Regional governance: strategies and disputes in health region management

OBJECTIVE To analyze the regional governance of the health systemin relation to management strategies and disputes.METHODOLOGICAL PROCEDURES A qualitative study with health managers from 19 municipalities in the health region of Bahia, Northeastern Brazil. Data were drawn from 17 semi-structured interviews of state, regional, and municipal health policymakers and managers; a focus group; observations of the regional interagency committee; and documents in 2012. The political-institutional and the organizational components were analyzed in the light of dialectical hermeneutics.RESULTS The regional interagency committee is the chief regional governance strategy/component and functions as a strategic tool for strengthening governance. It brings together a diversity of members responsible for decision making in the healthcare territories, who need to negotiate the allocation of funding and the distribution of facilities for common use in the region. The high turnover of health secretaries, their lack of autonomy from the local executive decisions, inadequate technical training to exercise their function, and the influence of party politics on decision making stand as obstacles to the regional interagency committee’s permeability to social demands. Funding is insufficient to enable the fulfillment of the officially integrated agreed-upon program or to boost public supply by the system, requiring that public managers procure services from the private market at values higher than the national health service price schedule (Brazilian Unified Health System Table). The study determined that “facilitators” under contract to health departments accelerated access to specialized (diagnostic, therapeutic and/or surgical) services in other municipalities by direct payment to physicians for procedure costs already covered by the Brazilian Unified Health System.CONCLUSIONS The characteristics identified a regionalized system with a conflictive pattern of governance and intermediate institutionalism. The regional interagency committee’s managerial routine needs to incorporate more democratic devices for connecting with educational institutions, devices that are more permeable to social demands relating to regional policy making.

Environmental and agricultural benefits of a management system designed for sandy loam soils of the humid tropics

A sustainable management of soils with low natural fertility on family farms in the humid tropics is a great challenge and overcoming it would be an enormous benefit for the environment and the farmers. The objective of this study was to assess the environmental and agronomic benefits of alley cropping, based on the evaluation of C sequestration, soil quality indicators, and corn yields. Combinations of four legumes were used in alley cropping systems in the following treatments: Clitoria fairchildiana + Cajanus cajan; Acacia mangium + Cajanus cajan; Leucaena leucocephala + Cajanus cajan; Clitoria fairchildiana + Leucaena leucocephala; Leucaena leucocephala + Acacia mangium and a control. Corn was used as a cash crop. The C content was determined in the different compartments of soil organic matter, CEC, available P, base saturation, percentage of water saturation, the period of the root hospitality factor below the critical level and corn yield. It was concluded that alley cropping could substitute the slash and burn system in the humid tropics. The main environmental benefit of alley cropping is the maintenance of a dynamic equilibrium between C input and output that could sustain up to 10 Mg ha-1 of C in the litter layer, decreasing atmospheric CO2 levels. Alley cropping is also beneficial from the agricultural point of view, because it increases base saturation and decreases physical resistance to root penetration in the soil layer 0 - 10 cm, which ensures the increase and sustainability of corn yield.

Bimodal pore distribution on soils under conservation management system for coffee crop

This study aims at detailing bimodal pore distribution by means of water retention curve in an oxidic-gibbsitic Latosol and in a kaolinitic cambisol Latossol under conservation management system of coffee crop. Samples were collected at depths of 20; 40; 80; 120 and 160 cm on coffee trees rows and between rows under oxidic-gibbsitic Latosol (LVd) and kaolinitic cambisol Latossol (LVAd). Water retention curve was determined at matrix potentials (Ψm) -1; -2; -4; -6; -10 kPa obtained from the suction unit; the Ψm of -33; -100; -500; -1,500 kPa were obtained by the Richards extractor, and WP4-T psychrometer was used to determine Ψm -1,500 to -300,000 kPa. The water retention data were adjusted to the double van Genuchten model by nonlinear model procedures of the R 2.12.1 software. Was estimated the model parameter and inflection point slope. The system promoted changes in soil structure and water retention for the conditions evaluated, and both showed bimodal pores distribution, which were stronger in LVd. There was a strong influence of mineralogy gibbsitic in the water retention more negative than Ψm -1500 kPa, reflected in the values of the residual water content.

Ambivalent implications of health care information systems: a study in the Brazilian public health care system

This article evaluates social implications of the "SIGA" Health Care Information System (HIS) in a public health care organization in the city of São Paulo. The evaluation was performed by means of an in-depth case study with patients and staff of a public health care organization, using qualitative and quantitative data. On the one hand, the system had consequences perceived as positive such as improved convenience and democratization of specialized treatment for patients and improvements in work organization. On the other hand, negative outcomes were reported, like difficulties faced by employees due to little familiarity with IT and an increase in the time needed to schedule appointments. Results show the ambiguity of the implications of HIS in developing countries, emphasizing the need for a more nuanced view of the evaluation of failures and successes and the importance of social contextual factors.

