SUMMARY OBJECTIVE: The objective of this study was to evaluate fresh medical graduates’ perceptions regarding the general aspects of ethics teaching in Brazilian medical schools. METHODS: A structured questionnaire was applied to 4,601 participants among the 16,323 physicians who registered in one of the 27 Regional Medical Councils of Brazil in 2015. Answers to four questions regarding general aspects of ethics education in medical school were analyzed. Sampling procedures involved two stratification variables: legal nature (public vs. private) of medical schools and monthly household income higher than 10 minimum wages. RESULTS: A large percentage of the participants had witnessed unethical behaviors during contact with patients (62.0%), toward coworkers (51.5%), and in relationships with patients’ families (34.4%) over the course of their medical training. Even though most of the responders (72.0%) totally agreed that patient-physician relationship and humanities education were part of their medical school curriculum, important topics such as conflicts of interest and end-of-life education were not satisfactorily addressed in the participants’ medical training. Statistically significant differences were found between the answers of public and private school graduates. CONCLUSION: Despite great efforts to improve medical ethics education, our findings suggest the persistence of deficits and inadequacies in the ethics training currently given in medical schools in Brazil. Further modifications in ethics training must be made to address the deficiencies shown in this study. This process should be accompanied by continuous evaluation.

RESUMO O ensaio abordou problemas para refletir, identificar contradições e formular estratégias políticas sobre a privatização do sistema de saúde no Brasil, especialmente as próprias acepções sobre o Sistema Único de Saúde (SUS), sobre o que é público e o que é privado. Constatou-se que as relações entre público e privado apreendidas somente por medidas (quantidade de unidades, atividades, recursos humanos e financeiros) estão subjacentes a interesses e negociações entre agentes e suas decisões políticas e a dificuldades para discernir os traços estruturais de um sistema de saúde desigual e segmentado das conjunturas políticas que os reproduzem. Trinta anos após a Constituição de 1988, houve avanços, impasses e retrocessos; assim como adaptações na compreensão do SUS e do setor privado.

ABSTRACT The essay discusses problems to reflect on, identify contradictions, as well as discern and formulate political strategies on the privatization of the health system in Brazil, especially the multiple meanings of the Unified Health System (SUS) and about what is public and what is private. It is observed that the relations between public and private seized only by measures (quantity of units, activities and human and financial resources) are underlying interests and negotiations between agents and their political decisions and difficulties to discern the structural features of an unequal health system and segmented from the political conjunctures that reproduce them. Thirty years after the 1988 Constitution, there have been advances, impasses and setbacks, as well as adjustments in the understanding of the SUS and the private sector.

RESUMO O ensaio abordou problemas para refletir, identificar contradições e formular estratégias políticas sobre a privatização do sistema de saúde no Brasil, especialmente as próprias acepções sobre o Sistema Único de Saúde (SUS), sobre o que é público e o que é privado. Constatou-se que as relações entre público e privado apreendidas somente por medidas (quantidade de unidades, atividades, recursos humanos e financeiros) estão subjacentes a interesses e negociações entre agentes e suas decisões políticas e a dificuldades para discernir os traços estruturais de um sistema de saúde desigual e segmentado das conjunturas políticas que os reproduzem. Trinta anos após a Constituição de 1988, houve avanços, impasses e retrocessos; assim como adaptações na compreensão do SUS e do setor privado.

ABSTRACT The essay discusses problems to reflect on, identify contradictions, as well as discern and formulate political strategies on the privatization of the health system in Brazil, especially the multiple meanings of the Unified Health System (SUS) and about what is public and what is private. It is observed that the relations between public and private seized only by measures (quantity of units, activities and human and financial resources) are underlying interests and negotiations between agents and their political decisions and difficulties to discern the structural features of an unequal health system and segmented from the political conjunctures that reproduce them. Thirty years after the 1988 Constitution, there have been advances, impasses and setbacks, as well as adjustments in the understanding of the SUS and the private sector.

