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espanolObjetivo. Analizar la gobernanza en el sistema de salud en Mexico, en las politicas frente a la pandemia por Covid-19. Material y metodos. Estudio cualitativo, analitico, realizado entre junio y noviembre de 2020. Se analizaron 41 entrevistas semiestructuradas que se aplicaron a acto-res clave del sistema de salud y que se organizaron en el software ATLAS.ti 9. El analisis se adhirio a los principios teorico-metodologicos del Marco Analitico de Gobernanza. Resultados. El problema: la formulacion de politicas fue centralizada; los actores: solo los altos mandos participan en las decisiones; las normas: los valores sociales y el liderazgo determinan su nivel de responsabilidad; toma de decisio-nes: los altos mandos reconocieron poder para proponer modificaciones al Marco Normativo; los nodos: las politicas federales fueron adaptadas a nivel estatal de manera diferen-ciada. Conclusiones. La gobernanza centralizada, los niveles diferenciados de convocatoria de los actores, su poder de decision, acuerdos, responsabilidad y liderazgo, definieron el alcance de la gobernanza y, a su vez, el nivel de respuesta ante la pandemia por Covid-19. EnglishObjective. Analyze governance in the Mexican health system, with regards to policies to combat the Covid-19 pandemic. Materials and methods. Qualitative, analytic study carried out from June to November, 2020. Forty-one semi-structured interviews with key actors in the health system were analyzed and organized in ATLAS.ti-v.9 software. The analysis followed theoretical-methodological principles of the Governance Analytical Framework. Results. The pro-blem: the policy-making was centralized; the actors: only high level actors participated in the decisions; decision-making: high level actors recognized power to propose modifications in the regulatory framework; nodes: federal policies were adapted at the state level in a differential manner. Conclusions.Centralized governance, differential levels of convocation of actors, decision-making power, level of agreements, as well as responsibility and leadership, all defined the reach of go-vernance and, in turn, the level of response to the Covid-19 pandemic.

To map the range of access barriers indicators for which data can be derived from household surveys in the Americas.A systematic mapping review study was conducted to identify access dimensions and indicators of access barriers for general health services already described in the literature; and identify whether data for those indicators could be derived from household surveys in the Americas and what was the methodology used in these surveys.The study found 49 eligible surveys (287 datasets) from 31 countries in the Americas from which 23 measures of access barriers could be generated. These indicators measure self-reported access barriers for unmet healthcare needs through forgone care, as well as delayed care, unsatisfaction with care and experiences during health service provision. Multiple barriers could be identified, although there was marked heterogeneity in variables included and how barriers were measured.This study identified tracer indicators that countries in the Americas could use to monitor the population that experience healthcare needs but fail to seek and obtain appropriate healthcare, and what the main barriers are. The surveys identified are well validated and allow the disaggregation of these indicators by equity stratifiers. Given the variability of the methodologies used in these surveys, comparability across countries could be limited. As such, their virtue lies in helping stakeholders compare levels of access barriers over time for a given country or a group of countries. Country buy-in will directly affect the extent to which access barriers data are collected, reported, and used.Mapear el rango de indicadores de barreras al acceso para los que se pueden obtener datos a partir de las encuestas de hogares en las Américas.Se llevó a cabo un estudio de revisión con un mapeo sistemático para identificar las dimensiones de acceso y los indicadores de las barreras al acceso a los servicios de salud en general descritos en la literatura; e identificar si los datos para esos indicadores podían obtenerse a partir de las encuestas de hogares en las Américas y cuál era la metodología utilizada en esas encuestas.Se encontraron 49 encuestas elegibles (287 conjuntos de datos) de 31 países de las Américas, a partir de las cuales se pudieron generar 23 medidas de barreras al acceso. Estos indicadores miden las barreras al acceso autoinformadas para las necesidades de atención sanitaria insatisfechas debido a atención no prestada, retraso en la atención, insatisfacción con la atención y experiencias durante la prestación de servicios de salud. Se identificaron múltiples barreras, aunque hubo una marcada heterogeneidad en las variables incluidas y en la forma en que se midieron las barreras.Se identificaron indicadores específicos que los países de las Américas podrían utilizar para monitorear a la población que experimenta necesidades de atención de salud pero no busca ni obtiene la atención sanitaria adecuada, y cuáles son las principales barreras. Las encuestas identificadas están bien validadas y permiten desagregar estos indicadores por estratificadores de equidad, pero dada la variabilidad de las metodologías utilizadas en las encuestas la comparabilidad entre los países podría ser limitada. Su principal valor radica en que ayudan a las partes interesadas a comparar los niveles de las barreras al acceso a lo largo del tiempo para un país determinado o un grupo de países. La aceptación de los países afectará de manera directa la medida en que se reúnan, notifiquen y utilicen los datos sobre las barreras al acceso.

Determine whether an association exists between access barriers reported by women aged 15-49 years and the use of essential health services for women and children in Latin America.Cross-sectional study using multivariate logistic regression models based on the demographic and health surveys of Bolivia, the Dominican Republic, Guatemala, Guyana, Haiti, Honduras, Nicaragua, and Peru.Geographical and financial barriers, the need to obtain permission to visit the doctor, or not wanting to go alone to a health facility significantly reduced the likelihood of completing prenatal checkups and having an assisted delivery. Women who reported difficulties obtaining permission to visit the doctor were less likely to have had a Pap smear in the past two or three years, to complete vaccination of their children, and to seek care for children with acute respiratory infection. Not wanting to go to a health center alone reduced the likelihood of using modern contraceptives.Women who reported barriers to access had a statistically significant lower probability of using essential health services for themselves and their children. Strategies aimed at removing barriers should focus not only on improving the range of services offered, but also address issues related to norms, gender roles, and women's empowerment if sustainable progress toward universal access is to be made.Determinar se existe associação entre as barreiras de acesso relatadas por mulheres de 15 a 49 anos e a utilização de serviços essenciais de saúde para mulheres e crianças na América Latina.Estudo transversal baseado em modelos de regressão logística multivariada de pesquisas demográficas e de saúde da Bolívia, do Haiti, de Honduras, da Guatemala, da Guiana, da Nicarágua, do Peru e da República Dominicana.Barreiras geográficas e financeiras, necessidade de obter permissão para ir ao médico ou não querer ir sozinha ao estabelecimento reduziram significativamente a probabilidade de realizar o pré-natal e ter um parto assistido. As mulheres que relataram dificuldade de obter permissão para ir ao médico apresentaram menor probabilidade de fazer o exame Papanicolau nos últimos 2-3 anos, completar a vacinação das crianças e procurar atendimento para seus filhos e filhas com quadro de infecção respiratória aguda. Não querer ir sozinha ao centro de saúde reduziu a probabilidade de utilizar métodos anticoncepcionais modernos.Constatou-se uma redução estatisticamente significativa da possibilidade de utilização de serviços essenciais de saúde por mulheres que relataram barreiras de acesso e por seus filhos e filhas. As estratégias destinadas a remover tais barreiras não devem se concentrar apenas na melhoria da oferta de serviços – devem também abordar questões relacionadas a normas, papéis de gênero e empoderamento das mulheres para que haja um progresso sustentável em direção ao acesso universal.

This article uses a health stewardship perspective to interpret the strengths of and challenges to national health authorities' capacities to respond to the COVID-19 pandemic through the renewed essential public health functions (EPHF) framework. Based on a literature review, this article argues that the institutional capacities required by countries to respond to the COVID-19 pandemic in the Americas included all four stages of the new EPHF policy cycle: assessment, policy development, allocation of resources and access. While health authorities provided these key functions (e.g. data analysis, intersectoral policy dialogues, allocation of additional funds), the interventions implemented depended on each 'country's own institutional structures. Health authorities faced significant challenges including fragmentation and the lack of institutional and personnel capacities, thus compromising the delivery of an effective and equitable response. In addition, the response to the pandemic has been uneven due to weaknesses in central leadership and coordination capacity, the politicization of the response and differences in the capacity to respond at subnational levels. Such challenges reflect structural weaknesses that existed prior to the onset of the pandemic, as well as the low prioritization of public health in agendas for health systems strengthening. A future agenda should prioritize improving structural elements while strengthening the stewardship capacities of health authorities and developing institutional structures that guarantee access to and universal coverage of health care.Este artigo utiliza uma perspectiva de gestão de saúde para interpretar os pontos fortes e os desafios das capacidades das autoridades nacionais de saúde na resposta à pandemia de COVID-19, por meio da estrutura renovada das funções essenciais de saúde pública (FESP). Com base em uma revisão da literatura, este artigo argumenta que as capacidades institucionais requeridas pelos países para responder à pandemia de COVID-19 nas Américas incluíram todas as quatro etapas do novo ciclo de políticas das FESP: avaliação, formulação de políticas, alocação de recursos e acesso. Embora as autoridades de saúde tenham fornecido essas funções essenciais (por exemplo, análise de dados, diálogos intersetoriais de política, alocação de fundos adicionais), as intervenções implementadas dependiam das próprias estruturas institucionais de cada país. As autoridades de saúde enfrentaram desafios significativos, incluindo a fragmentação e a falta de capacidades institucionais e de pessoal, comprometendo, assim, uma resposta eficaz e equitativa. Além disso, a resposta à pandemia tem sido desigual em decorrência de pontos fracos na liderança central e na capacidade de coordenação, da politização da resposta e de diferenças na capacidade de resposta nos níveis subnacionais. Tais desafios refletem as fragilidades estruturais que existiam antes do início da pandemia, bem como a baixa priorização da saúde pública nas agendas para o fortalecimento dos sistemas de saúde. Uma agenda futura deve priorizar a melhoria dos elementos estruturais, ao mesmo tempo em que fortalece as capacidades de gestão das autoridades de saúde e desenvolve estruturas institucionais que garantam o acesso à saúde e a cobertura universal de saúde.

