The article addresses the present configuration of Brazil’s health system. Although it is
defined... more The article addresses the present configuration of Brazil’s health system. Although it is defined as comprising universal access, hegemonic public funding and direct provision of care, today it is fragmented and under private sector hegemony, with strong inequity in health care provision. Comparison between health expenditure indicators in 26 emerging countries shows that state expenditures have been of lesser magnitude, even as compared with other emerging countries. Out-of-pocket expenditures are high and that compromises equity. The failures of Brazil´s health reform are seen as an outcome of the pattern of organization of domestic collective interests. It is argued that, as the Constitution proposed no veto against the market operating in the health sector, interests with greater voice have succeeded in imposing their preferences in decision-making arenas for private health care. The discussion is based on policy analysis literature and health system typologies. The data are analysed by descriptive statistics
The paper discusses the changes in the
social assistance component of social protection in
the t... more The paper discusses the changes in the social assistance component of social protection in the two decades that followed the 1988 Constitution. It discusses the transformations of social protection and social assistance in the past decades and the processes that in the 1990s advanced the reform of social assistance policies in Brazil without, however, producing great changes in how services were delievered. By 2000 there had been a great expansion of resources as well as benefits and services coverage in social assistance. This paper argues that conditional cash transfer programs, though created and spread in an international context of restrictive policies, when integrated into Brazil´s public and universal system of social assistance, substantively widened the scope of social protection. Some effects of the expansion in the Brazilian social protection system are identified: less income inequality; creation of an institutional capacity in the area of social assistance; the social, political and symbolic meaning of the inclusion of a large segment of the population in a public system of social assistance by means of a provision structure that does not belong to traditional devices of philanthropy and clientelism.
The article presents the methodology used to develop a health service responsiveness index (SRI).... more The article presents the methodology used to develop a health service responsiveness index (SRI). The index was based on patient data at the Evandro Chagas Research Institute, a unit of the Oswaldo Cruz Foundation in Rio de Janeiro, Brazil. Responsiveness refers to the health system's response to users' expectations. The SRI expresses patients' positive or negative perceptions in two dimensions: patient orientation and personal respect. The methodology integrates research data in an evaluation tool, with the aim of improving quality of services and directing interventions and monitoring changes over time.
The article discusses some data from a study on the opinions and perceptions of the labor situati... more The article discusses some data from a study on the opinions and perceptions of the labor situation and environment among health professionals and administrative workers at the Research Center of the Evandro Chagas Hospital (CPqHEC/FIOCRUZ) in Rio de Janeiro. Certain patterns of conflict observed in the study express the distribution of power and prestige which is typical of hospitals. Many of the meanings people ascribe to their experiences within the organization are mediated by social representations originating in the broader social context to which the organization belongs.
Procedures and perceptions of professionals and groups acting in the Brazilian health plan market... more Procedures and perceptions of professionals and groups acting in the Brazilian health plan market Resumo O objetivo do estudo é analisar o modo como, no Brasil, operadoras de planos e seguros de saúde, serviços hospitalares e médicos organizam o acesso aos serviços de saúde, e que mecanismos utilizam para economia de custos e de decisões. A análise faz uso da literatura de regulação em saúde e da estratégia do managed care. A partir de uma seleção intencional de operadoras baseada em número de beneficiários, modalidade organizacional e abrangência geográfica, foram selecionadas amostras probabilísticas de médicos e de serviços hospitalares. Os dados foram obtidos através de questionários com representantes das operadoras, médicos e hospitais a elas credenciados. Os resultados sugerem que as relações entre operadoras, médicos e hospitais se estabeleceram em bases herdadas do antigo sistema previdenciário, com pagamento predominante de serviços por tabelas fixas e contas abertas. Mecanismos mais complexos de financiamento, de compartilhamento de riscos e de busca pela eficiência são pouco experimentados. São frágeis os mecanismos de redução de agravos, assim como os incentivos ao uso adequado das tecnologias. Fatores moderadores de consumo ou barreiras de acesso são o meio mais comum de controle de custos. Pode-se concluir que a agenda do managed care é incipiente no caso brasileiro. Abstract This study analyzes the mechanisms used in Brazil by health plan and insurance operators, hospitals and physicians for organizing the access to health care services and their strategies towards cost reduction and decision-making. The study is based on the literature about regulation of the health services, with special focus on micro-management and managed care. From an intentional sample of health care organizations selected according to the number of beneficiaries, organizational modality and geographic criteria we selected probabilistic samples of doctors and hospital services. Data were collected through questionnaires applied to key informants from health care operators and affiliated doctors and hospitals. Results suggest that the relationships between health care organizations, physicians and hospitals follow basically patterns inherited from the former social security system, mainly with fixed pricing and open account payments. More complex financing mechanisms, risk sharing and efficiency strategies are of minor interest. Mechanisms for risk reduction and encouragement of adequate use of technologies are weak. Cost control is mainly based on co-payment and barriers to access to the services. We conclude that in Brazil managed care is still in its beginning.
