A carregar...
Publicação
Hospitais de primeira referência, distrito de saúde e estratégia dos cuidados de saúde primários em Moçambique
| Nome: | Descrição: | Tamanho: | Formato: | |
|---|---|---|---|---|
| 1.96 MB | Adobe PDF |
Autores
Orientador(es)
Resumo(s)
Esta tese é sobre os hospitais de primeira referência sem os quais não é possível haver “Saúde para todos”.
A estratégia dos cuidados de saúde primários é conceptualizada em alguns princípios básicos que incluem cuidados para todos (valores de justiça social), sustentáveis, com participação comunitária (as pessoas não são somente receptores de cuidados mas actores no processo de promoção da sua saúde e da dos outros) e acção intersectorial para a saúde. Durante os anos
80 os centros de saúde emergiram como operacionalização da estratégia dos cuidados de saúde primários, mas foi-se tornando evidente que necessitavam de apoio hospitalar. A evolução do pensamento sobre o papel dos centros de saúde e dos hospitais levou a retomar o conceito de
distrito de saúde. O distrito de saúde é o nível administrativo mais periférico do Sistema Nacional de Saúde, com área geográfica e população bem definidas, com centros de saúde e um primeiro nível de referência (hospital distrital), com todos os recursos da comunidade e outros prestadores de cuidados de saúde e com uma direcção que coordena todas as actividades de promoção, prevenção, curativas e de reabilitação da saúde.
No contexto de um distrito sanitário, os hospitais de primeira referência deveriam assegurar os cuidados e apoio tecnológico que por alguma razão (técnica, económica, operacional) não devam ser descentralizadas para um nível inferior. A referenciação a estes hospitais deveria fazer-se para a realização de exames auxiliares de diagnóstico, opinião de especialista, intervenção técnica ou hospitalização, entre outros.
Desde o fim da década de oitenta que não é fácil localizar evidência empírica sobre o que estão a fazer este tipo de hospitais e se alguma vez fizeram o que normativamente está designado como o que seria o seu papel e função.
Finalidade e objectivos. Esta tese tem como finalidade melhorar a compreensão do contributo dos hospitais de primeira referência para o desenvolvimento do sistema de saúde moçambicano e para a fundamentação da organização do sistema de saúde com base no distrito de saúde/sistema local de saúde.
A tese foi desenhada para atingir os seguintes objectivos: 1. Descrever empiricamente o perfil do hospital de primeira referência Moçambicano e sua evolução desde a independência; 2. Descrever empiricamente o perfil do distrito de saúde Moçambicano; 3. Descrever o papel e a
função esperada do hospital de primeira referência na estratégia de saúde de Moçambique e sua evolução desde a independência; 4. Identificar a diferença entre a função planeada e a função observada nos hospitais em estudo, nomeadamente no que concerne ao seu papel no distrito de
saúde moçambicano; 5. Caracterizar a evolução dos hospitais de primeira referência na África subsaariana.
Métodos Para alcançar a finalidade e objectivo enunciados desenhou-se um estudo explicativo sequencial em que há quatro sub-estudos:
• Hospitais de primeira referência na África subsaariana: revisão sistemática de literatura;
• O hospital de primeira referência no sistema de saúde moçambicano: revisão de literatura;
• Hospitais de primeira referência em Moçambique: estudo descritivo transversal;
• A evolução dos hospitais de primeira referência em Moçambique desde a independência: entrevistas a políticos responsáveis.
Resultados
O distrito de saúde em Moçambique caracterizou-se, em 2001, por escassez de oferta de cuidados hospitalares, heterogeneidade de modelos organizacionais, de referenciação de doentes, de formas de organizar o financiamento, do quadro de recursos humanos e da
distribuição de medicamentos.
Em 2001, os 31 hospitais de primeira referencia (HPR), em Moçambique, serviam, 250.000 habitantes, tinham cerca de uma centena de camas, um médico, um técnico de cirurgia, bloco operatório, enfermarias de medicina, pediatria, cirurgia e obstetrícia/ginecologia, e escassa capacidade de realização de exames de imagem e de laboratório. Realizavam a sua missão num contexto de escassez de recursos. A comparação dos dados de Moçambique com os disponíveis a nível africano revela, para Moçambique, menos recursos e mais população sob responsabilidade. O papel e funções definidoras do HPR, no distrito de saúde em Moçambique são: i) a prestação de cuidados de saúde (Cirurgia de urgência; Valências de medicina, cirurgia,
pediatria e obstetrícia-ginecologia; exames complementares de diagnóstico e serviços de apoio: exames de imagem, laboratório, transfusão de sangue; actividades preventivas, não sendo esta função consensual); ii) Supervisão; iii) Formação e iv) Referência.
