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It was noted that there are still many gaps inthe Brazilian literature about how to incorporate ISR into the system. Most of the articles addressed: Menucci DL. Carmo EH. Gerenciamento da pandemia da gripe A H1N1: One article discussed the need to adapt health surveillance in health care 24 Aith F, Dallari SG. The aim of this study is to analyze how ISR has been incorporated into the Brazilian legal-administrative system for sanitary control measures for freight, means of transportation and travelers, and to identify and discuss possible changes to the standards, procedures and competencies pertaining to surveillance activities, based on the understanding of the actors who are directly involved in its implementation.
An exploratory case study was conducted, using a qualitative approach 27 Minayo MCS. O Desafio do Conhecimento: Hucitec, Abrasco; Pesquisa Social: Vozes; The literature review provided input to create a core body of facts and was used as the basis to schedule interviews with key-informants 30 The snowball sampling technique was also used 31 Weiss RS.
Learning from stranger: New York: The Free Press; Six of the candidates indicated declined and five further nominees agreed to participate in this survey.
The interviews took place in Brasilia — DF, in November These were recorded, transcribed and codified, respecting the anonymity of the participants, each interviewee being given a number and referred to in the male gender. In addition, document analysis was undertaken to establish a relationship between the different views and observations registered, which was more useful as revisionary material rather than being used to construct the core body of facts which, together with information from the interviews, form the basis of the analysis of this article.
The analytical categories defined a priori and those that emerged from the field of research were the main changes that have emerged from the implementation of ISR , for standards, competencies and procedures related to the sanitary control activities for freight, modes of transport and travelers. According to fifteen interviewees, new rules resulting from the ISR have been introduced into the legal system while others have been altered. Only one interviewee thought that no changes have been made to existing standards or that others have emerged as a result; two interviewees made no comment.
For some interviewees, the ISR actually serves to apply pressure to ensure that exiting rules are observed, but which have been ignored by the companies operating in the area of the PAF E1, E The port areas were seen as those that have undergone most changes E1, E8, E14, E16 , while airports have maintained existing international regulations E1.
As regards frontiers — which are still not obliged to observe the ISR — there was only one account given of a proposal for regulation E1. With regards to travelers, it is understood that significant changes have been made: It was also noted that, during the ISR implementation process, new rules had been introduced, others revoked and changes made to existing standards, within the areas of health and epidemiological surveillance.
The apparent existence of a normative lacuna, as claimed by some of the actors involved, might have resulted from the inherent limitations of these standards to respond to the overall issues involved, as well as the eagerness of professional health surveillance agents to introduce rules for certain activities.
The ISR is a regulation with a broad scope and it is up to different countries to apply it internally through detailed regulations: A debate arose among the interviewees in connection with this decree; due to the understanding of the Legal Advisory Service Conjur at the Ministry of Health to the effect that presidential approval was requiredfor this act to become legally valid.
Conjur's position is supported in part by International Public Law with respect to the incorporation of treaties in national legal systems, although it cannot be ignored that the Regulation has been incorporated into non-statutory law. The position of the WHO in relation to their regulations is that signatory countries are given deadlines to establish provisos; if they do not do so, the country in question is required to enforce the regulation in question 6 6. Ventura D. O caso da pandemia de gripe A H1N1.
Dobra Editorial; Brazil did not establish provisos for the ISR, nor were any references found of observations or information being sent to the WHO, to clarify the necessary formalities required to incorporate the ISR.
The absence of presidential approval to validate the afore-mentioned decree is more of a formality in the area of law rather than a requirement to carry out suchservices, since administrative activities adhere to the requirements of the instrument, while national rulings are formed on the basis of the ISR text. According to seven of those interviewed, no changes were made to institutional competencies, while two interviewees believed that changes might occur based on future rulings E9, E Only one interviewee believed that changes had been made, if only a few.
One of the interviewees indicated that the Focus Point and the Strategic Information Center for Health Surveillance CIEVS , represent new capacities that have resulted from the ISR; however, according to this interviewee, the actual attributes have not changed, but risk logic has been incorporated instead, which makes it possible to perform more rationally: It is understood that ISR moves forward when it goes beyond a list of diseases and certificates to adopt an approach more centered on sanitary risks, which involves qualified professionals E2, E13, E15, E For some, the competencies have already been established; it was the professionals who found it difficult to understand their work objectives E2, E Changes to sanitary control competencies involving freight, modes of transport and travelers were not addressed: This issue reveals the complex nature of the organizational structure of the Unified Health System — SUS, especially in surveillance sectors responsible for taking action, often based on common objectives, but which are part of different logical frames and institutional and administrative structures, including the regulatory agency model.
When asked about possible conflicts or changes to competencies and about questions related to activities foreseen in ISR , ten of the interviewees responded politely, admitting that there is a good line of communication between the SVS and ANVISA, reiterating the need for these to work together and to articulate with local epidemiological surveillance services E1.
Even so, they expressed some reservations: Thus, in theory, this gives one agency the responsibility of imposing standards and, the other, the responsibility of carrying these out […]. A certain tension exists between these two institutional sectors: The matters over which the sanitary surveillance exerts control are crucial to the economic interests of the country and those who carry out examinations exert power 38 Foucault M.
Vigiar e Punir: Although ANVISA exerts power though the examinations it carries out — sanitary inspections, the policing powers it holds, etc. In Brazil, the sectorial structures that enforce ISR activities are of a complex nature. As well as areas of epidemiological and sanitary surveillance, which are central to sanitary control, the SVS also coordinates environmental health and occupational health, which are not covered in this study.
Sanitary and epidemiological surveillance services are organized according to systems: The National Epidemiological Surveillance System integrates Public Administration directly in its three management areas. However, the National Sanitary Surveillance System SNVS is indirectly integrated within the Federal ambit in three states — which have regulatory agencies — and directly so in municipalities and in the remaining states.
The international health regulations , tuberculosis and air travel. Travel Med Infect Dis ; 8 2: From this fragmented format and the separation of practices in different areas as if there were in fact two separate surveillance agencies 2 2. The position of the interviewees from the area of coordination or the senior hierarchical structure of the agencies is centered on maintaining the status quo, whereas in the SVS it is in the sense of errors in this model.
Although this was not a question asked, the issue of human resources was emphasized, with repeated issues being raised in relation to the different levels of qualifications that exist, a lack of capacity building, precarious contracts, difficulties related to the quantitative and qualification aspects of personnel.
It was claimed that ANVISA professionals need to perform epidemiological surveillance activities that are not exactly within their field of expertise, and that there are huge differences in the level of qualification of PAF professionals, ranging from a primary level of education to others with post-graduate degrees.
In the case of the Ministry of Health, the interviewees spoke in particular about insufficient personnel and lack of turnover, the precariousness of their contractual ties, remuneration and a series of critical problems involving human resources policies, both within the MS and in the states and municipalities E6. This issue arose both in matters related to competencies as well as procedures and converged to form an understanding that changes to competencies require changes in services and qualified professionals, and that the ISR has served to reveal this matter as a result of discussions about the roles that need to be performed in periods of crisis.
Lima YOR. Universidade Federal da Bahia; Silva ZP. A point of convergence among the interviewees was the need for changes in procedures conducted by the SVS and ANVISA, suggesting that ISR has helped to find alternatives to overcome weaknesses in the system and bring about changes to strengthen practices and to organize work procedures E7. Two interviewees did not mention the subject, but three interviewees understood that no changes had been made, but believed that the ISR has helped strengthen the systems of surveillance.
The main changes to procedures cited were: