RESUMEN Se presenta un consenso latinoamericano que permite estandarizar las definiciones de los diferentes niveles de resistencia a los antimicrobianos en bacterias de importancia en salud pública. Se describen los criterios de inclusión y exclusión para las metodologías a utilizar y para los antibióticos a incluir (por disponibilidad, relevancia y existencia de puntos de corte). Como propuesta piloto se eligieron tres microorganismos gramnegativos de gran impacto en el ambiente hospitalario ( Klebsiella pneumoniae , Pseudomonas aeruginosa y Acinetobacter spp.). La falta de puntos de corte para ciertos antibióticos (por ejemplo, tigeciclina, fosfomicina y colistina), claves para el tratamiento de infecciones causadas por estos patógenos que presentan multirresistencia o resistencia extendida, llevó a la necesidad de discutir y consensuar puntos de corte provisorios para la vigilancia de la resistencia a estos fármacos. Se abordó y consensuó también el uso de pruebas de sensibilidad alternativas a los métodos aprobados por las guías internacionales, de aplicación más sencilla como pruebas de rutina en los laboratorios de bacteriología clínica. El principal beneficio de este documento es proporcionar a los laboratorios latinoamericanos un marco estandarizado y consensuado para la identificación y la vigilancia constante y unificada de microorganismos resistentes. Las recomendaciones incluidas en este documento son el resultado consensuado por los representantes de los laboratorios nacionales de referencia de los países que integran la Red Latinoamericana de Vigilancia de la Resistencia a los Antibióticos coordinada por la Organización Panamericana de la Salud.

BackgroundBrazil faces huge health inequality challenges since not all municipalities have access to primary care physicians. The More Doctors Programme (MDP), which started in 2013, was born out of this recognition, providing more than 18 000 doctors in the first few years. However, the programme faced a restructuring at the end of 2018.MethodsWe construct a panel municipality-level data between 2008 and 2017 for 5570 municipalities in Brazil. We employ a difference-in-differences empirical approach, combined with propensity score matching, to study the impacts of the programme on hospitalisations for ambulatory care sensitive conditions and its costs. We explore heterogeneous impacts by age of the patients, type of admissions, and municipalities that were given priority.FindingsThe MDP reduced ambulatory admissions by 2.9 per cent (p value <0.10) and the costs by 3.7 per cent (p value <0.01) over the mean. The reduction was driven by infectious gastroenteritis, bacterial pneumonias, asthma, kidney and urinary infections, and pelvic inflammatory disease. The results held on the subsample of municipalities targeted by the programme. By comparing the benefits of the programme from the reduction in the costs of ambulatory admissions to the total financial costs of the MDP, the impacts allowed the government to save at least BRL 27.88 (US$ 6.9 million) between 2014 and 2017.ConclusionAddressing inequalities in the distribution of the medical workforce remains a global challenge. Our results inform the discussion on the current strategy adopted in Brazil to increase access to primary healthcare in underserved areas.

RESUMO Apesar de decorridos 40 anos da divulgação dos princípios de Alma-Ata, ainda persistem desafios para a consolidação da atenção primária à saúde (APS) como eixo norteador dos sistemas de saúde ao redor do globo. Dentre os desafios ainda presentes, merecem destaque as questões associadas à iniquidade na distribuição de recursos humanos em saúde. A experiência do Programa Mais Médicos (PMM) no Brasil é um exemplo de proposta voltada para a abordagem dessa agenda inconclusa de Alma-Ata. Ao modificar aspectos centrais da formação, provimento e alocação de profissionais médicos, o PMM mostrou-se uma saída viável para minimizar os desafios de escassez de profissionais. As avaliações do PMM, embora incipientes, produziram evidências positivas quanto a ampliação do acesso e melhoria da qualidade da APS no Brasil, um país de médio desenvolvimento econômico. Apesar disso, é premente a geração de evidências mais sólidas a respeito do impacto do PMM sobre indicadores de desempenho da APS. O debate apresentado ao longo deste trabalho discute a necessidade de se viabilizar estudos quase-experimentais capazes de mensurar o impacto do PMM junto à saúde da população. O artigo propõe, então, um conjunto de diretrizes que pode se configurar como um modelo aplicável para abordar desafios associados à escassez de profissionais em países de médio e baixo desenvolvimento econômico.

Objective. To forecast the impact of alternative scenarios of coverage changes in Brazil’s Family Health Strategy (Estratégia Saúde da Família) (ESF)—due to fiscal austerity measures and to the end of the Mais Médicos (More Doctors) Program (PMM)—on overall under-5 mortality rates (U5MRs) and under-70 mortality rates (U70MRs) from ambulatory care sensitive conditions (ACSCs) up through 2030. Methods. A synthetic cohort of 5 507 Brazilian municipalities was created for the period 2017-2030. A municipal-level microsimulation model was developed and validated using longitudinal data. Reductions in ESF coverage, and its effects on U5MRs and U70MRs from ACSCs, were forecast based on two probable austerity scenarios, as compared to the maintenance of current ESF coverage. Fixed effects longitudinal regression models were employed to account for secular trends, demographic and socioeconomic changes, variables related to health care, and program duration effects. Results. In comparison to maintaining stable ESF coverage, with the decrease in ESF coverage due to austerity measures and PMM termination, the mean U5MR and U70MR would be 13.2% and 8.6% higher, respectively, in 2030. The end of PMM would be responsible for a mean U5MR from ACSCs that is 4.3% higher and a U70MR from ACSCs that is 2.8% higher in 2030. The reduction of PMM coverage due only to the withdrawal of Cuban doctors who have been working in PMM would alone be responsible for a U5MR that is 3.2% higher, and a U70MR that is 2.0% higher in 2030. Conclusions. Reductions in primary health care coverage due to austerity measures and the end of the PMM could be responsible for many avoidable adult and child deaths in coming years in Brazil.

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