Abstract Background The infectious diseases specialist is a medical doctor dedicated to the management of infectious diseases in their individual and collective dimensions. Objectives The aim of this paper was to evaluate the current profile and distribution of infectious diseases specialists in Brazil. Methods This is a cross-sectional study using secondary data obtained from institutions that register medical specialists in Brazil. Variables of interest included gender, age, type of medical school (public or private) the specialist graduated from, time since finishing residency training in infectious diseases, and the interval between M.D. graduation and residency completion. Maps are used to study the geographical distribution of infectious diseases specialists. Results A total of 3229 infectious diseases specialist registries were counted, with 94.3% (3045) of individual counts (heads) represented by primary registries. The mean age was 43.3 years (SD 10.5), and a higher proportion of females was observed (57%; 95% CI 55.3–58.8). Most Brazilian infectious diseases specialists (58.5%) practice in the Southeastern region. However, when distribution rates were calculated, several states exhibited high concentration of infectious diseases specialists, when compared to the national rate (16.06). Interestingly, among specialists working in the Northeastern region, those trained locally had completed their residency programs more recently (8.7 yrs; 95% CI 7.9–9.5) than physicians trained elsewhere in the country (13.6 yrs: 95% CI 11.8–15.5). Conclusion Our study shows that Brazilian infectious diseases specialists are predominantly young and female doctors. Most have concluded a medical residency training program. The absolute majority practice in the Southeastern region. However, some states from the Northern, Northeastern and Southeastern regions exhibit specialist rates above the national average. In these areas, nonetheless, there is a strong concentration of infectious diseases specialists in state capitals and in metropolitan areas.

Resumo: A concentração e internacionalização de empresas de planos de saúde no Brasil conferiram-lhes feição financeira. Considerando a necessidade de compreender os padrões de acumulação desse setor, o trabalho examina estratégias de expansão das empresas de planos de saúde por meio da periodização de atributos da oferta e demanda e exame da trajetória patrimonial recente de um dos grandes grupos do setor. Entre os anos 1960 e 2000, ocorreram alterações na escala das demandas por planos de saúde e adesão das empresas a estratégias de acumulação de longo prazo. A partir do século XXI, as alterações nas estruturas societárias da maior empresa brasileira, compatíveis com o regime de acumulação financeirizada, resultaram na multiplicação de seu capital em um curto intervalo de tempo. O aprofundamento da segmentação do sistema de saúde, em um contexto marcado pela desaceleração da economia, questiona a preservação dos subsídios públicos para os planos privados.

Abstract: The concentration and internationalization of health plan companies in Brazil gave them a clearly financial face. Based on the need to understand the health care industry's capital accumulation patterns, the current study examines health plan companies' expansion strategies through the classification of their supply and demand characteristics by recent historical periods and an analysis of recent shareholding trends in one of the leading corporations in the Brazilian health care industry. The 1960s to 2000s witnessed changes in the scale of demands for health plans and adherence by companies to long-term accumulation strategies. Beginning in the early 21st century, changes in the shareholding structures of the largest Brazilian company, consistent with the financialization of its accumulation regime, resulted in the rapid multiplication of its capital. Deepening segmentation of the health care system in a context marked by the downturn in the national economy challenges the preservation of public subsidies for private health plans.

Resumen: La concentración e internacionalización de empresas de planes de salud en Brasil les han conferido un carácter financiero. Considerando la necesidad de comprender los padrones de acumulación de ese sector, el trabajo examina estrategias de expansión de las empresas de planes de salud, mediante la periodización de atributos de oferta y demanda y el examen de la trayectoria patrimonial reciente de uno de los grandes grupos del sector. Entre los años 1960 y 2000, se produjeron alteraciones en la escala de las demandas por parte de planes de salud y una adhesión de las empresas a estrategias de acumulación a largo plazo. A partir del siglo XXI, las alteraciones en las estructuras societarias de la mayor empresa brasileña, compatibles con el régimen de acumulación de carácter financiero, resultaron en la multiplicación de su capital en un corto intervalo de tiempo. La profundización de la segmentación del sistema de salud, en un contexto marcado por la desaceleración de la economía, cuestiona la preservación de los subsidios públicos para los planes privados.

