A adoção da diretriz de regionalização na organização de sistemas públicos de saúde é uma estratégia antiga na experiência internacional, já apontada no relatório Dawson, em 1920. No Brasil, conforma-se como algo recente e complexo, pois o forte movimento municipalista, ao mesmo tempo que expandiu a oferta de ações e serviços de saúde, gerou também iniquidade e desigualdade de acesso. Desse modo, a regionalização é um processo que busca gerar unidade regional, sem desconsiderar as particularidades/individualidades dos municípios. Procura romper com a fragmentação da atenção à saúde, favorecer a constituição de redes de atenção integradas e promover a equidade de acesso. Apesar do volume crescente de estudos sobre regionalização, verificou-se uma lacuna importante no que diz respeito a pesquisas que abordem as peculiaridades de regiões e redes de atenção à saúde envolvendo dois ou mais estados. O objetivo foi analisar o processo de constituição da Rede Interestadual de Atenção à Saúde do Vale Médio São Francisco - rede PE/BA. Foi realizado um estudo de caso exploratório de abordagem qualitativa, tendo como referencial teórico o neoinstitucionalismo e o ciclo de análise de política pública. Foram utilizados dados secundários (bibliografia, documentos e informações estatísticas) e primários (entrevista semiestruturada). Participaram vinte pessoas, sendo a maioria mulheres (65%) e com formação na área da saúde (85%). O resgate do processo de regionalização na Bahia e em Pernambuco é um fenômeno complexo, condicionado por um conjunto de variáveis de natureza histórico-cultural e político-institucional. As gestões estaduais implementaram ações significativas que favoreceram a ampliação de acesso, contudo, ainda convivem com a fragmentação e a concentração de serviços de maior densidade tecnológica na capital e nas cidades mais desenvolvidas. Quanto à criação da rede PE/BA, os achados empíricos demonstram que o intercâmbio de serviços e ações de saúde entre os municípios de Petrolina e Juazeiro, mesmo que informal, configurou-se como o grande marco histórico do caso em estudo. O reconhecimento por parte dos gestores municipais de que sozinhos não conseguiriam mobilizar os recursos necessários para resolver o problema resultou em um processo de cooperação a articulação que, gradativamente, construiu uma rede de política que deu notoriedade ao problema que passou então a integrar a agenda política das três esferas de governo. A formação da política e a tomada de decisão no caso específico aconteceram concomitantemente. Conformou-se em um amplo processo de debate envolvendo governo, trabalhadores e sociedade civil. A construção da proposta de constituição da rede não ficou limitada às regiões de Petrolina e de Juazeiro, pois, dada a robustez do movimento, agregou outras quatro regiões de saúde: duas de Pernambuco (Salgueiro e Ouricuri) e duas da Bahia (Paulo Afonso e Senhor do Bonfim). O projeto teve como substrato as normativas vigentes na época, sendo definidas como áreas estratégicas o fortalecimento da Atenção Primária à Saúde, redução da mortalidade materno-infantil, atenção às urgências e a regulação de acesso. Na fase de implantação, podem-se observar dois momentos distintos: um marcado por grande efervescência, com relações intergovernamentais cooperativas e solidárias que possibilitou a instituição de um colegiado de gestão interestadual e de uma central de regulação interestadual de leitos; e outro, mais recentemente, de relações intergovernamentais pouco cooperativas materializadas na grande dificuldade do colegiado de gestão interestadual em dar respostas às demandas da rede e no não cumprimento dos pactos firmados. Por outro lado, os indícios sinalizam para uma possibilidade de mudança no curso do processo. O sentimento de pertencimento à rede por parte dos gestores municipais, trabalhadores e população oportunizou uma mobilização que cobra a retomada da negociação e da pactuação pelos gestores estaduais, com vistas a qualificar e melhorar a resposta da rede às necessidades da população. A trajetória institucional do Sistema Único de Saúde e o modelo federativo brasileiro conformam-se como variáveis que limitam a criação de redes interestaduais. Em contrapartida, a análise permitiu identificar determinantes estruturais, institucionais, políticos, ideológicos e socioculturais que conformaram um contexto favorável à inovação no âmbito da conformação de redes regionalizadas / The adoption of the regionalization guideline in the organization of public health systems is an old strategy in international experience, as pointed out in the Dawson report in 1920. In Brazil, it is something recent and complex, since the strong municipalist movement, while expanding the supply of health actions and services, also generated inequity and inequality of access. That way, regionalization is a process that seeks to generate regional unity, without disregarding the