Many health systems are in the midst of transformation. They are slowly moving from the delivery of reactive care focused on individuals to considering proactive ways of supporting the health and well-being of populations. However, the road to what is often called ‘population-health management’ is rife with implementation challenges. One type of implementation support that has been used to navigate these challenges is technical assistance. Though the use of technical assistance is well documented, there is no consensus on a clear definition or understanding of how it can be used to support system transformation. This thesis contributes to the field of technical assistance through three qualitative studies. First, a critical interpretive synthesis develops a definition and logic model for technical assistance. This logic model integrates diverse academic and grey literature. It aims to draw clearer boundaries around technical assistance as a concept and provide a common language for researchers, technical assistance providers, and decision-makers to use. Second, a qualitative descriptive study explores the use of technical assistance in population-health management transformations in England and the U.S., examining what technical assistance has been provided, by whom, and in what areas of application. Finally, a case study unpacks the use of technical assistance for a recent health-system transformation in Ontario. It examines the influence that political factors related to institutions, ideas, interests and external events have on shaping its evolution. Together, these three studies provide greater clarity on the use of technical assistance in health-system transformations and the range of factors that may affect how it is conceptualized and operationalized. / Thesis / Candidate in Philosophy

Background: Enhancing the performance of front-line health workers serving vulnerable populations is crucial for redressing inequities. Traditional approaches have focused on introducing technical solutions, such as guidelines and incentives, to modify performance outcomes. Recognition of the complex social nature of health system function draws attention to the intangible software elements that shape performance, including the values, ideas, interests, and norms that guide human behavior and interactions. Insight into the operation of software elements can provide a base for people-focused solutions to support health workers and enable them to confront constraints in low resource settings. This study examines the social environment of the practice of front-line auxiliary nurses (AN) in rural Guatemala, in order to understand the role of health system software elements in enabling their performance and to gain insight into how organizational support can be strengthened through locally-relevant actions. Methods: A mixed methods approach provided a multi-level view of the AN practice environment, situated in the regional health system of the rural department of Alta Verapaz. Interviews with ANs and observations of practice were conducted to understand the values orienting them and how these shaped their relationships with patients and communities. A theory-driven case study of AN supervision was conducted in selected health posts to understand the values orienting supervisors in their role and examine how these shaped their relationships with ANs. The participatory method of concept mapping was used to examine the views of health workers, district and regional managers on actions to strengthen organizational support for the performance of ANs. Results: The values of nursing vocation and community connectedness were prominent in ANs’ interpretations of their work. In relationships, nursing principles oriented them to be attentive to understanding patient needs, and a shared ethnic identity and personal experience of local needs served as a base for engaging with local leaders in community work. The dominant orientation of supervisors in their role was managerial control, and it provided limited support. It contributed to standard-centered relationships with ANs focused on fulfillment of ministry criteria. Supervision oriented by a holistic understanding of ANs’ needs and the goal of improving patient care was more successful in enabling AN motivation. This relationship was characterized as people-centered, based in a shared interpretation of the value of work with patients and the responsive support provided to ANs’ problems. “Organizational climate of support across levels”, where working relationships are characterized by respectful treatment, attention to psycho-social well-being and responsiveness to needs, was identified by health-system actors as a top priority for improving performance. Conclusions: To enable performance, there needs to be a balance between attention to standards and attention to the human dimensions of health worker practice. The dominant approach to supervision did not recognize or build on AN values. Supervision and management should be oriented by a more holistic view of the ANs’ work and their needs, in order to promote a people-centered approach to working relationships. Locally relevant action to strengthen district and regional management’s support for AN performance should focus on operationalizing performance goals that go beyond standards to encompass care that responds to patient and community needs.