Resumo: A concentração e internacionalização de empresas de planos de saúde no Brasil conferiram-lhes feição financeira. Considerando a necessidade de compreender os padrões de acumulação desse setor, o trabalho examina estratégias de expansão das empresas de planos de saúde por meio da periodização de atributos da oferta e demanda e exame da trajetória patrimonial recente de um dos grandes grupos do setor. Entre os anos 1960 e 2000, ocorreram alterações na escala das demandas por planos de saúde e adesão das empresas a estratégias de acumulação de longo prazo. A partir do século XXI, as alterações nas estruturas societárias da maior empresa brasileira, compatíveis com o regime de acumulação financeirizada, resultaram na multiplicação de seu capital em um curto intervalo de tempo. O aprofundamento da segmentação do sistema de saúde, em um contexto marcado pela desaceleração da economia, questiona a preservação dos subsídios públicos para os planos privados.

Abstract: The concentration and internationalization of health plan companies in Brazil gave them a clearly financial face. Based on the need to understand the health care industry's capital accumulation patterns, the current study examines health plan companies' expansion strategies through the classification of their supply and demand characteristics by recent historical periods and an analysis of recent shareholding trends in one of the leading corporations in the Brazilian health care industry. The 1960s to 2000s witnessed changes in the scale of demands for health plans and adherence by companies to long-term accumulation strategies. Beginning in the early 21st century, changes in the shareholding structures of the largest Brazilian company, consistent with the financialization of its accumulation regime, resulted in the rapid multiplication of its capital. Deepening segmentation of the health care system in a context marked by the downturn in the national economy challenges the preservation of public subsidies for private health plans.

Resumen: La concentración e internacionalización de empresas de planes de salud en Brasil les han conferido un carácter financiero. Considerando la necesidad de comprender los padrones de acumulación de ese sector, el trabajo examina estrategias de expansión de las empresas de planes de salud, mediante la periodización de atributos de oferta y demanda y el examen de la trayectoria patrimonial reciente de uno de los grandes grupos del sector. Entre los años 1960 y 2000, se produjeron alteraciones en la escala de las demandas por parte de planes de salud y una adhesión de las empresas a estrategias de acumulación a largo plazo. A partir del siglo XXI, las alteraciones en las estructuras societarias de la mayor empresa brasileña, compatibles con el régimen de acumulación de carácter financiero, resultaron en la multiplicación de su capital en un corto intervalo de tiempo. La profundización de la segmentación del sistema de salud, en un contexto marcado por la desaceleración de la economía, cuestiona la preservación de los subsidios públicos para los planes privados.

CONTEXTO E OBJETIVO: Diante da existência no Brasil de uma política pública universal de fornecimento de medicamentos para tratamento do HIV e aids, o objetivo é descrever formas de relacionamento entre os médicos e as empresas farmacêuticas produtoras de antirretrovirais (ARVs). TIPO DE ESTUDO E LOCAL: Estudo epidemiológico de tipo transversal realizado no estado de São Paulo. MÉTODOS: Foi realizado cruzamento entre bancos de dados secundários e entrevistas estruturadas, por meio telefônico, em amostra de 300 médicos representativa de 2.361 profissionais que assistem pacientes com HIV e aids. RESULTADOS: Cerca de dois terços (64%) dos médicos entrevistados que prescrevem ARVs para tratamento de HIV e aids no Estado de São Paulo declararam que tiveram alguma relação com empresas farmacêuticas, sendo mais frequentes o recebimento de publicações (54%), de visita de propagandistas (51%) e de objetos de pequeno valor (47%). CONCLUSÃO: Destacam-se duas formas de relacionamento entre a indústria farmacêutica e os médicos que trabalham com HIV-aids: facilitação do acesso dos profissionais à educação continuada e promoção da marca de medicamentos antirretrovirais.