particularities/individualities of the municipalities. It seeks to break with the fragmentation of health care, favor the constitution of integrated networks of care and promote equity of access. Despite the increasing volume of studies on regionalization, there has been an important gap regarding research that addresses the peculiarities of health care regions and networks involving two or more states. The objective was to analyze the process of constitution of the Interstate Network of Health Care of the Vale Médio São Francisco - PE / BA network. An exploratory case study of qualitative approach was carried out, having as theoretical reference the neoinstitutionalism and the public policy analysis cycle. Secondary data (literature, documents and statistical information) and primary data (semi-structured interview) were used. Twenty people participated, most of them women (65%) and trained in the health field (85%). The rescue of the regionalization process in Bahia and Pernambuco is a complex phenomenon, conditioned by a set of historical, cultural and political-institutional variables. The state administrations implemented significant actions that favored the expansion of access, yet they still coexist with the fragmentation and concentration of services of greater technological density in the capital and in the more developed cities. With regard to the creation of the PE/BA network, the empirical findings show that the exchange of health services and actions between the municipalities of Petrolina and Juazeiro, even if informal, was the historical landmark of the case under study. The recognition by municipal managers that they alone would not be able to mobilize the necessary resources to solve the problem resulted in a process of cooperation and articulation that gradually built a network of policies that emphasized the problem that became part of the political agenda of the three spheres of government. The formation of the policy and the decision making in the specific case happened concurrently. It consisted of a broad process of debate involving the government, workers and civil society. The construction of the proposed network was not limited to the regions of Petrolina and Juazeiro, for, given the robustness of the movement, it added four other health regions: two from Pernambuco (Salgueiro and Ouricuri) and two from Bahia (Paulo Afonso and Senhor do Bonfim). The project had as a substrate the regulations in force at the time, being defined as strategic areas the strengthening of Primary Health Care, the reduction of maternal and child mortality, attention to urgencies, and access regulation. In the implementation phase, two distinct moments can be observed: one, marked by great effervescence, with intergovernmental cooperative and solidarity relations that made possible the institution of an interstate management collegiate and of an interstate regulation center of beds; and another one, more recently, of uncooperative intergovernmental relations materialized in the interstate management collegiate\'s great difficulty in responding to the demands of the network and in failing to comply with the signed pacts. On the other hand, the signs point to a possibility of change in the course of the process. The feeling of belonging to the network by part of the municipal managers, workers, and the population provided a mobilization that demands the resumption of negotiation and agreement by the state managers, in order to qualify and improve the network response to the needs of the population. The institutional trajectory of the Unified Health System and the Brazilian federative model are defined as variables that limit the creation of interstate networks. On the other hand, the analysis made it possible to identify structural, institutional, political, ideological, and sociocultural determinants that formed a favorable context for innovation in the scope of regionalized networks

Incomplete understanding of attrition from the physician workforce has hampered policy-makers’ efforts to achieve optimal alignment of the supply of physicians with population demand for medical services. This longitudinal study of Ontario primary care physicians uses health administrative data to characterize changes in physicians’ practice patterns over time. We examined the workload and scopes of practice of 21,240 physicians between 1992 and 2013. We found that physicians reduce their workloads gradually as they age, retiring from clinical practice at an average age of 70.5. Furthermore, we found that 60% of family physicians who stop providing comprehensive primary care continue to provide clinical services for an average of three years, with reduced workloads, before retiring fully. Our findings clarify the process of physician attrition from the workforce and will help to improve estimates of attrition and make physician workforce planning more accurate and effective.

