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Background The landscape of cutaneous melanoma (CM) diagnosis, staging, prognosis, and treatment has undergone fundamental changes in the past decade. While the benefits of new health resources are recognized, there is a distinct lack of accurate cost-of-illness information to aid healthcare decision makers. Methods The cost-of-illness study for CM was conducted from the perspective of two health systems in Brazil: the public health system (Unified Health System, SUS) and the private health system (Health Management Organization, HMO). The study considered the direct medical cost in a bottom-up analysis, using melanoma incidence, knowledge of the disease’s progression, and the overall survival rates. The executional costs for the complete healthcare delivery cycle were investigated considering different disease stages and possible clinical course variations. The structural cost was assessed qualitatively considering the health value chain in Brazil. Results CM represents a critical financial burden in Brazil, and the cost of illness varied according to the health system and by stage at diagnosis. HMO patient costs are approximately 10-fold and 90-fold more than a SUS patient in the early-stage and advanced disease, respectively. Overall, spending on advanced disease patients can be up to 34-fold (SUS) or 270-fold (HMO) higher than that required for the early-stage disease. Given the massive amount of resources spent by the SUS and HMO, significant efforts must be made to improve the health value chain to deliver the right mix of medical care goods and services using available resources. Conclusion The cost-of-illness study for CM has the potential to inform policymakers and decision-makers regarding the economic burden that melanoma impose on a society in terms of the use of health care services, assisting them in making projections of future health care costs and resource allocation decisions. We believe that cost-of-illness analysis from a strategic perspective could be of help in assessing executional costs and be used to support the change in structural costs required for long-term strategies related to the health value chain.

Zones of social abandonment are emerging everywhere in Brazil’s big cities—places like Vita, where the unwanted, the mentally ill, the sick, and the homeless are left to die. This haunting, unforgettable story centers on a young woman named Catarina, increasingly paralyzed and said to be mad, living out her time at Vita. Anthropologist João Biehl leads a detective-like journey to know Catarina; to unravel the cryptic, poetic words that are part of the “dictionary” she is compiling; and to trace the complex network of family, medicine, state, and economy in which her abandonment and pathology took form. An instant classic, Vita has been widely acclaimed for its bold fieldwork, theoretical innovation, and literary force. Reflecting on how Catarina’s life story continues, this updated edition offers the reader a powerful new afterword and gripping new photographs following Biehl and Eskerod’s return to Vita. Anthropology at its finest, Vita is essential reading for anyone who is grappling with how to understand the conditions of life, thought, and ethics in the contemporary world.

The aim of this study is to propose and validate a value assessment framework for Health Technology Assessment (HTA) for rare diseases drugs in Brazil. A scoping review was performed to identify criteria used by HTA agencies in countries with public healthcare systems when evaluating orphan drugs. Based on the findings, a criteria framework for rare disease drugs was proposed for Brazil. Content validity was conducted over three rounds using Delphi technique and content validity ratio (CVR) approach was employed to evaluate the ratings from the eighteen stakeholders (experts and patients). Twenty-nine HTA criteria for rare disease drugs were identified to compose the Brazilian framework. After three Delphi rounds, the final value framework comprised fifteen criteria categorized into four domains: disease-related factors, treatment-related factors, social and political factors, and economic factors. Among the most well-rated criteria by the CVR, considering the relevance attribute, were \"relevance of outcomes for a rare disease,\" \"impact on patient's quality of life,\" \"price negotiation,\" and \"adjusted cost-effectiveness threshold.\" On the other hand, \"budget impact threshold,\" \"innovative nature of treatment,\" and \"willingness to accept greater uncertainty in clinical evidence\" received negative evaluations and were excluded from the final framework. A value assessment framework validated by key stakeholders of rare diseases in Brazil could contribute to improve HTA transparency, decision making, and efficiency of the healthcare system, and inspire the development of a local guidance for rare-disease HTA.