p. 1-88 / Submitted by Santiago Fabio (fabio.ssantiago@hotmail.com) on 2013-04-23T18:17:42Z No. of bitstreams: 2 8888.pdf: 382847 bytes, checksum: ed263aa9321af8ef93a292a6dc501049 (MD5) 77777.pdf: 66202 bytes, checksum: d47d5560d4174bd4d3a3b340f72f0453 (MD5) / Approved for entry into archive by Maria Creuza Silva(mariakreuza@yahoo.com.br) on 2013-05-04T17:29:01Z (GMT) No. of bitstreams: 2 8888.pdf: 382847 bytes, checksum: ed263aa9321af8ef93a292a6dc501049 (MD5) 77777.pdf: 66202 bytes, checksum: d47d5560d4174bd4d3a3b340f72f0453 (MD5) / Made available in DSpace on 2013-05-04T17:29:01Z (GMT). No. of bitstreams: 2 8888.pdf: 382847 bytes, checksum: ed263aa9321af8ef93a292a6dc501049 (MD5) 77777.pdf: 66202 bytes, checksum: d47d5560d4174bd4d3a3b340f72f0453 (MD5) Previous issue date: 2010 / Com o objetivo de sistematizar as principais abordagens metodológicas voltadas para a avaliação de Sistemas de Saúde Públicos e Universais, foi realizada uma revisão sistemática da literatura e busca nos sites de governos nacionais de países selecionados. A busca de artigos científicos foi realizada nas bases de dados Scielo e Web of Science, e os documentos institucionais nos sites dos governos nacionais e de algumas organizações internacionais. Foram tomados como critérios para a análise: existência de referenciais teóricos que orientam a avaliação e os conceitos utilizados na abordagem metodológica, a perspectiva da avaliação (se externa ou interna), os níveis de análise selecionados no que diz respeito à gestão e dimensões/componentes do sistema, os atributos e indicadores selecionados, bem como formas de retroalimentação dos resultados. A maioria das abordagens metodológicas apóia-se na elaboração de modelos lógicos (framework) para definição das dimensões da avaliação e seleção de indicadores. Verificou-se ainda na maioria dos modelos a combinação das perspectivas externa e interna e incorporação do ponto de vista de diversos atores na seleção de indicadores. As dimensões relacionadas ao estado de saúde, determinantes da saúde, desempenho dos serviços e aspectos contextuais foram as mais frequentes. Os atributos mais priorizados dizem respeito à qualidade dos serviços, efetividade, eficiência e às relações entre os agentes das ações. A articulação da avaliação com o planejamento e a gestão foi referida em pequeno número de casos. Discutem-se limites e possibilidades de incorporação dos resultados da presente síntese na gestão dos sistemas de saúde. / Salvador

Philosophiae Doctor - PhD / The value of accountability as a key feature of strengthening health systems and reducing maternal, newborn and child mortality is increasingly emphasised globally, nationally and locally. Frontline health professionals and managers play a crucial role in promoting maternal, newborn and child health (MNCH) services in an equitable and accountable manner. They are at the interface between higher-level health system management and communities, facing demands from both sides and often expected to perform beyond their available means. Although accountability is a central topic in the governance of MNCH literature, it has mostly been approached at global and national levels, with little understanding of how accountability is integrated into the routine functioning of local health systems. This PhD explores the forms and functioning of accountability at the district level focusing on MNCH as a programmatic area with long-established institutional mechanisms (structures and processes) in South Africa (SA). The thesis is presented in the form of four empirical papers (published or submitted), exploring different dimensions of accountability, which are embedded in a series of narrative chapters. In this thesis, accountability is understood as a set of relations between an accountholder and ‘accountor’ (or duty bearer), in which the latter provides information or justification for actions or decisions taken, and faces the resulting consequences of his/her actions (reward or sanction). Accountability mechanisms are the means to regulate accountability relationships and include broad strategies, interventions or instruments. These mechanisms can take various forms including performance, financial and public accountability, and operate both vertically (accountability inside bureaucratic hierarchies, or towards external stakeholders and/or the community), or horizontally (between peers, ‘neighbour’ units, departments or ministries in a national health system). Drawing conceptually on the field of governance and considering the complexity of the accountability phenomenon, I adopted a case study approach to the PhD research, using a combination of policy document review, interviews (with managers, providers, community representatives and members of labour unions) and field observations, conducted iteratively over 16 months. The study was conducted in Gert Sibande District, one of the three South African health districts in Mpumalanga Province, with an in-depth focus on two of the seven sub-districts in the District. The research found that frontline health professionals have a clear understanding and conceptualisation of accountability in the SA health policy context, despite the reported inability to define accountability by health professionals described in the literature. Respondents referred to accountability as responsibility, answerability and virtue, and also argued for strengthening accountability mechanisms as critical to addressing maternal and child mortality. While deeming accountability as important, frontline professionals experienced the existing accountability mechanisms as ‘too much’ and indicated the desire for the streamlining of existing mechanisms. In this regard, the study documented numerous mechanisms at district level, almost all related to performance accountability in MNCH. These included a performance management system, quality assessment and accreditation processes, quarterly reviews, and death surveillance and response processes. The existence of multiple and overlapping accountability mechanisms engenders operational confusion and ‘accountability overload’ for frontline providers, encouraging empty bureaucratic compliance, while critical gaps – notably in community accountability – remain. In practice, at their best, some mechanisms operate following a reciprocal1 pathway of capacity building with resource provision (from management) and expectation for better performance (from providers). There were, however, contextual variations in the implementation and practice of the mechanisms between sub-district settings. The fieldwork observations and interviews were also able to document how formal institutionalised mechanisms are embedded within a complex system of informal accountability relationships and social norms (‘accountability ecosystem’) that enables or constrains the ability of frontline professionals to fulfil their tasks. In addition, using a Social Network Analysis approach, the research identified key actors and their involved network, which form the relational backdrop to the functioning of accountability mechanisms for MNCH. By revealing complex relationships and collaboration patterns among frontline health professionals, the study was able to show the multi-level action and multiple actors required to achieve MNCH goals.

