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Aim: Carry out a descriptive and organizational analysis of the Oral Health warehouse of the Municipal Health Department in a city in the South of Brazil in order to assist in its management. Methods: This case study is a descriptive and organizational analysis of the Oral Health warehouse of the Municipal Health Department. The Always Better Control (ABC) curve, and Vital Essential Desirable (VED) analysis and ABC-VED matrix was performed, in order to assist the warehouse's management. The first stage was a descriptive situational analysis. In the second stage, the supplies were classified by the ABC curve and the VED analysis. Subsequently, the ABC-VED matrix was carried out. Results: Changes were made together with the local manager, such as organizing the products, labeling the items in the proper places and, carrying out the inventory more frequently (monthly). Furthermore, the method the first in, first out (FIFO) was applied. Of the 120 inputs, 13% corresponded to 65% of the expenditures (class A). In class B, close to 26% of the items accounted for 25% of the expenditures. Class C accounted for 10% of the costs and 61% of total materials. In the VED analysis, 19.2% of the items were classified as vital, and 62% and 19% as essential and desirable, respectively. In ABC-VED matrix, 23.3% (72%) belonged to category I, while 63% (25.6%) and 13% (2%) were classified in categories II and III, respectively. Conclusion: The use of inventory control tools granted a better storage of products and made it easier to find the items. The ABC curve, VED analysis and ABC-VED analysis allowed greater control, considering both cost and importance of supplies. [ABSTRACT FROM AUTHOR]

Background: COVID-19 presented great challenges for not only those in the field of health care but also those undergoing medical training. The burden on health care services worldwide has limited the educational opportunities available for medical students due to social distancing requirements., Objective: In this paper, we describe a strategy that combines telehealth and medical training to mitigate the adverse effects of the COVID-19 pandemic., Methods: A toll-free telescreening service, Telecoronavirus, began operations in March 2020. This service was operated remotely by supervised medical students and was offered across all 417 municipalities (14.8 million inhabitants) in the Brazilian state of Bahia. Students recorded clinical and sociodemographic data by using a web-based application that was simultaneously accessed by medical volunteers for supervision purposes, as well as by state health authorities who conducted epidemiological surveillance and health management efforts. In parallel, students received up-to-date scientific information about COVID-19 via short educational videos prepared by professors. A continuously updated triage algorithm was conceived to provide consistent service., Results: The program operated for approximately 4 months, engaging 1396 medical students and 133 physicians. In total, 111,965 individuals residing in 343 municipalities used this service. Almost 70,000 individuals were advised to stay at home, and they received guidance to avoid disease transmission, potentially contributing to localized reductions in the spread of COVID-19. Additionally, the program promoted citizenship education for medical students, who were engaged in a real-life opportunity to fight the pandemic within their own communities. The objectives of the education, organization, and assistance domains of the Telecoronavirus program were successfully achieved according to the results of a web-based post-project survey that assessed physicians' and students' perceptions., Conclusions: In a prolonged pandemic scenario, a combination of remote tools and medical supervision via telehealth services may constitute a useful strategy for maintaining social distancing measures while preserving some practical aspects of medical education. A low-cost tool such as the Telecoronavirus program could be especially valuable in resource-limited health care scenarios, in addition to offering support for epidemiological surveillance actions., (©Thiago Cerqueira-Silva, Roberto Carreiro, Victor Nunes, Louran Passos, Bernardo F Canedo, Sofia Andrade, Pablo Ivan P Ramos, Ricardo Khouri, Carolina Barbosa Souza Santos, Jedson Dos Santos Nascimento, Aurea Angélica Paste, Ivan De Mattos Paiva Filho, Marília Santini-Oliveira, Álvaro Cruz, Manoel Barral-Netto, Viviane Boaventura. Originally published in JMIR Public Health and Surveillance (http://publichealth.jmir.org), 04.03.2021.)

Purpose: The present research aims to contribute to the comprehension of the product development process (PDP) of Assistive Technology (AT) through methodological multi-case studies in Brazil. The following considerations presented in the study are part of a Master's degree thesis, conducted from 2013 to 2015. Methodology: The research adopted a multi-case study methodology by selecting four product developers from the Assistive technology field in Brazil, focusing on physical disability. Results: According to the findings, this research discusses the possible influences of Emotional Collaborative Design on the process of Assistive Technology, aiming at enhancing new perspectives about such tools on the product development process. As a result, it was possible to set a delimitation of PDP of AT stages in the four cases approached, in most of the methodological steps empirically developed. Conclusion: Final considerations of the study, collaborate with the comprehension of the assistive product development, stating there is still a little emphasis on the design concepts throughout these processes, also illustrates the necessity for further studies about the product development in the area.Implications for rehabilitationThe visualization of a still scarce dialogue between the multiple areas that could contribute for AT development;The potential correlation between high dissatisfaction in several issues regarding use of ATs and the poor understanding of user needs;The predominance of a great functionality emphasis, and the negligence of the individual's emotional in AT development;The understanding that product design maybe is still poorly applied/understood in this field.

