a nationwide health services transactional database. A Hirshmann-Herfindahl index was applied to evaluate the markets concentration. Among the results, bilateral monopolies were made evident, both in insurance and hospital markets. Insurer selective contracting policy has the greatest impact on pricing with hospital monopoly heavy effect on health service prices. Colombian government has a challenge in regulating managed competition in order to maintain competition and access to healthcare. Health reforms using market competition as a mechanism for efficiency should follow closely health services market evolution in order to introduce effective regulatory policies.

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The rising prevalence, health burden, and cost of chronic diseases such as diabetes have accelerated global interest in innovative care models that use approaches such as community-based care and information technology to improve or transform disease prevention, diagnosis, and treatment. Although evidence on the effectiveness of innovative care models is emerging, scaling up or extending these models beyond their original setting has been difficult. We developed a framework to highlight policy barriers-institutional, regulatory, and financial-to the diffusion of transformative innovations in diabetes care. The framework builds on accountable care principles that support higher-value care, or better patient-level outcomes at lower cost. We applied this framework to three case studies from the United States, Mexico, and India to describe how innovators and policy leaders have addressed barriers, with a focus on important financing barriers to provider and consumer payment. The lessons have implications for policy reform to promote innovation through new funding approaches, institutional reforms, and performance measures with the goal of addressing the growing burdens of diabetes and other chronic diseases.

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BACKGROUND: The health sector reform in Colombia, initiated by Law 100 (1993) that introduced a managed competition model, is generally presented as a successful experience of improving access to care through a health insurance regulated market. The study's objective is to improve our understanding of the factors influencing access to the continuum of care in the Colombian managed competition model, from the social actors' point of view. METHODS: An exploratory, descriptive-interpretative qualitative study was carried out, based on case studies of four healthcare networks in rural and urban areas. Individual semi-structured interviews were conducted to a three stage theoretical sample: I) cases, II) providers and III) informants: insured and uninsured users (35), health professionals (51), administrative personnel (20), and providers' (18) and insurers' (10) managers. Narrative content analysis was conducted; segmented by cases, informant's groups and themes. RESULTS: Access, particularly to secondary care, is perceived as complex due to four groups of obstacles with synergetic effects: segmented insurance design with insufficient services covered; insurers' managed care and purchasing mechanisms; providers' networks structural and organizational limitations; and, poor living conditions. Insurers' and providers' values based on economic profit permeate all factors. Variations became apparent between the two geographical areas and insurance schemes. In the urban areas barriers related to market functioning predominate, whereas in the rural areas structural deficiencies in health services are linked to insufficient public funding. While financial obstacles are dominant in the subsidized regime, in the contributory scheme supply shortage prevails, related to insufficient private investment. CONCLUSIONS: The results show how in the Colombian healthcare system structural and organizational barriers to care access, that are common in developing countries, are widened by both the insurers' use of mechanisms that limit the utilization and the public healthcare providers' change of behavior in a competition environment. They provide evidence to question the promotion of the managed competition model in low and middle-income countries.

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O artigo procura caracterizar o mercado de planos individuais de assistência médica. São utilizados os dados do Sistema de Informações de Beneficiários (SIB/ANS/MS), referentes a maio de 2010, e calculados índices tradicionais de concentração (HHI, C1 e C4) para as capitais e para os 30 mercados com maior número de beneficiários de planos novos individuais de assistência médica. É também realizada uma breve análise da oferta de planos privados individuais de saúde a partir do Guia de Planos de Saúde da ANS. Verifica-se que no mercado de cerca de 7,6 milhões de beneficiários dos planos em pauta, 62,2% possuem planos de abrangência geográfica de tipo grupo de municípios. Na apuração dos indicadores de concentração, observa-se que somente duas capitais apresentam resultados compatíveis com os de mercados altamente competitivos: São Paulo e Rio de Janeiro. Quando considerada a abrangência geográfica dos planos, somente os de tipo grupo de municípios em São Paulo são passíveis desta classificação. Em relação aos 30 maiores municípios em termos de número de beneficiários, 22 apresentam índices compatíveis com mercados altamente concentrados. A verificação do perfil da oferta demonstra que, embora as operadoras ofertem uma gama de produtos aparentemente ampla, os beneficiários têm sua escolha limitada quando estabelecem características específicas dos produtos