Federalism and health policy: the intergovernmental committees in Brazil

OBJECTIVE To analyze the dynamics of operation of the Bipartite Committees in health care in the Brazilian states.METHODS The research included visits to 24 states, direct observation, document analysis, and performance of semi-structured interviews with state and local leaders. The characterization of each committee was performed between 2007 and 2010, and four dimensions were considered: (i) level of institutionality, classified as advanced, intermediate, or incipient; (ii) agenda of intergovernmental negotiations, classified as diversified/restricted, adapted/not adapted to the reality of each state, and shared/unshared between the state and municipalities; (iii) political processes, considering the character and scope of intergovernmental relations; and (iv) capacity of operation, assessed as high, moderate, or low.RESULTS Ten committees had advanced level of institutionality. The agenda of the negotiations was diversified in all states, and most of them were adapted to the state reality. However, one-third of the committees showed power inequalities between the government levels. Cooperative and interactive intergovernmental relations predominated in 54.0% of the states. The level of institutionality, scope of negotiations, and political processes influenced Bipartite Committees’ ability to formulate policies and coordinate health care at the federal level. Bipartite Committees with a high capacity of operation predominated in the South and Southeast regions, while those with a low capacity of operations predominated in the North and Northeast.CONCLUSIONS The regional differences in operation among Bipartite Interagency Committees suggest the influence of historical-structural variables (socioeconomic development, geographic barriers, characteristics of the health care system) in their capacity of intergovernmental health care management. However, structural problems can be overcome in some states through institutional and political changes. The creation of federal investments, varied by regions and states, is critical in overcoming the structural inequalities that affect political institutions. The operation of Bipartite Committees is a step forward; however, strengthening their ability to coordinate health care is crucial in the regional organization of the health care system in the Brazilian states.

Management of basic health units in municipalities of different size: profile and management instruments

Objective To identify the characteristics of managers and their use of management instruments in primary care and to analyze differences in these features among municipalities of different sizes. Method The present cross-sectional descriptive study was conducted at 108 basic health units from 21 municipalities in northern Paraná, Brazil. The data were collected using a semi-structured questionnaire during the second half of 2010. Results Most managers had graduate degrees and were female and nurses. The managers from the small municipalities were younger, their payment was lower, and they had less work experience. The use of management instruments was expressive for both the organization and work management; however, the instruments were used less in the small municipalities. Conclusion The managers were committed to their role; it is recommended that policies and guidance should be formulated at the federal and state levels to support small municipalities.

Quality perception in research laboratories from Fiocruz after QMS implementation

Quality Management System has been implemented at the René Rachou Research Center since 2003. This study investigated its importance for collaborators (Cs) in laboratories. This was a quantitative and descriptive study performed in a group of 113 collaborators. It was based on the World Health Organization handbook: Quality Practices in Basic Biomedical Research. The questionnaires evaluated the parameters using the Likert scale. Biosafety, training and ethics were considered to be the most important parameters. Supervision and quality assurance, data recording, study plan, SOPs and file storage achieved intermediate evaluation. The lower frequency of responses was obtained for result report, result verification, personnel and publishing practices. Understanding the perception of the collaborators allows the development of improvement actions aiming the construction of a training program directing strategies for disseminating quality.

Lack of access and continuity of adult health care: a national population-based survey

OBJECTIVE To describe the lack of access and continuity of health care in adults.METHODS A cross-sectional population-based study was performed on a sample of 12,402 adults aged 20 to 59 years in urban areas of 100 municipalities of 23 states in the five Brazilian geopolitical regions. Barriers to the access and continuity of health care and were investigated based on receiving, needing and seeking health care (hospitalization and accident/emergency care in the last 12 months; care provided by a doctor, by other health professional or home care in the last three months). Based on the results obtained by the description of the sample, a projection is provided for adults living in Brazilian urban areas.RESULTS The highest prevalence of lack of access to health services and to provision of care by health professionals was for hospitalization (3.0%), whilst the lowest prevalence was for care provided by a doctor (1.1%). The lack of access to care provided by other health professionals was 2.0%; to accident and emergency services, 2.1%; and to home care, 2.9%. As for prevalences, the greatest absolute lack of access occurred in emergency care (more than 360,000 adults). The main reasons were structural and organizational problems, such as unavailability of hospital beds, of health professionals, of appointments for the type of care needed and charges made for care.CONCLUSIONS The universal right to health care in Brazil has not yet been achieved. These projections can help health care management in scaling the efforts needed to overcome this problem, such as expanding the infrastructure of health services and the workforce.

