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Primary health care (PHC) has increased in global relevance as it has been demonstrated to be a useful strategy to promote community access to health services. Multilateral organizations and national governments have reached a consensus regarding the basic principles of PHC, but the application of these varies from country to country due to the particularities of local health systems.This article aims to review and summarize PHC strategies and the configuration of health networks in Latin American and Caribbean countries.The review was carried out using keywords in at least 9 databases. Papers in languages other than English, Portuguese, and Spanish were excluded, while non-refereed articles and regional gray literature were incorporated. As a result, 1,146 papers were identified. After three instances of analysis, 142 articles were selected for this investigation. Data were analyzed according to an analysis by theme.The evidence collected on health reforms in the region reflects the need to intensify care strategies supported by PHC and care networks. These must be resilient to changes in the population's needs and must be able to adapt to contexts of epidemiological accumulation.

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A new public policy was instituted in Argentina for free distribution of subdermal contraceptive implants to women aged 15-24 years old in the public healthcare system. The objective of this study is to determine the extent to which this population adhered to the implant, as well as predictors of continuation. The retrospective cohort study was based on a telephone survey of a random sample of 1101 Ministry of Health-registered implant users concerning the continuation of use, satisfaction with the method and side-effects, and reasons for removal. Descriptive statistics and multivariate regression analysis were used to explore the association between adherence and having received contraceptive counselling, satisfaction, and side effects. We found high levels of adherence (87%) and satisfaction (94%). Common reported side effects were amenorrhoea or infrequent bleeding, perceived weight gain, increased menstrual bleeding and headaches. Multivariate regression analysis indicates that, among adolescents, having received contraceptive counselling increased comfort, while frequent bleeding at six months hindered trust. Participants who had a history of a prior delivery or who had themselves primarily chosen the method were less likely to request the removal of the implant. Our results support the public policy of free implant distribution in the public health sector. This is a sustainable public policy that contributes to equity and access to effective contraception. It is appropriate for adolescents and young women and will also reduce unintended pregnancies. Our results suggest that counselling patients is key prior to insertion of the implant, as it improves acceptability and continuation.

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BACKGROUND: During the first decade of the current century, Latin American countries have shown high and consistent economic growth rates, increasing per capita GDP and reducing poverty. Social indicators improved in even the poorest and least equitable countries in the region. In terms of health care results, marked advances were made in infant mortality rates. OBJECTIVE: The aim of this paper is to identify if decreasing poverty rates in Latin America and the Caribbean during the first decade of the century have had an effect on health inequality, specifically by reducing the health care equity gap and, if so, whether that trend and its effects were distributed evenly at the sub-national level. METHODS: Basic statistical tools were applied to national and sub-national administrative data for eleven Latin American countries (Argentina, Belize, Bolivia, Brazil, Colombia, Dominican Republic, El Salvador, Mexico, Nicaragua, Peru, and Uruguay) to compare the evolution of a set of social determinants with a classic health care outcome, such infant mortality) during the period 1995-2012. This document proposes a set of indicators to analyze relative evolution of results and convergence to equity, and to discuss general trends in health care reforms across the region. RESULTS: The document shows a correspondence between poverty reduction, and improvement of health care indicators at a regional level, though national differences persist. In some cases, like Brazil and Peru, the reduction in infant mortality rates is coupled with significant movements towards health equity. This trend is different in Bolivia, where the drop in poverty is not followed by better outcomes in poor departments. At the same, results are not necessarily linked to health systems organization and/or specific reforms. For instance, both Brazil and Peru pursue in applying decentralized solutions, although the incentive mechanisms are quite different: the former has a supply side structure at the public provision level while the latter has implemented mixed payment systems. CONCLUSION: While some of the same instruments and measures of effectiveness in health care reforms appear across the region, specific impact evaluations should be performed. To reduce the equity gap in Latin America requires not only major improvements in social determinants but also the design and implementation of sound institutional policy and more robust regulatory frameworks (institutional determinants) so that more resources yield better practices.

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Por primera vez en la historia reciente somos testigos de cómo los sistemas de salud ocupan un lugar central en la agenda política. Ello ocurre bajo las peores circunstancias: una epidemia global que golpea a todos los países, sobre la cual, en un principio, no había información suficiente sobre cómo combatirla efectivamente. Intentando identificar aprendizajes y oportunidades de la adversidad, propongo esbozar algunos elementos que contribuyan al debate sobre cómo fortalecer la capacidad de respuesta de los esquemas de cobertura en salud de América Latina y el Caribe ante estos fenómenos que ponen a prueba la capacidad de las redes de atención sanitaria y desnudan las limitaciones de los mecanismos de protección financiera. La segmentación sistémica solo permite una respuesta equitativa y de calidad para la pandemia, si la coordinación entre las partes involucra todas las dimensiones del modelo organizacional, particularmente vigilancia epidemiológica, funcionamiento en red y gestión de la información.