Background: Pharmaceutical care services have been recognized as the most highly regarded professional pharmacy practice model that allows the identification, intervention, and resolution of drug related problems. This practice provides significant clinical outcomes and can reduce direct and indirect costs for health systems. However, its implementation can be complex and challenging, needing study experiences that aims at overcoming obstacles, especially in free and universal healthcare systems. The objective of this study is to evaluate the implementation of Ambulatory Care Pharmacy services for older adults at Paulista Institute of Geriatrics and Gerontology (IPGG), which is recognized in the city of São Paulo for offering pharmaceutical care services for over 10 years continuously. This initiative and process is independent of external academic interventions or educational institutions. It is hoped that the results may also contribute to advancing the implementation of pharmaceutical care service in similar health systems., Design: This is a case study using multiple sources of data. Qualitative and quantitative data were collected from institutional documents, by participant observation and interviews. Initial themes were identified by content analysis and analyzed under the context-mechanism-outcome configurations (CMO Configurations) in realistic evaluation., Setting: Geriatrics and Gerontology Institute of São Paulo (known as IPGG)., Participants: Eleven health professionals and three pharmaceutical care service users., Results: Three CMO configurations were identified and accepted: "Scenario Construction mediated by educational processes", "Contribution to complex needs resolution", and "Organizational Visibility". The CMO (Context-Mechanism-Outcomes) configuration "Logistic activities discourage clinical pharmaceutical services implantation" was denied due to the influence of accepted CMOs., Conclusions: Educational processes which value transdisciplinary knowledge exchanges provide resources required to overcome important obstacles present during pharmaceutical care implementation. Thus, providing and seeking knowledge to build and offer context-consistent clinical health services as well as fulfilling organizational environment requirements can be the key to implement pharmaceutical care service.

The creation of consensus and agreement among managers of the Unified Health System (SUS) was analyzed in Regional Interagency Commissions of two metropolitan scenarios, by means of a multiple case study for comparative analysis between the Metropolitan Region of Fortaleza-Ceará and the Metropolitan Region of Salvador-Bahia. The theoretical reference used was based on Mario Testa's work and on Habermas' Theory of Communicative Action. The data production merged documental analysis, interviews with managers of state, municipal and federal levels with direct observation of meetings of the Regional Interagency Commission, the State Health Council, the Bipartite Interagency Commission, meetings between central and regional levels, in addition to extended meetings of the Health Municipal Offices Council, in both states. The problems related to Agreed and Integrated Programming and to the underfunding of SUS were common points in the scenarios studied. Such problems are interlinked and interfere in an important way in the interinstitutional relations between the municipalities, highlighting the dispute for resources as an obstacle for the creation of consensus and agreement, based on the dialogue and understanding between actors.

This paper analyzes policies and management tools aimed at the regional organization of specialized care in Ceará. A case study was developed in a health region based on 18 interviews with regional and municipal managers and health professionals and visits to services. Several factors enabled advances in the organization of specialized care: the preponderant role of the State Health Secretariat in the regional health coordination of actions and services, providing infrastructure, financing with redistribution of resources and technical support to municipalities; implantation of regional Polyclinic and Specialized Dental Care Centers through the Public Health Consortium; and logistics support of transport system. The institutional framework of Municipal Health Secretaries Council and the participatory functioning of the Regional Interagency Committee provided adequate space for the regional governance. Challenges remain for the integration of the network, qualification of care regulation, and provision of hospital care in the region. The results reinforce the importance of public and universal arrangements for the provision of comprehensive health care that can reduce inequities.

Micro-costing studies still deserving for methods orientation that contribute to achieve a patient-specific resource use level of analysis. Time-driven activity-based costing (TDABC) is often employed by health organizations in micro-costing studies with that objective. However, the literature shows many deviations in the implementation of TDABC, which might compromise the accuracy of the results obtained. One reason for that can be attributed to the non-existence of a step-by-step orientation to conduct cost analytics with the TDABC specific for micro-costing studies in healthcare. This article aimed at exploring the literature and practical cases to propose an eight-step framework to apply TDABC in micro-costing studies for health care organizations. The 8-step TDABC framework is presented and detailed exploring online spreadsheets already coded to demonstrate data structure and math formula building. A list of analyses that can be performed is suggested, including an explanation about the information that each analysis can provide to increase the organization capability to orient decision making. The case study developed show that actual micro-costing of health care processes can be achieved with the 8-step TDABC framework and its use in future researches can contribute to increase the number of studies that achieve high-quality level in cost information, and consequently, in health resource evaluation.