Household-based malaria control in a highly endemic area of Africa (Tanzania): determinants of transmission and disease and indicators for monitoring - Kilombero Malaria Project

The Kilombero Malaria Project (KMP) attemps to define opperationally useful indicators of levels of transmission and disease and health system relevant monitoring indicators to evaluate the impact of disease control at the community or health facility level. The KMP is longitudinal community based study (N = 1024) in rural Southern Tanzania, investigating risk factors for malarial morbidity and developing household based malaria control strategies. Biweekly morbidity and bimonthly serological, parasitological and drug consumption surveys are carried out in all study households. Mosquito densities are measured biweekly in 50 sentinel houses by timed light traps. Determinants of transmission and indicators of exposure were not strongly aggregated within households. Subjective morbidity (recalled fever), objective morbidity (elevated body temperature and high parasitaemia) and chloroquine consumption were strongly aggregated within a few households. Nested analysis of anti-NANP40 antibody suggest that only approximately 30% of the titer variance can explained by household clustering and that the largest proportion of antibody titer variability must be explained by non-measured behavioral determinants relating to an individual's level of exposure within a household. Indicators for evaluation and monitoring and outcome measures are described within the context of health service management to describe control measure output in terms of community effectiveness.

The nurse in the management of materials in teaching hospitals

OBJECTIVETo present the nurse's integration within materials management of six teaching hospitals of Paraná - Brazil, and to describe the activities performed by nurses within this process.METHODA study of a qualitative approach and descriptive nature, conducted in teaching hospitals in Paraná, between June and August of 2013. The data collection was conducted through semi-structured interviews with eight nurses who worked in materials management; data were analyzed using content analysis.RESULTSThese showed that nurses perform ten categories of activities, distributed into four of the five steps of the materials management process.CONCLUSIONThe nurse, in performing of these activities, in addition to favoring the development of participative management, contributes to the organization, planning, and the standardization of the hospital supply process, giving greater credibility to the work with professionals who use the materials, and to the suppliers.

Effect of management systems and cover crops on organic matter dynamics of soil under vegetables

Vegetable production in conservation tillage has increased in Brazil, with positive effects on the soil quality. Since management systems alter the quantity and quality of organic matter, this study evaluated the influence of different management systems and cover crops on the organic matter dynamics of a dystrophic Red Latosol under vegetables. The treatments consisted of the combination of three soil tillage systems: no-tillage (NT), reduced tillage (RT) and conventional tillage (CT) and of two cover crops: maize monoculture and maize-mucuna intercrop. Vegetables were grown in the winter and the cover crops in the summer for straw production. The experiment was arranged in a randomized block design with four replications. Soil samples were collected between the crop rows in three layers (0.0-0.05, 0.05-0.10, and 0.10-0.30 m) twice: in October, before planting cover crops for straw, and in July, during vegetable cultivation. The total organic carbon (TOC), microbial biomass carbon (MBC), oxidizable fractions, and the carbon fractions fulvic acid (C FA), humic acid (C HA) and humin (C HUM) were determined. The main changes in these properties occurred in the upper layers (0.0-0.05 and 0.05-0.10 m) where, in general, TOC levels were highest in NT with maize straw. The MBC levels were lowest in CT systems, indicating sensitivity to soil disturbance. Under mucuna, the levels of C HA were lower in RT than NT systems, while the C FA levels were lower in RT than CT. For vegetable production, the C HUM values were lowest in the 0.05-0.10 m layer under CT. With regard to the oxidizable fractions, the tillage systems differed only in the most labile C fractions, with higher levels in NT than CT in the 0.0-0.05 m layer in both summer and winter, with no differences between these systems in the other layers. The cabbage yield was not influenced by the soil management system, but benefited from the mulch production of the preceding maize-mucuna intercrop as cover plant.

Structural changes and degradation of Red Latosols under different management systems for 20 years

Soils are the foundation of terrestrial ecosystems and their role in food production is fundamental, although physical degradation has been observed in recent years, caused by different cultural practices that modify structures and consequently the functioning of soils. The objective of this study was to evaluate possible structural changes and degradation in an Oxisol under different managements for 20 years: no-tillage cultivation with and without crop rotation, perennial crop and conventional tillage, plus a forested area (reference). Initially, the crop profile was described and subsequently, 10 samples per management system and forest soil were collected to quantify soil organic matter, flocculation degree, bulk density, and macroporosity. The results indicated structural changes down to a soil depth of 50 cm, with predominance of structural units ∆μ (intermediate compaction level) under perennial crop and no-tillage crop rotation, and of structural units ∆ (compacted) under conventional tillage and no-tillage. The soil was increasingly degraded in the increasing order: forest => no-tillage crop rotation => perennial crop => no-tillage without crop rotation => conventional tillage. In all managements, the values of organic matter and macroporosity were always below and bulk density always above those of the reference area (forest) and, under no-tillage crop rotation and perennial crop, the flocculation degree was proportionally equal to that of the reference area.