En el presente artículo se utiliza una perspectiva de rectoría de la salud, con el fin de interpretar las fortalezas y los obstáculos relativos a las capacidades de las autoridades nacionales de salud para responder ante la pandemia de COVID-19, a través del marco renovado de las funciones esenciales de salud pública (FESP). Sobre la base de una revisión bibliográfica, se sostiene que las capacidades institucionales que necesitan los países de la Región de las Américas para responder ante la pandemia de COVID-19 incluyen las cuatro etapas del nuevo ciclo de políticas en las FESP: la evaluación, la formulación de políticas, la asignación de recursos y el acceso. Aunque las autoridades de salud proporcionaron las funciones esenciales (por ejemplo, análisis de datos, diálogos intersectoriales en materia de políticas y asignación de fondos adicionales), las intervenciones que se implementaron estuvieron sujetas a las estructuras institucionales de cada país. Las autoridades de salud tuvieron que hacer frente a desafíos considerables como la fragmentación y la falta de capacidades institucionales y de personal, lo que pone en peligro la ejecución de actividades de respuesta eficaces y equitativas. Además, la respuesta a la pandemia ha sido desigual debido a algunas debilidades en la capacidad central de liderazgo y coordinación, la politización de las actividades de respuesta y las diferencias en la capacidad de respuesta a nivel subnacional. Esos desafíos son el reflejo de deficiencias estructurales que ya existían antes de que comenzara la pandemia, así como de la asignación de una prioridad baja a la salud pública en la agenda para el fortalecimiento de los sistemas de salud. En las agendas que se elaboren en el futuro debe darse prioridad a mejorar los elementos estructurales, fortalecer las capacidades de rectoría de las autoridades de salud y crear estructuras institucionales que garanticen tanto el acceso universal a la atención de salud como la cobertura universal de salud.

Objetivo. Determinar si existe una asociación entre las barreras de acceso informadas por mujeres de 15-49 años y la utilización de servicios esenciales de salud para mujeres, niños y niñas en América Latina. Método. Estudio transversal con base en modelos de regresión multivariada logística a partir de las Encuestas de Demografía y Salud de Bolivia, Haití, Honduras, Guatemala, Guyana, Nicaragua, Perú y República Dominicana. Resultados. Las barreras geográficas y financieras, la necesidad de obtener permiso para visitar al médico o no querer ir sola al establecimiento redujo significativamente la probabilidad de completar los controles prenatales y de tener un parto asistido. Las mujeres que notificaron dificultades para obtener permiso para visitar al médico redujeron su probabilidad de tener un examen de Papanicolau en los últimos 2 o 3 años, completar la vacunación de niños y niñas, y la probabilidad de buscar atención para sus hijos e hijas con cuadros de infección respiratoria aguda. No querer ir sola al centro de salud redujo la probabilidad de usar métodos anticonceptivos modernos. Conclusiones. La notificación de barreras de acceso por parte de las mujeres redujo de forma estadísticamente significativa la posibilidad de utilizar servicios esenciales de salud para ellas y para sus hijos e hijas. Las estrategias orientadas a eliminar barreras no solo deben enfocarse en mejorar la oferta de servicios, sino también abordar aspectos relacionados con las normas, los roles de género y el empoderamiento de las mujeres si se espera avanzar de manera sostenible hacia el acceso universal.

Summary box The COVID-19 pandemic has resulted in terrible loss of life, disproportionately impacting the poor and those with underlying health conditions, devastating lives and livelihoods as a consequence of its effect on economic activity. Weak health system responses, chronic and longstanding underinvestment, and inadequate policies to tackle the root causes of inequity that most affect those living in conditions of vulnerability to access needed health and social services have exacerbated the problem. In addition, this pandemic has confirmed the precarious relationship and interdependence of health and the economy in the context of a disease outbreak.1 2 The impact on economies and sustainable development is evident, with COVID-19 uncovering the structural deficiencies and inequities in access to health services and social protection. The region of the Americas, similar to the rest …

To identify advantages and challenges of using household survey data to measure access barriers to health services in the Americas and to report findings from most recent surveys.Descriptive cross-sectional study using data retrieved from publicly available nationally representative household surveys carried out in 27 countries of the Americas. Values for indicators of access barriers for forgone care were generated using available datasets and reports from the countries. Results were disaggregated by wealth quintiles according to income or asset-based wealth levels.Most surveys were similar in general approach and in the categories of their content. However, country-specific questionnaires varied by country, which hindered cross-country comparisons. On average, about one-third of people experienced multiple barriers to forgone appropriate care. There was great variability between countries in the experience of these barriers, although disparities were relatively consistent across countries. People in the poorest wealth quintile were more likely to experience barriers related to acceptability issues, financial and geographic access, and availability of resources.The analysis indicates major inequalities by wealth status and uneven progress in multiple access barriers that hinder progress towards the goals of equity as part of the Sustainable Development Goals and universal health in the Americas. Access barriers were multiple, which highlights the need for integrated and multisectoral approaches to tackle them. Given the variability between instruments across countries, future efforts are needed to standardize questionnaires and improve data quality and availability for regional monitoring of access barriers.Determinar las ventajas y los problemas de la utilización de datos de las encuestas de hogares para medir las barreras al acceso a los servicios de salud en las Américas, e informar los resultados de las encuestas más recientes.Estudio descriptivo transversal que empleó datos de encuestas de hogares representativas a nivel nacional y disponibles públicamente, realizadas en 27 países de las Américas. Se generaron valores para los indicadores de las barreras al acceso a la búsqueda de servicios de salud utilizando los conjuntos de datos e informes disponibles de los países. Los resultados se desagregaron por quintiles de riqueza según ingreso o niveles de riqueza basado en activos.La mayoría de las encuestas fueron similares en cuanto al enfoque general y a las categorías de su contenido. Sin embargo, los cuestionarios específicos eran diferentes para cada país, lo que dificultó las comparaciones entre ellos. En promedio, alrededor de un tercio de las personas experimentaron múltiples barreras para acceder una atención sanitaria adecuada. Hubo gran variabilidad entre los países en cuanto a la experiencia de esas barreras, aunque las disparidades fueron relativamente constantes entre los países. Las personas del quintil de riqueza más desfavorecido tuvieron más probabilidades de experimentar barreras en lo que respecta a la aceptabilidad, la accesibilidad geográfica y financiera y la disponibilidad de recursos.Existen grandes desigualdades basadas en la situación de riqueza y un progreso desigual para superar las múltiples barreras al acceso que obstaculizan el avance hacia los objetivos de equidad que forman parte de los Objetivos de Desarrollo Sostenible y de la salud universal en las Américas. Las barreras al acceso son múltiples, lo que pone de relieve la necesidad de adoptar enfoques integrados y multisectoriales para enfrentarlas. La variabilidad de los instrumentos empleados en los distintos países sugiere que en el futuro es necesario estandarizar los cuestionarios y mejorar la calidad y la disponibilidad de los datos para la vigilancia regional de las barreras al acceso.

RESUMEN El objetivo del trabajo es construir un marco conceptual de monitoreo sobre los avances de politicas y acciones orientadas a alcanzar la salud universal. Se revisaron modelos conceptuales y propuestas metodologicas relacionados con el monitoreo del acceso y la cobertura universal de salud. Se realizo tambien una revision de la literatura para seleccionar indicadores relevantes. Esta revision fue complementada con un proceso de consulta con expertos en sistemas de salud de la Region de las Americas. Se desarrollo un marco integral para el monitoreo de politicas y acciones para el acceso y la cobertura universal de salud. El marco de monitoreo contiene cuatro componentes (acciones estrategicas, resultados inmediatos, resultados intermedios y resultados de impacto) e identifica un conjunto de opciones politicas para guiar la transformacion de los sistemas de salud hacia el acceso y la cobertura universal de salud. Se eligieron 64 indicadores entre un total de 500 indicadores para la evaluacion de los componentes del marco de monitoreo. El abordaje propuesto para la utilizacion del marco se basa en la medicion de inequidades en las condiciones de acceso y cobertura, asi como en la recoleccion de evidencia cualitativa sobre el grado de ejecucion de politicas y acciones. El marco propuesto podria contribuir a fortalecer los procesos de transformacion de los sistemas de salud para avanzar hacia el acceso y la cobertura universal de salud.

