Notas sobre o futuro do SUS: breve exame de caminhos e descaminhos trilhados em um horizonte de incertezas e desalentos

Privatization and Oligopolies of the Renal Replacement Therapy Sector on Contemporary Capitalism: A Systematic Review and the Brazilian Scenario

Worldwide the assistance on renal replacement therapy (RRT) is carried out mainly by private for-profit services and in a market with increase in mergers and acquisitions. The aim of this study was to conduct an integrative systematic review on privatization and oligopolies in the RRT sector in the context of contemporary capitalism. The inclusion criteria were scientific articles without language restrictions and that addressed the themes of oligopoly or privatization of RRT market. Studies published before 1990 were excluded. The exploratory search for publications was carried out on February 13, 2024 on the Virtual Health Library Regional Portal (VHL). Using the step-by-step of PRISMA flowchart, 34 articles were retrieved, of which 31 addressed the RRT sector in the United States and 26 compared for-profit dialysis units or those belonging to large organizations with non-profit or public ones. The main effects of privatization and oligopolies, evaluated by the studies, were: mortality, hospitalization, use of peritoneal dialysis and registration for kidney transplantation. When considering these outcomes, 19 (73%) articles showed worse results in private units or those belonging to large organizations, six (23%) studies were in favor of privatization or oligopolies and one study was neutral (4%). In summary, most of the articles included in this systematic review showed deleterious effects of oligopolization and privatization of the RRT sector on the patients served. Possible explanations for this result could be the presence of conflicts of interest in the RRT sector and the lack of incentive to implement the chronic kidney disease care line. The predominance of articles from a single nation may suggest that few countries have transparent mechanisms to monitor the quality of care and outcomes of patients on chronic dialysis.

Desafios atuais e futuros do uso da medicina de precisão no acesso ao diagnóstico e tratamento de câncer no Brasil

Este artigo busca refletir, cultural e eticamente, sobre os desafios atuais e futuros da incorporação de novas biotecnologias de diagnóstico e tratamento de câncer no Brasil, bem como seu impacto no acesso e no controle do câncer no país. Para tanto, esta pesquisa parte da problematização da literatura sobre o tema e dos resultados de um estudo, que realizou uma websurvey com especialistas médicos dos setores público e privado brasileiros, associados às dez sociedades oncológicas mais representativas do país, atuantes nas áreas da clínica, cirurgia, radioterapia, patologia e diagnóstico. A discussão do estudo desenvolve-se em torno de três eixos temáticos: conhecimento e expectativas sobre o advento das novas tecnologias para o diagnóstico e tratamento do câncer; considerações estruturais e éticas envolvidas no uso atual e futuro das novas tecnologias; e possíveis cenários associados ao uso e aplicação das novas tecnologias para o diagnóstico e tratamento do câncer. Foram suscitadas algumas questões: novos paradigmas tecnológicos beneficiarão todos os usuários do Sistema Único de Saúde (SUS) ou serão privilégios de poucos? Diminuirão as discrepâncias em termos de oferta de distribuição de serviços, de recursos tecnológicos e de acesso ao diagnóstico e tratamento do câncer? Como diversos segmentos da sociedade poderão participar e influir nesse processo? Que tipos de cenários poderão ainda compor esse quadro? Visando contribuir com o planejamento da atenção ao câncer no Brasil, o artigo finaliza propondo o desenvolvimento de futuras ações a partir de cinco dimensões estratégicas: dimensão econômica; dimensão científica, de inovação e tecnológica; dimensão estrutural; dimensão cultural; e dimensão reguladora.

[Transition of morbidity and mortality in Brazil: a challenge on the thirtieth anniversary of the SUS]

In 2020, the 30th anniversary of the publication of the Organic Laws of the Unified Health System was celebrated. Since then, the change in the profile of morbidity and mortality has been a challenge to management to ensure that the health services can attend the significant heterogeneity of approximately 6,000 municipalities. To achieve this, it is necessary to monitor the leading indicators of the country. The scope of this study was to present an overview of trends in mortality and morbidity in Brazil between 1990 and 2019. Data from the Study on the Global Burden of Disease was used to describe morbidity and mortality by major groupings (infectious diseases, chronic diseases, and external causes), according to gender and age groups. There was a reduction in morbidity and mortality in the period, irrespective of the cause or age group, albeit with a varied difference between the sexes depending on the cause. The contribution of chronic diseases increases with age, with a marked difference according to gender. The curves for mortality and years lost due to disability have a typical profile, with a different pattern of curves for men due to external causes, with marked excess mortality at young ages. The trend confirms the decline of indicators in a linear manner over the period.