No description available.

This work builds on the use of several Mathematical Modeling tools to develop approaches that address relevant, real and previously unanswered questions related to the improvement of Public Health Systems, in three particular instances. First, this thesis analyzes the variation in state-level vaccination coverage during the emergency response to the 2009 H1N1 pandemic influenza outbreak in the United States. The analysis considers the overall adults population and two priority sub-populations: children and high-risk adults. We focus on quantifying the association between vaccination coverage and the supply chain and distribution system decisions, during the vaccine shortage period, while controlling for other commonly recognized factors such as previous vaccinations, socio-economic characteristics, health seeking behavior and health infrastructure. The variables analyzed are generally correlated, and the problem has a limited sample size with a much larger number of independent variables. The findings of this research have been published in Vaccine and presented to the Centers for Disease Control and Prevention. Second, the research approaches the problem of estimating childhood obesity prevalence in small geographic areas in the U. S. Obesity is recognized as one of the major health problems in the country, and attending this condition in children is of major importance to deal with the sources of the overall problem. The ability to target interventions to the most affected children populations is necessary to achieve cost effective solutions. But local accurate obesity data is hard to obtain and missing for most of the small areas in the country. The research focuses on estimating prevalence of obesity and overweight status in children in small geographical areas in the absence of surveillance and detailed sampling. Our modeling approach is built in two stages. The first one uses a logistic regression model that links individual characteristics to high-BMI status, and generates samples of the empirical distribution of its coefficients though bootstrap re-sampling. The second uses simulation to generate virtual population samples of the small areas, which are then combined with the logistic model samples to estimate prevalence. Confidence intervals are built though re-sampling. A very important feature of our approach is that all of its inputs are from publicly available data, which gives availability for the replication of the methodology to any health stakeholder in the US. The model estimates were validated by using separate models for adults and children in a state with available data. Estimates obtained from our modeling approach were used by a large healthcare provider to geographically target interventions for pediatric obesity. Third, the thesis presents an introductory analysis of the possible effects of partial disruptions to critical supply chains due to absenteeism caused by a generalized flu-like illness in the US. For this analysis, we first construct a plausible national food supply chain for milk and then we simulate its disruption. To build the supply chain we used public information regarding production, consumption, and major milk processors and bottlers, and fitted it into a supply network though optimization. Then, to analyze the effects of flow disruptions of the supply chain, we built a simulation of the operation of the network and virtually generated absenteeism, mildly disrupting the supply chain flows by the proportional absences. We used information on potential absenteeism in work groups from an influenza simulator. Our initial analysis shows that absenteeism may create variations along the supply chain, similar to those described in the bullwhip effect analysis literature, even in the absence of supply shortages and without variations in pricing or demand, for which we find no prior reference in the literature.