To present summary measures of socioeconomic inequalities in access barriers to health services in Colombia, El Salvador, Paraguay, and Peru.This cross-sectional study used data from nationally - representative household surveys in Colombia, El Salvador, Peru, and Paraguay to analyze income-related inequalities in barriers to seeking health services. Households that reported having a health problem (disease/accident) and not seeking professional health care were considered to be facing access barriers. The measures of inequality were the slope index of inequality and relative index of inequality.Inequality trends were mixed across the four countries. All showed improvement, but large inequality gaps persisted between the highest and lowest income quintiles, despite health care reforms. Relative inequality gaps were highest in Colombia (60%), followed by Paraguay (30%), Peru (20%), and El Salvador (20%).The effect of national policy initiatives on equity to accessing health services should be the object of future analysis. There is also a need for research on national and regional monitoring of access barriers and explanatory factors for why people do not seek care, even when having a health problem.Presentar algunas mediciones de las desigualdades socioeconómicas que representan obstáculos para el acceso a los servicios de salud en Colombia, El Salvador, Paraguay y Perú.En este estudio transversal se tomaron datos de encuestas realizadas en hogares representativas a nivel nacional en Colombia, El Salvador, Perú y Paraguay. Mediante estos datos se analizaron las desigualdades en los ingresos como obstáculos para recurrir a los servicios de salud. Los hogares donde se informó algún problema de salud (enfermedad o accidente) y sus habitantes no recurrieron a ningún tipo de atención profesional fueron considerados como población que enfrenta obstáculos para acceder a estos servicios. Para medir la desigualdad se usó el índice de desigualdad de la pendiente y el índice relativo de desigualdad.Las tendencias de desigualdad fueron divergentes entre estos países. Se observó un grado de avance en cada país, aunque subsistieron grandes brechas entre el quintil de ingresos superiores y el inferior, a pesar de que hubo reformas en la atención de salud. Las brechas en cuanto al índice relativo de desigualdad fueron más elevadas en Colombia (60%), seguido de Paraguay (30%), Perú (20%) y El Salvador (20%).La repercusión que tienen las iniciativas de política nacional sobre la igualdad de acceso a los servicios de salud debería ser objeto de análisis en un futuro. Asimismo, es necesario que se realicen investigaciones en cuanto al seguimiento a nivel nacional y regional de los obstáculos al acceso a los servicios de salud y los factores explicativos que indiquen porqué las personas no acuden a los servicios incluso cuando presentan un problema de salud.Apresentar indicadores das desigualdades socioeconómicas no acesso aos serviços de saúde na Colombia, El Salvador, Paraguai e Peru.Este estudo transversal utilizou dados de pesquisas domiciliares representativas da realidade nacional na Colómbia, El Salvador, Peru e Paraguai com o objetivo de analisar as desigualdades relacionadas a renda no acesso aos serviços de saúde. Os domicílios que relataram a presença de um problema de saúde (doença/acidente) e nao buscaram cuidados de saúde profissionais foram considerados como domicílios que apresentavam barreiras no acesso aos serviços de saúde. Os indicadores de desigualdade foram o indice absoluto de desigualdade (As tendencias relativas a desigualdade foram mistas nos quatro países. Todos apresentaram melhorias, mas ainda persistem grandes disparidades entre os quintis com renda mais alta e mais baixa, apesar das reformas nos sistemas de saúde. A desigualdade relativa foi mais elevada na Colómbia (60%), seguida do Paraguai (30%), Peru (20%) e El Salvador (20%).O efeito das iniciativas políticas nacionais sobre a equidade no acesso aos serviços de saúde deve ser o tema de análises futuras. Também é preciso pesquisar o monitoramento nacional e regional das barreiras no acesso aos serviços e os fatores que explicam por que as pessoas nao buscam cuidados de saúde, mesmo quando apresentam um problema de saúde.

La eficiencia de los sistemas de salud ha sido y continua siendo uno de los objetivos de politicas de reforma de los sistemas de salud en el mundo y en las Americas. Incluso,ha sido considerada una dimension critica y constituye un objetivo intermedio crucial en los marcos analiticos que describen el funcionamiento del sistema de salud...

Objetivo: Analizar la relacion entre modelos de financiamiento y la organizacion con costos y desempeno de los servicios de los subsistemas de salud de Rosario,Argentina. Material y metodos: Los modelos de financiamiento y organizacion se caracterizaron utilizando informacion secundaria. Se calcularon los costos utilizando la metodologia SHA/ OMS. Se midio el desempeno con una encuesta poblacional (n=822). Resultados: Subsistema publico: financiamiento integrado verticalmente y servicios organizados desde la estrategia de atencion primaria contribuyeron a bajos costos y alto desempeno en continuidad y orientacion de la atencion con debilidades en accesibilidad e integralidad. Subsistema privado: integracion contractual y debiles mecanismos de regulacion y coordinacion condujeron a resultados opuestos a los del subsistema publico. Seguridad social: integracion contractual y fuertes mecanismos de regulacion y coordinacion contribuyeron a costos intermedios y un alto desempeno general. Conclusiones: El modelo de financiamiento y organizacion tiene una fuerte influencia sobre los costos y el desempeno de los servicios.

Background: Most Latin American health systems are comprised of public (PubS), social security (SSS) and private (PrS) subsystems. These subsystems coexist, causing health care fragmentation and population segmentation. Objective: To estimate the extent of subsystem cross-coverage in a geographically bounded population (Rosario city) and to compare the subsystems' performance on primary health care (PHC) dimensions. Methods: Through a cross-sectional, interviewer-administered survey to a representative sample (n = 822) of the Rosario population, we measured the percentage of cross-coverage (people with usual source of care in one subsystem but also covered by another subsystem) and the health services' performance by core PHC dimensions, as reported by each subsystem's usual users. We compared the subsystems' performance using chi-square analysis and one-way analysis of variance testing. We analyzed whether the observed differences were coherent with the predominant institutional and organizational features of each subsystem. Results: Overall, 39.3% of the population was affiliated with the PubS, 44.8% with the SSS and 15.9% with the PrS. Cross-coverage was reported by 40.6% of respondents. The performance of the PubS was weak on accessibility but strong on person-and-community-oriented care, the opposite of the PrS. The SSS combined the strengths of the other two subsystems. Conclusion: Rosario's health system has a high percentage of cross-coverage, contributing to issues of fragmentation, segmentation, financial inequity and inefficiency. The overall performance of the SSS was better than that of the PrS and PubS, though each subsystem had a particular performance pattern with areas of strength and weakness that were consistent with their institutional and organizational profiles. Fil: Yavich, Natalia. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Rosario; Argentina. Universidad Nacional de Rosario. Centro de Estudios Interdisciplinarios; Argentina Fil: Báscolo, Ernesto Pablo. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Rosario; Argentina. Universidad Nacional de Rosario. Centro de Estudios Interdisciplinarios; Argentina Fil: Haggerty, Jeannie. McGill University; Canadá

In Argentina, during the decade of the 1990s major changes were introduced into the regulatory framework of the national obras sociales, or union-based health coverage plans. Using data from the Federal Administration of Public Income (AFIP) [Administración Federal de Ingresos Públicos], this study evaluates for the years 2004 and 2011: a) the importance of obras sociales within the healthcare system, b) the degree of concentration of this health social security subsystem, and c) the inequalities in the availability of funds among the obras sociales and their beneficiaries. The results show an increased importance of obras sociales within the Argentine health system. The concentration of funds distributed to the most important institutions within the subsystem showed no change, while the concentration of contributors to these institutions slightly increased and that of beneficiaries decreased. Finally, a reduction of the inequalities in funds per beneficiary received by different institutions was observed. This trend can be explained, among other factors, by the attenuation of wage differentials between branches of economic activity and the actions of the so-called Solidarity Redistribution Fund.

This report presents the results of a consensus decision making process conducted to elaborate a renewed conceptual framework of the essential public health functions for the Americas. The emerging framework consists of four pillars encompassing action-oriented components relating to the new scope and concerns of public health. The four pillars call for adopting a human rights approach to public health, addressing the social determinants of health, ensuring access to both individuals and population-based services, and expanding the stewardship role of health authorities through a collaborative implementation of public health functions. Public health functions were conceptualized as a set of capacities that are part of an integrated policy cycle the encompasses four stages: assessment, policy development, allocation of resources, and access. The framework provides a road map for evaluation and development by health authorities of integrated enabling public health policies through intersectoral collaboration. The application of the framework would require engaging countries working to improve public health through national assessments and systematic incorporation of these findings into quality improvement efforts and sectoral and intersectoral decision-making processes around policy and investments priorities promoted by governments. Work is ongoing in the definition of a list of public health functions that gives operational clarity to each dimension of this framework and guides performance evaluation.En este informe se presentan los resultados de un proceso de toma de decisiones por consenso realizado para elaborar un marco conceptual renovado de las funciones esenciales de salud pública para las Américas. El marco resultante consta de cuatro pilares que abarcan componentes orientados a la acción relacionados con el nuevo alcance y las nuevas preocupaciones de la salud pública. Los cuatro pilares exigen la adopción de un enfoque de la salud pública basado en los derechos humanos, el abordaje de los determinantes sociales de la salud, la garantía de acceso a los servicios de salud tanto a nivel individual como de la población, y la ampliación de la función de rectoría de las autoridades sanitarias mediante una aplicación colaborativa de las funciones de salud pública. Las funciones de salud pública se conceptualizaron como un conjunto de capacidades que forman parte de un ciclo integrado de políticas que comprende cuatro etapas: evaluación, elaboración de políticas, asignación de recursos y acceso. El marco proporciona una hoja de ruta para la evaluación y el desarrollo por parte de las autoridades sanitarias de políticas de salud pública integradas y habilitantes mediante la colaboración intersectorial. La aplicación del marco exigiría el compromiso de los países para mejorar la salud pública mediante evaluaciones nacionales y la incorporación sistemática de sus conclusiones en las actividades de mejoramiento de la calidad y en los procesos de toma de decisiones sectoriales e intersectoriales acerca de las prioridades en materia de políticas e inversiones promovidas por los gobiernos. Se está trabajando en la definición de una lista de funciones de salud pública que dé claridad operacional a cada dimensión de este marco y oriente la evaluación de su desempeño.