Multidisciplinary treatment for patients with chronic kidney disease in pre-dialysis minimizes costs: a four-year retrospective cohort analysis

INTRODUCTION

Chronic kidney disease (CKD) can progress to end-stage renal disease (ESRD), and clinical studies show that this progression can be slowed. The objective of this study was to estimate the costs to Brazil's public health system (SUS) throughout the course of CKD in the pre-dialysis stage compared to the costs to the SUS of dialysis treatment (DT).

METHODS

A retrospective cohort study was conducted to analyze clinical and laboratory variables; the outcome analyzed was need for DT. To assess cost, a microcosting survey was conducted according to the Methodological Guidelines for Economic Evaluations in Healthcare and the National Program for Cost Management, both recommended by the Brazilian Ministry of Health for economic studies.

RESULTS

A total of 5,689 patients were followed between 2011 and 2014, and 537 met the inclusion criteria. Average costs increased substantially as the disease progressed. The average cost incurred in stage G1 in Brazilian reals was R$ 7,110.78, (US$1,832.06) and in stage G5, it was R$ 26,814.08 (US$6,908.53), accumulated over the four years.

CONCLUSION

A pre-dialysis care program may reduce by R$ 33,023.12 ± 1,676.80 (US$ 8,508.26 ± 432.02) the average cost for each year of DT avoided, which is sufficient to cover the program's operation, minimizing cost. These results signal to public health policy makers the real possibility of achieving significant cost reduction in the medium term for CKD care (4 years), to a program that disbursed R$ 24 billion (US$ 6.8 billion) for DT in Brazil between 2009 and 2018.

Financing needs, spending projection, and the future of health in Brazil

In this paper we adopt a growth accounting projection model to estimate and characterize health-financing needs in Brazil as well as to assess the extent to which financing needs may diverge from spending capacity in the future. We estimate an annual increase of 0.71% in the share of projected financing needs relative to GDP, with excess growth rates being 0.74% and 0.69% for the public and private health sectors, respectively. Institutional reforms and public spending restrictions may leverage public-private segmentation in health financing throughout the next decades, thus potentially leading to losses of equity in the system. Our projections contribute to a scant empirical literature on health financing sustainability in low- and middle-income countries and shed light on the role of spending capacity and institutional constraints over the path towards universal health coverage.

Posicionamento dos representantes dos usuários no Conselho Estadual de Saúde da Bahia diante do agravamento do subfinanciamento do SUS em 2016-2018

Resumo O objetivo desse trabalho é analisar o posicionamento dos representantes dos usuários no Conselho Estadual de Saúde da Bahia (CES-BA) diante das decisões do Governo Federal relativas ao financiamento do Sistema Único de Saúde (SUS) no período 2016-2018. O referencial teórico se baseia na noção de participação incorporada no arcabouço jurídico político do SUS, que institui a criação de Conselhos de Saúde e a realização de Conferências de Saúde como espaços de formulação, monitoramento e avaliação de políticas de saúde nos diversos níveis organizativos do sistema. A coleta de dados foi realizada por meio de revisões documentais e entrevistas aos representantes do segmento usuários no conselho. Os resultados contemplam a caracterização do perfil político-associativo das entidades representadas no CES-BA e o posicionamento dos conselheiros sobre as mudanças no financiamento do SUS no período 2016-2018. Discute-se a baixa representatividade de alguns grupos populacionais no CES-BA e a percepção acerca da Emenda Constitucional 95 e da influência dos partidos políticos na dinâmica dos conselhos. A conclusão ressalta a importância relativa da qualificação técnica diante da experiência acumulada pelos conselheiros e a necessidade de articulação destes com as bases sociais que pretendem representar, especialmente na atual conjuntura política brasileira.

Spatial density of adolescents aged 14 years old, victims of dental: A longitudinal study

BACKGROUND/AIM

Knowledge about the spatial density of the domiciles of dental trauma victims can assist in the identification of the most vulnerable areas and contribute to the planning of prevention, promotion, control, and treatment actions, focusing on the most affected areas. The aim of this study was to analyze the spatial density of domiciles of 14-year-old adolescent victims of dental trauma, in the city of Diamantina, Brazil, after a two-year follow-up period.