There is a paucity of literature evaluating mass casualty systems and no clear 'gold standard' for measuring the efficacy of information decision support systems or triage systems that can be used in mass casualty events. The purpose of this research was the preliminary validation of a comprehensive conceptual model for a mass casualty continuum of care. This research examined key relationships among entities/factors needed to provide real-time visibility of data that track patients, personnel, resources and potential hazards that influence outcomes of care during mass casualty events.A modified Delphi technique was used to validate the proposed model using a panel of experts. The four research questions measured the extent to which experts agreed that the: 1) ten constructs represent appropriate predictors of outcomes of care during mass casualty events; 2) proposed relationships among the constructs provide valid representations of mass casualty triage; 3) proposed indicators for each construct represent appropriate measurements for the constructs; and 4) the proposed model is seen as useful to the further study of information and technology requirements during mass casualty events. The usefulness of the online Delphi process was also evaluated.A purposeful sample of 18 experts who work in the field of emergency preparedness/response was selected from across the United States. Computer, Internet and email applications were used to facilitate a modified Delphi technique through which experts provided initial validation for the proposed conceptual model. Two rounds of the Delphi process were needed to satisfy the criteria for consensus and/or stability related to the constructs, relationships and indicators in the model. Experts viewed the proposed model as relatively useful (Mean = 5.3 on a 7-point scale). Experts rated the online Delphi process favorably.Constructs, relationships and indicators presented in this model are viewed as preliminary. Future research is needed to develop the tools to measure the constructs and then test the model as a framework for studying effects and outcomes of mass casualty events. This study provides a foundation for understanding the complex context in which mass casualty events take place and the factors that influence outcomes of care.

Nesta investigação analisamos a visão dos gerentes das Unidades Básicas de Saúde (UBS) a cerca da problemática da Tuberculose (TB) em um município do interior do Estado de São Paulo. Participaram do estudo 14 gerentes de UBS, sendo a coleta dos dados realizada por meio de entrevista que enfocava a TB na agenda municipal, foi aplicado um questionário fechado e ao final deste uma questão aberta, que permitiu aos sujeitos manifestarem livremente as dificuldades no controle da TB no âmbito da gerência local. A entrevista se deu após o consentimento livre e esclarecido. Para o tratamento dos dados utilizamos o Programa Statística 8.0 da Statsoft, e, por meio deste, elaboramos tabelas de freqüência simples e para os dados qualitativos, utilizamos a técnica de análise de conteúdo, modalidade temática, surgindo três categorias temáticas: 1) A gerência da UBS no controle da TB: um campo de desafios; 2) Ações gerenciais do controle da TB na Atenção Básica (AB): potencialidades e limites; 3) O Controle da TB na AB: a visão gerencial. Os sujeitos do estudo atuam a mais de cinco anos na função de gerentes e a maioria deles toma a TB como uma doença prioritária no quadro sanitário local, de forma que, 81,3% deles a considera como doença prioritária no quadro sanitário do município, e apenas 12,5% expõem que, às vezes, a consideram prioritária. Quanto à participação deles na discussão e definição de ações para o controle da TB no município mais de 50% participam às vezes ou quase nunca, nos permitindo refletir o quão estes gerentes estão imbuídos desta temática. Observamos que há pontualidade do enfoque da TB na AB, ou seja, nas campanhas e semana da TB. Essa característica de focalização das ações, presente nas falas dos sujeitos remete a cultura presente na organização dos sistemas locais de saúde, refletindo no campo do planejamento. A demora no diagnóstico foi relatada pelos gerentes, fazendo com que o doente retorne várias vezes à unidade de saúde em busca de uma solução para seus sintomas. Somado à demora o estigma é algo aparece na fala dos sujeitos e necessita ser trabalhado, uma vez que ambos implicam diretamente no planejamento e organização das ações do controle da TB na AB. Os dados nos mostram que 50% dos gestores não participam e/ou não sabem em relação à definição de linhas específicas para a TB, no repasse de recursos para o município. A subnotificação é uma preocupação apontada pelos gerentes que possuem pouco conhecimento do Programa de Controle da Tuberculose (PCT), bem como, dos casos de TB de sua área de abrangência. Nos seus depoimentos fica explícito uma gerência técnico-burocrática, com debilidades nas dimensões do planejamento e na organização das atividades da UBS que gerenciam. Assim, os gerentes assistenciais do contexto sanitário estudado necessitam recompor aspectos da gerência, como o planejamento e a organização como formas de viabilizar a política de controle da TB, de acordo com os preceitos jurídico-legais e as normatizações inerentes ao PCT. / In this study we analyzed the view of Basic Health Unit (BHU) managers about the Tuberculosis (TB) issue in a city in the interior of São Paulo state. Fourteen BHU managers participated in the study. Data collection took place through interviews that focused on TB in the municipal agenda. A closed questionnaire was administered, and, at the end, an open question was also applied, which allowed for subjects to freely express the difficulties to control TB in the scope of local management. The interview was carried out after obtaining free and informed consent. Data analysis was performed using the Statsoft software Statística 8.0, which was also used to create simple frequency tables, and thematic content analysis was used for the qualitative data. Thus, three thematic categories emerged: 1) Managing the BHU in TB control: a field of challenges; 2) Managerial actions for TB control in Primary Care (PC); strengths and limits; 3) TB Control in PC: the managerial view. The study subjects have worked as managers for over five years and most consider TB a priority disease in the local health setting. In fact, 81.3% of them consider it a priority disease in the municipal health setting, and only 12.5% state that they sometimes consider it a priority. As to their participation in the discussion and definition oft TB control actions in the city, over 50% sometimes or almost never participate. This shows how deep these managers are imbued with this theme. We observed that TB is strongly focused in PC, i.e., in the campaigns and TB week. This characteristic of focusing on actions, present in the subjects statements, recalls the present culture of the local health system organization, having an effect on the field of planning. Managers reported there is a delay in diagnosis, which implies that the patient comes back several times to the health unit searching for a solution to his or her symptoms. In addition to that delay, subjects also state the stigma, which also needs to be solved since both have a direct effect on the planning and organization of TB control actions in PC. The data show that 50% of the managers do not participate and/or do not know about the definition of specific lines for TB, in terms of transferring resources in the municipality. Underreported cases are a concern pointed out by managers who have little knowledge about the Tuberculosis Control Program (TCP), as well as TB cases in their area. Their statements clearly state a technicalbureaucratic management, deficient in the activity planning and organization dimensions at the BHU they manage. Hence, health care managers in the studied context need to recompose management aspects like planning and organization as ways to make the TB control policy feasible according to the legal precepts and regulations inherent in the TCP.

INTRODUÇÃO: Promulgadas em 2000 as Metas de Desenvolvimento do Milênio destacam-se internacionalmente como importante política de cooperação para o desenvolvimento. Resultado do empenho da Organização das Nações Unidas caracteriza-se como uma tentativa de diminuir as disparidades sociais e econômicas no início do século XXI. Constituída por oito Metas, com prazo final para cumprimento em 2015. O objetivo 8.E da oitava Meta é definido como a cooperação com a indústria farmacêutica e visa, proporcionar o acesso a medicamentos essenciais com preços acessíveis nos países em desenvolvimento. OBJETIVOS: descreveu-se por meio das recomendações dos Relatórios da ONU o progresso do Objetivo 8.E e as políticas públicas de saúde no Brasil, Cuba e México. METODOLOGIA O estudo caracterizou-se por um estudo de caso descritivo e exploratório realizado por meio do estudo das recomendações governamentais estabelecidas nos relatórios da ONU relativos ao Objetivo 8.E, no período de 2000 a 2012, de documentos oficiais dos três países estudados e de revisão de literatura sobre o assunto. RESULTADOS: verificou-se que as propostas estabelecidas nos Relatórios da ONU para garantia do acesso a medicamentos apresentaram-se como políticas públicas nacionais executadas por meio dos sistemas de saúde dos três países estudados antes da promulgação das Metas do Milênio. CONSIDERAÇÕES FINAIS: em âmbito internacional As Metas do Milênio apresentam importância na cooperação para o desenvolvimento internacional observou-se, contudo, que os sistemas de saúde, existentes nos países estudados, apresentaram papel fundamental na política de acesso a medicamentos essenciais e, decorrentemente, no cumprimento das recomendações estabelecidas para os Estados-membros do Objetivo 8.E de forma independente do financiamento e estratégias de cooperação internacional / INTRODUCTION : Enacted in 2000, the Millennium Development Goals stand out internationally as an important development cooperation policy . Resulting of the commitment of the United Nations they are characterized as an attempt to reduce social and economic disparities in the XXI century . Composed of eight goals , with deadline for compliance in 2015 . The Target 8.E of the eighth Goal is defined as in cooperation with the pharmaceutical industry to provide access to affordable essential drugs in developing countries . OBJECTIVES : describe by means of the recommendations of the UN reports progress on the Target 8.E and public health policies in Brazil , Cuba and Mexico. METHODOLOGY The study was characterized by a descriptive case study and exploratory