Purpose: Although there are general methodologies for lean implementation in manufacturing companies, a specific methodology for the implementation of lean healthcare in hospitals has not been addressed by the literature. Addressing this gap, the purpose of this paper is to develop a practice-driven methodology for implementing lean in hospital operations., Design/methodology/approach: Three case studies were conducted to collect evidence on the lean implementation process in Brazilian hospitals. From empirical evidence and literature, the implementation methodology was proposed and submitted to critical assessment by experts from the field., Findings: The process of lean implementation was very similar in all cases, triggered by strategic planning and operationalized by continuous improvement projects. On the other hand, in all cases, the lean implementation teams had to deal with employees' resistance. These findings were valuable inputs to the development of the implementation methodology. After refinement, it was proposed a feasible, useful and user-friendly methodology., Research Limitations/implications: The proposed methodology was raised from the practice through case study research. However, the proposed methodology was not fully applied, and the associated performance measures were not elaborated in this paper. Therefore, more case studies and applications will be necessary to generalize the findings., Practical Implications: The methodology provides practical guidelines that support lean implementation in hospital operations. Although it demands adaptations for each specific hospital setting, this initial step may encourage hospital managers to start the lean journey., Originality/value: This study addressed the gap in the literature regarding the lack of methodologies for implementing lean healthcare in hospital operations. The methodology synthesizes the knowledge, principles and tools of lean thinking that can be applied in hospital operations.

Background: In the United States (US) and Brazil, obesity has emerged as a health epidemic. This article is driven by the following research questions: how did the US and Brazil's federal institutions respond to obesity? And how did these responses affect policy implementation? The aim of this article is therefore to conduct a comparative case study analysis of how these nations' institutions responded in order to determine the key lessons learned., Methods: This study uses primary and secondary qualitative data to substantiate causal arguments and factual claims., Results: Brazil shows that converting preexisting federal agencies working in primary healthcare to emphasize the provision of obesity prevention services can facilitate policy implementation, especially in rural areas. Brazil also reveals the importance of targeting federal grant support to the highest obesity prevalence areas and imposing grant conditionalities, while illustrating how the incorporation of social health movements into the bureaucracy facilitates the early adoption of nutrition and obesity policies. None of these reforms were pursued in the US., Conclusions: Brazil's government has engaged in innovative institutional conversion processes aiding its ability to sustain its centralized influence when implementing obesity policy. The US government's adoption of Brazil's institutional innovations may help to strengthen its policy response.

The training of future physicians should be concurrent with the development of different skills and attitudes. This warrants the need to regularly provide students with opportunities for self-development throughout their academic career. This approach was exemplified in a medical school in the Brazilian Amazon, where students were allowed to play the role of high school teachers. As part of this exercise, they conducted reinforcement classes for high school students to increase the number of university admissions. The medical students were solely responsible for organizing and implementing this project, giving them the opportunity to develop teaching and leadership skills, enhance their understanding of communication and administration and contribute toward the society.

Background: The Community Health Workers (CHWs) Programme was launched in Luanda, Angola, in 2007 as an initiative of the provincial government. The aim of this study was to assess its implementation process., Methods: This is a case study with documental analysis, CHWs reports data, individual interviews and focus groups., Results: Until June 2009, the programme had placed in the community 2,548 trained CHWs, providing potential coverage for 261,357 families. Analysis of qualitative data suggested an association of CHWs with improvements in maternal and child access to health care, as well as an increase in the demand for health services, generating further need to improve service capacity. Nevertheless, critical points for programme sustainability were identified., Conclusions: For continuity and scaling up, the programme needs medium- and long-term technical, political and financial support. The results of this study may be useful in strengthening and reformulating the planning of the CHWs programme in Luanda and in Angola. Moreover, the lessons learned with this experience can also provide insight for the development of CHWs programmes in other parts of the world. By means of cooperation, Brazil has supported the implementation of this CHWs programme and can potentially contribute to its improvement.