CONTEXT AND OBJECTIVE: Given that Brazil has a universal public policy for supplying medications to treat HIV and AIDS, the aim here was to describe the forms of relationship between physicians and the pharmaceutical companies that produce antiretrovirals (ARVs). DESIGN AND SETTING: Cross-sectional epidemiological study conducted in the state of São Paulo. METHODS : Secondary database linkage was used, with structured interviews conducted by telephone among a sample group of 300 physicians representing 2,361 professionals who care for patients with HIV and AIDS. RESULTS : Around two thirds (64%) of the physicians prescribing ARVs for HIV and AIDS treatment in the state of São Paulo who were interviewed declared that they had some form of relationship with pharmaceutical companies, of which the most frequent were receipt of publications (54%), visits by sales promoters (51%) and receipt of small-value objects (47%). CONCLUSIONS: Two forms of relationship between the pharmaceutical industry and physicians who deal with HIV and AIDS can be highlighted: facilitation of professionals' access to continuing education; and antiretroviral drug brand name promotion.

OBJETIVO: Analisar o perfil dos médicos que prescreveram antirretrovirais (ARV) no Estado de São Paulo para o tratamento de pessoas infectadas pelo HIV. MÉTODOS: Foram analisadas as características sociodemográficas, de formação técnico-científica e a experiência dos profissionais que prescreveram os ARV entre outubro de 2007 e maio de 2009, utilizando-se informações obtidas nos bancos de dados do Ministério da Saúde, Conselho Regional de Medicina do Estado São Paulo, Comissão Nacional de Residência Médica e plataforma Lattes. RESULTADOS: A prescrição regular de ARV para 74 mil pacientes foi realizada por 1609 médicos, que apresentam distribuição similar segundo sexo, têm entre 30 anos e 49 anos, residem principalmente na região metropolitana de São Paulo, são formados em média há 16,1 anos, em 93 escolas médicas do país e possuem alguma formação em especialidades médicas (67,5%), especialmente em infectologia (38,9%). Cada médico prescreveu ARV em média para 10 pacientes, sendo que 51,6% prescreveram para 20 ou mais pacientes. Entre os profissionais, 62% reúnem conhecimento específico ou experiência para o tratamento de pessoas com HIV, sendo que 2,7% das prescrições foram realizadas por profissionais que não apresentaram nenhuma dessas condições. Regiões com alta incidência de Aids apresentaram menor número de prescritores, como Barretos e Baixada Santista, reunindo as maiores concentrações de profissionais sem conhecimento específico ou experiência no Estado de São Paulo. CONCLUSÃO: A maioria das pessoas com HIV recebem prescrições de médicos que apresentam os requisitos de conhecimento e/ou experiência. Porém, o grande número de prescritores sem as qualificações mínimas e o reduzido número de médicos em regiões de maior incidência de Aids implicam importantes desafios para universalizar adequada atenção à saúde de pessoas com HIV.

OBJECTIVE: Analysis of the professional profile of physicians who prescribe antiretroviral drugs (ARV) to HIV infected persons in the State of São Paulo. METHODS: Databases from different sources, namely Ministry of Health, São Paulo State Regional Medical Council, National Commission on Medical Residency and the Lattes platform, were consulted. Data concerning socio-demographic characteristics, academic and professional background and experience for the period from October 2007 to May 2009 were analyzed. RESULTS: The regular ARV prescription for 74 thousand patients was issued by 1,609 physicians whose characteristics are: evenly distributed according to gender, aged between 30 to 49 years, live in the metropolitan area of Greater São Paulo, graduated 16.1 years ago on the average, come from 93 different Brazilian medical schools, hold a specialty diploma in 67.5% of cases, most of them in the field of Infectious Diseases (38.9%). The mean number of patients per physician was 10, though 51.6% of physicians prescribed for 20 or more patients. Of these physicians 62% reported specific knowledge or experience with HIV care , although 2.7% of all prescriptions were issued by physicians without this specific qualification. Regions of high AIDS incidence showed a smaller number of prescribing physicians. The cities of Registro and Ribeirão Preto showed the highest concentration of physicians lacking proper credentials. CONCLUSION: The absolute majority of HIV patients receives their prescriptions from duly trained and experienced physicians. Nevertheless, the large number of non-qualified physicians together with the reduced number of physicians in HIV high incidence regions make up the major challenge for comprehensive and adequate care of HIV patients.