MATERIAL AND METHODS

This longitudinal study was carried out with 584 adolescents between 2013 and 2015. Dental trauma, overjet, and lip protection were assessed by two trained and calibrated examiners (K > 0.70). Information about binge drinking was collected among the adolescents through the Alcohol Use Disorders Identification Test and sociodemographic indicators were obtained through a questionnaire answered by the caregivers of the adolescents. Spatial analyses were performed to evaluate the spatial density of adolescents with dental trauma and the independent variables of interest according to the domicile using Ripley's K function and the Kernel Map.

RESULTS

Ripley's K function revealed spatial aggregation of the domiciles of adolescent victims of dental trauma in relation to males, binge drinking and overjet, with a confidence interval of 95%. The higher density of domiciles with adolescents with two or more traumatized teeth was found in the north-east region of the city. Boys were the most affected, their homes were located in the north, north-west, and south-east regions at baseline and follow-up. The largest density of domiciles of adolescents with overjet greater than 5 mm and inadequate lip protection was in the north-east region. Similar spatial distribution was identified for binge drinking for both years.

CONCLUSION

The majority of adolescents with dental trauma lived in the north-east and south-east regions, characterized by high population density and greater social vulnerability.

Morbidades autorreferidas por usuários de espaços comunitários de atividade física

Objetivo: analisar as morbidades autorreferidas relacionadas com as condições sociodemográficas dos usuários de espaços comunitários de atividade física.Materiais e métodos: estudo transversal, com abordagem quantitativa, realizado com 433 usuários do Sistema Único de Saúde, na macrorregião Cariri, Ceará, Brasil. A coleta ocorreu por meio de formulário estruturado a partir do modelo de questionário da Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico, operacionalizada pelo Ministério da Saúde do Brasil.Resultados: a média de idade dos participantes do estudo foi de 42,92 anos (DP ± 17,4); a de renda familiar foi de R$ 1.486,30 (DP ± 1.015,0). Verificou-se predomínio do sexo feminino associado à maior prevalência de hipertensão (p = 0,001) e de dislipidemia (p = 0,003). A idade mais elevada relacionou-se aos diagnósticos médicos de hipertensão (53,85 anos, DP ± 15,64), dislipidemia (59,54 anos, DP ± 15,25) e diabetes (52,42 anos, DP ± 16,66).Conclusão: a análise das características sociais e econômicas permitiu verificar a associação de morbidades como hipertensão, diabetes e dislipidemia com o sexo, a idade, a renda e a escolaridade; esses fatores são causais para o desenvolvimento das doenças crônicas não transmissíveis.

Mortality associated with alternative policy options for primary care and the Mais Médicos (More Doctors) Program in Brazil: forecasting future scenarios

Objective.

To forecast the impact of alternative scenarios of coverage changes in Brazil’s Family Health Strategy (Estratégia Saúde da Família) (ESF)—due to fiscal austerity measures and to the end of the Mais Médicos (More Doctors) Program (PMM)—on overall under-5 mortality rates (U5MRs) and under-70 mortality rates (U70MRs) from ambulatory care sensitive conditions (ACSCs) up through 2030.

Methods.

A synthetic cohort of 5 507 Brazilian municipalities was created for the period 2017-2030. A municipal-level microsimulation model was developed and validated using longitudinal data. Reductions in ESF coverage, and its effects on U5MRs and U70MRs from ACSCs, were forecast based on two probable austerity scenarios, as compared to the maintenance of current ESF coverage. Fixed effects longitudinal regression models were employed to account for secular trends, demographic and socioeconomic changes, variables related to health care, and program duration effects.

Results.

In comparison to maintaining stable ESF coverage, with the decrease in ESF coverage due to austerity measures and PMM termination, the mean U5MR and U70MR would be 13.2% and 8.6% higher, respectively, in 2030. The end of PMM would be responsible for a mean U5MR from ACSCs that is 4.3% higher and a U70MR from ACSCs that is 2.8% higher in 2030. The reduction of PMM coverage due only to the withdrawal of Cuban doctors who have been working in PMM would alone be responsible for a U5MR that is 3.2% higher, and a U70MR that is 2.0% higher in 2030.

Conclusions.

