Background The INBUILD trial investigated the efficacy and safety of nintedanib versus placebo in patients with progressive fibrosing interstitial lung diseases (ILDs) other than idiopathic pulmonary fibrosis (IPF). We aimed to establish the effects of nintedanib in subgroups based on ILD diagnosis. Methods The INBUILD trial was a randomised, double-blind, placebo-controlled, parallel group trial done at 153 sites in 15 countries. Participants had an investigator-diagnosed fibrosing ILD other than IPF, with chest imaging features of fibrosis of more than 10% extent on high resolution CT (HRCT), forced vital capacity (FVC) of 45% or more predicted, and diffusing capacity of the lung for carbon monoxide (DLco) of at least 30% and less than 80% predicted. Participants fulfilled protocol-defined criteria for ILD progression in the 24 months before screening, despite management considered appropriate in clinical practice for the individual ILD. Participants were randomly assigned 1:1 by means of a pseudorandom number generator to receive nintedanib 150 mg twice daily or placebo for at least 52 weeks. Participants, investigators, and other personnel involved in the trial and analysis were masked to treatment assignment until after database lock. In this subgroup analysis, we assessed the rate of decline in FVC (mL/year) over 52 weeks in patients who received at least one dose of nintedanib or placebo in five prespecified subgroups based on the ILD diagnoses documented by the investigators: hypersensitivity pneumonitis, autoimmune ILDs, idiopathic non-specific interstitial pneumonia, unclassifiable idiopathic interstitial pneumonia, and other ILDs. The trial has been completed and is registered with ClinicalTrials.gov, number NCT02999178.

Dentro dos Estudos de Linha de Base do Proesf, a partir de uma extensa análise de dados secundários e entrevistas com os principais atores do sistema de saúde municipal, identificaram-se modelos de atenção básica e graus de efetividade, eficácia, sustentabilidade e governabilidade dos sistemas municipais de saúde e de atenção básica dos municípios paulistas com mais de 100 mil habitantes. O artigo apresenta e discute ainda os principais obstáculos externos e internos (setoriais) enfrentados para a estruturação da Atenção Básica nesses municípios. Os obstáculos externos são decorrentes do perfil de urbanização e de velhos e novos problemas sociais expressos em situações de extrema desigualdade inter e intramunicipais, sabendo-se que o seu enfrentamento depende de uma série de políticas públicas intersetoriais, principalmente, no campo social e do trabalho. Já os obstáculos internos ou setoriais são decorrentes da forma como se distribuem os serviços e as tecnologias em saúde e do padrão de organização dos serviços, cuja solução depende de políticas de saúde específicas voltadas principalmente para a problemática das regiões metropolitanas e para maior eficácia e sustentabilidade dos sistemas municipais e de atenção básica.

US analysts and decisionmakers interested in comparative health policy typically turn to European perspectives, but Brazil-notwithstanding its far smaller gross domestic product and lower per capita health expenditures and technological investments-offers an example with surprising relevance to the US health policy context. Not only is Brazil comparable to the United States in size, racial/ethnic and geographic diversity, federal system of government, and problems of social inequality. Within the health system the incremental nature of reforms, the large role of the private sector, the multitiered patchwork of coverage, and the historically large population excluded from health insurance coverage resonate with health policy challenges and developments in the United States.

O artigo trata da relação entre Estado e saúde apresentando as dificuldades para a sua conceituação e a retomada da sua trajetória na Europa e no Brasil. Mostra aspectos para a reflexão desta relação com a consagração da saúde como direito social e dever do Estado pela Constituição Federal e indica os desafios postos ao Sistema Único de Saúde.