Background: This article presents the results of an investigation into the thermal aspect of workplaces of the metallurgical branch of furniture manufacturing, looking for the number of dissatisfied people in the environment., Objectives: This study aims to analyze the thermal suitability of a metallurgical industrial environment, from four interpretations of vote +1/-1 (slightly warm or slightly cool) on the thermal sensation range, reported by workers., Methods: The methodological approach consists of quantitative research and a literature review set for this work, composed of spreadsheets and statistical processing of data. Data collection took place through the use of environmental variables measurement equipment and software for statistical assistance., Results: The results indicate an average above 35% of workers dissatisfied with the environment, thus, portraying the lack of suitability., Conclusions: It was noted, further, that, although average temperatures may be between 21°C to 28°C, workplace improvements can be made, so that the thermal sensations will be satisfactory.

Few steps like turning off the tap while brushing your teeth, turn off the lights when leaving a room, recycle waste or using recycling bags are considered sustainable attitudes. Sustainable development is one that meets the needs of the present generation without compromising the future generations and it doesn't deplete resources for the future. Consume with conscious is a sustainable habit and usability of products contributes to this. The goal of this paper is to prove that the usability of software contributes positivity or negativity for sustainability. By calculating the amount of electrical power dissipated by an electronic device, you can discover the amount of energy lost by it, and consequently, to relate this quantity with the amount charged by the concessionaire for each kWh of energy used. It was concluded that a software with low usability cause users to lose a lot of time interacting with it and thus spend more energy and money that goes against the concept of sustainability.

The purpose of this study was to assess the benefits of an exercise program associated to the educational phase of the "Back School Program" in the quality of life of workers from a cigar factory. This is a case study conducted over four months with three activities a week, two times a day, with the third day devoted to educational activities, focusing on healthy lifestyle, correct posture, postural orientations, daily living and work activities, work motivation, and other issues.

A usability evaluation technique to evaluate user interfaces is introduces. The technique is effective and affordable for small manufacturing companies. By using this technique, an integration of users' feedbacks and some usability concepts, a product can be 3 times easier to use among potential users and more than 5 times easier to use among motivated users. In addition, the technique can be implemented with the company's employees as participants.

Several people buy products that they will never use or even know what for. Feelings associated with pleasure, spontaneity and possession of something are reasons why people buy products without considering if they really need it or not if it will be useful or not, etc.. The collective buying sites are going up and offer products and services with great discounts. This study aims to relate the emotional design and usability concerning to collective buying sites and identify the reasons that influence people when it comes to buy something online.

This work is based on the study of pioneering sustainable product development initiatives, and the analysis was guided by the cradle-to-cradle concept, which sees the waste of a given process as raw material for another, just like it happens in nature. Several studies on human factors have focused on factory conditions and workers dealing with product assembly. This research, however, relates more to consumer behavior, product use and end-of-life. The purchase of more environmentally- friendly products, in particular, is heavily influenced by the information made available by the companies. In this scenario, this article discusses three early but notable efforts on green product development, focusing on the disclosure practices adopted by the companies regarding the composition of their products. Research and data collection has focused on the footwear industry, whose products satisfy a basic human need and are ubiquitous worldwide. The use of hazardous materials and chemicals in shoe manufacturing, particularly the use of chromium - a highly toxic element - in addition to toxic solvents and adhesives and non-recyclable synthetic materials can pose serious risks to human health and the environment, even though the consumer usually is not aware of all the relevant characteristics of this kind of product.

Complexity theory has been adopted by a number of studies as a benchmark to investigate the performance of socio-technical systems, especially those that are characterized by relevant cognitive work. However, there is little guidance on how to assess, systematically, the extent to which a system is complex. The main objective of this study is to carry out a systematic analysis of a SAMU (Mobile Emergency Medical Service) Medical Regulation Center in Brazil, based on the core characteristics of complex systems presented by previous studies. The assessment was based on direct observations and nine interviews: three of them with regulator of emergencies medical doctor, three with radio operators and three with telephone attendants. The results indicated that, to a great extent, the core characteristics of complexity are magnified) due to basic shortcomings in the design of the work system. Thus, some recommendations are put forward with a view to reducing unnecessary complexity that hinders the performance of the socio-technical system.

The objective of this study was to describe the network structure and factors associated with collaboration in two networks that promote physical activity (PA) in Brazil and Colombia. Organizations that focus on studying and promoting PA in Brazil (35) and Colombia (53) were identified using a modified one-step reputational snowball sampling process. Participants completed an on-line survey between December 2008 and March 2009 for the Brazil network, and between April and June 2009 for the Colombia network. Network stochastic modeling was used to investigate the likelihood of reported inter-organizational collaboration. While structural features of networks were significant predictors of collaboration within each network, the coefficients and other network characteristics differed. Brazil's PA network was decentralized with a larger number of shared partnerships. Colombia's PA network was centralized and collaboration was influenced by perceived importance of peer organizations. On average, organizations in the PA network of Colombia reported facing more barriers (1.5 vs. 2.5 barriers) for collaboration. Future studies should focus on how these different network structures affect the implementation and uptake of evidence-based PA interventions., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