Background The intertwined relation between public and private care in Brazil is reshaping the medical profession, possibly affecting the distribution and profile of the country’s medical workforce. Physicians’ simultaneous engagement in public and private services is a common and unregulated practice in Brazil, but the influence played by contextual factors and personal characteristics over dual practice engagement are still poorly understood. This study aimed at exploring the sociodemographic profile of Brazilian physicians to shed light on the links between their personal characteristics and their distribution across public and private services. Methods A nation-wide cross-sectional study using primary data was conducted in 2014. A representative sample size of 2400 physicians was calculated based  on the National Council of Medicine database registries; telephone interviews were conducted to explore physicians’ sociodemographic characteristics and their engagement with public and private services. Results From the 2400 physicians included, 51.45% were currently working in both the public and private services, while 26.95% and 21.58% were working exclusively in the private and public sectors, respectively. Public sector physicians were found to be younger (PR 0.84 [0.68–0.89]; PR 0.47 [0.38–0.56]), less experienced (PR 0.78 [0.73–0.94]; PR 0.44 [0.36–0.53]) and predominantly female (PR 0.79 [0.71–0.88]; PR 0.68 [0.6–0.78]) when compared to dual and private practitioners; their income was substantially lower than those working exclusively for the private (PR 0.58 [0.48–0.69]) and mixed sectors (PR 0.31 [0.25–0.37]). Conversely, physicians from the private sector were found to be typically senior (PR 1.96 [1.58–2.43]), specialized (PR 1.29 [1.17–1.42]) and male (PR 1.35 [1.21–1.51]), often working less than 20 h per week (PR 2.04 [1.4–2.96]). Dual practitioners were mostly middle-aged (PR 1.3 [1.16–1.45]), male specialists with 10 to 30 years of medical practice (PR 1.23 [1.11–1.37]). Conclusion The study shows that more than half of Brazilian physicians currently engage with dual practice, while only one fifth dedicate exclusively to public services, highlighting also substantial differences in socio-demographic and work-related characteristics between public, private and dual-practitioners. These results are consistent with the international literature suggesting that physicians’ sociodemographic characteristics can help predict dual practice forms and prevalence in a country.

Resumo Por meio de um esforço analítico-interpretativo de releitura dos fatos históricos apresentados acerca da ideia, da proposta, do movimento e do processo da Reforma Sanitária Brasileira (RSB), e à luz das teorias e críticas decolonial e feminista negra, este artigo de cunho ensaístico tem como objetivo propor um giro epistemológico e político para uma práxis sanitária decolonial. Em um primeiro momento, reflete acerca de alguns pontos de incoerência de certas dimensões da RSB que possivelmente contribuíram para que houvesse promessas não cumpridas em sua proposta. Na segunda parte do trabalho, (re)posiciona a analítica concernente à situação de colonialidade no Brasil com relação ao que está em jogo, na tentativa de “redemocratizar a vida” neste país. Finalmente, evidencia-se que, apesar de haver muito a avançar, asseguradamente a RSB não é um “movimento desnaturado”. Abstract By an analytical-interpretative effort of re-reading the historical facts regarding the idea, proposal, movement, and process of the Brazilian Health Care Reform (HCR) in light of decolonial and Black Feminist theories and critics, this study aims to propose an epistemological and political turn toward a decolonial health praxis. In a first moment, it reflects about some points of incoherence of certain dimensions in the HCR proposal. The second part of this studyd (re)positions this analysis concerning the coloniality situation in Brazil regarding what lies at stake in the attempt of “life redemocratization” in this country. Finally, it highlights that despite much progress to be made, the Brazilian Health Reform is assuredly not a “denatured movement.”

Zones of social abandonment are emerging everywhere in Brazil's big cities-places like Vita, where the unwanted, the mentally ill, the sick, and the homeless are left to die. This haunting, unforgettable story centers on a young woman named Catarina, increasingly paralyzed and said to be mad, living out her time at Vita. Anthropologist João Biehl leads a detective-like journey to know Catarina; to unravel the cryptic, poetic words that are part of the \"dictionary\" she is compiling; and to trace the complex network of family, medicine, state, and economy in which her abandonment and pathology took form. As Biehl painstakingly relates Catarina's words to a vanished world and elucidates her condition, we learn of subjectivities unmade and remade under economic pressures, pharmaceuticals as moral technologies, a public common sense that lets the unsound and unproductive die, and anthropology's unique power to work through these juxtaposed fields. Reissued nearly ten years after its initial publication with a new afterword and more compelling photos, Vita is an essential read for anyone who is grappling with how to understand the conditions of life, thought and ethics in the contemporary world.

