DILEMAS PARA O USO DE SOLUÇÕES ALTERNATIVAS DE SANEAMENTO RURAL: UMA AVALIAÇÃO A PARTIR DO PROGRAMA MINHA CASA MINHA VIDA RURAL EM PONTALINA, GOIÁS

The differences in care of sanitation services between the rural and urban population is old and persistent in Brazil. Even the normative and institutional changes in the sector, with the approval of the Federal Basic Sanitation Policy in 2007, were not enough to change this scenario. As a strategy for the rural environment, we saw the implementation of technological sanitation solutions under the Minha Casa Minha Vida Rural Program (PMCMVR). Considering this action, this research analyzed the component of basic sanitation in homes subsidized by the Minha Casa Minha Vida Rural Program (PMCMVR) using the municipality of Pontalina, in Goiás, as research locus. The methodology was based on the case study, adopting quali-quanti research procedures. Field research and quantitative analysis of the documents of the Rural PMCMVR were carried out. The evaluation parameters were: available funding; existence of technical advice; technologies offered; and integrated care to the four axes of basic sanitation. As a result, it was observed that the PMCMVR has the potential to articulate the sectoral housing policy with the sector's sanitation policy, however, in relation to the latter, the Program does not yet meet the four components of basic sanitation in an integrated way. Many of the actions and initiatives depend on the entrepreneurship and protagonism of beneficiaries, organizing entities or other non-governmental organizations that mediate between the rural population and public policies.A garantia dos serviços de saneamento para a população rural é assimétrica quando comparada aos serviços prestados à população urbana, é também antiga e persiste, ainda hoje, no Brasil. Diante desse cenário, a pesquisa analisou o componente de saneamento básico nas residências subsidiadas pelo Programa Minha Casa Minha Vida Rural (PMCMV) a partir de estudo de caso, com a realização da pesquisa em campo e análise de documentos do programa em Pontalina, Goiás. Os parâmetros de avaliação foram: financiamento disponibilizado; existência de assessoria técnica; tecnologias ofertadas; e atendimento de forma integrada aos quatro eixos do saneamento básico. Observou-se que o PMCMVR tem potencial de articulação da política setorial de habitação com a política setorial de saneamento, entretanto, o Programa ainda não atende aos quatro componentes do saneamento básico de forma integrada. Muitas ações e iniciativas dependem do empreendedorismo e do protagonismo dos beneficiários, das entidades organizadoras ou de outras organizações não governamentais que fazem a mediação entre a população rural e as políticas pública

Health-status outcomes with invasive or conservative care in coronary disease

BACKGROUND In the ISCHEMIA trial, an invasive strategy with angiographic assessment and revascularization did not reduce clinical events among patients with stable ischemic heart disease and moderate or severe ischemia. A secondary objective of the trial was to assess angina-related health status among these patients. METHODS We assessed angina-related symptoms, function, and quality of life with the Seattle Angina Questionnaire (SAQ) at randomization, at months 1.5, 3, and 6, and every 6 months thereafter in participants who had been randomly assigned to an invasive treatment strategy (2295 participants) or a conservative strategy (2322). Mixed-effects cumulative probability models within a Bayesian framework were used to estimate differences between the treatment groups. The primary outcome of this health-status analysis was the SAQ summary score (scores range from 0 to 100, with higher scores indicating better health status). All analyses were performed in the overall population and according to baseline angina frequency. RESULTS At baseline, 35% of patients reported having no angina in the previous month. SAQ summary scores increased in both treatment groups, with increases at 3, 12, and 36 months that were 4.1 points (95% credible interval, 3.2 to 5.0), 4.2 points (95% credible interval, 3.3 to 5.1), and 2.9 points (95% credible interval, 2.2 to 3.7) higher with the invasive strategy than with the conservative strategy. Differences were larger among participants who had more frequent angina at baseline (8.5 vs. 0.1 points at 3 months and 5.3 vs. 1.2 points at 36 months among participants with daily or weekly angina as compared with no angina). CONCLUSIONS In the overall trial population with moderate or severe ischemia, which included 35% of participants without angina at baseline, patients randomly assigned to the invasive strategy had greater improvement in angina-related health status than those assigned to the conservative strategy. The modest mean differences favoring the invasive strategy in the overall group reflected minimal differences among asymptomatic patients and larger differences among patients who had had angina at baseline

Initial invasive or conservative strategy for stable coronary disease

BACKGROUND Among patients with stable coronary disease and moderate or severe ischemia, whether clinical outcomes are better in those who receive an invasive intervention plus medical therapy than in those who receive medical therapy alone is uncertain. METHODS We randomly assigned 5179 patients with moderate or severe ischemia to an initial invasive strategy (angiography and revascularization when feasible) and medical therapy or to an initial conservative strategy of medical therapy alone and angiography if medical therapy failed. The primary outcome was a composite of death from cardiovascular causes, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. A key secondary outcome was death from cardiovascular causes or myocardial infarction. RESULTS Over a median of 3.2 years, 318 primary outcome events occurred in the invasive-strategy group and 352 occurred in the conservative-strategy group. At 6 months, the cumulative event rate was 5.3% in the invasive-strategy group and 3.4% in the conservative-strategy group (difference, 1.9 percentage points; 95% confidence interval [CI], 0.8 to 3.0); at 5 years, the cumulative event rate was 16.4% and 18.2%, respectively (difference, 121.8 percentage points; 95% CI, 124.7 to 1.0). Results were similar with respect to the key secondary outcome. The incidence of the primary outcome was sensitive to the definition of myocardial infarction; a secondary analysis yielded more procedural myocardial infarctions of uncertain clinical importance. There were 145 deaths in the invasive-strategy group and 144 deaths in the conservative-strategy group (hazard ratio, 1.05; 95% CI, 0.83 to 1.32). CONCLUSIONS Among patients with stable coronary disease and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of ischemic cardiovascular events or death from any cause over a median of 3.2 years. The trial findings were sensitive to the definition of myocardial infarction that was used