El articulo presenta un panorama de la Atencion Primaria de Salud en Suramerica a partir de mapeos realizados en los 12 paises segun una matriz analitica organizada en las dimensiones: conduccion, financiamiento, caracteristicas de la prestacion y organizacion, coordinacion de cuidados e integracion a la red de servicios, fuerza de trabajo, participacion social, accion intersectorial e interculturalidad. Se observa diversidad en la implementacion y de abordajes de APS, condicionada por directrices politicas, modalidades de proteccion social y segmentacion de los sistemas de salud. Se destacan iniciativas innovadoras de atencion primaria integral y se identifican los principales desafios.

/pdf/panorama-de-la-atencion-primaria-de-salud-en-suramerica-4xp2k5ape5.pdf

Panorama de la Atención Primaria de Salud en Suramérica: concepciones, componentes y desafíos

Doctors' experience of coordination across care levels and associated factors. A cross-sectional study in public healthcare networks of six Latin American countries.

An adequate use of referral and reply letters-the main form of communication between primary care (PC) and out-patient secondary care (SC)-helps to avoid medical errors, test duplications and delays in diagnosis. However, it has been little studied to date in Latin America. The aim is to determine the level and characteristics of PC and SC doctors' use of referral and reply letters and to explore influencing factors in public healthcare networks of Argentina, Brazil, Chile, Colombia, Mexico and Uruguay. A cross-sectional study was conducted through a survey of PC and SC doctors working in public healthcare networks (348 doctors per country). The COORDENA questionnaire was applied to measure the frequency of use and receipt of referral and reply letters, quality of contents, timeliness and difficulties in using them. Descriptive analyses were conducted and a multivariate logistic regression model was generated to assess the relationship between frequent use and associated factors. The great majority of doctors claim that they send referral letters to the other level. However, only half of SC doctors (a higher proportion in Chile and Mexico) report that they receive referral letters and <20% of PC doctors receive a reply from specialists. Insufficient recording of data is reported in terms of medical history, tests and medication and the reason for referral. The factor associated with frequent use of the referral letter is doctors' age, while the use of reply letters is associated with identifying PC doctors as care coordinators, knowing them and trusting in their clinical skills, and receiving referral letters. Significant problems are revealed in the use of referral and reply letters which may affect quality of care. Multifaceted strategies are required that foster a direct contact between doctors and a better understanding of the PC-based model.

/pdf/understanding-communication-breakdown-in-the-outpatient-3t5lllfzk7.pdf

Understanding communication breakdown in the outpatient referral process in Latin America: a cross-sectional study on the use of clinical correspondence in public healthcare networks of six countries.

/pdf/basic-health-care-or-primary-health-care-1lo0gj4lmp.pdf

Basic health care or primary health care

Resumo O artigo analisa a implementacao de redes integradas de servicos de saude (RISS) e de estrategias para a coordenacao do cuidado pela APS no sistema de saude do Chile em seu segmento publico. Foram realizadas entrevistas semiestruturadas com “policymakers” do sistema publico de saude e academia, complementado por analise documental e revisao bibliografica. O pais destaca-se pela institucionalizacao de instrumentos de coordenacao do cuidado amplamente reconhecidos como mapas de derivacao, medico gestor de demanda, prontuarios eletronicos e, sobretudo, definicao de protocolos, sob forte lideranca do Ministerio da Saude e conducao pelos gestores dos “Servicios de Salud”, espaco regional de construcao das RISS. Contudo, identificam-se camadas de segmentacao e fragmentacao no interior do subsistema publico com a manutencao da livre-eleicao para consultas especializadas e duplas filas de espera – uma para os procedimentos com garantias explicitas de acesso e outra para os demais. A experiencia chilena demonstra a necessidade de maior protagonismo da APS para que seja capaz de assumir a conducao das RISS. No pais, as redes parecem orbitar ao redor de grandes e potentes hospitais. Elementos do contexto mais amplo do sistema de saude tambem condicionam avancos e impasses no desenvolvimento das estrategias analisadas.