O parto e o nascimento são eventos de grande relevância. O atendimento especializado à mulher por ocasião do parto é fundamental para a redução da mortalidade materna e neonatal, porém muitas mulheres em países de baixa e média renda são assistidas fora das unidades de saúde, sem ajuda especializada. Nesta pesquisa, avaliamos o impacto da regionalização do acesso aos serviços de saúde responsáveis pela atenção ao parto e ao nascimento enquanto política pública instituída no Rio Grande do Sul em 2004. Identificamos os óbitos infantis evitáveis, relacionados a partos ocorridos em hospitais de pequeno porte, em especial aqueles com ocorrência de nascimentos inferior a 104 partos anuais e localizados em pequenos municípios. A realocação dos partos desses estabelecimentos para outros de maior ocorrência foi definida como uma das ações para a redução da mortalidade infantil. Os nascimentos e óbitos infantis registrados em 2004 foram selecionados por município de ocorrência hospitalar do nascimento e distribuídos em cinco estratos de parto anual: 1 a < 104; 104 a < 208; 208 a < 365; 365 e +; e zero. Analisamos os coeficientes de mortalidade neonatal precoce, neonatal tardia, infantil tardia e infantil por estrato de parto anual em 2004 e em 2013, 10 anos após a instituição da regionalização. Os municípios do menor estrato de ocorrência de nascimentos foram considerados prioritários nesse processo. Analisamos, também, diversas variáveis relacionadas à mãe, ao parto e nascimento, ao recém-nascido, ao nível de desenvolvimento municipal e sua relevância em relação à regionalização. Para cada óbito ocorrido no primeiro ano de vida em 2004 e em 2013, identificamos o município de ocorrência do nascimento da criança falecida e calculamos os coeficientes de mortalidade por município de ocorrência do nascimento para cada estrato de parto. O período 2004 a 2013 apresentou redução dos coeficientes de mortalidade infantil em todos os componentes por faixa etária de ocorrência do óbito e por estrato de parto. No nível estadual, o coeficiente de mortalidade neonatal precoce por município de residência da mãe caiu de 7,20 para 4,93, o de mortalidade neonatal tardia de 2,87 para 2,22, o de mortalidade infantil tardia de 5,09 para 3,46 e o de mortalidade infantil de 15,16 para 10,61. Houve uma redução estatisticamente significativa dos coeficientes de mortalidade neonatal precoce, mortalidade infantil tardia e mortalidade infantil no conjunto dos 55 municípios regionalizados e dos coeficientes de mortalidade neonatal precoce, mortalidade neonatal tardia, mortalidade infantil tardia e mortalidade infantil no conjunto de 214 municípios referência de parto à gestante de risco habitual. Em conclusão, a estratégia foi eficiente para a redução da mortalidade infantil em nível estadual, tanto nos 55 municípios com parto regionalizado quanto nos 58 municípios que receberam gestantes desses municípios com parto regionalizado, assim como nos demais 156 municípios referência de parto à gestante de risco habitual que não receberam gestantes desses municípios com parto regionalizado. / Delivery and childbirth are very important events. However, many women in low- and middle-income countries receive care outside health facilities, without specialized assistance. In this study, we evaluated the impact of regionalization of access to health services involving delivery and birth care as a public policy implemented in Rio Grande do Sul in 2004. We identified preventable neonatal deaths related to births occurring in small hospitals, especially those with a rate of less than 104 births per year and located in small municipalities. Relocation of deliveries from these hospitals to other facilities with higher birth rates was defined as an action to reduce infant mortality. All births and infant deaths recorded in 2004 were selected according to the municipality where the hospital birth occurred and distributed in five strata of annual childbirth: 1 to < 104; 104 to < 208; 208 to < 365; 365 and +; and zero. We analyzed early neonatal, late neonatal, late infant and infant mortality rates by annual childbirth stratum in 2004 and in 2013, 10 years after the implementation of regionalization. Municipalities within the lowest stratum of hospital births were considered a priority in the regionalization process. We also analyzed several variables related to the mother, the birth, the neonate, the level of municipal development, and its relevance in relation to regionalization. For each death in the first year of life occurring in 2004 and in 2013, we identified the municipality where the deceased child was born and calculated mortality rates by municipality of hospital birth for each childbirth stratum. The 2004-2013 period showed a reduction in mortality rates in all components per age at death and per childbirth stratum. At the state level, early neonatal mortality rate per mother’s place of residence dropped from 7.20 to 4.93, late neonatal mortality rate from 2.87 to 2,22, late infant mortality rate from 5.09 to 3.46, and infant mortality rate from 15.16 to 10.61. There was a statistically significant reduction in early neonatal mortality, late infant mortality and infant mortality rates in the group of 55 regionalized municipalities and in early neonatal mortality, late neonatal mortality, late infant mortality and infant mortality rates in the group of 214 municipalities serving as referral centers for normal-risk delivery. In conclusion, the strategy was effective in reducing infant mortality at the state level, both in the 55 municipalities with regionalized delivery care and in the 58 municipalities that received pregnant women from these municipalities, as well as in the remaining 156 municipalities identified as referral centers for normal-risk deliveries that did not receive pregnant women from the municipalities with regionalized delivery care.