Este artigo apresenta uma revisão e análise da assistência farmacêutica como parte integrante do sistema de atenção primária à saúde, no qual a qualidade do uso de medicamentos está diretamente relacionada à qualidade do serviço de saúde e aos elementos para a avaliação desta. As Unidades Básicas de Saúde constituem a principal porta de entrada do sistema de assistência à saúde estatal em nosso país. Entretanto, o vínculo do serviço farmacêutico está relacionado com o modelo curativo, centrado na consulta médica e pronto atendimento, com a farmácia apenas atendendo a essas demandas. A atividade de orientação aos usuários na farmácia das Unidades Básicas de Saúde torna-se praticamente impossível, pois na farmácia deságuam quase todas as mazelas do sistema de saúde, por estar no elo final do processo de atendimento. A solução do problema, no âmbito geral, não será simples, se mantida a forma como o serviço está estruturado, pois grande parte das pressões de demanda não depende do serviço de saúde em si, mas de políticas sociais inclusivas, as quais têm impacto direto nas condições de saúde da população. No âmbito específico, é fundamental que os gestores racionalizem a utilização dos medicamentos desde a prescrição até a utilização por parte do usuário.

Background In Brazil, the COVID-19 pandemic found the universal and public Unified Health System (SUS) with problems accumulated over time, due, among other reasons, to low investments, and disparities in resource distribution. The preparedness and response of the healthcare system, involving the SUS and a private sector, was affected by large socioeconomic and healthcare access inequities. This work was aimed at offering an overview of COVID-19 inpatient mortality during the pandemic in Brazil, exploring factors associated with its variations and, specifically, differences across public, private (for-profit) and philanthropic (private non-profit) inpatient healthcare units, providers, and non-providers of services to the SUS. Methods This cross-sectional study used public secondary data. The main data source was the SIVEP-Gripe, which comprises data on severe acute respiratory illness records prospectively collected. We also employed the National Record of Health Establishments, the SUS’ Hospitalization Information System and municipalities' data from IBGE. We considered adult COVID-19 hospitalizations registered in SIVEP-Gripe from February 2020 to December 2022 in inpatient healthcare units with a minimum of 100 cases in the period. Data analyses explored the occurrence of inpatient mortality, employing general linear mixed models to identify the effects of patients', health care processes', healthcare units' and municipalities' characteristics on it. Results About 70% of the COVID-19 hospitalizations in Brazil were covered by the SUS, which attended the more vulnerable population groups and had worse inpatient mortality. In general, non-SUS private and philanthropic hospitals, mostly reimbursed by healthcare insurance plans accessible for more privileged socioeconomic classes, presented the best outcomes. Southern Brazil had the best performance among the macro-regions. Black and indigenous individuals, residents of lower HDI municipalities, and those hospitalized out of their residence city presented higher odds of inpatient mortality. Moreover, adjusted inpatient mortality rates were higher in the pandemic peak moments and were significantly reduced after COVID-19 vaccination reaching a reasonable coverage, from July 2021. Conclusions COVID-19 exposed socioeconomic and healthcare inequalities and the importance and weaknesses of SUS in Brazil. This work indicates the need to revert the disinvestment in the universal public system, a fundamental policy for reduction of inequities in the country.

This article, which aims to explore questions relating to SUS at 30 and to dialogue with other studies, presents an overview of the positive drivers, the obstacles and the threats to Brazil's Unified Health System. It points to a lack of prioritizing the SUS on the part of the government, underfunding and attacks on the system made by capital's policies. The article also suggests that one of the most significant threats to SUS is the financialization of health, linked to the financial dominance. It concludes by arguing that the SUS is not consolidated, justifying alliances between democratic, popular and socialist forces, with new strategies, tactics and forms of organization to face up to the power of capital and its representatives in society and in the State.

Governance is increasingly recognized as an important factor in health system performance, yet conceptually and practically it remains poorly understood and subject to often vague and competing notions of both what its role is and how to address its weaknesses. This overview article for the symposium on health governance presents a model of health governance that focuses on the multiplicity of societal actors in health systems, the distribution of roles and responsibilities among them and their ability and willingness to fulfil these roles and responsibilities. This focus highlights the principal-agent linkages among actors and the resulting incentives for good governance and health system performance. The discussion identifies three disconnects that constitute challenges for health system strengthening interventions that target improving governance: (1) the gap between the good governance agenda and existing capacities, (2) the discrepancy between formal and informal governance and (3) the inattention to sociopolitical power dynamics. The article summarizes the three country cases in the symposium and highlights their governance findings: health sector reform in China, financial management of health resources in Brazilian municipalities and budget reform in hospitals in Lesotho. The concluding sections clarify how the three cases apply the model's principal-agent linkages and highlight the importance of filling the gaps remaining between problem diagnosis and the development of practical guidance that supports 'best fit' solutions and accommodates political realities in health systems strengthening.