Characterize health system reform processes implemented in eight Latin American countries and evaluate their results in terms of health access and coverage conditions.Data from nationally representative household surveys were used to characterize health system reform processes in Chile, Colombia, El Salvador, Guatemala, Mexico, Paraguay, Peru, and Uruguay and to assess resulting conditions governing health care access and coverage.Five countries introduced changes to expand financial coverage, with a perspective on primary health care limited to the expansion of health service packages, while three countries prioritized changes in health service organization based on a more comprehensive approach to primary health care. Countries in the first group increased insurance coverage but saw no improvement in access to health services. In the second group of countries, important barriers to access continue to exist despite improvements.Health system reforms can be described in terms of the type of transformations promoted. Reforms that focus on expanding insurance coverage improve financial protection but do not result in positive changes in access. Reforms that prioritize transformations in the organization of health services lead to improved access, yet a large proportion of the population continues to report barriers to access in the countries studied. The socioeconomic conditions of the population and unstable policies stand in the way of achieving more significant progress.Caracterizar os processos de reforma do sistema de saúde implementados em oito países da América Latina e avaliar os resultados obtidos quanto ao acesso e cobertura de saúde.Foi realizada uma caracterização combinada dos processos de transformação dos sistemas de saúde do Chile, Colômbia, El Salvador, Guatemala, México, Paraguai, Peru e Uruguai com a avaliação da situação de acesso e cobertura de saúde a partir de dados obtidos em pesquisas nacionais de domicílios representativas dos países estudados.Cinco países empreenderam mudanças para ampliar a cobertura financeira, com uma perspectiva de atenção primária limitada à ampliação dos pacotes de serviços de saúde, e três países priorizaram mudanças na organização dos serviços de saúde, com uma perspectiva mais abrangente à atenção primária à saúde. Nos países do primeiro grupo, ocorreu a ampliação da cobertura do seguro de saúde, porém sem melhoria do acesso aos serviços. Nos países do segundo grupo, houve melhorias, mas continuam existindo grandes barreiras de acesso.As reformas do sistema de saúde podem ser caracterizadas pelo tipo de transformação ocorrida. Reformas direcionadas a ampliar a cobertura do seguro de saúde aumentam a cobertura financeira, porém não resultam em mudanças favorecendo o acesso. As reformas que priorizam mudanças na organização dos serviços de saúde resultam em melhorias de acesso, porém persistem as barreiras de acesso a uma grande parcela da população nesses países. A condição socioeconômica da população e a instabilidade das políticas impedem alcançar um progresso mais significativo.

Comparison can be an important resource for identifying trends or interventions that improve the quality of health services. Although Portugal and Spain have accumulated important knowledge in primary health care-PHC driven national systems, the Ibero-American countries have not been object of comparative studies. This paper presents an assessment using an analytical dashboard created by the Ibero-American Observatory on Policies and Health Systems. It discusses aspects that have stood out in monitoring the service systems of Argentina, Brazil, Colombia, Spain, Paraguay, Peru, and Portugal throughout the 21st century's first decade. Forty-five indicators and time series showing the highest completeness degree divided into social determinants, conditions and performance were analyzed. Three trends are common to almost all countries: overweight increase, negative trade balance for pharmaceutical products, and an increase in health system expenditure. This convergence trend reveals the need for changes in the way of regulating, organizing and delivering health services with public policies and practices that guarantee comprehensive care, including health promotion actions enabling systems sustainability.A comparação é um recurso importante para identificar tendências ou intervenções que melhorem a qualidade dos serviços. Os países ibero-americanos não têm sido objeto de estudos dessa ordem, embora Portugal e Espanha venham acumulando um conhecimento relevante na condução de sistemas nacionais orientados pela atenção primária. O trabalho apresenta os resultados da matriz analítica do Observatório Iberoamericano de Políticas e Sistemas de Saúde, discutindo aspectos que se destacaram no acompanhamento dos sistemas de serviços da Argentina, Brasil, Colômbia, Espanha, Paraguai, Peru e Portugal, ao longo da primeira década do século XXI. Foi feita a análise de séries temporais de quarenta e cinco indicadores que apresentavam maior grau de completitude, divididos em determinantes sociais, condicionantes e desempenho. Três tendências são comuns a quase todos os países: aumento de sobrepeso, desequilíbrio da balança comercial em produtos farmacêuticos e aumento nos gastos dos sistemas. Este padrão de convergência mostra a necessidade de mudanças no modo de regular, organizar e prestar serviços com práticas e políticas públicas que garantam um cuidado integral, mas incorporem ações intersetoriais e de promoção permitindo a sustentabilidade dos sistemas.

In 2014, the Pan American Health Organization member countries signed the Strategy for Universal Access to Health and Universal Health Coverage. In it, they committed to increasing public health expenditure until reaching the benchmark of 6% of gross domestic product (GDP). The objective of this paper is to determine, for each country in the Region, if they can reach this goal by economic growth alone and, if so, how long it would take.Using World Bank and World Health Organization data, elasticity of public health expenditure with regard to GDP was estimated for each country. Real economic growth and International Monetary Fund projections for 2016-2021 were used to project the expenditure series and determine the year each country would reach 6% of GDP.Six countries have already reached the 6% goal. The Latin American and Caribbean countries that have achieved it are those that have single health systems, based on universal access and coverage. If current prioritization of public health expenditure is maintained, three countries could reach the goal in the next decade. Four more countries would reach it before mid-century, ten in the second half of the century, and one would have to wait until the next century. Finally, 13 countries would never reach the proposed goal.This analysis demonstrates the limitations of economic growth as a source of fiscal space. Other sources will need to be tapped, such as increased tax collection, specific health taxes, and greater efficiency in public spending, which will require social and political dialogue in the countries regarding their commitment to universal health principles.Em 2014, os Estados Membros da Organização Pan-Americana da Saúde firmaram a Estratégia para o acesso universal à saúde e cobertura universal de saúde com a qual se comprometeram a aumentar o gasto público em saúde até atingir a meta de referência de 6% do produto interno bruto (PIB). O objetivo deste estudo foi determinar se cada um dos países da Região conseguiria atingir esta meta apenas com o crescimento econômico e, neste caso, em que prazo.O estudo se baseou em dados obtidos do Banco Mundial e da Organização Mundial de Saúde (OMS). Foi estimada a elasticidade do gasto público em saúde com relação ao PIB para cada país. A partir do crescimento econômico real e do crescimento projetado pelo Fundo Monetário Internacional para o período 2016–2021, foi feita a projeção dos gastos e determinado o ano em que seriam alcançados 6% do PIB.Seis países já atingiram a meta de 6%. Os países da América Latina e Caribe que atingiram esta meta são os que têm um sistema de saúde único baseado no acesso e cobertura universais. Se for mantida a priorização atual do gasto público em saúde, três países conseguiriam alcançar a meta na próxima década. Outros quatro países atingiriam a meta antes de meados do século, 10 na segunda metade deste século e um somente a alcançaria no século seguinte. E, por fim, 13 países nunca atingiriam a meta proposta.Esta análise demonstra as limitações do crescimento econômico como fonte de espaço fiscal. Será necessário recorrer a outras fontes, como maior arrecadação tributária, impostos próprios para a saúde e maior eficiência no gasto público, o que demanda dos países um diálogo social e político quanto ao compromisso com os princípios de saúde universal.

Este artículo tiene por objetivo reconocer los lineamientos y desafíos queplantea la implementación de la (Atención Primaria de la Salud) aps desdeel enfoque de Derechos Humanos. A estos efectos se parte de una revisióny análisis del surgimiento del concepto de Atención Primaria de la Salud(aps), sus concepciones, modo de implementación e interrelaciones con elsistema de salud, el derecho a la salud y el contexto socio-político, económicoy cultural. A partir de este análisis se concluye que: a) la implementaciónde la aps desde el enfoque de Derechos Humanos implica no sólo reconocera la aps como una estrategia sanitaria, un principio que guía y orienta lasacciones en salud y organiza los niveles de atención sino también como unaherramienta eminentemente política y social de constitución de ciudadaníay por lo tanto, relevante para la construcción de un marco legal nacional ysupranacional que obligue al Estado a actuar como garante y promotor delderecho a la salud b) la salud es un derecho humano fundamental e inescindiblede otros derechos económicos, sociales y culturales y c) las políticaspúblicas y los sistemas de salud deben estar basados en aps a los efectos degarantizar el acceso universal a la salud. This paper is aimed at recognising the guidelines and challenges raised by the implementation of phc from a Human Rights approach. With this purpose we reviewed and analysed the origins of the primary health care (phc) concept, its meanings, implementation and interrelationships with the health system, the right to health and the social, political, economic and cultural context. As a result of this analysis we concluded that: a) the implementation of phc from a Human Rights approach means not just its recognition as a health strategy for organizing the health system and guiding principle for health actions but as a political and social tool for citizenship construction and as relevant concept for the development of national and supranational regulatory frameworks to compel the State to actas a guarantor and promoter of the right to health b) the right to health has to be recognised as a fundamental human right, inextricable from other economic, social and cultural rights and c) public policies and health systems needs to be based on phc in order to guarantee universal health access. Fil: Echegoyemberry, Maria Natalia. Centro de Estudios e Investigación en Ciencias Sociales; Argentina Fil: Castiglia, Gabriela. Centro de Estudios e Investigación en Ciencias Sociales; Argentina Fil: Yavich, Natalia. Centro de Estudios e Investigación en Ciencias Sociales; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Rosario; Argentina Fil: Báscolo, Ernesto Pablo. Centro de Estudios e Investigación en Ciencias Sociales; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Rosario; Argentina