Thesis (M.C.P.)--Massachusetts Institute of Technology, Dept. of Urban Studies and Planning; and, (M.S.)--Massachusetts Institute of Technology, Alfred P. Sloan School of Management, 1981. / MICROFICHE COPY AVAILABLE IN ARCHIVES, DEWEY, AND ROTCH. / Bibliography: leaves 95-97. / by Lisa Joy Endlich. / M.C.P.

Thesis. 1975. M.C.P.--Massachusetts Institute of Technology. Dept. of Urban Studies and Planning. / Bibliography: leaves 186-189. / by Shelley F. Bernstein, E. Michael Paul Thomas. / M.C.P.

Thesis. 1976. M.C.P.--Massachusetts Institute of Technology. Dept. of Urban Studies and Planning. / Microfiche copy available in Archives and Rotch. / Bibliography: leaves 120-122. / by Victor John Franckiewicz, Jr. / M.C.P.

O presente estudo apresenta quatro cenários tecnológicos do setor de medicina diagnóstica no Brasil para o ano de 2025. Trata do rastreamento de possíveis futuros do setor a partir da identificação e análise de seus fundamentos no tempo presente, indicando como organizações podem se preparar para esses futuros. A pesquisa foi desenvolvida buscando respostas às seguintes questões: Como rastrear eventos futuros a partir dos sinais emitidos no presente? Quais são os fundamentos no tempo presente que projetam o futuro? Quais são os quatro principais possíveis cenários tecnológicos no setor de medicina diagnóstica? Quais sinais de aviso emitidos no presente a serem rastreados e monitorados tendo em vista esses possíveis cenários futuros? Quais são as decisões e medidas fundamentais a serem tomadas hoje tendo em vista esses possíveis futuros? A pesquisa foi realizada a partir de pesquisa bibliográfica preliminar e a realização de sete entrevistas semiestruturadas. Adotou-se a estratégia de pesquisa qualitativa Grounded Theory combinada com técnicas de cenários intuitivo-lógicos, permitindo o rastreamento de possíveis eventos futuros a partir dos sinais existentes no presente. Identificou-se as tecnologias de point of care e medicina personalizada como os principais fundamentos para o futuro de setor de medicina diagnóstica. Foram gerados quatro cenários tecnológicos para o setor denominados Boutique da Saúde, Tele SUS, Saúde Alternativa e Saúde Personalizada. Cinco sinais de aviso de desenvolvimento de cenários foram identificados: grau de investimento do poder público, grau de regulação do poder público, grau de relevância para a população, grau de investimento da iniciativa privada, grau de desenvolvimento das pesquisas e produção de conhecimentos em medicina personalizada e tecnologias point of care. Por fim depurou-se quatro diretrizes preparação dos gestores de organizações medicina diagnóstica ente os quatro cenários desenvolvidos: incorporar o planejamento por cenários no planejamento estratégico da organização; incrementar as capacidades de produção de pesquisa endógena e de absorção de pesquisas externas sobre as temáticas de point of care, prontuário eletrônico do paciente e medicina personalizada; investir na formação continuada de suas equipes nessas temáticas ou contar com consultoria especializada na área; criar formas de monitoramento continuado dos fatos e acontecimentos que definem o setor. / The present study presents four technological scenarios of diagnostic medicine sector in Brazil for the year 2025. About possible future tracking of the sector from the identification and analysis of its reasons in the present tense, indicating how organizations can prepare for those future. The research was developed seeking answers to the following questions: how to trace future events from the signals emitted in the present? What are the fundamentals in the present time designing the future? What are the four main possible technological scenarios in the field of diagnostic medicine? Which issued this warning signs to be tracked and monitored with a view to these possible future scenarios? What are the key measures and decisions to be taken today aimed at these possible futures? The research was conducted from preliminary bibliographical research and seven interviews semi-structured. Adopted the strategy of