This study analyzes the mechanisms used in Brazil by health plan and insurance operators, hospita... more This study analyzes the mechanisms used in Brazil by health plan and insurance operators, hospitals and physicians for organizing the access to health care services and their strategies towards cost reduction and decision-making. The study is based on the literature about regulation of the health services, with special focus on micro-management and managed care. From an intentional sample of health care organizations selected according to the number of beneficiaries, organizational modality and geographic criteria we selected probabilistic samples of doctors and hospital services. Data were collected through questionnaires applied to key informants from health care operators and affiliated doctors and hospitals. Results suggest that the relationships between health care organizations, physicians and hospitals follow basically patterns inherited from the former social security system, mainly with fixed pricing and open account payments. More complex financing mechanisms, risk sharing and efficiency strategies are of minor interest. Mechanisms for risk reduction and encouragement of adequate use of technologies are weak. Cost control is mainly based on co-payment and barriers to access to the services. We conclude that in Brazil managed care is still in its beginning.
This article presents the methodological basis for elaborating an Organizational Perceptions Inde... more This article presents the methodological basis for elaborating an Organizational Perceptions Index. The tool allows one to grasp the perceptions of organization members and solve some problems identified in the process. It is assumed that perceptions are the result of individual and collective subjectivities, the latter referring to culturally-bounded, socially-constructed representations. The Organizational Perceptions Index expresses the positive or negative perceptions of organization members and integrates data related to four organizational dimensions: infra-structure, management, environment, and culture. The methodology integrates research data in an evaluation tool, with the aim of orienting interventions and monitoring changes over time.
This article discusses the participation of patients in health services through social support gr... more This article discusses the participation of patients in health services through social support groups. Based on a qualitative research, with semi-structured questions and participant observation, one of the roles of Associação Lutando para Viver (ALpViver) acting withing Instituto de Pesquisa Evandro Chagas (IPCEC), is analysed. The group's actions were considered as promoting patient's autonomy, increasing their self-steem and avoiding loneliness. It was concluded that it is possible to establish an active place for users of public health services, through the valorization of a participative culture. Resumo Este artigo discute alguns aspectos da participação de usuários de um serviço público de saúde, o Instituto de Pesquisa Clínica Evandro Chagas (IPCEC/Fiocruz), em uma associação de pacientes, a Associação Lutando para Viver (ALpViver). Baseado em pesquisa qualitativa, com entrevistas semi-estruturadas e observação participante, o trabalho analisa o papel dessa associação, na visão de profissionais do hospital e pacientes, a partir dos conceitos de rede social, apoio social e empowerment. A relevância deste estudo se dá a partir da noção de que a valorização de uma cultura participativa dentro das instituições de saúde contribui para aumentar a autonomia e elevar a auto-estima dos usuários, melhorando a qualidade de vida e de saúde dos mesmos.
This article discusses the participation of patients in health services through social support gr... more This article discusses the participation of patients in health services through social support groups. Based on a qualitative research, with semi-structured questions and participant observation, one of the roles of Associação Lutando para Viver (ALpViver) acting withing Instituto de Pesquisa Evandro Chagas (IPCEC), is analysed. The group's actions were considered as promoting patient's autonomy, increasing their self-steem and avoiding loneliness. It was concluded that it is possible to establish an active place for users of public health services, through the valorization of a participative culture. Resumo Este artigo discute alguns aspectos da participação de usuários de um serviço público de saúde, o Instituto de Pesquisa Clínica Evandro Chagas (IPCEC/Fiocruz), em uma associação de pacientes, a Associação Lutando para Viver (ALpViver). Baseado em pesquisa qualitativa, com entrevistas semi-estruturadas e observação participante, o trabalho analisa o papel dessa associação, na visão de profissionais do hospital e pacientes, a partir dos conceitos de rede social, apoio social e empowerment. A relevância deste estudo se dá a partir da noção de que a valorização de uma cultura participativa dentro das instituições de saúde contribui para aumentar a autonomia e elevar a auto-estima dos usuários, melhorando a qualidade de vida e de saúde dos mesmos.
The paper discusses the concepts of "user's satisfaction", "responsiveness", "humanization" and p... more The paper discusses the concepts of "user's satisfaction", "responsiveness", "humanization" and patient's rights, focusing on their convergences and differences, as well as their reliability when used in the evaluation of health services and systems. Satisfaction and responsiveness are viewed as operational concepts, integrating users views, while humanization and patientss rights concern to normative principles which serve as grounds for policies and programs. While satisfaction studies put a light on the patients role in health services and systems, the concept of responsiveness strengthened its position, giving him the status of an individual and citizen, that is, a subject of universal rights. This conceptual and methodological framework is viewed as part of a paradigm of rights individual, social and political , which is used also in the area of evaluation of quality and health care.
The article addresses the present configuration of Brazil’s health system. Although it is
defined... more The article addresses the present configuration of Brazil’s health system. Although it is defined as comprising universal access, hegemonic public funding and direct provision of care, today it is fragmented and under private sector hegemony, with strong inequity in health care provision. Comparison between health expenditure indicators in 26 emerging countries shows that state expenditures have been of lesser magnitude, even as compared with other emerging countries. Out-of-pocket expenditures are high and that compromises equity. The failures of Brazil´s health reform are seen as an outcome of the pattern of organization of domestic collective interests. It is argued that, as the Constitution proposed no veto against the market operating in the health sector, interests with greater voice have succeeded in imposing their preferences in decision-making arenas for private health care. The discussion is based on policy analysis literature and health system typologies. The data are analysed by descriptive statistics
The paper discusses the changes in the
social assistance component of social protection in
the t... more The paper discusses the changes in the social assistance component of social protection in the two decades that followed the 1988 Constitution. It discusses the transformations of social protection and social assistance in the past decades and the processes that in the 1990s advanced the reform of social assistance policies in Brazil without, however, producing great changes in how services were delievered. By 2000 there had been a great expansion of resources as well as benefits and services coverage in social assistance. This paper argues that conditional cash transfer programs, though created and spread in an international context of restrictive policies, when integrated into Brazil´s public and universal system of social assistance, substantively widened the scope of social protection. Some effects of the expansion in the Brazilian social protection system are identified: less income inequality; creation of an institutional capacity in the area of social assistance; the social, political and symbolic meaning of the inclusion of a large segment of the population in a public system of social assistance by means of a provision structure that does not belong to traditional devices of philanthropy and clientelism.
The article presents the methodology used to develop a health service responsiveness index (SRI).... more The article presents the methodology used to develop a health service responsiveness index (SRI). The index was based on patient data at the Evandro Chagas Research Institute, a unit of the Oswaldo Cruz Foundation in Rio de Janeiro, Brazil. Responsiveness refers to the health system's response to users' expectations. The SRI expresses patients' positive or negative perceptions in two dimensions: patient orientation and personal respect. The methodology integrates research data in an evaluation tool, with the aim of improving quality of services and directing interventions and monitoring changes over time.
The article discusses some data from a study on the opinions and perceptions of the labor situati... more The article discusses some data from a study on the opinions and perceptions of the labor situation and environment among health professionals and administrative workers at the Research Center of the Evandro Chagas Hospital (CPqHEC/FIOCRUZ) in Rio de Janeiro. Certain patterns of conflict observed in the study express the distribution of power and prestige which is typical of hospitals. Many of the meanings people ascribe to their experiences within the organization are mediated by social representations originating in the broader social context to which the organization belongs.