For the first time in recent history, we are witnessing health systems taking center stage on the political agenda. This is happening under the worst circumstances: a global epidemic that is hitting all countries, about which, at the beginning, there was not enough information on how to fight it effectively. To identify lessons learned and opportunities from adversity, I propose to outline some elements to contribute to the debate on how to strengthen the response capacity of health coverage schemes in Latin America and the Caribbean to these phenomena that test the capacity of health care networks and expose the limitations of financial protection mechanisms. Systemic segmentation only allows an equitable and quality response to the pandemic if the coordination between the parties involves all the dimensions of the organizational model, particularly epidemiological surveillance, networking and information management.

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Objetivo: Este artículo analiza las miradas de los diferentes funcionarios/as involucrados en las problemáticas de salud detectadas en la población adolescente, destacando las estrategias e intervenciones diseñadas para responder tales necesidades y cómo la gestión logra articularse para alcanzar los objetivos de política planteados. Metodología: Se diseñó un mapeo de actores común a las jurisdicciones analizadas (Chaco, Jujuy, Salta, Misiones y La Rioja), efectuándose entre 10 y 12 entrevistas por provincia, mediando consentimiento informado, entre los meses de octubre y noviembre de 2016. Resultados: La recolección de opiniones y experiencias de gestión muestran que no existe una estrategia en salud adolescente en el país, aunque sí abordajes planificados aislados, tanto desde algunos programas nacionales, o a través de algunas iniciativas específicas implementadas desde las provincias. Ello no implica necesariamente falta de compromiso de las/os funcionaras/os involucrados: la alta rotación agudiza el desafío, en tanto la coordinación informal descansa en vínculos individuales, que requieren recomponerse en cada cambio de responsable.

Objective: This article analyzes the opinions of public servants involved in health problems concerning adolescents, focusing on the strategies and interventions designed to address such needs, and how they manage to articulate actions in order to achieve objectives. Method: A common mapping of actors was designed for the analyzed locations (Chaco, Jujuy, Salta, Misiones and La Rioja), 10-12 interviews were done in each province, prior informed consent, between October and November 2016. Results: The opinions gathered and management experiences show that there is no stated strategy in adolescent health in the country; however, there are isolated planned approaches as part of national programs, or through specific initiatives in the provinces. This does not necessarily imply lack of commitment from civil servants: their high turnover exacerbates the challenge; informal coordination relies on individual links, which require reorganization with every change of person in charge. Conclusions: The study shows gaps leading to identify and implement policies for adolescents. These gaps go from the recognition or not of a new paradigm based on persons of rights as well as its correlation with real actions showing that such paradigm is recognized and translated into concrete actions, knowledge transmission and consistent allocation of resources. As a result, it is observed that there is not a shared strategy regarding adolescence health in the country; instead we find non-coordinated and isolated approaches, with many gaps, particularly related to mental health and addictions.

O objetivo deste trabalho analisa os olhares dos diferentes funcionários / as envolvidos em problemas de saúde detectados na população adolescente, salientando as estratégias e intervenções desenhadas para acodir a tais necessidades e como a gestão consegue articular para atingir os objetivos políticos propostos. Metodologia: Desenhou-se um mapeamento de atores comuns às jurisdições analisadas (Chaco, Jujuy, Salta, Misiones e La Rioja), realizado entre 10 e 12 entrevistas por província foi projetado, após consentimento informado, entre os meses de outubro e novembro de 2016. Os resultados : A coleta de opiniões e experiências de gestão mostram que não existe uma estratégia sobre a saúde dos adolescentes no país, embora haja abordagens planejadas isoladamente bem de alguns programas nacionais como através de algumas iniciativas específicas implementadas a partir das províncias. Isto não implica necessariamente uma falta de compromisso dos/as funcionários/as envolvidos: a alta rotatividade alavanca o desafio, enquanto a coordenação informal repousa em vínculos individuais, que requerem se recompor a cada troca de responsáveis. Conclusões: O estudo mostra a presença de lacunas no olhar que leva a identificar e implementar políticas para a adolescência. Essas lacunas se estendem desde o reconhecimento ou não de um novo paradigma baseado em sujeitos de direito, bem como em sua contraparte real em ações que mostrem que este paradigma é efetivamente reconhecido e traduzido em intenções, conhecimentos sobre a sua abordagem, e alocação de recursos consistentes com tais princípios. Como resultado, observa-se que não há necessariamente uma estratégia comum sobre a saúde dos adolescentes no país, mas abordagens planejadas isoladamente, com faltas marcadas, particularmente relacionados ao tratamento da saúde mental e adicções.