The objective of this article is to describe and analyze the development of indicators used to identify strengths and deficiencies in public dental healthcare services in the municipality of Cambé, Paraná. The methodology employed was a historical-organizational case study. A theoretical model of the service was developed for evaluation planning. To achieve this, information was collected from triangulation of methods (interviews, document analysis and observation). A matrix was then developed which presents analysis dimensions, criteria, indicators, punctuation, parameters and sources of information. Three workshops were staged during the process with local service professionals in order to verify whether both the logical model and the matrix represented the service adequately. The period for collecting data was from November 2006 through July, 2007. As a result, a flowchart of the organization of the public dental health service and a matrix with two-dimensional analysis, twelve criteria and twenty-four indicators, was developed. The development of indicators favoring the participation of people involved with the practice has enabled more comprehensive and realistic evaluation planning.

The formation of healthcare consortia is a management strategy adopted by a number of cities in Brazil in order to minimize the difficulties the population has in access to services of greater technological complexity. As administrators are the main governmental actors in the promotion of this strategy, the aim of the present study was to identify the motives, expectations and difficulties faced by the mayors, and secretaries of health that make up a healthcare consortium undergoing a formation process in the rural, coastal zone of the state of Pernambuco. A descriptive, qualitative, case study was conducted. Data collection was carried out through semi-structured interviews held with mayors and secretaries of health of the municipalities participating in the consortium. Data were analyzed by means of content analysis, using the NVivo 2.0 software program. The administrators cited difficulty in access to specialized services and the high cost of transporting patients to distant locations for treatment as motives for the formation of the consortium. With the implantation of this healthcare strategy, the expectations are a reduction in costs regarding patient transportation, an increase in access to services of greater complexity, and negotiations with other spheres of government. The main difficulties faced are political-partisan conflicts and excessive bureaucracy. Although there were no considerable divergences in the administrators' perceptions, it was evident that those who initiated the formation of the consortium offered a deeper, more detailed discourse, thereby demonstrating greater involvement when compared to those who offered continuity to the process., (Copyright © 2010 John Wiley & Sons, Ltd.)

The objective of this paper is to demonstrate that a combination of a behavior-based monitoring process--using an at-risk behavior and unsafe condition observation system--and an observation-based safety adherence monitoring process that can indicate the compliance level with well-defined and agreed safety critical aspects and operational practices and procedures will be an effective safety management tool. This tool herein described represents a particular case, developed by a Praxair Inc. subsidiary in Brazil. Other safety surveillance systems usually adopted in industrial environments can rarely be used on construction sites. They also do not share information, knowledge and skills among the safety staff and other professionals invited to observe, usually covering specific tasks or specific professionals only, not a complete working area, which causes functional observing and monitoring limitations in terms of capturing behaviors and environmental safety issues. This tool also offers a wide range of learning opportunities and continuous improvement.

Objective: To analyze work organization in psychosocial healthcare services from the logic of the service management field., Methods: Organizational analysis was performed, using a case study in a psychosocial healthcare service located in the city of São Paulo, Southeastern Brazil, between 2006 and 2007. A total of five sources of information were analyzed: Ministério da Saúde (Brazilian Ministry of Health) documents, research reports made in the service studied, service records, interviews with healthcare workers and managers and simple observation. Interviews dealt with objectives, results and assessment of work process. Each source was treated differently, according to its purpose. A subsequent dialogue about the results obtained aimed to make a set of observations on which the case study was founded., Results: The service proposes to deliver a very intangible result, which views the user in their social context. The intended change in the user's conditions was described as 'the person living better'. Such condition is difficult to be defined and understood in terms of the details and limits of this change, thus hindering measurement of results. In addition, the work process involves activities which are not routinary, not predictable and sometimes simultaneous, so that the team finds it difficult to recognize and legitimize efforts made to perform work, a fact described as 'work invisibility' by workers., Conclusions: The assessment process was found to be a complex aspect of this intangibility, associated with inadequacy and insufficiency of the municipal health system's management structure to include a service of this nature. Results enabled better understanding of a field of work where workers' and users' subjectivity is inherent in the service management process.

This article presents the results of a case study aimed at identifying challenges for the delivery of primary health care in a health district in the city of São Paulo, Brazil, considering comprehensiveness as a central device for organizing work at this level of care. Five units in the district's primary care network were studied. We collected the data by observing work routines and flows, conducting interviews with managers and health professionals from different backgrounds, and through focus groups with family health teams. The analysis shows a mismatch between users' characteristics and their presumed needs and the heterogeneity of the health professionals' perceptions concerning their work. Lack of staff and time and difficulties with referrals were the main problems identified by interviewees.