Os HPR são o nível mais negligenciado dos cuidados de saúde em Moçambique. Apesar da contínua presença de objectivos de desenvolvimento dos HPR nos documentos de planeamento, os HPR, basicamente, reabilitados, são praticamente os mesmos desde a independência. Já em
relação à sua actividade, ao número de profissionais e à sua qualificação (número de médicos e técnicos de cirurgia), parece ter havido uma evolução favorável.
Em termos internacionais, embora pareça haver concordância normativa em termos do que deve ser o hospital de distrito desde a década de 80, pouco se tem feito para monitorizar a implementação e desenvolvimento das suas funções.
Conclusões
Uma das formas das universidades contribuírem para as reformas é pela criação e organização de conhecimento. Este conhecimento é necessário a alguns níveis que a seguir se apresentam: 1. Conhecimento sobre financiamento, custos e despesas dos HPR e dos distritos de saúde.
Para fazer convergir os mecanismos de financiamento com as reformas dos CSP, necessárias para reorientar os sistemas de saúde, para a “Saúde para todos”, é necessário ter conhecimento de como é feito actualmente o financiamento dos distritos (que critérios, que quantias, que
processos, que dificuldades) e, dentro dos distritos, dos HPR.
2. Adequação dos meios técnicos aos problemas de saúde e resultados da intervenção dos HPR.
É necessário conhecer e monitorizar os problemas de saúde dos distritos, os recursos disponíveis, os obstáculos ao acesso aos cuidados e ao cumprimento da missão dos HPR, documentando a efectividade da intervenção dos HPR.
3. Papel social e político do hospital. O HPR tem uma função técnica, mas há outros papéis que estão menos documentados como os papéis social, económico e político.
4. Arranjos organizacionais no distrito e complementaridade de funções.
Persiste a necessidade de melhor documentar papéis, funções, objectivos e procedimentos entre as diferentes unidades de saúde do distrito ao nível distrital. Talvez seja desejável ter soluções distritais de complementaridade entre unidades sanitárias diferentes, atendendo ao contexto, mas isso deve ser descrito e avaliado.
5. Processos políticos de implementação dos distritos de saúde / sistemas locais de saúde.
Há necessidade de identificar as dificuldades de implementação dos HPR e do distrito de saúde, de analisar e clarificar o conhecimento sobre posições e actuações dos diferentes actores e interesses.
Em Moçambique, todas as reformas necessárias a melhorar o acesso, nomeadamente a cuidados de saúde hospitalares, a um nível próximo das populações e para um conjunto de serviços essenciais, vão exigir aumento de investimentos externos, reorientações de investimentos internos e fortalecimento interno nas capacidades de coordenação, negociação e regulação do Ministério da Saúde Moçambicano.