The present article analyzes the implementation of the Family Health Program (FHP) IntroduçãoA implantação do Programa Saúde da Família (PSF) vem se configurando como a principal estratégia na organização da atenção básica levada a cabo pelo Ministério da Saúde (MS). Neste cenário, assume especial importância o estudo dos processos de implantação do PSF nas metrópoles, pois é exatamente nessas cidades onde se poderá confirmar ou não o êxito da estratégia assumida. Recorde-se que, atualmente, cerca de 75 milhões de habitantes residem nas 36 regiões metropolitanas brasileiras e que estes espaços configuram-se como centrais para a concretização de qualquer política de saúde que se pretenda universal e equânime, como o próprio Sistema Único de Saúde (SUS) 1 .A cobertura populacional do PSF nas regiões metropolitanas e nas cidades com mais de 500 mil habitantes vem alcançando percentuais inferiores às coberturas nacionais como um todo. Em 1998, a cobertura do PSF no país alcançava 1,96% e, em 2003, chegou a 33,32%; no mesmo período, nas grandes cidades, estes valores passam de 0,98% para 17,22% 2 .No entanto, na maior cidade brasileira, São Paulo, o quadro encontrado difere do verificado na grande maioria das outras metrópoles, pois o PSF foi assumido como estratégia de reorganização da atenção à saúde a partir de 2001. Desde então, essa cidade concentra o maior nú-mero de equipes de saúde da família em ativi-

The Baseline Studies on the Project for Expansion and Consolidation of the Family Health Strategy created primary health care indicators and models for the 62 municipalities with more than 100,000 inhabitants in São Paulo State, Brazil, and identified varying patterns for these indicators and models in relation to different urban dynamics in the State. The studies showed the need to reflect on health in relation to urban land use. The main objective was to gain a better understanding of how urban dynamics influence the health system's profile, organization, and operation, based on which it was possible to extract some hypotheses and discussions regarding how urbanization in São Paulo State creates challenges for the expansion and consolidation of primary health care and the Family Health Program in these municipalities.

NO PRESENTE artigo trata-se de analisar o Plano de Assistência à Saúde da Prefeitura do Município de São Paulo na perspectiva da gestão dos sistemas de saúde e da preservação dos direitos sociais. Apresenta-se uma breve retrospectiva da construção da saúde enquanto um direito social nas sociedades contemporâneas e traça-se o quadro das políticas de saúde no Brasil, em anos recentes, enfatizando seu processo de descentralização para a esfera municipal. Examina-se o PAS como alternativa de gestão e conclui-se pela incapacidade da sua regulação pelas forças de mercado e a sua inconsistência ideológica frente aos preceitos liberais para o setor saúde. Encerra-se com um breve balanço dos legados proporcionados por essa experiência de gestão.
IN THIS ARTICLE is analysed the Health Care Plan (Plano de Assistencia à Saúde - PAS) of the municipality of São Paulo from the perspective of the health system management and of preservation of social rights. It is presented a brief historical retrospective of the construction of health as a social right in contemporary societies, and a picture of health policies in Brazil in recent years emphasizing its decentralization process towards the municipal level. It is also examined the PAS as a management alternative and it is concluded that market forces are unable to regulate it and that it has ideological inconsistencies when faced to the liberal principles in force in the health sector. The author finishes the article with a brief balance of the legacy provided by this management experience

OBJECTIVE: To present the methodological approach used to defi ne the profi le of health services utilization by the population enrolled in the Family Health Program. METHODS:Three patterns of services utilization accessed by the population were considered: residual, partial and full. These patterns were identifi ed based on the range of actions of the Family Health Program that are accessed by the population. An enquiry was conducted in 2006 with two-stage sampling in an area characterized by high levels of social exclusion in the city of São Paulo, Brazil. In the fi rst stage, 960 people participating in family health teams were drawn and classifi ed by the community-based health agents as "full use" or not of the health services. In the second stage, 173 drawn subjects were then classifi ed according to the patterns of services utilization. RESULTS:Subjects were classified as full users (16%), partial users (57%) and residual users (26%), and had different social and demographic characteristics. There was a selective and focused utilization of the services offered by the Family Health Program. Being male, having a level of schooling above the fi fth grade of elementary school, having a paid job and accessing medical care systems implied lower adhesion to the services, even though the study focused on regions with few options of healthcare services. Even in areas of high social exclusion and low offer of health services, 25% of the enrolled population did not use the services offered at the Family Health Units, receiving only home visits. CONCLUSIONS:Methodologies that are capable of capturing distinct patterns of health services utilization by the population may contribute to improve services evaluation.