RESUMO Coordenação do cuidado significa estabelecer conexões de modo a alcançar o objetivo maior de prover/atender às necessidades e preferências dos usuários na oferta de cuidados em saúde, com elevado valor, qualidade e continuidade. O presente ensaio faz uma revisão dos estudos, teóricos e empíricos, sobre coordenação do cuidado, tendo como objetivo norteador a identificação de políticas, estratégias e instrumentos para alcance de melhor coordenação no Sistema Único de Saúde. A síntese é realizada a partir de três dimensões, consideradas centrais para análise desse atributo no contexto da Atenção Primária à Saúde (APS) brasileira: posição da Estratégia Saúde da Família na rede assistencial; integração entre níveis assistenciais e interfaces com a regulação assistencial; e integração horizontal com outros dispositivos de atenção e cuidado no território. Buscou-se identificar conceitos, evidências, resultados e desafios acerca da coordenação do cuidado no cenário nacional, assim como formular uma 'agenda estratégica pró-coordenação' que reconhece os avanços alcançados, mas também a incompletude dessas iniciativas. Na medida em que o fortalecimento da APS é uma das mais potentes medidas pró-coordenação, a diminuição de investimentos e de prioridade na Estratégia Saúde da Família representa o enfraquecimento da consolidação de arranjos sistêmicos, capazes de garantir a integralidade da atenção.
The aim of this article was to reflect on the challenges faced in building the Health Regions and Networks in Brazil. These reflections result from studies conducted in several health regions. The central challenges for the constitution of the Health Regions and Networks are as follows: the Care Model, Primary Health Care, Care for Users with Chronic Diseases, and Hospital Care. In order to consolidate the regions and networks the organization needs to incorporate an ethical sense: focusing on social, public and individual needs, derived from comprehensive care, human and social rights, in broad, multi-scale and inter-sectorial interactions, with the constitution of a systemic, regionalized innovation. Of prime importance is the capacity to devise which general principles are responsible for maintaining the unity(mode of care), seeking to outline the coherence of the different provision models that the system might develop according to the social needs in regional settings. Without that, users will continue to seek and create ways of accessing health services that challenge the rationale of those very services. Hospital reform is also required to integrate and reorient the hospital networks. These reflections are important for the SUS to uphold its solidarity project, expressed in the trinity of universality-comprehensiveness-equality.
The socioeconomic development, supply and complexity of health actions and services in a regional context may be considered structural constraints to the success of the current process of health care regionalization in Brazil. The main objective of this study is to identify the structural determinants of the regionalization process by building a typology of health regions in Brazil. A typology of Brazilian health regions was developed from available secondary data sources. The dimensions and groups that form the typology were identified through factor analysis and cluster analysis. The type of service provider both for out and inpatients was also identified. Results: the regions were classified into five independent groups according to their socioeconomic profile and characteristics of the health service supply. The characterization of Brazilian health regions through the typology demonstrates high levels of heterogeneity throughout Brazil, and the complex organization of the regional health systems. The proposed typology could contribute to future research and better understanding of this complex and contradictory scenario, supporting the urgently required development of integrated regional public policies that simultaneously involve economic and social development and the strengthening of regional spaces of governance in order to promote the organization of regional health systems grounded on the principles of the SUS (Brazilian National Health System), under a shared, joint management with the objective of ensuring the universal right to health.
RESUMO A concepção de uma Atenção Primária à Saúde (APS) abrangente e sua qualidade podem ser avaliadas por meio da efetivação dos atributos: primeiro contato, longitudinalidade, abrangência/integralidade e coordenação. O artigo teve por objetivo analisar a consecução dos atributos da APS na prática das equipes, na perspectiva dos profissionais e usuários, comparando-se os resultados do Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ-AB), entre os ciclos 1 e 2. Estudo quantitativo, com identificação das equipes participantes dos dois ciclos e operacionalização dos atributos da APS por meio da seleção de variáveis PMAQ-AB pertinentes a cada atributo. Foram comparados os resultados nacionais de 12.680 Unidades Básicas de Saúde (UBS), 15.668 equipes e 58.517 usuários. Apenas parte dos atributos apresentou melhorias do ciclo 1 para o ciclo 2. Os melhores resultados foram primeiro contato e integralidade, confirmando gradual constituição da UBS como serviço de porta de entrada acessível, com escopo diversificado de ações, ainda que insuficientes. Os atributos com pior avaliação foram longitudinalidade, com baixa continuidade e qualidade da relação profissional-paciente; e coordenação, por dificuldades de acesso às consultas especializadas e insuficientes registros compartilhados.PALAVRAS-CHAVE Atenção Primária à Saúde. Acesso. Integralidade.ABSTRACT The concept of a comprehensive Primary Health Care (PHC) and its quality can be evaluated by the effectiveness of the following attributes: first contact service, longitudinality, comprehensiveness and coordination. The objective of this article is to analyze the effectiveness of PHC attributes in team practice from the perspective of professionals and users, comparing the results of the National Program for Access and Quality Improvement in Primary Health Care (PMAQ-AB), between cycles 1 and 2. Quantitative study, with identification of the teams participating in the two cycles and operationalization of the PHS attributes through the selection of PMAQ-AB variables relevant to each attribute. We compared the national results of 12.680 Basic Health Units, 15.668 teams and 58.517 users. Some attributes improved from cycle 1 to cycle 2. The best results were first contact and comprehensiveness, confirming the gradual constitution of the Basic Health Units as an accessible first contact service, with a diversified scope of actions, although insufficient. The attributes with worse evaluation were longitudinality, with low continuity and quality of the professional-patient relationship; and coordination, due to difficulties of access to specialized care and insufficient shared records.
Resumo A tipologia da estrutura das 38.812 unidades básicas de saúde (UBS) brasileiras foi elaborada com base nos resultados do censo do ciclo 1 do Programa
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