Procedures and perceptions of professionals and groups acting in the Brazilian health plan market... more Procedures and perceptions of professionals and groups acting in the Brazilian health plan market Resumo O objetivo do estudo é analisar o modo como, no Brasil, operadoras de planos e seguros de saúde, serviços hospitalares e médicos organizam o acesso aos serviços de saúde, e que mecanismos utilizam para economia de custos e de decisões. A análise faz uso da literatura de regulação em saúde e da estratégia do managed care. A partir de uma seleção intencional de operadoras baseada em número de beneficiários, modalidade organizacional e abrangência geográfica, foram selecionadas amostras probabilísticas de médicos e de serviços hospitalares. Os dados foram obtidos através de questionários com representantes das operadoras, médicos e hospitais a elas credenciados. Os resultados sugerem que as relações entre operadoras, médicos e hospitais se estabeleceram em bases herdadas do antigo sistema previdenciário, com pagamento predominante de serviços por tabelas fixas e contas abertas. Mecanismos mais complexos de financiamento, de compartilhamento de riscos e de busca pela eficiência são pouco experimentados. São frágeis os mecanismos de redução de agravos, assim como os incentivos ao uso adequado das tecnologias. Fatores moderadores de consumo ou barreiras de acesso são o meio mais comum de controle de custos. Pode-se concluir que a agenda do managed care é incipiente no caso brasileiro. Abstract This study analyzes the mechanisms used in Brazil by health plan and insurance operators, hospitals and physicians for organizing the access to health care services and their strategies towards cost reduction and decision-making. The study is based on the literature about regulation of the health services, with special focus on micro-management and managed care. From an intentional sample of health care organizations selected according to the number of beneficiaries, organizational modality and geographic criteria we selected probabilistic samples of doctors and hospital services. Data were collected through questionnaires applied to key informants from health care operators and affiliated doctors and hospitals. Results suggest that the relationships between health care organizations, physicians and hospitals follow basically patterns inherited from the former social security system, mainly with fixed pricing and open account payments. More complex financing mechanisms, risk sharing and efficiency strategies are of minor interest. Mechanisms for risk reduction and encouragement of adequate use of technologies are weak. Cost control is mainly based on co-payment and barriers to access to the services. We conclude that in Brazil managed care is still in its beginning.
This study analyzes the mechanisms used in Brazil by health plan and insurance operators, hospita... more This study analyzes the mechanisms used in Brazil by health plan and insurance operators, hospitals and physicians for organizing the access to health care services and their strategies towards cost reduction and decision-making. The study is based on the literature about regulation of the health services, with special focus on micro-management and managed care. From an intentional sample of health care organizations selected according to the number of beneficiaries, organizational modality and geographic criteria we selected probabilistic samples of doctors and hospital services. Data were collected through questionnaires applied to key informants from health care operators and affiliated doctors and hospitals. Results suggest that the relationships between health care organizations, physicians and hospitals follow basically patterns inherited from the former social security system, mainly with fixed pricing and open account payments. More complex financing mechanisms, risk sharing and efficiency strategies are of minor interest. Mechanisms for risk reduction and encouragement of adequate use of technologies are weak. Cost control is mainly based on co-payment and barriers to access to the services. We conclude that in Brazil managed care is still in its beginning.
This article presents the methodological basis for elaborating an Organizational Perceptions Inde... more This article presents the methodological basis for elaborating an Organizational Perceptions Index. The tool allows one to grasp the perceptions of organization members and solve some problems identified in the process. It is assumed that perceptions are the result of individual and collective subjectivities, the latter referring to culturally-bounded, socially-constructed representations. The Organizational Perceptions Index expresses the positive or negative perceptions of organization members and integrates data related to four organizational dimensions: infra-structure, management, environment, and culture. The methodology integrates research data in an evaluation tool, with the aim of orienting interventions and monitoring changes over time.
This article discusses the participation of patients in health services through social support gr... more This article discusses the participation of patients in health services through social support groups. Based on a qualitative research, with semi-structured questions and participant observation, one of the roles of Associação Lutando para Viver (ALpViver) acting withing Instituto de Pesquisa Evandro Chagas (IPCEC), is analysed. The group's actions were considered as promoting patient's autonomy, increasing their self-steem and avoiding loneliness. It was concluded that it is possible to establish an active place for users of public health services, through the valorization of a participative culture. Resumo Este artigo discute alguns aspectos da participação de usuários de um serviço público de saúde, o Instituto de Pesquisa Clínica Evandro Chagas (IPCEC/Fiocruz), em uma associação de pacientes, a Associação Lutando para Viver (ALpViver). Baseado em pesquisa qualitativa, com entrevistas semi-estruturadas e observação participante, o trabalho analisa o papel dessa associação, na visão de profissionais do hospital e pacientes, a partir dos conceitos de rede social, apoio social e empowerment. A relevância deste estudo se dá a partir da noção de que a valorização de uma cultura participativa dentro das instituições de saúde contribui para aumentar a autonomia e elevar a auto-estima dos usuários, melhorando a qualidade de vida e de saúde dos mesmos.