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Primary health care (PHC) is recognized as a key component of health systems. Evidence of the impact of PHC on the health and development of the population supports this assertion. Moreover, the experience acquired in developed and developing countries has demonstrated that PHC can be adapted to diff erent political, social, and cultural contexts. The demographic, social and epidemiological changes that have occurred since the Alma-Ata Conference entail the need for an in-depth review of the PHC strategy so that it can respond to the health and development needs of the world population. PAHO’s proposal for the renewal of PHC is based on Resolution CD44.R6,1 of September 2003, which invited Member States to adopt a series of recommendations to strengthen PHC. The Resolution also urged PAHO to: consider the principles of PHC in technical cooperation activities, particularly those related to the MDGs; evaluate diff erent PHC-based systems and identify and disseminate good practices; propose a strategy for training health workers on PHC; and support PHC models at the local level. In response to this mandate, in May 2004, PAHO/WHO established a working group (WG) to make suggestions on future strategic and programmatic orientations on PHC. This process was directed by the offi ce of the Assistant Director (AD) and coordinated by the Health Services Organization Unit of the Technology and Health Services Delivery Area (THS/OS). The fi rst objective of the WG was to prepare the PHC position paper based on the legacy of Alma-Ata, the lessons learned in PHC, and the experience acquired in the reform processes. The position paper benefi ted from comments and suggestions by experts from within and outside the Region. In July 2005, the Regional Consultation was held in Montevideo, Uruguay, with the participation of representatives from 30 countries, who prepared the draft of the Regional Declaration on PHC. On September 29, 2005, the 46th Directing Council2 ratifi ed the Regional Declaration...

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[Introducción] La Atención Primaria de Salud (APS) es reconocida como componente clave de los Sistemas de Salud; este reconocimiento se sustenta en la evidencia de su impacto sobre la salud y desarrollo de la población. Así mismo, las experiencias acumuladas tanto en países desarrollados como en proceso de desarrollo han demostrado que la APS puede ser adaptada a los distintos contextos políticos, sociales y culturales. Por otra parte, los cambios demográfi cos, sociales y epidemiológicos producidos desde la celebración de la Conferencia de Alma Ata acarrean la necesidad de una revisión profunda de la estrategia de APS para que pueda dar respuesta a las necesidades en salud y desarrollo de la población en el mundo. La propuesta de la OPS para la renovación de APS se inició a partir de la Resolución 1 CD44.R6 de septiembre de 2003, en la que se invita a los estados miembros a adoptar una serie de recomendaciones para fortalecer la APS. Además insta a la OPS a tener en cuenta los principios de la APS en las actividades de los programas de cooperación técnica, esencialmente los relacionados con los ODM; evaluar diferentes sistemas basados en la APS e identifi car y diseminar las mejores prácticas; concurrir en la capacitación de trabajadores de la salud para la APS; apoyar modelos de APS defi nidos a nivel local. En respuesta al mandato anterior, la OPS/OMS estableció en mayo 2004 el Grupo de Trabajo (GT) sobre APS para que hiciera sugerencias sobre las futuras orientaciones estratégicas y programáticas en APS; dicho proceso es liderado desde la ofi cina de la Directora Adjunta (AD) y coordinado por la unidad de Organización de Servicios, del área de Tecnología y Prestación de Servicios de Salud (THS/OS).

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El documento trata de los Sistemas de Salud basados en la Atención Primaria de Salud; este reconocimiento se sustenta en la evidencia de su impacto sobre la salud y desarrollo de la población. Así mismo, las experiencias acumuladas tanto en países desarrollados como en proceso de desarrollo han demostrado que la APS puede ser adaptada a los distintos contextos políticos, sociales y culturales.