/pdf/network-integration-and-care-coordination-the-case-of-chile-klhvpq0amr.pdf

Network integration and care coordination: the case of Chile's health system

Introduction Although fragmentation in the provision of healthcare is considered an important obstacle to effective care, there is scant evidence on best practices in care coordination in Latin America. The aim is to evaluate the effectiveness of a participatory shared care strategy in improving coordination across care levels and related care quality, in health services networks in six different healthcare systems of Latin America. Methods and analysis A controlled before and after quasi-experimental study taking a participatory action research approach. In each country, two comparable healthcare networks were selected—intervention and control. The study contains four phases: (1) A baseline study to establish network performance in care coordination and continuity across care levels, using (A) qualitative methods: semi-structured interviews and focus groups with a criterion sample of health managers, professionals and users; and (B) quantitative methods: two questionnaire surveys with samples of 174 primary and secondary care physicians and 392 users with chronic conditions per network. Sample size was calculated to detect a proportion difference of 15% and 10%, before and after intervention (α=0.05; β=0.2 in a two-sided test); (2) a bottom-up participatory design and implementation of shared care strategies involving micro-level care coordination interventions to improve the adequacy of patient referral and information transfer. Strategies are selected through a participatory process by the local steering committee (local policymakers, health care network professionals, managers, users and researchers), supported by appropriate training; (3) Evaluation of the effectiveness of interventions by measuring changes in levels of care coordination and continuity 18 months after implementation, applying the same design as in the baseline study; (4) Cross-country comparative analysis. Ethics and dissemination This study complies with international and national legal stipulations on ethics. Conditions of the study procedure were approved by each country9s ethical committee. A variety of dissemination activities are implemented addressing the main stakeholders. Registration No.257 Clinical Research Register of the Santa Fe Health Department, Argentina.

https://bmjopen.bmj.com/content/bmjopen/5/7/e007037.full.pdf

Evaluating the effectiveness of care integration strategies in different healthcare systems in Latin America: the EQUITY-LA II quasi-experimental study protocol

La Atencion Primaria de la Salud, un concepto amplio y difundido, es colocado en debate en el presente articulo. Sin embargo, esa es, una tarea nada sencilla, dado el fuerte caracter idealista de sus principios y postulados. A traves de diversos mecanismos, como develar sus antecedentes inmediatos y remotos, la deteccion de modelos en conflicto, de contradicciones conceptuales y el uso extensivo de preguntas, diversas afirmaciones doctrinarias, que parecen de toda obviedad, son puestas en entredicho. Se invita asi al lector/a a una 'deconstruccion' del concepto de Atencion Primaria de la Salud, de cara a producir nuevas propuestas mas estrategicas y eficaces para que los trabajadores de salud, donde quiera que se desempenen, cuenten con herramientas para enfrentar la creciente mercantilizacion del sector.

/pdf/atencion-primaria-de-la-salud-en-debate-4tk1laaw2a.pdf

Atención Primaria de la Salud en Debate

RESUMEN Luego de cuarenta anos de instalada en el firmamento sanitario, la Atencion Primaria de la Salud (APS) se encuentra como nunca antes frente a la posibilidad de ser re-escrita. No se trata de esos intentos de reafirmacion o ampliacion que se vivieron a los 25 (Organizacion Panamericana de la Salud - OPS) o a los 30 anos (Organizacion Mundial de la Salud - OMS); se trata de un intento de reeditar los gestos y los simbolos de la historica reunion que ocurriera en Alma Ata. El contexto internacional es diferente al de 1978, por lo que existen fundados temores que la nueva declaracion constituya un retroceso respecto a la Declaracion original. Al menos el primer borrador que la OMS puso a circular refuerza esa preocupacion al subsumir la APS a la controversial iniciativa de la OMS y del Banco Mundial: cobertura universal en Salud. Como antes y como siempre el resultado final dependera mas bien de la forma como las comunidades y los trabajadores de salud reinterpreten la propuesta en cada lugar concreto.

/pdf/la-atencion-primaria-en-la-encrucijada-desplegar-su-48aw5nfp43.pdf

La atención primaria en la encrucijada: desplegar su potencial transformador o quedar instrumentados en una nueva ofensiva privatizadora

Una reconstruccion del campo de la salud en Argentina ha permitido verificar que, bajo la denominacion generica de la Atencion Primaria de Salud, se han cobijado un conjunto de dispositivos de atencion provenientes de diferentes tradiciones de la Salud Publica, entretejidas a su vez por los disimiles modelos politicos que se sucedieron en Argentina antes y despues de 1978. El plan de la presente investigacion previo una fase de indagacion con referentes historicos de la Atencion Primaria de Salud y una de trabajo con responsables de los procesos de formacion de posgrados que participaron en el proceso de construccion de conocimiento y en la especulacion sobre la aplicacion de los resultados.

/pdf/atencion-primaria-de-salud-en-argentina-proliferacion-1zhteizos5.pdf

Atención Primaria de Salud en Argentina: proliferación desordenada y modelos en conflicto

/pdf/users-perception-of-relational-continuity-of-care-in-six-1wd72v10q7.pdf

Mario Rovere

Papers

Evaluating the effectiveness of care integration strategies in different healthcare systems in Latin America: the EQUITY-LA II quasi-experimental study protocol

Atención Primaria de la Salud en Debate

La atención primaria en la encrucijada: desplegar su potencial transformador o quedar instrumentados en una nueva ofensiva privatizadora

Atención Primaria de Salud en Argentina: proliferación desordenada y modelos en conflicto

Users perception of relational continuity of care in six Latin America countries healthcare networksMarianna Vitaloni