This thesis is about first referral hospitals (FRH) in a district health system based on primary health care principles. Its focus is on Mozambique. A district health system based on primary health care is a self-contained segment of the national health system. It comprises a well-defined population. It includes all institutions and individuals providing health care in the district. A district health system therefore consists of a large variety of interrelated elements that contribute to health in homes, schools, work places, and communities, through the health and other related sectors. It includes self-care and all health care workers and facilities, up to and including the hospital at the first referral level and the appropriate laboratory, other diagnostic, and logistic support services. Its component elements need to be well coordinated by an officer assigned to this function in order to draw together all these elements and institutions into a fully comprehensive range of promotive, preventive, curative, and rehabilitative health activities. The empirical evidence is scarce, since the end of the eighties, on what first referral hospitals are doing and if their reality is close to what has been written and decided about their functions in the district. Objectives This thesis aims to improve understanding of the contribution of first referral hospitals to the development of the Mozambican health system and to contribute to the development of the District Health System. The thesis was designed to achieve the following objectives: 1. to describe FRH in Mozambique and their evolution since Mozambique’s independence; 2. to describe the profile of the health district of Mozambique; 3. to describe the expected roles and functions of FRH in Mozambique since independence; 4. to identify the difference between the planned and observed roles and functions of FRH; 5. to contribute to understanding the current status of FRH in Sub-Saharan Africa Methods To achieve the objectives, a sequential explanatory design was used and four sub-studies were performed: • First referral hospitals in Sub-Saharan Africa: a systematic review of the literature; • First referral hospitals in Mozambican health system: a literature review; • First referral hospitals in Mozambican: cross-sectional study; • The development of first referral hospitals in Mozambique since independence: interviews with policymakers. Results and discussion The health district in Mozambique was characterized, in 2001, by a shortage of supply of hospital care, heterogeneity of organizational models, referral systems, and ways of organising their finances, human resources and distribution of medicines. In 2001, the 31 FRH in Mozambique served 250.000 inhabitants, had about a hundred beds, a physician, one assistant medical officer for surgery, one operating room, wards of medicine, pediatrics, surgery and obstetrics/gynecology, and little ability to perform imaging and laboratory tests. The comparison of the data available from other Sub-Saharan hospitals and Mozambique showed, for Mozambique, fewer resources and more population under FRH responsibility. The role and functions that define the HPR in the health district in Mozambique are: i) the provision of health care (Emergency surgery; Care in areas of medicine, surgery, pediatrics and obstetrics-gynecology; diagnostic exams and support services: imaging, laboratory, blood transfusion; prevention activities is not a consensual function), ii) supervision, iii) training and iv) reference. The FRH is the neglected level of health care in Mozambique. Despite the continued presence of development objectives for FRH in Mozambican strategic plans, FRH with some minor improvements, are virtually the same since independence. In relation to its activity, the number of professionals and their professional qualifications (number of physicians and assistant medical officers for surgery) FRH underwent a favourable evolution since independence. It seems that internationally, an agreement exists since the 80's about what FRH should be and do but little has been done to monitor the implementation and development of their functions Conclusions One of the ways universities contribute to health care reforms is by the creation and organization of knowledge. For FRH this knowledge is necessary at some levels that are listed below: 1. Knowledge on funding, costs and expenses of the FRH and health districts. To converge funding mechanisms with Primary Health Care reforms, necessary to reorient health systems for the "Health for all" objective, knowledge is needed on current mechanisms and paths of funding of health districts and within districts of FRH (what criteria, what amounts, which processes, difficulties).xiv2. Adequacy of technical resources to health problems and outcomes of FRH intervention. It is necessary to know and monitor health problems of districts, available resources, barriers to access care and barriers to the fulfilment of FRH mission, documenting the effectiveness of the intervention of FRH. 3. Hospital social and political role. The FRH has a technical role, but there are other roles that are less well documented as the social roles (e.g. employer) and political (nation building, State presence). 4. Organizational arrangements in the district: no gaps, no overlapping. There remains a need to better document the roles, functions, objectives and procedures among the different health units at district level. Even if flexible arrangements are desirable, where different districts distribute functions between the different health units in different ways, this should be described and evaluated. 5. Implementing District Health Systems – health policy analysis There is need to identify barriers to implementation of the District Health Systems and FRH, to describe the processes of implementation and to know the positions and actions of different actors. In Mozambique, all necessary reforms to improve access, including access to hospital care, to a level close to the populations and to a defined package of services will require increased foreign investment, shifts in domestic investment and strengthening of Ministry’s of Health of Mozambique coordination, negotiation and regulation capacities.