In 2014, the member countries of the Pan American Health Organization signed the Strategy for Universal Access to Health and Universal Health Coverage. In it, they committed to increasing public expenditure on health until reaching the benchmark of 6% of gross domestic product (GDP). The objective of this paper is to determine, for each country in the Region, whether they can reach this target through economic growth alone and, if so, how long it would take.Using World Bank and World Health Organization data, elasticity of public health expenditure (PHE) with respect to GDP was estimated for each country. Real economic growth and International Monetary Fund projections for 2016-2021 were used to project the expenditure series and determine the year each country would reach 6% of GDP.Six countries have already reached the 6% target. The Latin American and Caribbean countries that have achieved it are those that have single health systems, based on universal access and coverage. If current prioritization of PHE is maintained, three countries could reach the target in the next decade. Four more countries would reach it before mid-century, 10 in the second half of the century, and one would have to wait until the next century. Finally, 13 countries would never reach the proposed target.This analysis demonstrates the limitations of economic growth as a source of fiscal space. Other sources will need to be tapped, such as increased tax collection, specific health taxes, and greater efficiency in public spending, which will require social and political dialogue in the countries regarding their commitment to universal health principles.En 2014, los países miembros de la Organización Panamericana de la Salud firmaron la Estrategia para el acceso universal a salud y cobertura universal de salud. En ella, se comprometieron a aumentar el gasto público en salud hasta alcanzar la meta referencial de 6% del producto interno bruto (PIB). El objetivo de este trabajo es determinar, para cada uno de los países de la Región, si pueden alcanzar esta meta solo con crecimiento económico y, en el caso de ser posible, en qué plazos lo harían.Se utilizaron datos del Banco Mundial y de la Organización Mundial de Salud y se estimaron las elasticidades del gasto público en salud con respecto al PIB para cada país. Con base en el crecimiento económico real y el proyectado por el Fondo Monetario Internacional 2016–2021, se proyectó la serie de gasto y se determinó el año en el que alcanzarían 6% del producto.Seis países ya han alcanzado la meta de 6%. Los países de América Latina y el Caribe que la han logrado son aquellos que mantienen sistemas de salud únicos, basados en acceso y cobertura universales. Si se mantiene la priorización actual del gasto público en salud, tres países podrían alcanzar la meta en la próxima década. Otros cuatro países lo harían antes de medio siglo, diez en la segunda mitad y uno tendría que esperar hasta la próxima centuria. Por último, 13 países nunca alcanzarían la meta propuesta.Este análisis demuestra las limitaciones del crecimiento económico como fuente de espacio fiscal. Será necesario recurrir a otras fuentes como mayor recaudación tributaria, impuestos específicos en salud y mayor eficiencia en el gasto público, lo que demandará un diálogo social y político de los países en torno al compromiso con los principios de la salud universal.Em 2014, os Estados Membros da Organização Pan-Americana da Saúde firmaram a Estratégia para o acesso universal à saúde e cobertura universal de saúde com a qual se comprometeram a aumentar o gasto público em saúde até atingir a meta de referência de 6% do produto interno bruto (PIB). O objetivo deste estudo foi determinar se cada um dos países da Região conseguiria atingir esta meta apenas com o crescimento econômico e, neste caso, em que prazo.O estudo se baseou em dados obtidos do Banco Mundial e da Organização Mundial de Saúde (OMS). Foi estimada a elasticidade do gasto público em saúde com relação ao PIB para cada país. A partir do crescimento econômico real e do crescimento projetado pelo Fundo Monetário Internacional para o período 2016–2021, foi feita a projeção dos gastos e determinado o ano em que seriam alcançados 6% do PIB.Seis países já atingiram a meta de 6%. Os países da América Latina e Caribe que atingiram esta meta são os que têm um sistema de saúde único baseado no acesso e cobertura universais. Se for mantida a priorização atual do gasto público em saúde, três países conseguiriam alcançar a meta na próxima década. Outros quatro países atingiriam a meta antes de meados do século, 10 na segunda metade deste século e um somente a alcançaria no século seguinte. E, por fim, 13 países nunca atingiriam a meta proposta.Esta análise demonstra as limitações do crescimento econômico como fonte de espaço fiscal. Será necessário recorrer a outras fontes, como maior arrecadação tributária, impostos próprios para a saúde e maior eficiência no gasto público, o que demanda dos países um diálogo social e político quanto ao compromisso com os princípios de saúde universal.

Objective. Evaluate if the Insurance strengthened the primary care role and enhanced healthcare access and comprehensiveness. Materials and methods. Through a household survey (n=2 413; year 2006) we collected data on utilization of health services by under 8 year old beneficiaries from 8 municipalities. We used hypothesis tests to identify significant differences between municipal profiles of Insurance implementation and beneficiaries grouped by utilization patterns. Results. Although more than 95% of children received medical healthcare in each municipality (using the Insurance and other services), the Insurance utilization varied significantly by municipal profile. Access to comprehensive healthcare and consultation rates were significantly higher for those beneficiaries who used the Insurance along with other health services, compared with those who only used the Insurance services. Use of hospitals was significantly lower within Insurance users. Conclusion. The Insurance was more effective when implemented and used in conjunction with the municipal networks of health services.

Objetivo: Analizar la relación entre modelos de financiamiento y la organización con costos y desempeño de los servicios de los subsistemas de salud de Rosario,Argentina. Material y métodos: Los modelos de financiamiento y organización se caracterizaron utilizando información secundaria. Se calcularon los costos utilizando la metodología SHA/ OMS. Se midió el desempeño con una encuesta poblacional (n=822). Resultados: Subsistema público: financiamiento integrado verticalmente y servicios organizados desde la estrategia de atención primaria contribuyeron a bajos costos y alto desempeño en continuidad y orientación de la atención con debilidades en accesibilidad e integralidad. Subsistema privado: integración contractual y débiles mecanismos de regulación y coordinación condujeron a resultados opuestos a los del subsistema público. Seguridad social: integración contractual y fuertes mecanismos de regulación y coordinación contribuyeron a costos intermedios y un alto desempeño general. Conclusiones: El modelo de financiamiento y organización tiene una fuerte influencia sobre los costos y el desempeño de los servicios. Objective: To analyze the relationship between health system financing and services organization models with costs and health services performance in each of Rosario's health sub-systems. Materials and methods: The financing and organization models were characterized using secondary data. Costs were calculated using the WHO/SHA methodology. Healthcare quality was measured by a household survey (n=822). Results: Public subsystem:Vertically integrated funding and primary healthcare as a leading strategy to provide services produced low costs and individual-oriented healthcare but with weak accessibility conditions and comprehensiveness. Private subsystem: Contractual integration and weak regulatory and coordination mechanisms produced effects opposed to those of the public sub-system. Social security: Contractual integration and strong regulatory and coordination mechanisms contributed to intermediate costs and overall high performance. Conclusion: Each subsystem financing and services organization model had a strong and heterogeneous influence on costs and health services performance. Fil: Yavich, Natalia. Universidad Nacional de Rosario. Centro de Estudios Interdisciplinarios; Argentina Fil: Báscolo, Ernesto Pablo. Universidad Nacional de Rosario. Centro de Estudios Interdisciplinarios; Argentina

Este artículo tiene como objetivo reconocer diferentes aplicaciones del concepto de eficiencia para dilucidar sus alcances y establecer sus posibles relaciones con la búsqueda de equidad en salud. Con esta intención serealiza un análisis de las implicancias en eficiencia que se desprenden de la estrategia de acceso universal a la salud y cobertura universal en salud, también llamada estrategia de salud universal (SU), de la Organización Panamericana de la Salud (OPS). Fil: Cid, Camilo. Organización Panamericana de la Salud; Estados Unidos Fil: Báscolo, Ernesto Pablo. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Rosario; Argentina. Organización Panamericana de la Salud; Estados Unidos Fil: Morales, Cristian. Organización Panamericana de la Salud; Cuba

Background: Primary health care (PHC)-based reforms have had different results in Latin America. Little attention has been paid to the enablers of collective action capacities required to produce a comprehensive PHC approach. Objective: To analyse the enablers of collective action capacities to transform health systems towards a comprehensive PHC approach in Latin American PHC-based reforms. Methods: We conducted a longitudinal, retrospective case study of three municipal PHC-based reforms in Bolivia and Argentina. We used multiple data sources and methodologies: Document review; interviews with policymakers, managers and practitioners; and household and services surveys. We used temporal bracketing to analyse how the dynamic of interaction between the institutional reform process and the collective action characteristics enabled or hindered the enablers of collective action capacities required to produce the envisioned changes. Results: The institutional structuring dynamics and collective action capacities were different in each case. In Cochabamba, there was an 'interrupted' structuring process that achieved the establishment of a primary level with a selective PHC approach. In Vicente López, there was a 'path-dependency' structuring process that permitted the consolidation of a 'primary care' approach, but with limited influence in hospitals. In Rosario, there was a 'dialectic' structuring process that favoured the development of the capacities needed to consolidate a comprehensive PHC approach that permeates the entire system. Conclusion: The institutional change processes achieved the development of a primary health care level with different degrees of consolidation and system-wide influence given how the characteristics of each collective action enabled or hindered the 'structuring' processes. Fil: Báscolo, Ernesto Pablo. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Rosario; Argentina. Universidad Nacional de Rosario. Centro de Estudios Interdisciplinarios; Argentina Fil: Yavich, Natalia. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Rosario; Argentina. Universidad Nacional de Rosario. Centro de Estudios Interdisciplinarios; Argentina Fil: Jean-Louis Denis. École Nationale d’Administration Publique; Canadá

Since the eighties, most Latin American (LA) countries experienced important social and health improvements as well as profound socio-epidemiological and cultural changes. During this period, the Primary health care (PHC) has been at the core of many reforms. The reforms, with different levels of success, tried to shift from a selective PHC approach to a comprehensive PHC approach. In this context PHC was called upon to address a wider range of problems including the long-standing challenges of still-uncontrolled infectious diseases and maternal-child health, other previously-overlooked problems, such as chronic diseases, traffic accidents, social and domestic violence, mental and oral health, and problem drug use and emerging problems such as HIV, H1N1 and Zika virus. This article presents a special issue of the Family Practice: the International Journal for Research in Primary Care that addresses central challenges of PHC in the LA Region. This issue includes studies from 13 countries of LA. There are two groups of articles: one that tackles analysis of quality and effectiveness of PHC in different health systems, services and programs and a second group made up of studies that analyze the political, institutional and organizational determinants of the PHC development.While the articles joint by this issue along with the existent body of PHC have produced significant scientific contributions, PHC research in LA is still limited and insufficiently guided by the countries' priorities, rules and its health systems and population characteristics. Fil: Yavich, Natalia. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Rosario; Argentina. Universidad Nacional de Rosario. Centro de Estudios Interdisciplinarios; Argentina Fil: Báscolo, Ernesto Pablo. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Rosario; Argentina. Universidad Nacional de Rosario. Centro de Estudios Interdisciplinarios; Argentina

