https://tedebc.ufma.br/jspui/handle/tede/1009 2026-07-21T08:01:33Z https://tedebc.ufma.br/jspui/handle/tede/7125 Título: Análise espaço-temporal da distribuição de fisioterapeutas e de atendimentos fisioterapêuticos ambulatoriais no sistema único de saúde, Brasil Autor: MARQUES, Maria Jhany da Silva Primeiro orientador: ALVES, Cláudia Maria Coelho Abstract: The provision of physical therapy services in the SUS is marked by inequalities. This thesis analyzed the spatiotemporal distribution of physical therapists and outpatient care in the SUS in Brazil and Maranhão (MA). Two ecological studies were conducted using official public data. The first investigated the evolution in the number of physical therapists and visits in Brazil from 2008 to 2019, in relation to per capita Gross Domestic Product (GDP) and per capita SUS budget. The second analyzed the distribution of these professionals and outpatient production in MA from 2022 to 2024, considering socioeconomic, demographic, structural, mobility, and accessibility factors. Analyses included covariance, Pearson correlations, and Tukey’s test in the national study, and association tests, Moran’s indices, and spatial regression in the Maranhão study. In Brazil, GDP per capita showed a positive correlation with physical therapists in all federative units (FUs) and with visits in seven FUs, especially Paraíba (r=0.96), Acre (r=0.88), and Amazonas (r=0.84). Visits correlated with per capita SUS budget in Acre (r=0.84), Amazonas (r=0.76), Tocantins (r=0.73), Paraíba (r=0.65), and Rondônia (r=0.64). In Maranhão, municipalities with coverage <1 physical therapist/10,000 inhabitants decreased from 53 to 19, those with rates ≥6.67/10,000 increased from 1 to 9, and more than 120 municipalities had no recorded visits. High-High clusters of coverage and production were concentrated in the eastern, central-eastern, and western areas. Physical therapist coverage was associated with specialty centers (β=0.115) and per capita SUS budget (β=0.001) in health regions, and with GDP per capita (β=6.839) and polyclinics (β=0.298) in municipalities. Visits were associated with trauma hospitals (β=188.252) in health regions, and with primary health care units (β=2.190), trauma hospitals (β=4.559), and hospitalizations for musculoskeletal surgeries (β=589.786) in municipalities. It is concluded that, in Brazil, GDP per capita and SUS budget per capita were positively associated with the availability of physical therapists and outpatient production, especially in the Northern FUs. In Maranhão, territorial inequalities and care gaps persisted in the provision of physical therapy in the SUS, associated with socioeconomic and structural factors.. Instituição: Universidade Federal do Maranhão Tipo do documento: Tese 2026-04-28T00:00:00Z https://tedebc.ufma.br/jspui/handle/tede/7113 Título: Assistência oncológica mamária pública e privada em São Luís Maranhão: vivências médicas durante a pandemia de covid-19 Autor: SANTOS, Jéssica Mendes Costa de Freitas Primeiro orientador: ALVES, Maria Teresa Seabra Soares de Britto e Abstract: The COVID-19 pandemic produced profound repercussions on breast cancer care in Brazil, affecting both the public and private health sectors. This thesis aimed to analyze, from the perspective of specialist physicians, the impacts of the pandemic on the organization of care and on clinical practices related to breast cancer in São Luís, Maranhão, with emphasis on inequalities between sectors and on changes generated by technological mediation. The study is based on the hypothesis that health crises can aggravate pre-existing disparities and reconfigure routines and meanings of health care, especially in contexts marked by the historical segmentation of the health system. This is a qualitative study based on 18 semi-structured interviews with physicians specializing in breast cancer care who worked in both public and private sectors during and after the pandemic. Data analysis followed the procedures of content analysis (Bardin), guided by thematic categories related to the chronological trajectory of the pandemic and to transformations resulting from the virtualization of care. The thesis is composed of two scientific articles. The first analyzes the experiences of professionals across different phases of the pandemic, revealing organizational, emotional, and structural impacts on the health system. The second discusses the effects of digital mediation—such as telehealth, social media, and digital platforms—on oncological practice, highlighting both innovations and ethical, technical, and communicational tensions. The findings indicate that, although important institutional adaptations occurred, historical inequalities deepened, and technological mediation, far from being neutral, produced new forms of exclusion and professional overload. It is concluded that the pandemic acted as a catalyst for changes in ways of caring, communicating, and organizing health work, whose effects still demand critical analysis and the development of equity-oriented public policies. This thesis contributes to the field of Collective Health by integrating structural analysis, attentive listening to professional experiences, and ethical reflection on cancer care in times of crisis. Instituição: Universidade Federal do Maranhão Tipo do documento: Tese 2026-04-29T00:00:00Z https://tedebc.ufma.br/jspui/handle/tede/6923 Título: SISTEMA DE SAÚDE NO MARANHÃO: O PÚBLICO E O PRIVADO SOB A PERSPECTIVA DE GESTORES, GERENTES, EMPRESÁRIOS E PROFISSIONAIS DE SAÚDE Autor: CAMPOS, Douglas Moraes Primeiro orientador: PINHO, Judith Rafaelle Oliveira Abstract: This thesis investigates the interactions between the public and private healthcare systems in Maranhão, based on the perspectives of managers, administrators, healthcare professionals, and business owners. The perspective situated from different positions “within the system” and these agents’ reflections on their daily work practices contributed to an understanding of tensions in the public-private relationship, particularly regarding the coordination of federal entities, human resource management, the role of Social Health Organizations (SHO), and the expansion of Low-Cost Clinics in the state capital. The analysis of these issues