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INTRODUCCIÓN: El funcionamiento del sistema de salud se basa en las características de sus recursos humanos y en el modo en que ellos se coordinan y complementan para cubrir las necesidades de la población. OBJETIVOS: Analizar las características contractuales de los salarios médicos en Argentina, sus montos y composición, en el contexto de un sistema público de salud descentralizado. MÉTODOS: Se realizaron estudios de caso en cinco jurisdicciones de Argentina: Ciudad Autónoma de Buenos Aires, Chaco, La Rioja, Neuquén y Salta. En cada una de ellas se seleccionaron tres hospitales públicos. Se llevaron a cabo encuestas de elección múltiple a una muestra representativa del personal médico. Como fuente de información secundaria, se contó con la base de salarios médicos proporcionada por el Departamento de Recursos Humanos de cada Ministerio de Salud. RESULTADOS: La capacidad en la definición de reglas de juego pertinentes a los arreglos contractuales, niveles y composición del salario es extremadamente amplia entre jurisdicciones e incluso entre instituciones hospitalarias. Se observa gran nivel de formalización de los contratos laborales, diversidad en las estructuras de incentivos y gestión, y brechas significativas entre hospitales dentro de cada jurisdicción. CONCLUSIONES: La temática de remuneraciones médicas en Argentina presenta una amplia riqueza no sólo de casos y particularidades por jurisdicción, sino también de perspectivas alternativas de abordaje.

INTRODUCTION: The functioning of the health system is based on the characteristics of the human resources and on how they coordinate and complement each other to cover the population's needs. OBJECTIVES: To analyze the contractual characteristics of physician wages in Argentina as well as their amounts and composition, in the context of a decentralized public health system. METHODS: Case studies were performed in five jurisdictions in Argentina: Buenos Aires City, Chaco, La Rioja, Neuquén and Salta. In each of them, three public hospitals were selected. Multiple-choice surveys were conducted on a representative sample of medical personnel. Databases of medical wages were used as secondary source of information, they were provided by the Human Resources Department of each Ministry of Health. RESULTS: The capacity to define "game rules" relevant to contractual arrangements, wage levels and structure is extremely wide between jurisdictions and even between hospitals. The analysis showed a high level of formalization of labor contracts, diversity in management and incentive structures, and significant gaps between hospitals within each jurisdiction. CONCLUSIONS: The topic of medical remuneration in Argentina presents not only a wide variety of cases and peculiarities by jurisdiction, but also many alternative approaches.

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International evidence show that screening for colorectal cancer is cost-effective; however, in Argentina is unknown. OBJECTIVE: The study shows the results of a cost-effectiveness evaluation based on two alternative mechanisms: annual faecal immunochemical testing (FIT), and colonoscopy every ten years in Argentina. METHODS: The study develops a Mar- kov model in ten stages, based on information provided by the INC, prior literature review and on-line questionnaires to physicians enrolled in the four major scientific societies related to cancer. Cost information arrived from the Na- tional Superintendence of Social Health Insurances and a sample of managers in social and private insurance schemes. RESULTS: The most cost-effective strategy consisted annual FIT, in comparison no intervention and colonoscopy every 10 years. The incremental cost effectiveness ratio (ICER) of FIT versus no intervention was of 980.5 pesos per QALY The findings were robust to deterministic sensitivity analysis. CONCLUSIONS: We confirmed that screening for CRC is a cost-effective intervention. Whereas the CCR is one of the leading causes of mortality in Argentina, these results support the widespread use of screening for CRC using anual FIT which proves to be highly cost effective for the country.

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INTRODUCCION: Los/as adolescentes tienen bajos indicadores de morbimortalidad. Sin embargo, presentan problemáticas particulares que pueden condicionar su desarrollo saludable y que deben ser analizadas, ya que se trata de una población prioritaria desde la prevención sanitaria y con larga expectativa de vida.OBJETIVOS: Conocer la situación de salud/enfermedad de los/asadolescentes en el norte argentino. Identificar sus necesidades realesy percibidas, así como las barreras de acceso a los servicios de salud,particularmente en materia de salud sexual, adicciones, alimentacióny suicidio. METODOS: El estudio incluyó los siguientes pasos: 1) revisiónde bibliografía y normativa sobre salud adolescente; 2) mapeo de actores y entrevistas a referentes locales; 3) aplicación de una encuesta autoadministrada a adolescentes de escuelas públicas en seis provincias argentinas; 4) análisis cuanticualitativo de las encuestas y entrevistas. RESULTADOS: Aunque la percepción y las dolencias correspondieron a perfiles de baja necesidad, del total de adolescentes que consignaron problemas de salud, sólo la mitad consultó al sistema, y la mayoría dijo que prefería recurrir a su entorno cercano (padres, amigos). Las preocupaciones adolescentes no estuvieron vinculadas necesariamente con el estado de salud, sino con planteosy problemas emergentes de su edad. Más allá de las barreras geográficas,se observaron limitaciones institucionales y familiares querestringen el vínculo entre el sistema de salud y los/as adolescentes.CONCLUSIONES: Los resultados muestran espacios vacantes departicipación (del sistema y del entorno familiar, comunitario y escolar) para que los requerimientos de información y atención de los/as adolescentes se traduzcan en demandas y en un mejor acceso.