qualitative research Grounded Theory combined with intuitive-logical scenarios techniques, allowing the tracing of possible future events from the existing signs in the present. Of technologies identified point of care and personalized medicine as the main foundation for the future of diagnostic medicine sector. Four technological scenarios were generated for the sector called Boutique of health, Tele SUS alternative health and health, custom. Five warning signs of development scenarios have been identified: investment grade public power, degree of regulation of public authority, degree of relevance to the population, degree of investment from private enterprise, degree of development of research and production of knowledge in personalized medicine and point of care technologies. Finally four debug assistants guidelines preparation of managers of diagnostic medicine organizations between the four scenarios developed: incorporate planning for the Organization\'s strategic planning scenarios; increase the production capacities of endogenous research and absorption of external research on the themes of point of care, electronic patient record, and personalized medicine; invest in continuing training of their teams in these thematic or rely on expert advice in the area; creating continued monitoring forms of facts and events that define the industry.

O estudo que se segue é uma proposta de reflexão sobre a programação de saúde para a população usuária do SUS, em especial a assistência oncológica, as sucessivas estratégias político-administrativas e medidas de soluções a serem ofertadas à população portadora de câncer. Percebe-se o desequilíbrio entre a operacionalidade real e a operacionalidade suposta ideal, para dar conta dos casos novos de câncer (CNC)/ano, a atenção à saúde concentrada nos grandes centros urbanos, reflexo de um estímulo a investimentos em saúde direcionados aos centros urbanos, localidades de maior crescimento econômico e social. Objetivando o balanço de uma experiência de programação a partir das necessidades, tomamos como norte o Projeto Expande, para a análise da real assistência em oncologia no país, que se traduz no conjunto: oferta de serviço necessidade de tratamento específico para a população demanda, identificando déficit e necessidade. Nesse sentido, com base na programação e nas informações de produtividade SUS/Brasil, disponíveis no INCA , optamos por acompanhar os dados referentes ao ano 2008, quantificados e analisados, tendo como ponto de partida a estimativa de CNC/ano 2008, parâmetros assistenciais estimativa de necessidade máxima). Este estudo, com esse modelo, objetivou levantar subsídios que supostamente contribuam para o aprimoramento da Política de Atenção ao Câncer, em especial uma Política de Expansão Oncológica para o país. / The study is a proposal for consideration of health programming for the SUS users, in particular, cancer care, successive political and administrative measures strategies and solutions offered to people with cancer. One sees the real imbalance between the operation and operability considered ideal, to account for new cases of cancer (CNC) / year, health care concentrated in large urban centers, reflecting a stimulus to health investments targeted to urban centers, locations of greatest economic and social growth. In order to balance experience from the programming needs, we based ourselves on the Expande Project, for the analysis of real care in oncology in the country, which is reflected in the set: the provision of service - specific treatment for the population - demand, identifying deficits and need. Accordingly, based on the schedule and information productivity - SUS / Brazil, available at INCA - we decided to follow the data for the year 2008, quantified and analyzed, taking as its starting point the estimated CNC / 2008, health care parameters (maximum estimate of need). Based on this model, this study aimed to gather information that presumably contributes to the enhancement of the Cancer Care Politics, especially Oncology Expansion Policy for the country.