This article discusses the participation of patients in health services through social support gr... more This article discusses the participation of patients in health services through social support groups. Based on a qualitative research, with semi-structured questions and participant observation, one of the roles of Associação Lutando para Viver (ALpViver) acting withing Instituto de Pesquisa Evandro Chagas (IPCEC), is analysed. The group's actions were considered as promoting patient's autonomy, increasing their self-steem and avoiding loneliness. It was concluded that it is possible to establish an active place for users of public health services, through the valorization of a participative culture. Resumo Este artigo discute alguns aspectos da participação de usuários de um serviço público de saúde, o Instituto de Pesquisa Clínica Evandro Chagas (IPCEC/Fiocruz), em uma associação de pacientes, a Associação Lutando para Viver (ALpViver). Baseado em pesquisa qualitativa, com entrevistas semi-estruturadas e observação participante, o trabalho analisa o papel dessa associação, na visão de profissionais do hospital e pacientes, a partir dos conceitos de rede social, apoio social e empowerment. A relevância deste estudo se dá a partir da noção de que a valorização de uma cultura participativa dentro das instituições de saúde contribui para aumentar a autonomia e elevar a auto-estima dos usuários, melhorando a qualidade de vida e de saúde dos mesmos.
The paper discusses the concepts of "user's satisfaction", "responsiveness", "humanization" and p... more The paper discusses the concepts of "user's satisfaction", "responsiveness", "humanization" and patient's rights, focusing on their convergences and differences, as well as their reliability when used in the evaluation of health services and systems. Satisfaction and responsiveness are viewed as operational concepts, integrating users views, while humanization and patientss rights concern to normative principles which serve as grounds for policies and programs. While satisfaction studies put a light on the patients role in health services and systems, the concept of responsiveness strengthened its position, giving him the status of an individual and citizen, that is, a subject of universal rights. This conceptual and methodological framework is viewed as part of a paradigm of rights individual, social and political , which is used also in the area of evaluation of quality and health care.
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Papers by Jeni Vaitsman
defined as comprising universal access, hegemonic public funding and direct provision of care,
today it is fragmented and under private sector hegemony, with strong inequity in health care
provision. Comparison between health expenditure indicators in 26 emerging countries shows that
state expenditures have been of lesser magnitude, even as compared with other emerging countries.
Out-of-pocket expenditures are high and that compromises equity. The failures of Brazil´s health
reform are seen as an outcome of the pattern of organization of domestic collective interests. It is
argued that, as the Constitution proposed no veto against the market operating in the health sector,
interests with greater voice have succeeded in imposing their preferences in decision-making arenas
for private health care. The discussion is based on policy analysis literature and health system
typologies. The data are analysed by descriptive statistics
social assistance component of social protection in
the two decades that followed the 1988 Constitution.
It discusses the transformations of social protection
and social assistance in the past decades and the processes
that in the 1990s advanced the reform of social
assistance policies in Brazil without, however, producing
great changes in how services were delievered.
By 2000 there had been a great expansion of
resources as well as benefits and services coverage in
social assistance. This paper argues that conditional
cash transfer programs, though created and spread in
an international context of restrictive policies, when
integrated into Brazil´s public and universal system
of social assistance, substantively widened the scope
of social protection. Some effects of the expansion in
the Brazilian social protection system are identified:
less income inequality; creation of an institutional
capacity in the area of social assistance; the social,
political and symbolic meaning of the inclusion of a
large segment of the population in a public system of
social assistance by means of a provision structure
that does not belong to traditional devices of philanthropy
and clientelism.
defined as comprising universal access, hegemonic public funding and direct provision of care,
today it is fragmented and under private sector hegemony, with strong inequity in health care
provision. Comparison between health expenditure indicators in 26 emerging countries shows that
state expenditures have been of lesser magnitude, even as compared with other emerging countries.
Out-of-pocket expenditures are high and that compromises equity. The failures of Brazil´s health
reform are seen as an outcome of the pattern of organization of domestic collective interests. It is
argued that, as the Constitution proposed no veto against the market operating in the health sector,
interests with greater voice have succeeded in imposing their preferences in decision-making arenas
for private health care. The discussion is based on policy analysis literature and health system
typologies. The data are analysed by descriptive statistics
social assistance component of social protection in
the two decades that followed the 1988 Constitution.
It discusses the transformations of social protection
and social assistance in the past decades and the processes
that in the 1990s advanced the reform of social
assistance policies in Brazil without, however, producing
great changes in how services were delievered.
By 2000 there had been a great expansion of
resources as well as benefits and services coverage in
social assistance. This paper argues that conditional
cash transfer programs, though created and spread in
an international context of restrictive policies, when
integrated into Brazil´s public and universal system
of social assistance, substantively widened the scope
of social protection. Some effects of the expansion in
the Brazilian social protection system are identified:
less income inequality; creation of an institutional
capacity in the area of social assistance; the social,
political and symbolic meaning of the inclusion of a
large segment of the population in a public system of
social assistance by means of a provision structure
that does not belong to traditional devices of philanthropy
and clientelism.