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La Atención Primaria de Salud (APS) es reconocida como componente clave de los Sistemas de Salud; este reconocimiento se sustenta en la evidencia de su impacto sobre la salud y desarrollo de la población. Así mismo, las experiencias acumuladas tanto en países desarrollados como en proceso de desarrollo han demostrado que la APS puede ser adaptada a los distintos contextos políticos, sociales y culturales. Por otra parte, los cambios demográficos, sociales y epidemiológicos producidos desde la celebración de la Conferencia de Alma Ata acarrean la necesidad de una revisión profunda de la estrategia de APS para que pueda dar respuesta a las necesidades en salud y desarrollo de la población en el mundo. La propuesta de la OPS para la renovación de APS se inició a partir de la Resolución 1 CD44.R6 de septiembre de 2003, en la que se invita a los estados miembros a adoptar una serie de recomendaciones para fortalecer la APS. Además insta a la OPS a tener en cuenta los principios de la APS en las actividades de los programas de cooperación técnica, esencialmente los relacionados con los ODM; evaluar diferentes sistemas basados en la APS e identificar y diseminar las mejores prácticas; concurrir en la capacitación de trabajadores de la salud para la APS; apoyar modelos de APS definidos a nivel local. En respuesta al mandato anterior, la OPS/OMS estableció en mayo 2004 el Grupo de Trabajo (GT) sobre APS para que hiciera sugerencias sobre las futuras orientaciones estratégicas y programáticas en APS; dicho proceso es liderado desde la oficina de la Directora Adjunta (AD) y coordinado por la unidad de Organización de Servicios, del área de Tecnología y Prestación de Servicios de Salud (THS/OS). (AU)

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O objetivo deste estudo foi verificar o perfil e as diferenças nas características antropométricas de jovens nadadores brasileiros, de distintas categorias, em ambos os gêneros. Foram avaliados 90 nadadores do sexo masculino e 70 do sexo feminino das categorias Infantil (12-13 anos), juvenil (14-15 anos) e junior (16-18 anos). As variáveis antropométricas mensuradas foram: massa corporal (Kg), estatura (m), IMC (Kg/m2), massa magra (kg), massa gorda (kg) e envergadura (m). O percentual de gordura (%G) foi obtido através da equação de Lohman. Na estatística, foi utilizado o teste Anova two way seguido de post hoc Tukey, com p<0,05. No gênero masculino, a categoria junior apresentou maior massa corporal, estatura, envergadura e massa magra em relação aos grupos infantil e juvenil. Para o gênero feminino, a massa corporal foi superior na categoria junior comparada à infantil e a juvenil. Foram observadas estatura, envergadura, massa magra e massa gorda maiores na categoria junior, quando comparadas à infantil. No sexo feminino, a categoria juvenil apresentou maior massa corporal e massa magra em relação ao grupo infantil. Na categoria infantil, os meninos apresentaram maior massa corporal e massa magra em relação às meninas. Na categoria juvenil, o masculino teve maior massa corporal, estatura, envergadura e massa magra em relação ao feminino, que teve maior %G. Na categoria junior, os meninos apresentaram maior massa corporal, estatura, envergadura e massa magra em relação às meninas, que apresentaram maior %G. Conclui-se que, existem diferenças nas variáveis antropométricas entre as categorias, em ambos os gêneros, entretanto, para o grupo feminino as diferenças antropométricas entre as categorias infantil e juvenil são menos evidentes, provavelmente, devido às alterações orgânicas e hormonais que ocorrem prematuramente em meninas.