Objective: To comprehend the stigma against people with mental disorders still persists in the culture of general hospitals and acts as a limiting factor in the implementation of psychiatric units in general hospitals in Brazil., Methodological Procedures: A qualitative social survey was outlined based on action research strategy as of the agreement to adopt a psychiatric unit in a general hospital in Taubaté, Southeastern Brazil. Data was obtained through interviews, participant observation and talks on the psychiatric unit project given to the hospital's clinical staff., Results: The investment made by the healthcare authority enabled the stigmatizing conceptions (violence, moral weakness and untreatability) present in the hospital culture in question to be resignified by means of clinical and sanitary discussions, which enabled the implementation of the psychiatric unit. The analysis showed that these concepts persist in this context because of a healthcare system that limits the access of people with mental disorders., Conclusions: The attitude of the healthcare authority, who decided to adequately fund the general hospital's psychiatric unit and exerted his influence over the hospital, was decisive for the outcome of the case. The main difficulty in implementing psychiatric units at general hospitals is not the overcoming the existing stigma in the culture of general hospitals, but rather a difficulty which is strategic in nature: the lack of an affirmative policy for these units.

Since the 1990 s, international guidelines have recommended the incorporation of STD/AIDS prevention in primary care. In Brazil, the Ministry of Health has made investments to include such preventive activities. This in-depth case study is an evaluation of the implementation of these activities in a family health unit in Greater Metropolitan São Paulo. The study analyzed the unit's activities as a whole and the specific STD/ AIDS prevention activities by means of direct observations and semi-structured interviews with the unit's professional health staff. The unit's technological characteristics were similar to those of traditional Brazilian primary care services, with limited potential for achieving the principle of comprehensive care. STD/AIDS prevention activities had been incorporated, but were devoid of important technological meanings like dialogue and specific attention to users' uniqueness. This characteristic and others reveal a tension between the program's technological proposals and the current technological profile of primary care. However, the identification of this tension could favor reflection on new values in routine primary care, thereby favoring the achievement of more comprehensive technological arrangements.

Understanding the effects of health decentralization policies in Brazil requires different methodological approaches to capture the issue's complexity from distinct angles. Five case studies were thus performed to evaluate the degree of implementation of components related to decentralization of the health system management in selected municipalities (counties) in Bahia State, Brazil. A logical model was elaborated with definitions related to policy goals. A comparative study of the five municipalities, considered "exemplary cases", showed that decentralization alone does not explain the organizational changes in the municipal health systems. Local government characteristics such as the municipal master plan, governing capacity, and governance proved important for heath care changes. The main problems and insufficiencies were found in the system's management and quality of healthcare delivered to the population. The authors discuss their findings and identify critical areas for future interventions with special emphasis on the institutionalization of planning and evaluation and the development of inter-sector projects.

In Brazil, genetic counseling is usually available in university-affiliated medical genetics services located in tertiary centers that provide cancer diagnosis and treatment. The present study aims to describe the structure and characteristics of three cancer genetic services in Brazilian public health care hospitals and discuss alternatives for the identification and prevention of hereditary cancer syndromes in developing countries. The three services presented here are similar in their structure, routine procedures for cancer risk estimation and criteria for the indication of genetic testing. They all demand that genetic counseling be an essential part of the cancer risk evaluation process, before and after cancer predisposition testing. However, when high-risk patients are identified, all services describe difficulties in the access and continuity of genetic and medical services to the patient and his/her at-risk relatives. The services differ in the type of population served, reflecting distinct referral guidelines. This study emphasizes the importance of the creation of new cancer genetic services in other Brazilian regions and the necessity for establishing a collaborative network to facilitate the diagnosis and research of cancer genetic syndromes., (Copyright 2007 S. Karger AG, Basel.)

The Brazilian Ministry of Health in collaboration with the Municipality of Motuca and the School of Public Health at the University of São Paulo set up in 2002 the Motuca Healthy Municipality project with the aim of improving the population's health and quality of life. The project used a participatory and holistic approach, which addressed the social determinants and structural inequities, and called for strategies of community empowerment, social participation, intersectoral networking and good governance. All local and public actors from rural and urban areas were consulted and participated in the project to collect information on the living conditions and challenges to better wellbeing. This participatory methodology allowed in turn developing cultural and socially appropriate initiatives to improve local governance and standards of living on a long-term basis. Although there is still the challenge to maintain the momentum and reenergize the efforts, the project serves as a model for further efforts to evaluate the effectiveness of participatory intervention and research methodologies to promote health and well-being in communities.