In Argentina, during the decade of the 1990s major changes were introduced in the regulatory framework of the so called Obras Sociales Nacionales (OSN). Using data from the AFIP, the present study evaluates for the years 2004 and 2011: i) the importance of OSNs within the healthcare system, ii) the degree of concentration of this subsystem of the social security in health, iii) the inequalities in the availability of funds between the OSN and its beneficiaries. The results show that OSNs increased its importance within the Argentinean health system. The number of institutions remained almost the same, as also did the level of concentration of contributors, beneficiaries and funds in the most important institutions of the subsystem. Finally, a reduction of the inequalities in funds per beneficiary received by different institutions was observed. This trend can be explained, among other factors, by the attenuation of wage differentials between branches of economic activity and the actions of the so-called Solidarity Redistribution Fund. En Argentina, durante la década de 1990 se introdujeron grandes cambios en el marco regulatorio de las obras sociales nacionales. A partir de datos de la Administración Federal de Ingresos Públicos, el presente estudio compara para los años 2004 y 2011: a) el peso de las obras sociales dentro del sistema de salud argentino; b) el grado de concentración de este subsistema de la seguridad social en salud; y c) la desigualdad en la disponibilidad de fondos per cápita entre obras sociales y beneficiarios. Los resultados revelan un incremento de la importancia de las obras sociales dentro del sistema de salud; la cantidad de instituciones se mantuvo prácticamente invariante y la concentración de los fondos distribuidos en las entidades más importantes del subsistema no muestra cambios, mientras que la de cotizantes aumenta levemente y disminuye la de beneficiarios. Además, se registró una reducción en las desigualdades en los fondos por beneficiario, la cual podría estar asociada a la atenuación de las diferencias salariales entre los diferentes sectores de la economía y al accionar del Fondo Solidario de Redistribución. Fil: Arnaudo, María Florencia. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Bahía Blanca. Instituto de Investigaciones Económicas y Sociales del Sur. Universidad Nacional del Sur. Departamento de Economía. Instituto de Investigaciones Económicas y Sociales del Sur; Argentina Fil: Lago, Fernando Pablo. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Bahía Blanca. Instituto de Investigaciones Económicas y Sociales del Sur. Universidad Nacional del Sur. Departamento de Economía. Instituto de Investigaciones Económicas y Sociales del Sur; Argentina Fil: Moscoso, Nebel Silvana. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Bahía Blanca. Instituto de Investigaciones Económicas y Sociales del Sur. Universidad Nacional del Sur. Departamento de Economía. Instituto de Investigaciones Económicas y Sociales del Sur; Argentina Fil: Báscolo, Ernesto Pablo. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Universidad Nacional de Rosario. Centro de Estudios Interdisciplinarios; Argentina Fil: Yavich, Natalia. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Universidad Nacional de Rosario. Centro de Estudios Interdisciplinarios; Argentina

Resumen El propósito de este trabajo es explorar el perfil del litigio por el acceso a la atención de la salud, tramitado ante la Corte Suprema de Justicia Argentina, y reflexionar sobre su potencial para influir sobre la equidad y el derecho a la salud, en el marco de un proceso de crecimiento de la judicialización. Se llevó a cabo un análisis documental de 125 litigios con sentencias dictadas entre 1994 y 2013. Se observó una preeminencia de la reclamación individual (88% reclamantes personas físicas individuales), y de reclamantes afiliados a la seguridad social o a seguros privados (64%), con un esquema típico del derecho privado (87% reclama cobertura de un servicio médico). El 75% de los fallos ordenaron brindar los servicios de salud reclamados, sin visibilizar los fallos del sistema de salud, ni ordenar acciones para promover la equidad y garantizar el derecho a la salud, que alcancen a otras personas sometidas a la misma situación que el reclamante. La judicialización, hasta el momento, no está promoviendo activamente la equidad, el derecho a la salud y el diálogo interinstitucional. Abstract This article explores the characteristics of lawsuits for obtaining access to healthcare through the Argentine Supreme Court and reflects on the potential to influence health rights and equity in a context of growing litigation. An analysis of documents from 125 lawsuits with verdicts issued from 1994 to 2013 showed a majority of individual claims (88% of claimants were individual physical persons), and of claimants covered by social security or private insurance (64%) with typical private legal counsel (87% claiming coverage of a medical service). 75% of the verdicts simply ordered the provision of the claimed health services, without highlighting failures in the healthcare system or mandating measures to promote equity and guarantee the right to health for other persons subject to the same situation as the claimant. Thus far, litigation in health has failed to actively promote either health equity, the right to health, or inter-institutional dialogue. Resumo O propósito deste trabalho é explorar o perfil do litígio pelo acesso à atenção da saúde tramitado ante a Suprema Corte de Justiça Argentina, e refletir sobre seu potencial para influir sobre a equidade e o direito à saúde, no marco de um processo de crescimento da judicialização. Levou-se a cabo uma análise documentária de 125 litígios com sentenças ditadas entre 1994 e 2013. Observou-se uma preeminência do reclamo individual (88% dos reclamantes são pessoas físicas individuais), e de reclamantes filiados à segurança social ou a seguros privados (64%) com um esquema típico do direito privado (87% reclamam cobertura de um serviço médico). Os 75% das sentenças ordenaram brindar os serviços de saúde reclamados, sem dar visibilidade às falhas do sistema de saúde nem ordenar ações para promover a equidade e garantir o direito à saúde que atinjam a outras pessoas submetidas à mesma situação que o reclamante. A judicialização, até o momento, não promove ativamente a equidade, o direito à saúde e o diálogo interinstitucional.

El desarrollo de los procesos de implementación de las políticas de APS en América Latina sigue siendo un desafío pendiente. Es necesario reconocer la economía política de los procesos de implementación de las políticas de APS desde una perspectiva de gobernanza, caracterizada por las estrategias de regulación promovidas y los procesos políticos. La promoción de valores sociales, normas organizacionales o la introducción de nuevos incentivos económicos serán componentes de diferentes modos de gobernanza promovidos en las reformas de los sistemas de salud. Se consideran los factores institucionales de los sistemas de protección social en AL, sus capacidades, limitaciones redistributivas y las disputas de economía política presentes en las estrategias de reforma, explicadas por la conflictividad entre los intereses (económicos y necesidades) y valores presentes en los actores involucrados. La forma en cómo se dirimen este proceso político influye sobre los modos de regulación instalados en los procesos de implementación de las políticas de APS. La capacidad de rectoría del Estado y los niveles de segmentación de los sistemas de salud condicionan la efectividad de las estrategias de reforma para dirimir la conflictividad de las políticas implementadas.The development of implementation processes of PHC policies in Latin America, is a challenge yet to be tackled. It is necessary to acknowledge the political economy related to the implementation processes of PHC policies in Latin America from a governance perspective, characterized by the regulatory strategies used and the political processes. The promotion of social values, organizational policies or the introduction of new financial incentives are components of different forms of governance used in health system reforms. The institutional factors of social protection systems in Latin America are considered. Their potential, redistribution limitations and the political economy disputes of the reform strategies are explained by the conflict between the economic and related interests and values of the actors involved. This dynamic of the political process influences regulatory modes inherent in the processes of implementation of PHC policies. The State's governing capacity and levels of health system segmentation impinge on the effectiveness of reform strategies for resolving the conflicts in the policies implemented.

OBJECTIVE To determinate the clarity, relevance and per tinence of a primary health care evaluation strategy for different Latin American health sub-systems. MATERIAL AND METHODS This strategy was assessed using workshops held with decision makers and administrative managers from a public health organization, a social insurance and a private insurance health organization. The study took place in the province of Santa Fe (Argentina) between May 2006 and May 2007. RESULTS The strategy was determined to be clear and relevant by all organizations, but highly applicable only in the public case. The social-insurance and private cases questioned the pertinence of objectives related to community participation, intersectoral actions and a focus on social determinants of health, in addition to considering it necessary to restrict the scope of ideas related to universal access and equity with regard to their client population. DISCUSSION The evaluation of the pertinence of the strategy was explained by the particularities of the institutional context, as well as the goals and survival strategies used by each organization.

Introduction: Latin American health systems are generally described as comprising three health sub-systems that segregate the population in separate segments. The private sub-system (PrS) is usually described as serving the rich population with high quality standards; the public sub-system (PubS) as serving the poor population with low quality standards; and the social security (SS) falling some place in between. We argue that this is an oversimplified picture that persists because of the lack and fragmentation of data and the failure to recognize changes occurred in the private health market during the last decades. This work compares the performance of the PubS, SS and PrS health services in Rosario city. The findings are intended to contribute to the reflection and the current efforts to move forward to integrated and PHC-based health systems and to achieve universal health access and coverage in Latin America. Theory/Methods: This cross-sectional study compares the performance of the PubS, SS and PrS through a household survey to a representative sample of 822 inhabitants of Rosario Municipality, stratified by age with a confidence interval of 95% and 3.5% precision. The questionnaire included questions on population health status and insurance, demographic and socio-economic conditions, health services use and perception for core dimensions and sub-dimensions of PHC performance. The individuals were assigned to a health sub-system based on their affiliation of the self-reported usual provider to one of the health sub-systems. We did not consider health insurance as a stratified variable because of the high percentage of people with more than one type of insurance, as well as insured individuals that use public services. Sub-systems were compared to look for significant differences in PHC performance and in demographic socio-economic and health status) using Chi Square analysis for categorical variables and one-way ANOVA test for numerical variables. We use a categorical nonlinear

In Argentina, during the decade of the 1990s major changes were introduced into the regulatory framework of the national obras sociales, or union-based health coverage plans. Using data from the Federal Administration of Public Income (AFIP) [Administración Federal de Ingresos Públicos], this study evaluates for the years 2004 and 2011: a) the importance of obras sociales within the healthcare system, b) the degree of concentration of this health social security subsystem, and c) the inequalities in the availability of funds among the obras sociales and their beneficiaries. The results show an increased importance of obras sociales within the Argentine health system. The concentration of funds distributed to the most important institutions within the subsystem showed no change, while the concentration of contributors to these institutions slightly increased and that of beneficiaries decreased. Finally, a reduction of the inequalities in funds per beneficiary received by different institutions was observed. This trend can be explained, among other factors, by the attenuation of wage differentials between branches of economic activity and the actions of the so-called Solidarity Redistribution Fund.

