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INFORME ALTERNATIVO SOBRE LA SALUD EN AMERICA LATINAContextualized and Effective Formsof Practice in Health CareClinical forms of practice should be linked toclear health outcomes and not merely to rigid and abstractprotocols. A way of coping with this, is to adapteffective methods of practice to the social and culturalcontext wherein the process of health illness develops,to ensure the undertaking of each health problem withintegrality and continuity.We understand clinical healthcare as the development and sustentation of an interpersonalconnection, where the therapeutic team isconstantly responsible for the course of action of care,even if it would include inter-consultations or referencesin other levels.This clinical practice must be reformulatedpermanently in reference to the epidemiologicalsituation of the territory and be subjected to the localplanning process. In this sense, we began working inthe appointment of rightful claimants to basic teams ofreference. Each team, composed by a minimum of onedoctor and one nurse, assumes the responsibility of thehealth care of a number of families, and operates astheir agent in the net of services.To implement this, thebasic health team counts on the assistance of the restof the professionals of the local interdisciplinary team,and the resources of the service network, so as to makecertain the maximal degree of problem resolution,and the appropriate use of technology.This network includesan emergency care system; three hospitals ofmedium complexity; a maternity; a children’s hospital;an adult’s hospital equipped for high complexity problems;second and third level rehabilitation centers; anda Center for Ambulatory Medical Specialties.The laterhas the specific institutional mission of providing withthe response, with specialized inter-consultation andcomplementary studies, to the necessities submitted inthe health centers, with which patients obtain the appointmentfor specialized care without having to movefrom one place to another, and the reference/counterreferenceof patients and cases is the object of a specificmanagement. The Center of Ambulatory MedicalSpecialties houses a central laboratory where the samplestaken daily in the health centers are processed.Progressively, the assignation of responsibilities territoriallydelimited to the specialists is being worked on,with the intention that each one of them will developa stable association with a definite number of referenceteams, and will collaborate effectively in the resolutionof clinical problems by means of advising, drillingor inter-consultation procedures, depending on thebest way, defined by the situation, to combine specificknowledge with contextual knowledge.Hospitalization pursues to sustain longitudinallythe therapeutic linkage, for this reason the hospitalteams include the ambulatory reference teams in thediscussion of each therapeutic project. The developmentof domiciliary hospitalization has allowed a risingnumber of ill subjects to exercise the right to be at homereceiving a more adequate, singularized, and efficientcare than they would in the hospital context.The medicines necessary for ambulatory careand hospitalization are made available gratuitously asthrough a therapeutic formulary that contains all requiredspecifics, in different pharmaceutical modes; aguide which was constructed with the participation ofdoctors and pharmacists of the network. A significantpart of that medication is produced by the Laboratoryof Medical Specialties, a public entity that has promotednew medicine distribution policies and has confrontedthe risks of absolute dependence on the market.At present, it produces nearly the totality of parenteralsolutions that are used in the various serviceunits of the Department and forty items that consistof pills and injectable products. Processes of continuouseducation and auditing aim at rationalizing prescriptions,simultaneously they hinder the adherence tochronic treatments seeking integral devices, which ensurethat rationality.220
Observatorio Latinoamericano de Salud.Equity in the access to services entails also theequity in the access to quality and appropriate technologyand, at no rate, the state ceases assuming the responsibilityof an integral response regarding care necessities,either furnishing directly or acquiring the response.Thefact that this local initiative is developed ina provincial and national context with no commitmentof the state beyond the "basic packages" of serviceshas pervaded this decision with growing challenges inits concretion. Rosario has not abandoned this challenge,attributable to the political value inherent toinstituting as a universal right what other would considernonessential for the poor. From the municipalstate, if a technology proves to be necessary, this isworked on so that it is made available for all; if it is dispensable,this is managed so that no one has accessibilityto it. A policy concerning an appropriate technologyis founded in this principle, and this is translatedto the citizenry’s conscience of their right.Prevention and rehabilitation are conceived ofintegrated to the care process, in a manner that specificareas of support contribute with regard to mentalhealth, health of women, the AIDS problem and the addictions,tuberculosis, immunizations, the inclusion ofpeople with incapacities.The process of transformation of clinical formsof practice has permitted 22.000 women to chooseoral contraception, which they receive freely in municipalservice units, and other 3.500 annually to decideto use the DIU, IUD freely, too. Unwanted pregnancyhas reduced to a value of less than 4% of the total, thePublic Health Department having assumed the care of60% of all the births occurred in the public sector. Immunizationscoverage has reached 90% for the youngerthan two years old. In spite of the structural deteriorationof living conditions in the country, the numberof undernourished annually diagnosed in the municipalhealth centers remains stable and the census ofstature in first grade students made in 2003 have similarresults than that of 1997. In the treatment of tuberculosis,88% of adherence to it has been accomplished,which contrasts tremendously with the limited 50%that was obtained at the beginning of the changingprocess. Mortality caused by AIDS has decreased significantlyamong the residents of the city of Rosario:from 12 deaths of each 1.000 inhabitants in 1996, to 4deaths of each 100.000 inhabitants in 2003.The precedents are some of the indicators of aprocess that has initiated, which is still not entirely given,which denotes a daily struggle against the inertiaof the status quo.Strategies to achieve equity inthe utilization of servicesKeeping to the conviction that inequity makespeople ill more than poverty, the management has understoodthat equity is brought about insofar as servicesare used in function of necessity, which generallyvaries in a way inversely proportional to the capacityof supply. Pursuing equity has meant knowing the population’sdistribution of inequality in terms of livingconditions and its consequent distribution of illnessand death, and to develop strategies of positive discriminationthat are capable of accounting for the peculiaritiesof each situation and ensuring the right tohealth as well as people’s dignity and freedom, cultivatingthe capacities of listening, flexibility and dialoguebetween the health services and the heterogeneousnecessities of the community. This has implied constructing,in all the contact points of citizens and thenet of services, devices of admission that interrogatethe necessity behind the demand, and analyzing continuallythe barriers to the access to services in the spacesof local planning.It is more than enough to say that the changingprocess encounters important obstacles within the221
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PEOPLE’S HEALTH ASSEMBLY 2GLOBAL
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LATIN AMERICAN HEALTH WATCHAlternat
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"Our elders taught us that the cele
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12. Neoliberalism, Pesticide Use an
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1Alternative Health Report :A Tool
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Observatorio Latinoamericano de Sal
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Monopoly,Inequity and Health
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INFORME ALTERNATIVO SOBRE LA SALUD
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3The Right to Health and the Free T
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Institutionalizationof Violenceand
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EconomicFundamentalism,Legal Regres
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Life and Healthas Commodities
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Cultural Agresi nUniculturality and
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Biodiversity:Destructionand Monopol
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