SOIL FUNGISTASIS AGAINST FUSARIUM GRAMINEARUM UNDER DIFFERENT CROP MANAGEMENT SYSTEMS

Soil management, in terms of tillage and cropping systems, strongly influences the biological properties of soil involved in the suppression of plant diseases. Fungistasis mediated by soil microbiota is an important component of disease-suppressive soils. We evaluated the influence of different management systems on fungistasis against Fusarium graminearum, the relationship of fungistasis to the bacterial profile of the soil, and the possible mechanisms involved in this process. Samples were taken from a long-term experiment set up in a Paleudult soil under conventional tillage or no-tillage management and three cropping systems: black oat (Avena strigose L.) + vetch (Vicia sativa L.)/maize (Zea mays L.) + cowpea (Vigna sinensis L.), black oat/maize, and vetch/maize. Soil fungistasis was evaluated in terms of reduction of radial growth of F. graminearum, and bacterial diversity was assessed using ribosomal intergenic spacer analysis (RISA). A total of 120 bacterial isolates were obtained and evaluated for antibiosis, and production of volatile compounds and siderophores. No-tillage soil samples showed the highest level of F. graminearum fungistasis by sharply reducing the development of this pathogen. Of the cropping systems tested, the vetch + black oat/maize + cowpea system showed the highest fungistasis and the oat/maize system showed the lowest. The management system also affected the genetic profile of the bacteria isolated, with the systems from fungistatic soils showing greater similarity. Although there was no clear relationship between soil management and the characteristics of the bacterial isolates, we may conclude that antibiosis and the production of siderophores were the main mechanisms accounting for fungistasis.

Early Changes in Soil Metabolic Diversity and Bacterial Community Structure in Sugarcane under Two Harvest Management Systems

Preharvest burning is widely used in Brazil for sugarcane cropping. However, due to environmental restrictions, harvest without burning is becoming the predominant option. Consequently, changes in the microbial community are expected from crop residue accumulation on the soil surface, as well as alterations in soil metabolic diversity as of the first harvest. Because biological properties respond quickly and can be used to monitor environmental changes, we evaluated soil metabolic diversity and bacterial community structure after the first harvest under sugarcane management without burning compared to management with preharvest burning. Soil samples were collected under three sugarcane varieties (SP813250, SP801842 and RB72454) and two harvest management systems (without and with preharvest burning). Microbial biomass C (MBC), carbon (C) substrate utilization profiles, bacterial community structure (based on profiles of 16S rRNA gene amplicons), and soil chemical properties were determined. MBC was not different among the treatments. C-substrate utilization and metabolic diversity were lower in soil without burning, except for the evenness index of C-substrate utilization. Soil samples under the variety SP801842 showed the greatest changes in substrate utilization and metabolic diversity, but showed no differences in bacterial community structure, regardless of the harvest management system. In conclusion, combined analysis of soil chemical and microbiological data can detect early changes in microbial metabolic capacity and diversity, with lower values in management without burning. However, after the first harvest, there were no changes in the soil bacterial community structure detected by PCR-DGGE under the sugarcane variety SP801842. Therefore, the metabolic profile is a more sensitive indicator of early changes in the soil microbial community caused by the harvest management system.

Physical Properties of a Hapludox after Three Decades under Different Soil Management Systems

ABSTRACT Changes in soil physical properties due to different management systems occur slowly, and long-term studies are needed to assess soil quality. The objectives of this study were to evaluate the effects of soil management systems and liming methods on the physical properties of a Latossolo Bruno Alumínico típico (Hapludox). A long-term experiment that began in 1978 with conventional and no-tillage systems was assessed. In addition, different liming methods (no lime, incorporated lime, and lime on the soil surface) have been applied since 1987 and were also evaluated in this study. Moreover, an area of native forest was evaluated and considered a reference for the natural condition of the soil. Soil physical properties were evaluated in layers to a depth of 1.00 m. Compared to native forest, the conventional tillage and no-tillage systems had higher soil bulk density, penetration resistance, and microporosity, and lower aggregate stability and macroporosity. Compared to the conventional tillage system, long-term no-tillage improved the structure of the Hapludox, as evidenced by increased microporosity and aggregate stability, especially in the soil surface layer. In no-tillage with lime applications sporadically incorporated, soil physical properties did not differ from no-tillage without lime and with lime applied on the soil surface, indicating that this practice maintains the physical quality of soil under no-tillage. Liming in a conventional tillage system improved soil aggregation and reduces penetration resistance in the soil layers near the soil surface. No-tillage was the main practice related to improvement of soil physical quality, and liming methods did not influence soil physical properties in this soil management system.