Existe una notoria ausencia de coherencia conceptual en el uso de los términos gobernabilidad y gobernanza (considerado sinónimo de "gobernancia") en América Latina, tanto en ciencias sociales y políticas, como en el dominio de la salud. Esto se expresa con mayor fuerza en una diferente comprensión del término gobernanza por parte de los investigadores, un uso heterogéneo en ámbitos académicos, su desconocimiento por parte de los tomadores de decisión, y una gran confusión y ambigüedad de significados en su uso por parte de unos y de otros. En contraposición al uso predominante de carácter normativo, promocionado por parte de la mayoría de las agencias internacionales, se propone aquí el desarrollo y aplicación de un marco conceptual-analítico de gobernanza para la investigación en sistemas y servicios de salud. Los avances en el diseño del marco metodológico fueron aplicados en una investigación de evaluación del Seguro Público de Salud de Provincia de Buenos Aires, Argentina. Ello permitió valorar su utilidad como herramienta para sistematizar la complejidad social, política e institucional de los procesos de formulación e implementación de las políticas de salud.

Analyze the sustainability and integration of priority programs in the framework of the Pan American Health Organization’s 2014 Strategy for Universal Access to Health and Universal Health Coverage (Universal Health).A non-systematic review was carried out of the recent literature focused on analysis of integration and sustainability.The main result extracted from the literature review is the need to address sustainability in a way that goes beyond the limits of any analysis restricted to financial sustainability. Although integration and sustainability are not interpreted uniformly, an approach that includes integration as a facilitating factor of the EPI sustainability process does stand out.Effectiveness of EPI integration strategies depends to a large extent on considering the presence, strengthening, and transformation of organizational and institutional structures that facilitate the participation of actors with the technical and political ability to ensure its implementation processes. Thus, political processes can be weighed that legitimize an agenda to include EPI in the Universal Health strategy and, accordingly, as an integral part of health systems strengthening.Avaliar a sustentabilidade e a integração do Programa ampliado de imunização (PAI) como parte da estratégia de acesso universal à saúde e cobertura universal de saúde da Organização Pan-Americana da Saúde (OPAS) de 2014.Uma revisão não sistemática da literatura científica recente foi realizada dando enfoque à análise da integração e sustentabilidade do PAI.O principal achado é a necessidade de contemplar a sustentabilidade além da análise de sustentabilidade financeira. Embora a integração e a sustentabilidade não sejam interpretadas de forma homogênea na literatura, são destacadas as virtudes de uma abordagem que conceba a integração como um fator facilitador do processo de sustentabilidade do PAI.A efetividade das estratégias de integração do PAI depende em grande parte da existência, fortalecimento e transformação das estruturas organizacionais e institucionais facilitando a participação dos interessados com capacidade técnica e política para garantir os processos de implementação. Desse modo, será possível examinar com atenção os processos políticos que legitimam a agenda de inclusão do PAI na estratégia de saúde universal e, portanto, como parte integrante do fortalecimento dos sistemas de saúde.

This article explores the characteristics of lawsuits for obtaining access to healthcare through the Argentine Supreme Court and reflects on the potential to influence health rights and equity in a context of growing litigation. An analysis of documents from 125 lawsuits with verdicts issued from 1994 to 2013 showed a majority of individual claims (88% of claimants were individual physical persons), and of claimants covered by social security or private insurance (64%) with typical private legal counsel (87% claiming coverage of a medical service). 75% of the verdicts simply ordered the provision of the claimed health services, without highlighting failures in the healthcare system or mandating measures to promote equity and guarantee the right to health for other persons subject to the same situation as the claimant. Thus far, litigation in health has failed to actively promote either health equity, the right to health, or inter-institutional dialogue.

En las últimas décadas el gasto total en salud (gts) ha aumentado tanto en las economías desarrolladas como en las emergentes. El presente trabajo es un estudio ecológico descriptivo y mixto. Tomando una muestra de 192 países agrupados por niveles de ingresos, se analizó: i) los patrones de financiamiento público del gts, ii) la proporción que representó el gasto público en salud en los gastos generales de gobierno, y iii) la hipótesis de Globerman y Vining referida a la existencia de una correlación negativa entre el financiamiento público y el gts como porcentaje del pbi. Los resultados muestran que los gobiernos que más se involucran en el sector salud poseen en promedio un gts per cápita más alto. Asimismo, la relación entre financiamiento público del gts y gts como porcentaje del pbi es negativa y estadísticamente significativa solo en los países ricos de la ocde y en los pobres. Over the last decades, total health expenditure (the) has increased, not only in developed economies but also in emerging ones. This paper is a descriptive and mixed ecological study. We took a sample of 192 countries grouped by income levels, and analyzed i) the patterns of public funding of the, ii) the share of public health expenditure in the general government budgets, and iii) the Globermann and Vining hypothesis about the existence of a negative correlation between the proportion of the financed by the governments and the as a percentage of the gdp. We found that governments most involved in the health sector showed, on average, a higher per capita the. We also found that the relationship between public funding of the and the the as a percentage of gdp is negative and statistically significant only in rich oecd countries and the poor ones. Nas últimas décadas a despesa total em saúde (DTS) aumentou tanto nas economias desenvolvidas como nas emergentes. O presente trabalho é um estudo ecológico descritivo e misturado. Tomando uma amostra de 192 países agrupados por nível de renda, foram analisados: i) os padrões de financiamento público do DTS, ii) a proporção que representou a despesa pública em saúde nas despesas gerais de governo, e iii) a hipótese de Globerman e Vining referida à existência de uma correlação negativa entre financiamento público e DTS como porcentagem do PBI. Os resultados demostram que os governos que mais estão envolvidos com o setor da saúde possuem em média um DTS per capita mais alto. Além disso, a relação entre financiamento público do DTS e DTS como porcentagem do PBI é negativa e estatisticamente significativa apenas nos países ricos da OCDE e nos pobres. Fil: Báscolo, Ernesto Pablo. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Rosario; Argentina. Universidad Nacional de Rosario; Argentina Fil: Lago, Fernando Pablo. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Universidad Nacional del Sur; Argentina Fil: Geri, Milva. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Bahía Blanca. Instituto de Investigaciones Económicas y Sociales del Sur. Universidad Nacional del Sur. Departamento de Economía. Instituto de Investigaciones Económicas y Sociales del Sur; Argentina Fil: Moscoso, Nebel Silvana. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Bahía Blanca. Instituto de Investigaciones Económicas y Sociales del Sur. Universidad Nacional del Sur. Departamento de Economía. Instituto de Investigaciones Económicas y Sociales del Sur; Argentina Fil: Arnaudo, María Florencia. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Bahía Blanca. Instituto de Investigaciones Económicas y Sociales del Sur. Universidad Nacional del Sur. Departamento de Economía. Instituto de Investigaciones Económicas y Sociales del Sur; Argentina

El objetivo de este trabajo es analizar la influencia de la configuracion del capital social de las politicas de atencion primaria de la salud (APS) sobre las condiciones de acceso a los servicios de salud. Se llevo a cabo un estudio de casos multiples (Cochabamba-Bolivia, Rosario y Vicente Lopez-Argentina) retrospectivo (1990-2008). El concepto de capital social fue entendido como el resultado de la relacion entre Estado y sociedad. En Rosario se lograron mejoras sustantivas en las condiciones de acceso a partir de la creacion de nuevas estructuras en donde profesionales de APS establecieron vinculos de cooperacion con actores del Estado municipal, movimientos sociales y gestores y medicos especialistas de hospitales. En Vicente Lopez, las mejoras en las condiciones de acceso a los servicios de salud fueron mas limitadas debido a que los cambios en la relacion Estado y sociedad solo involucraron a profesionales del primer nivel de atencion sin mecanismos de cooperacion estables con actores claves de los hospitales, el nivel municipal y los movimientos sociales. Por ultimo, en Cochabamba, las mejoras en las condiciones de acceso fueron marginales debido a que los profesionales del sistema de servicios de salud se opusieron a la alianza establecida entre los movimientos sociales y los actores del Estado municipal para generar cambios en el sistema de salud. Este estudio permite reconocer la influencia de la configuracion entre Estado y sociedad para modelar las relaciones de poder que subyacen al proceso de implementacion de las reformas del sector salud y sus resultados.

El desarrollo de los procesos de implementación de las políticas de APS en América Latina sigue siendo un desafío pendiente. Es necesario reconocer la economía política de los procesos de implementación de las políticas de APS desde una perspectiva de gobernanza, caracterizada por las estrategias de regulación promovidas y los procesos políticos. La promoción de valores sociales, normas organizacionales o la introducción de nuevos incentivos económicos serán componentes de diferentes modos de gobernanza promovidos en las reformas de los sistemas de salud. Se consideran los factores institucionales de los sistemas de protección social en AL, sus capacidades, limitaciones redistributivas y las disputas de economía política presentes en las estrategias de reforma, explicadas por la conflictividad entre los intereses (económicos y necesidades) y valores presentes en los actores involucrados. La forma en cómo se dirimen este proceso político influye sobre los modos de regulación instalados en los procesos de implementación de las políticas de APS. La capacidad de rectoría del Estado y los niveles de segmentación de los sistemas de salud condicionan la efectividad de las estrategias de reforma para dirimir la conflictividad de las políticas implementadas. The development of implementation processes of PHC policies in Latin America, is a challenge yet to be tackled. It is necessary to acknowledge the political economy related to the implementation processes of PHC policies in Latin America from a governance perspective, characterized by the regulatory strategies used and the political processes. The promotion of social values, organizational policies or the introduction of new financial incentives are components of different forms of governance used in health system reforms. The institutional factors of social protection systems in Latin America are considered. Their potential, redistribution limitations and the political economy disputes of the reform strategies are explained by the conflict between the economic and related interests and values of the actors involved. This dynamic of the political process influences regulatory modes inherent in the processes of implementation of PHC policies. The State's governing capacity and levels of health system segmentation impinge on the effectiveness of reform strategies for resolving the conflicts in the policies implemented.