This thesis is about first referral hospitals (FRH) in a district health system based on primary health care principles. Its focus is on Mozambique. A district health system based on primary health care is a self-contained segment of the national health system. It comprises a well-defined population. It includes all institutions and individuals providing health care in the district. A district health system therefore consists of a large variety of interrelated elements that contribute to health in homes, schools, work places, and communities, through the health and other related sectors. It includes self-care and all health care workers and facilities, up to and including the hospital at the first referral level and the appropriate laboratory, other diagnostic, and logistic support services. Its component elements need to be well coordinated by an officer assigned to this function in order to draw together all these elements and institutions into a fully comprehensive range of promotive, preventive, curative, and rehabilitative health activities. The empirical evidence is scarce, since the end of the eighties, on what first referral hospitals are doing and if their reality is close to what has been written and decided about their functions in the district. Objectives This thesis aims to improve understanding of the contribution of first referral hospitals to the development of the Mozambican health system and to contribute to the development of the District Health System. The thesis was designed to achieve the following objectives: 1. to describe FRH in Mozambique and their evolution since Mozambique’s independence; 2. to describe the profile of the health district of Mozambique; 3. to describe the expected roles and functions of FRH in Mozambique since independence; 4. to identify the difference between the planned and observed roles and functions of FRH; 5. to contribute to understanding the current status of FRH in Sub-Saharan Africa Methods To achieve the objectives, a sequential explanatory design was used and four sub-studies were performed: • First referral hospitals in Sub-Saharan Africa: a systematic review of the literature; • First referral hospitals in Mozambican health system: a literature review; • First referral hospitals in Mozambican: cross-sectional study; • The development of first referral hospitals in Mozambique since independence: interviews with policymakers. Results and discussion The health district in Mozambique was characterized, in 2001, by a shortage of supply of hospital care, heterogeneity of organizational models, referral systems, and ways of organising their finances, human resources and distribution of medicines. In 2001, the 31 FRH in Mozambique served 250.000 inhabitants, had about a hundred beds, a physician, one assistant medical officer for surgery, one operating room, wards of medicine, pediatrics, surgery and obstetrics/gynecology, and little ability to perform imaging and laboratory tests. The comparison of the data available from other Sub-Saharan hospitals and Mozambique showed, for Mozambique, fewer resources and more population under FRH responsibility. The role and functions that define the HPR in the health district in Mozambique are: i) the provision of health care (Emergency surgery; Care in areas of medicine, surgery, pediatrics and obstetrics-gynecology; diagnostic exams and support services: imaging, laboratory, blood transfusion; prevention activities is not a consensual function), ii) supervision, iii) training and iv) reference. The FRH is the neglected level of health care in Mozambique. Despite the continued presence of development objectives for FRH in Mozambican strategic plans, FRH with some minor improvements, are virtually the same since independence. In relation to its activity, the number of professionals and their professional qualifications (number of physicians and assistant medical officers for surgery) FRH underwent a favourable evolution since independence. It seems that internationally, an agreement exists since the 80's about what FRH should be and do but little has been done to monitor the implementation and development of their functions Conclusions One of the ways universities contribute to health care reforms is by the creation and organization of knowledge. For FRH this knowledge is necessary at some levels that are listed below: 1. Knowledge on funding, costs and expenses of the FRH and health districts. To converge funding mechanisms with Primary Health Care reforms, necessary to reorient health systems for the "Health for all" objective, knowledge is needed on current mechanisms and paths of funding of health districts and within districts of FRH (what criteria, what amounts, which processes, difficulties).xiv2. Adequacy of technical resources to health problems and outcomes of FRH intervention. It is necessary to know and monitor health problems of districts, available resources, barriers to access care and barriers to the fulfilment of FRH mission, documenting the effectiveness of the intervention of FRH. 3. Hospital social and political role. The FRH has a technical role, but there are other roles that are less well documented as the social roles (e.g. employer) and political (nation building, State presence). 4. Organizational arrangements in the district: no gaps, no overlapping. There remains a need to better document the roles, functions, objectives and procedures among the different health units at district level. Even if flexible arrangements are desirable, where different districts distribute functions between the different health units in different ways, this should be described and evaluated. 5. Implementing District Health Systems – health policy analysis There is need to identify barriers to implementation of the District Health Systems and FRH, to describe the processes of implementation and to know the positions and actions of different actors. In Mozambique, all necessary reforms to improve access, including access to hospital care, to a level close to the populations and to a defined package of services will require increased foreign investment, shifts in domestic investment and strengthening of Ministry’s of Health of Mozambique coordination, negotiation and regulation capacities.
Descrição
Palavras-chave
Saúde pública Hospitais Hospitais de primeira referência Cuidados de saúde primária Distrito de saúde Centro de saúde Sistema de saúde Actores sociais Políticas de saúde Moçambique
Contexto Educativo
Citação
Editora
Instituto de Higiene e Medicina Tropical