Thesis (MPH) --University of Limpopo, 2011 / Since 1994, the post apartheid government and the Department of Health have developed and implemented a number of policies and pieces of legislation that impacted directly and indirectly on the delivery of health services such as the general public health, health personnel, financial matters, transportation of medicines and foodstuffs. These policies were timeously received by the hospitals from National Office, Provincial Departments and Local Government, but were not implemented due to numerous challenges. This study explores the health policy implementation challenges facing implementers in the public health sector in the Capricorn district in Limpopo that constrain them from rendering their managerial functions effectively and thus, impact negatively on policy implementation and service delivery. The objective of the study is to explore the challenges with a view of describing the nature and causes of the challenges, explore and document them, develop suggestions for minimizing these challenges and subsequently suggesting possible solutions. The study focused on the Capricorn district in Limpopo Province. The district is the biggest among the five districts and has eight functional hospitals which are under the leadership of Chief Executive Officers (CEO). The researcher used both qualitative and quantitative (mixed) research methods. The methodology entailed the distribution of self-administered questionnaires containing closed and open ended questions to the management of Capricorn district hospitals. The results obtained in this study revealed that there are numerous challenges that constrain policy implementers from implementing health policies effectively and efficiently in their work environments. These challenges range between poor incentives, lack of equipment, lack of office space, lack of dedicated transport for outreach, budget constraints, shortage of resources – human and physical, lack of career mobility, poor working conditions, communication problems and poor supervision style. These challenges impact negatively on policy implementation.It is therefore recommended that the comprehensive strategy to maximize the health workers’ motivation in the health sector has to involve a mix of financial and non-financial incentives, the provincial department of health and Social Development should open some communication lines with the service providers at grass root level in order to address some of the issues before they become chronic challenges, there should also be regular meetings where feedback about provincial and national issues are addressed to the service providers. The current system of dissemination of information from the province and national government to the hospitals is apparently not clear.

The number of elderly in the U.S. (i.e., individuals age 65 years or older) is growing at a rapid rate. While the current proportion of elderly persons living in U.S. is estimated to be little over 14%, it will soon reach up to 20% in next 10 years. In addition, it is anticipated that the elderly population will soon outnumber the younger generations, for the first time in U.S. history. With the rapid shift we are witnessing in the U.S. population, the World Health Organization (WHO) informs that the leading cause of death in U.S. has also shifted: from infections to chronic illnesses. The majority of elderly individuals will suffer from at least one chronic illness, and many will live longer than ever, with complex multiple healthcare needs. The demands for specialized end of life (EoL) care among frail elderly will continue to rise, and it is among the top research priorities to identify best practices in EoL care and understand how best to facilitate patient-centered care in healthcare settings. In order to increase awareness in the importance of quality care provided to those who are near EoL, the Institute of Medicine (IOM; now the National Academy of Medicine) recommended a nation-wide implementation of an advance care planning tool, the POLST (Physician Orders for Life-Sustaining Treatment). Designed specifically for frail individuals living with serious illnesses, the POLST program is used to elicit care preferences and deliver goal-concordant care. Making patients’ specific care wishes actionable and transferrable, it aims to preserve one’s autonomy, and to allow them to die with dignity. This dissertation aims to evaluate the POLST program, from its effectiveness, dissemination, to outcomes associated with its maturity status. The first chapter provides background information on the aging population the importance of advance care planning among frail elderly persons. The POLST program is introduced and I lay out the three research aims and the significance of each topic. Chapter 2 contains a systematic review of scientific evidence on the concordance between documented care wishes and actual care delivered to the POLST users. It explains specific care interventions that yielded high concordant care, as well as ones that had mixed results. In chapter 3, an environmental scan of a state-specific POLST program across all U.S. states and Washington D.C. is presented; the scan examined maturity status, specific care options mentioned/ absent as well as descriptive statistics on the association between presence of infection/pain-related care options and the POLST program maturity status. In chapter 4, a quantitative analysis aimed at examining the impacts of the POLST program maturity status on a patient-level outcome (i.e., nursing home death) is presented. In it, multiple large datasets were used to generate a representative sample of the U.S. nursing home population. I then applied multivariate logistic regression modeling to estimate associations. Lastly, chapter 5 synthesizes the findings of this dissertation as well as strengths and limitations. It then shares recommendations for policy, clinical practice and future research.