This paper discusses Brazil's efforts to provide essential medicines for its population while meeting international trade obligations. In the 1950s and 1960s, Brazil's pharmaceutical industry was largely overtaken by foreign companies. To counteract this, Brazil enacted a law in 1971 that allowed the production of patented drugs in order to provide affordable medicines, encourage research and development, and reduce dependency on imports. Eventually, pressure from the United States government (through tariffs and sanctions) drove Brazil to introduce pharmaceutical patent laws. Local interests prevailed, however, through Brazil's liberal interpretation of the TRIPS Agreement, which included a provision that pharmaceutical products must be "worked" or manufactured locally or the government could turn to the use of compulsory licensing. Brazil's willingness to use the threat of compulsory licensing compelled drug companies to lower HIV/AIDS drug prices substantially. Finally, the paper discusses how Canada can facilitate improving drug access in Latin America through helping Brazil expand its role as a manufacturer and providing medicines to countries without manufacturing capabilities.

This article analyzes the management system in a health district in the State of Rio Grande do Sul, Brazil, through qualitative analysis, using a case study as the methodology and macro-organization theory as the analytical framework. For the current management system in the 6th Health Region, a clear mission statement and wide acceptance by health workers are facilitating factors for the current organizational practices within the health system. Nevertheless, the way health coordinators are currently prioritizing their time has diverted necessary resources from critical problems towards more remedial issues. The 6th Health Region has encouraged social control (or public oversight) in order to improve accountability. However, there is room for improvement in quality assurance management, since there were no well-defined goals, objectives, or accountability. Decentralized consultancy provided to the municipalities and the funding model itself have both promoted decentralization and autonomy, although the strategy requires better regional integration and greater commitment in managerial practices.

This paper presents part of a doctoral dissertation that developed a theoretical model capable of identifying managerial performance in various administrative levels of a Municipal Health Secretariat. The methodology was a case study of the Municipal Health Secretariat in Campo Grande, capital of the State of Mato Grosso do Sul, Brazil. The theoretical model was based on recent debates emphasizing the need to modernize public administration, with an emphasis on efficacy and efficiency in the organizations as a whole. Some 31 interviews were conducted with the objective of identifying the managers' performance, through questions based on their daily practices in planning, organization, direction, and control. Managers from higher hierarchical levels obtained better results, while those in basic health units generally developed activities and complied with decisions passed down by imposition, with limited capacity to plan, organize, or control activities pertaining to their management sphere. These results stem partially from the charismatic leadership and centralizing administration of the current management in the municipal health system.

This case study is based on research performed by the Bahia State Health Secretariat (SESAB), aimed at analyzing management practices during the implementation of a State government administrative reform. The institutional agenda shows evidence of limited participation by civil society and technical and operational staff in problem selection and prioritization, resulting from a work process pressured by high-level executive government staff. Decisions regarding "output" (projects, services, and activities) were made under the responsibility of subordinate operational levels and did not appear as issues in the institutional routine. Concerns related to "input" (financial and human resources) consumed most of the high-level efforts, with internal and external negotiations and compromises to assure access to them. Meanwhile the possible "outcome", namely public health status, represents the "occult subject" of the institutional discourse. Information emerges in institutional disputes as a technical "power resource" in its medical, epidemiological, health, and administrative dimensions. The issue of government "representation" and allied interests is based on ideological dispositions and authoritarian practices, thus contradicting the need for management transparency and modernization.

Purpose: This paper aims to investigate whether an organisation's configuration, with regard to its operating environment, could have a bearing on the learning that occurs within the organisation because the configuration can be considered an artefact capable of enabling learning and capable of facilitating the storage and utilisation of the results of learning. This raises an interesting question about the ability of organisations to shape the configuration that enables and facilitates them, which in turn would shape the learning itself., Design/methodology/approach: Reported in this paper is research in healthcare organisations in Brazil and Australia that use a multidisciplinary model of care delivery which test these relationships., Findings: The paper's findings indicate that in the Brazilian case learning has to do with the formal acquisition of knowledge for use within professions, by professionals who are in practice and teaching. In the Australian case learning has to do with the flexible acquisition of knowledge across professions, within and between teams. ORIGINALITY/APPROACH: This paper is useful to those wishing to facilitate learning in an organisation.