study conducted by the governmental recommendations set out in the UN reports relating to Target 8.E in the period from 2000 to 2012 , the official documents of the three countries studied and literature review on the subject . RESULTS : we found that the proposals set out in UN reports for ensuring access to medicines presented as national public policies were implemented by health systems of the three countries studied prior to the enactment of the Millennium Goals . CONCLUSION : internationally, the Millennium Goals have importance in development cooperation, however was noted that the health systems in the countries studied , displayed major role in access to essential medicines and so forth in compliance with the recommendations established for the Member States of the Objective 8.E independently of international financing and international cooperation strategies

Introdução O desenvolvimento das Relações Internacionais como disciplina a fez abarcar estudos de integração regional, cooperação internacional e, mais recentemente, saúde. O processo de globalização e uma maior interação entre os países culminaram na criação de blocos regionais de cooperação, sendo um exemplo expoente na América do Sul a União das Nações Sul-Americanas - UNASUL. Cooperação em saúde global por meio de convergência política dentro dos blocos é possível, e para isso é necessário o conhecimento dos sistemas de saúde de cada país. O Brasil, dentro da tradição de sua política externa e da defesa da Diplomacia da Saúde Global, busca cooperar com os países da UNASUL em questões de saúde. Objetivos - Descrever a ação de Organizações Internacionais e sua atuação em saúde; descrever ações de cooperação em saúde do Brasil; identificar aspectos contextuais dos sistemas de saúde e da cooperação internacional em saúde da Bolívia e da Venezuela. Métodos O procedimento metodológico é qualitativo. Dentro dos métodos possíveis, utilizou-se o descritivo e a pesquisa histórica. A descrição foi utilizada nos dois países estudados para caracterizar seus sistemas de saúde, e a pesquisa histórica, para entender os processos de reforma desses sistemas. Resultados Organizações Internacionais trabalham de diferentes formas a saúde, mas sempre a relacionando com o objetivo principal da instituição. OMS e Banco Mundial são as organizações que mais lidam com o tema. O Brasil, na década de 90, começou a debater sobre saúde em conferências internacionais, e desde os anos 2000 amplia sua cooperação em saúde com países africanos, asiáticos e latinoamericanos. Também estimula o debate da saúde no MERCOSUL e na UNASUL. Os sistemas de saúde da Bolívia e da Venezuela, que foram reformados nos anos 80 e 90, têm atualmente como meta a universalidade; contudo seus sistemas continuam mistos, com presença de um subsetor público, privado e previdenciário. Conclusões - Há um esforço conjunto do Brasil, da Bolívia, da Venezuela e da UNASUL para que a saúde de suas populações melhore em qualidade. Estes quatro atores, igualmente, utilizam o tema saúde como uma questão para cooperação e um propósito para integração. / Introduction The development of International Relations as a discipline embraces studies regarding regional integration, international cooperation, and more recently, health. The globalization process and a higher level of interaction amongst the countries culminated in the establishment of regional cooperation blocs. A representative example of this outcome in South America is the Union of South American Nations UNASUR. Cooperation in health via policy convergence within the blocs is possible, and this requires the knowledge of each countrys health system performance. Brazil, within its foreign policy tradition and its Global Health Diplomacy advocacy, seeks to cooperate with other UNASUR countries on health issues. Objectives To describe the work of International Organizations as well as their performance on health issues; to describe Brazilian cooperation in health; to identify contextual features of the health systems and of the international cooperation in health of Bolivia and Venezuela. Methods The methodological approach is qualitative, and both descriptive procedure and historical research were used. Description was used in the countries health systems scrutiny; and historical research was used to understand these systems reform process. Results International Organizations address health issues with different approaches, but they always relate it to the institutions main objective. WHO and World Bank are the organizations that the most deal with the topic. Brazil, in the 90s, started debating health in international conferences, and since the 2000 decade expands the countrys cooperation in health with African, Asian and Latin-American States. Moreover, Brazil encourages debates concerning health within MERCOSUR and UNASUR. The Bolivian and the Venezuelan health systems, which underwent a reform process during the 80s and the 90s decade, have currently as a goal universal access to health; however, their health systems are still of mixed types, with the presence of public, private and social security subsectors. Conclusion There is a joint effort of Brazil, Bolivia, Venezuela and UNASUR to accomplish an improvement in their populations health. These actors understand health both as a subject for cooperation and as a purpose for integration.