INTRODUCTION: Adolescents have low mortality and morbidity rates. However, there are certain problemsconditioning a healthy development which should be analyzed as a priority, from a prevention perspective, for this population with long life expectancy. OBJECTIVES: To know the health/disease status of adolescents in Northern Argentina. To identify real andperceived needs as well as barriers in access to health services, focusing on sexual health, addictions, nutrition and suicide. METHODS: The study included following steps: 1) literature review and survey of current legislation on adolescent health; 2) mapping of actors and interviews with local key informants; 3) self-administered survey to adolescents of public schools in six Argentine provinces; 4) qualitative and quantitative analysis of surveys and interviews. RESULTS: Although perceptions and complaints belonged to low-need profiles, only half of theadolescents reporting health problems used the health system to get information, and most of them said they preferred to talk with parents and friends. Adolescent concerns were notnecessarily related to health status, but to issues of their age group. Apart from geographical barriers, family and institutional reasons were found to limit the relationship between healthsystem and adolescents. CONCLUSIONS: Results show spacesfor participation which should be occupied by the health care system and family, community and school environment, so that information and attention requirements can be reflectedin demands and a better access.

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La equidad es inherente a todo planeamiento, a toda idea y toda acción política, y puede constituirse como principio y objetivo en sí misma, erigiéndose así como un valor social. Por esta razón, resulta imposible pensar un planteamiento actual de la atención de la salud sin que la misma aparezca como tema prioritario. La equidad en salud es un valor ético, inherentemente normativo, que está basado en el principio de justicia distributiva y en consonancia con los principios de derechos humanos. No obstante, es necesario desterrar la ilusión de que el problema de la equidad en salud puede ser resuelto en el discurso de la ética universal (1)...

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Introducción De acuerdo con los resultados de la última Encuesta Nacional de Nutrición y Salud del Ministerio de Salud en Argentina, el bajo peso y la desnutrición crónica (talla/edad) son las deficiencias nutricionales más significativas a nivel nacional. Además, la obesidad se presenta como un problema en ascenso que afecta en forma desigual a las regiones argentinas, y la anemia en menores de 2 años se encuentra todavía lejos de ser controlada. Objetivo Analizar la evolución de la estrategia pública en el diseño e implementación de los programas orientados a mejorar la situación nutricional de la población. Métodos Se realizó un repaso de los programas alimentarios nacionales implementados en las últimas dos décadas en la Argentina, analizando la focalización geográfica y poblacional, las prestaciones ofrecidas y la modalidad organizativa. Resultados Luego de 25 años de intervenciones en materia alimentaria, las deficiencias nutricionales son aún un problema a resolver. Uno de los desafíos más importantes fue identificar los mecanismos eficaces que permitan transferir capacidades a los beneficiarios más allá de la duración de los programas. Conclusiones La alimentación debe ser considerada por los tomadores de decisiones como uno de los principales indicadores sanitarios. Por ello, es importante fortalecer la presencia del área de Salud Pública en las intervenciones de política alimentaria para que ellas se orienten a evitar el deterioro de la salud y mejorar la calidad de vida de la población.

Introduction According to the last Argentinean National Survey of Nutrition and Health (2005) held by the Health Ministry, low weight and chronic undernourishment are the most important nutritional problems in the country. Besides, obesity emerges as a growing problem affecting the Argentinian regions whereas, anemia (iron deficit) in under 2-years-old children is still far from being considered under control. Objective To analyze the evolution of the public strategy for the design and implementation of nutritional programs aimed at improving the nutritional condition of population in Argentina. Methods The national nutritional programs implemented in the last two decades were reviewed, followed by the analysis of the geographic and population focalization, the goods and services offered, and organization modality. Results After 25 years of food interventions, the nutritional deficiencies are yet to be solved. One of the main challenges was to identify the effective mechanisms that allowed transferring capacities to the beneficiaries, regardless of the duration of the programs. Conclusions Feeding should be taken into account by the decision makers as one of the main health indicators. Therefore, it is important to strengthen the involvement of the public health area in the food policy interventions, so that these can be directed toward preventing health deterioration and improving the quality of life of the population.