With 773 beds and 3696 employees, the Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto (HCFMRP)-Universidade de São Paulo, is one of the largest medical institutions in Latin America. The complete process of prescribing and distributing medication at HCFMRP involves the following stages: prescribing (physicians); ordering (infirmary); separating and dispensing (main drugstore); verifying and administering (infirmary). This was a manual process, normally taking place in the morning. Bottlenecks were inevitable and the risk of errors was elevated. An information system (IS) was devised and implemented with a view to controlling such problems. This article addresses the construction of this system and reports on a survey in which different groups of users have evaluated the project.

A general approach to curriculum design in the context of Problem-Based Learning (PBL) is outlined. Ten general 'steps' for problem-based curriculum development are proposed, using the case study methodology to describe the underlying iterative process. Examples are given from the case of the development of a public health professions education curriculum. The process starts with defining the purpose of the curriculum. General objectives are generated in a top-down fashion. The prior knowledge, skills and misconceptions of future students are considered. A preliminary schedule of the curriculum is developed, including sketches of unit blueprints. These are further elaborated. Unit subgoals are related to planned educational activities. Only then, are the learning materials created, with problem writing as the most important aspect. In developing a problem-based curriculum, assessment deserves special attention, because of its influence on the learning process. Finally, educational organization, curriculum management and evaluation procedures are considered.

The evaluation of the current definition, classification and quantification of hospital waste being carried out by hospitals in different countries is extremely important to avoid improper waste management practices. In this work, the waste management from a 400-bed Brazilian hospital which generates about 386 kg per day of hospital waste was studied. The generation rate of just over one kg per bed per day was considered small, although more than 50% of the waste from non-isolation wards consisted of food waste. It was also interesting to note that the highest generation rate per patient per day was found in private rooms and the lowest rate in the public ones. The waste practices used in this hospital are discussed in terms of current Brazilian legislation.

This article describes the organizational characteristics of the UNIMED medical cooperative in Brazil. After an overview of UNIMED's share in the current health plan market, the author analyzes its organizational structure, historical evolution, and contractual regimen with member physicians, including the formula used to calculate the payment schedule for physician services. The plan currently includes 367 local member cooperatives, operating in over 80% of Brazil's counties, with 41% of existing physicians to serve 7% of the population. The organization's history began with local cooperatives and subsequently federations, the confederation, and other companies in the group. The organizational design and dynamics favor a high degree of decentralization and autonomy, subordination of all components in the system to the physician cooperative command, and the occurrence of internal disputes and conflicts between individual interests and those of the organization.

This study outlines the beginnings and principles of the "Participatory" Movement (MP), which was created in opposition to the policies developed by the administration of the Brazilian Association of Nursing (ABEn). It starts in the 1980's, and criticizes ABEn for: a) reproducing the official policies and the medical industry's interest; b) being a centralizing and authoritarian organization; c) focusing mainly on the scientific and cultural development of nurses, while minimizing the importance of political-professional reflection, as well as the role of the profession and professional associations in the social-historical context; d) not participating in the formulation of public health policies. The "Participatory" Movement wins the elections of ABEn and takes over the association in 1986. The results of this new practice are still under construction. The achievements and withdrawals of ABEn will depend on our capacity of building a profession that is technically competent, critical, creative and, above all, socially acknowledged as an ally in the defense of the right to health.

The objective of this case study report is to stress the way nursing professionals in the federal state of Goiás are represented. It was concluded the Brazilian Association of Nursing (ABEn) in Goiás and other educational institutions, have promoted changes in the practices, attitudes and behavior of the nursing professionals through the incentive and investment on courses, seminars and other kind of events. The study also shows that the efforts to qualify the nursing profession have increased the participation of these workers in areas, which were not disputed by them before.

This study has as its objective the discussion of the nursing professionals' responsibility regarding their participation in professional associations, such as the Brazilian Association of Nursing (ABEn), the Regional Board of Nursing and the Nursing Union. The investigation was carried out with nurses from a private and a public educational institution and also from a private institution of assistance. As a result, it was verified that the participation of nurses in the organizations mentioned above is still scarce, but there is already some awareness of the need for integrating them.

This article complements the substantial body of literature produced over the last three decades on the export of hazards from developed countries to developing countries. After reviewing the central arguments proposed by this literature, the authors add to the debate by focusing on the role of national actors in the importation of these hazards, based on the experience of late 1970s' developments in the petrochemical industry in Brazil. The Brazilian case indicates that social struggles and/or interactions among actors in developing and developed nations determine to what extent hazardous technologies are imported without environmental controls and to what extent their hazardous effects are controlled by these nations. This study suggests that the future development of a more inclusive theory of export-import of hazardous technologies and products should take into account the dialectical relationship established between social actors internal to the exporting and importing countries.