The development of implementation processes of PHC policies in Latin America, is a challenge yet to be tackled. It is necessary to acknowledge the political economy related to the implementation processes of PHC policies in Latin America from a governance perspective, characterized by the regulatory strategies used and the political processes. The promotion of social values, organizational policies or the introduction of new financial incentives are components of different forms of governance used in health system reforms. The institutional factors of social protection systems in Latin America are considered. Their potential, redistribution limitations and the political economy disputes of the reform strategies are explained by the conflict between the economic and related interests and values of the actors involved. This dynamic of the political process influences regulatory modes inherent in the processes of implementation of PHC policies. The State's governing capacity and levels of health system segmentation impinge on the effectiveness of reform strategies for resolving the conflicts in the policies implemented.

Objetivo Describir el desarrollo de la política de APS promovida por el municipio de Rosario. Métodos Se condujo un estudio de caso durante 2007 y 2008. Se recogieron datos de fuentes secundarias y primarias (entrevistas, censo organizacional y observaciones). Se identificaron etapas del desarrollo de la APS a partir del reconocimiento de las normas sociales que produjeron cambios institucionales y de la estructura, modelo de gestión y atención de los servicios de salud municipales. Se reconocieron y caracterizaron los modos de gobernanza (clan, jerárquico y/o incentivos) prevalecientes en cada etapa. Resultados Se identificaron entre 1990 y 2008 cuatro etapas: 1990-1995/modo jerárquico: organización del primer nivel de atención con autonomía de los hospitales. 1995-2000/modo clan: desarrollo de los colegiados de gestión y la participación comunitaria. 2000-2004/modo clan: maduración del “movimiento de APS” en competencia con hospitales. 2004-2008/modo clan-jerárquico: crisis del “movimiento” y construcción de normas tendientes hacia el fortalecimiento de una red integrada. Discusión El fortalecimiento y empoderamiento del primer nivel de atención produjo innovaciones que favorecieron: la consolidación de un “movimiento de APS” con fuerte compromiso social y una mejora en el desempeño de los servicios. El modo de gobernanza de clan (regulación de la acción colectiva a partir de la adhesión voluntaria a valores compartidos) fue crucial para el desarrollo de la APS entre 1995 al 2004. Más tarde, la fragmentación del movimiento y los desafíos de mejorar la integración del sistema requirieron del desarrollo de mecanismos de regulación jerárquicos complementarios al modo de clan.

Se desarrolla un marco analítico para explicar las condiciones de efectividad de diferentes estrategias que promueven sistemas integrados de servicios de salud basados en atención primaria de la salud (APS) en América Latina. Con una pers­pectiva de economía política, se caracterizan diferentes modos de gobernanza (clan, incentivos y jerárquicos) para representar alternativas formas de regulación que promueven innovaciones en organización de la provisión de los servicios. Se presentan condiciones necesarias para garantizar la efectividad de los modos de gobernanza y sus implicancias en términos de puestas en juego. La construcción institucional de un sistema integrado de salud es interpretado como producto de un proceso social, en donde se combinan diferentes modos de gobernanza, que ope­ran con diferentes formas de resolución de los aspectos normativos de regulación de la provisión de los servicios (con el modo jerárquico), de la distribución de re­cursos (con el modo incentivos) y sobre los valores sociales que legitiman este proceso (con el modo clan).

Describing the development of PHC policy as promoted by Rosario Municipality (Argentina).A case-study was carried out during 2007 and 2008. Data was collected from secondary and primary sources (interviews, organisational census and observations). PHC development stages were identified by recognising the social norms which produced institutional change and transformation in municipal health services structure and health care and management models. The prevailing modes of governance in each stage were reconognised and characterised (clan, hierarchy and/or incentives).Four stages were identified between 1990 and 2008: 1990-1995/hierarchical mode: primary health care level organisation autonomied from hospitals. 1995-2000/ clan mode: developing of participatory managerial boards and community participation. 2000-2004/ clan mode: maturation of the "PHC movement" in competition with hospitals. 2004-2008/ clan-hierarchical mode: "movement's" crisis and constructions of norms tending towards enhancing an integrated network.Strengthening and empowering first-level health-care produced innovation favouring: the consolidation of a "PHC movement" having strong social commitment and improved services performance. The clan governance mode (regulating collective action via voluntary adhesion to shared values) was crucial for developing PHC between 1995 and 2004. Later on, the movement's fragmentation and the challenges of integrating the health system required developing hierarchical regulation mechanisms to complement the governance clan mode regulation.

An analytical framework was developed for explaining the conditions for the effectiveness of different strategies promoting integrated primary health-care (PHC) service-based systems in Latin-America. Different modes of governance (clan, incentives and hierarchy) were characterised from a political economics viewpoint for representing alternative forms of regulation promoting innovation in health-service-providing organisations. The necessary conditions for guaranteeing the modes of governance's effectiveness are presented, as are their implications in terms of posts in play. The institutional construction of an integrated health system is interpreted as being a product of a social process in which different modes of governance are combined, operating with different ways of resolving normative aspects for regulating service provision (with the hierarchical mode), resource distribution (with the incentives mode) and on the social values legitimising such process (with the clan mode).

A multiple-case study was conducted to explain the relationship between the governance of the Buenos Aires Public Health Insurance (PHI) implementation process and its effectiveness in 8 municipalities. The heterogeneity in the effectiveness of PHI implementation was explained by the characteristics of the governance implementation process. The local health authorities' position on the PHI (favorable reception, formal acceptance, or rejection) influenced the nature of the articulation of the PHI within the municipal health system. Support for local management teams on the part of the municipal health and social development authorities affected the possibilities of implementing strategies to overcome unfavorable context-related conditions.

In the Latin American region there is a notable absence of conceptual coherency in the use of the terms governability and governance. This is true for their application to both the social and political sciences and health. Researchers' understanding of governance varies, and the concept is used heterogeneously within academic circles, with ignorance of the term on the part of decision-makers and great confusion and ambiguity in the meanings used by researchers and decision-makers in the health sector. Instead of the prevailing normative use, promoted by most international agencies, a conceptual and analytical framework for governance is proposed here for health systems and services research. Advances in the design of this framework were used to evaluate the public health insurance program in Buenos Aires, Argentina, which allowed the use of the analytical framework to be assessed as a tool for systemizing the social, political, and institutional complexity of the health policy formulation and implementation processes.

Este artículo analiza el proceso de interacción entre el equipo de investigación del Instituto de la Salud Juan Lazarte y el equipo de gestión del Seguro Público de Salud (SPS) de la Provincia de Buenos Aires, Argentina, durante el diseño y desarrollo de la investigación Análisis de las Capacidades Institucionales y Evaluación de Desempeño del SPS. Dada la existencia de distintos espacios de interacción entre el equipo de gestión del SPS y el equipo de investigación, su relación es caracterizada como una aplicación del "modelo de interacción", desde una perspectiva transdiciplinaria. Este abordaje promueve interfases que permiten el desarrollo de procesos de negociación y colaboración entre las "comunidades" científicas y políticas. La aplicación de este modelo de interacción desencadenó cambios en el marco conceptual y metodológico, y sobre aspectos sustantivos del proceso de implementación del Seguro Público de Salud Materno Infantil. This article analyzes the process of interaction between the Instituto de la Salud Juan Lazarte research team and the Buenos Aires Public Health Insurance (PHI) management team during the design and development of the study titled "PHI Institutional Capability Analysis and Performance Evaluation", currently underway. From a cross-disciplinary perspective, examining different areas of interaction between the SPS management team and the research team, the relationship is characterized as an application of the "interaction model". This approach promotes the construction of interfaces that allow the development of negotiation and collaboration between the scientific and political "communities". Application of this model has produced changes in the conceptual and methodological framework and in substantive issues during implementation of the SPSMI.

This paper offers a critical review of the theoretical literature on the relationship between the production of scientific knowledge and its use in policy formulation and implementation. Extensive academic output, using a diversity of approaches and analytical frameworks, has sought to systematize knowledge transfer categories and strategies with a view to improving the application of scientific knowledge. A considerable part of this thinking addresses the problem from a more traditional perspective, which (explicitly or implicitly) regards research results as an "accumulable product", depicts the decision-making process simplistically and linearly, and thus restricts strategies to the suiting of research endeavors to needs. Newer approaches place greater importance on the complexity of policymaking and the knowledge production process, which are integrated into and explained in particular political and institutional settings. Although the application of knowledge transfer ideas to health policy and systems research does generate some interesting contributions, a long process of theoretical thinking lies ahead. Este texto presenta una revisión crítica de la producción teórica dedicada a la reflexión de la relación entre la producción del conocimiento científico y su utilización en el proceso de formulación e implementación de políticas. Una extensa producción académica ha procurado una sistematización de categorías y estrategias de transferencia de conocimiento con el propósito de mejorar la aplicación del conocimiento científico, desde diversas perspectivas y distintos marcos de análisis. Parte importante de esa reflexión aborda el problema desde una perspectiva más tradicional, que asume (explícita o implícitamente) una concepción de los resultados de la investigación como un "producto acumulable", mientras el proceso decisorio se presenta en forma simplista y lineal, restringiendo las estrategias a la adecuación entre necesidades y los esfuerzos de la investigación. Con nuevos abordajes, se revaloriza la complejidad de la creación de políticas y del proceso de producción del conocimiento para la acción, integrados y explicados en un marco político e institucional particular. A pesar de que la aplicación de las ideas de transferencia de conocimiento aplicada al campo de la investigación en políticas y sistemas de salud genera algunos aportes interesantes, un largo camino de reflexión teórica queda pendiente.