through the intertwining of the pathways traversed by these agents allowed for the contextualization of issues raised at the local-regional level. Grounded in the Social and Human Sciences in Health, the research employed mixed methods, combining semi-structured interviews and georeferencing in the capital, São Luís. The results highlight tensions between the Unified Health System (UHS) and the private sector, driven by the selective expansion of the market and the overload of the public network. In the study, SHO and Low-Cost Clinics, which are dependent on the public sector, are presented by their representatives as alternatives for unmet demands within the SUS. The participants emphasized that Primary Health Care (PHC) has been severely affected by hospital-centric policies, leading to the fragmentation of Health Care Networks (HCNs), the precariousness of employment relationships, and hospital overcrowding, even as hospital care expands in rural areas. This scenario unfolds in a context in which the state of Maranhão has progressively opened space, within the UHS framework, for private entities to operate in the provision of healthcare services and hospital management. Through georeferencing, it was demonstrated that the expansion of Low-Cost Clinics is not random; these entities occupy areas of high population density in the center and in some outlying areas of São Luís, located near Basic Health Units (UBS). In this sense, actions coexist within the territory in which the value of health differs: as a universal right and as an economic asset, access to which is mediated by payment. The analysis identifies the expansion of the private sector’s presence in healthcare provision and management within the UHS, reconfiguring care and creating tension around health as a right in the face of its commodification. Instituição: Universidade Federal do Maranhão Tipo do documento: Tese; Trabalho sob sigilo. Motivo: O sigilo se dá pois há artigos não publicados e que estão em processo de submissão em revistas científicas que exigem exclusividade na disponibilização dos dados. Data Provável de Liberação: 24 meses. 2026-03-30T00:00:00Z https://tedebc.ufma.br/jspui/handle/tede/6297 Título: ANÁLISE DE SOBREVIDA DE PACIENTES COM COVID-19 INTERNADOS EM HOSPITAIS DO BRASIL Autor: MARTINS NETO, Carlos Primeiro orientador: OLIVEIRA, Bruno Luciano Carneiro Alves de Abstract: COVID-19 is an infectious disease caused by SARS-CoV-2. This virus has high transmissibility and can develop severe pneumonia that manifests as Severe Acute Respiratory Syndrome (SARS), which impacts patient survival. This thesis aimed to analyze the associated factors and potential interactions between predictors with the survival of patients hospitalized for SARS due to COVID-19 in Brazil. Data from adults and the elderly reported in the Influenza Epidemiological Surveillance Information System (SIVEP-Gripe) of the Ministry of Health were used. The first article analyzed the survival of patients hospitalized with COVID-19- related Severe Acute Respiratory Syndrome (SARS) and identified risk groups for COVID-19 mortality based on potential interactions among predictors. This was a retrospective longitudinal study using data from 1,756,917 cases admitted between February 16, 2020, and December 31, 2022. Survival tree analysis was employed to identify potential interactions among predictors. A separate model was constructed for each study year. The case fatality rate was 33.2%. Lower survival was observed among those who underwent invasive mechanical ventilation and were 80 years or older during the three years of the pandemic. Black and mixedrace individuals were predictors of death in the years 2020 and 2021, coinciding with increased healthcare system demand due to a higher number of cases. The objective of the second article was to analyze the influence of individual and contextual factors related to hospital and municipality care on the survival of patients with COVID-19-related Severe Acute Respiratory Syndrome (SARS). This study involved a hospital-based cohort of 159,948 cases admitted in 2022. Contextual variables were derived from the National Registry of Health Establishments, indicators from the municipalities that contribute to the Sustainable Cities Development Index - Brazil, and the Social Inequalities Index for COVID-19 proposed by the Center for Data Integration and Knowledge for Health (Cidacs/Fiocruz). The outcome was hospital survival within 90 days. Survival tree analysis and Cox regression were used to analyze survival. The survival tree identified 8 groups with varying probabilities of survival. Elderly patients who underwent invasive mechanical ventilation and were hospitalized in cities with low tax revenue percentages had a higher risk of death compared to adults (p < 0.001) who did not receive mechanical ventilation and were admitted to hospitals not affiliated with the Unified Health System (SUS). The objective of the third article was to analyze the influence of the organization and composition of hospital establishments - whether affiliated with the Unified Health System (SUS) or not - and their impact on the survival of patients with COVID-19-related Severe Acute Respiratory Syndrome (SARS). This study involved a hospital-based cohort of 159,948 cases admitted in 2022. In hospitals affiliated with the SUS, 32.7% of the patients progressed to death, compared to 21.4% in non-SUS services. The survival of patients hospitalized within the SUS was lower (p < 0.001), with predictors including invasive mechanical ventilation, age, hospital size, and ICU admission. Among patients in non-SUS hospitals, in addition to these variables, predictors also included region, ECG/bed monitoring rate, and physician/bed rate. It is concluded that individual and contextual factors influence the survival of these patients, revealing inequalities not only in direct patient care but also in the organization, functioning, and performance of hospital services. Therefore, it is necessary to review and modify the relationship between the Brazilian public and private healthcare systems and strengthen the public system further to reduce observed inequities. Instituição: Universidade Federal do Maranhão Tipo do documento: Tese 2024-02-05T00:00:00Z