The objective of this study was to establish the profi le as well as the differences in anthropometric characteristics of Brazilian young swimmers of different categories in both sexes. Ninety male and 70 female swimmers were measured in the following categories: 1 (12-13 years), 2 (14-15 years) and 3 (16-18 years). Anthropometric variables analyzed were: body mass (Kg), stature (m), BMI (Kg/m2), fat free mass (LBM, kg), fat mass (kg) and arm span (m). The percent of body fat (% fat) was estimated using the Lohman equation. Two-way ANOVA was used followed by the TukeyÆs post-hoc test, with p< 0.05. For males, the category 3 presented higher body mass, stature, arm span and LBM in relation to the other categories. For females, body mass was higher in category 3 when compared to categories 1 and 2. It was observed higher stature, arm span, LBM andfat mass for category 3 when compared to 1. Category 2 presented higher body mass and LBM than category 1. Comparing to girls, boys in the category 2 had higher BMI and LBM than girls. For both categories 2 and 3, males showed higher body mass, stature, arm span and LBM than females, which, in turn, had higher % fat. It was concluded that anthropometric variables are different between categories for both sexes, however, among girls differences between categories 1 and 2 were less evident, probably because of early maturation changes in females.

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One of the primary objectives of Colombian social health insurance reform was to increase competition among for-profit insurers. Unfortunately, the flat capitated formula creates an opportunity for sickness funds to maximize reimbursement gains by cream skimming--selecting against unhealthy individuals. This paper explores sickness fund selection behavior to evaluate the efficiency losses associated with the introduction of managed competition in Colombia. Data from a 1997 Colombian household survey are analyzed with a bivariate probit model with partial observability using instrumental variables. The model yields some evidence of sickness fund selection based on health status. Public policy options to discourage risk selection by health status are discussed.

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Law 100 introduced the Health Sector Reform in Colombia, a model of managed competition. This article addresses the effects of this model in terms of output and outcomes of TB control. Trends in main TB control indicators were analysed using secondary data sources, and 25 interviews were done with key informants from public and private insurers and provider institutions, and from the health directorate level. We found a deterioration in the performance of TB control: a decreasing number of BCG vaccine doses applied, a reduction in case finding and contacts identification, low cure rates and an increasing loss of follow up, which mainly affects poor people. Fragmentation occurred as the atomization and discontinuity of the technical processes took place, there was a lack of coordination, as well as a breakdown between individual and collective interventions, and the health information system began to disintegrate. The introduction of the Managed Competition (MC) in Colombia appeared to have adverse effects on TB control due to the dominance of the economic rationality in the health system and the weak state stewardship. Our recommendations are to restructure the reform's public health component, strengthen the technical capacity in public health of the state, mainly at the local and departmental levels, and to improve the health information system by reorienting its objectives to public health goals.

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BACKGROUND: In 1993, Colombia enacted and subsequently implemented a radical reform in its system of providing health care for the poor, moving in a short time from a traditional model of providing health services in public hospitals to a managed competition model in which the government buys health insurance for the poor. This study examines and attempts to draw lessons from the early experience with this reform. METHODS: Information was gathered from document reviews and interviews with key actors at both the national and local levels. Other quantitative data, such as data from existing national surveys and financial operating data, were also used as available. RESULTS: The new system made important achievements in its first few years, including the enrollment of 7 million Colombians (about half of the targeted population) in health insurance plans and improving access to care. Nevertheless, there were substantial problems with the lack of managerial infrastructure and flow of information needed for the new system to function properly. Because of these difficulties, substantial resources were wasted, and insurance coverage did not always result in true access to health care. CONCLUSIONS: Other countries contemplating similar reforms should educate health administrators and the public, and establish solid administrative capacity in advance of implementation. In Colombia, many initial problems still need to be overcome while maintaining and extending the programme's important accomplishments.

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The challenge of achieving community participation as a component of health sector reform is especially great in low- and middle-income countries where there is limited experience of community participation in social policy making. This paper concentrates on the social representations of different actors at different levels of the health care system in Colombia that may hinder or enable effective implementation of the participatory policy. The study took place in Cali, Colombia and focused on two institutional mechanisms created by the state to channel citizen participation into the health sector, i.e. user associations and customer service offices. This is a case study with multiple sources of evidence using a combination of quantitative and qualitative social science methods. The analysis of respondents' representations revealed a range of practical concerns and considerable degree of scepticism among public and private sector institutions, consumer groups and individual citizens about user participation. Although participation in Colombia has been introduced on political, managerial and ethical grounds, this study has found that health care users do not yet have a meaningful seat around the table of decision-making bodies.

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