Reductions in primary health care coverage due to austerity measures and the end of the PMM could be responsible for many avoidable adult and child deaths in coming years in Brazil.

A crise financeira e a saúde: o caso do município do Rio de Janeiro, Brasil

Resumo Este estudo explorou os efeitos da crise financeira nas receitas e despesas, na produção de serviços e indicadores de saúde e de desempenho no município do Rio de Janeiro no período de 2013 a 2018. Analisou-se receitas, despesas, parâmetros de provisão de serviços e indicadores de desempenho e de saúde, a partir de dados de acesso livre e restrito. Utilizou-se a análise institucional de Giddens. As receitas e despesas sofreram redução, sendo maiores nos investimentos e receitas não vinculadas. A provisão de serviços encolheu, com queda da cobertura na Atenção Primária, produção ambulatorial, internações totais, número de leitos, médicos e agentes comunitários de saúde, cirurgias realizadas e taxa de ocupação de hospitais. Os tempos de espera para ambulâncias, exames e consultas ambulatoriais, bem como o número de solicitações pendentes na regulação aumentaram. Indicadores de saúde e desempenho persistiram, em sua maioria, dentro dos parâmetros anteriores, corroborando a potência assistencial da Atenção Primária, apesar do impacto financeiro e estrutural da austeridade. A conjuntura atual ameaça o direito à saúde e as respostas governamentais, como a desvinculação de receitas, sinalizam uma ampliação desse risco.

Underfunding and federal budget of SUS: preliminary references for additional resource allocation

This paper aims to identify new sources of revenue for the additional allocation of resources to meet the population's health needs fixed in the federal budget expenses, in the context of the Unified Health System (SUS) underfunding process and the negative effects of Constitutional Amendment 95/2016 for this process - verified decrease in the proportion of federal net current revenue destined to SUS. From this perspective, it is necessary to address the problem of underfunding by linking the search for additional resources with new sources of funding with actions and public health services that will be improved, expanded and created, of which criteria are: regarding sources, exclusivity for SUS, non regressive taxing and review of revenue waiver; and, regarding uses, prioritization of primary care as reference of the health care network and appreciation of civil servants in the health area. The result calculated for the sources ranged from R$ 92 billion to R$ 100 billion, higher than the R$ 30.5 billion calculated for uses under the described terms. A documentary research was conducted to collect data from secondary sources, especially in the reports sent to the National Health Council by the Ministry of Health.

A retomada do processo de implementação da Política Nacional de Educação Permanente em Saúde no Brasil

RESUMO Este trabalho teve por objetivos descrever e analisar as mais recentes iniciativas realizadas, no âmbito da gestão federal, para a implementação e fortalecimento da Política Nacional de Educação Permanente em Saúde (PNEPS). Toma como referencial o ciclo da política pública de Kingdon, descrevendo como se deu a inclusão desse tema na agenda governamental, em 2003, e analisa o conteúdo dos documentos que materializam as propostas da Política. Em seguida, concentra-se na descrição e análise do movimento desencadeado em 2017-2018, com a realização de uma série de eventos regionais, dos quais resultaram a identificação das fragilidades enfrentadas nesse processo de implementação da PNEPS, subsidiando um conjunto de propostas, que referenciam as iniciativas desencadeadas, visando à efetiva implementação da PNEPS no âmbito do Sistema Único de Saúde.

Os sistemas universais de saúde e o futuro do Sistema Único de Saúde (SUS)

RESUMO Com o objetivo de discutir a situação atual, limites e possibilidades do Sistema Único de Saúde (SUS) nos próximos anos, tendo em conta as mudanças nos sistemas universais de saúde, este ensaio apresenta uma breve revisão da literatura sobre sistemas e reformas setoriais em saúde. Registra as tendências orientadas para o mercado, discutindo certas diferenças entre sistemas universais de saúde e a proposta político-ideológica de cobertura universal de saúde. Destaca diversos obstáculos no desenvolvimento histórico do SUS, especialmente o subfinanciamento crônico e a falta de prioridade pelos governos. Comenta as ameaças à consolidação e o risco de desmonte do SUS ante as políticas econômicas ultraliberais e as propostas que defendem sistemas de saúde orientados para o mercado. Conclui reiterando que o maior desafio do SUS continua sendo político, sublinhando a relevância das lutas em defesa da democracia e das conquistas civilizatórias que integram o projeto da Reforma Sanitária Brasileira.