Public and private: insurance companies and medical care in Mexico

During the late 70's and early 80's in Mexico, as in the rest of Latin-America, sanitary policies were directed to support the growth of the private sector of health care at the expense of the public sector. This work analyzes the evolution of the health insurance market as a part of the privatization process of health care. The analysis based on economic data, provides the political profile behind the privatization process as well as the changes in the relations between the State and the health sector. The central hypothesis is that the State promotes and supports the growth of the private market of medical care via a series of legal, fiscal and market procedures. It also discusses the State roll in the legal changes related to the national insurance activity. A comparative analysis is made about the evolution of the insurance industry in Argentina, Brazil, Chile and Mexico during the period 1986-1992, with a particular enfasis in the last country. One of the principal results is that the Premium/GNP and Premium/per capita, display a general growth in the 4 countries. This growth is faster for Mexico for each one) because the privatization process occurred only during the most recent years. For the 1984-1991 period in Mexico the direct premium as percentage of the GNP raised from 0.86% to 1.32%. If one focussed only in the insurance for health and accidents branches the rice goes form 8.84% in 1984 to 19.08% in 1991. This indicates that the insurance industry is one of the main targets of the privatization process of the health care system in Mexico. This is also shown by the State support to fast expansion of the big medical industrial complex of the country. Considering this situation in the continuity of the neoliberal model of Mexico, this will profound the inequity and inequality.     

The long-term role of national non-government development organizations in primary health care: lessons from Banglades

This paper discusses the future role of national non-governmentdevelopment organizations (NGDOs) in health development. Takingthe case of Bangladesh it is shown how some national NGDOs havedeveloped into large professional organizations and how theirposition relates both to foreign donor support and the state.It is argued that the future contribution of national NGDOsto the development of primary health care (PHC) may be considerable,including strengthening of health care delivery by governmentstaff. A division of tasks and responsibilities between stateand national NGDOs must be based on complementarity. The discussionalso has relevance for countries where state involvement indevelopment and sustenance of PHC is diminishing because ofeconomic problems.     

UNDERTAKING RESEARCH FOR THE BENEFIT OF THE RURAL COMMUNITY

ABSTRACT: This paper discusses the importance of disseminating clinical research findings to improve nursing practice and, ultimately, the health of rural Australia. It is argued that nursing in all settings must be practised within the context of changing healthcare trends. Currently, these changes include the restructuring of health services toward a greater emphasis on community-based services, a redirection of the focus of care toward population health rather than hospital-based service provision, multidisciplinary clinical decision-making with the community as partner, and the need for all health professionals to maintain fiscal and clinical accountability. To chart the process and outcomes of care in these changing circumstances requires ongoing, systematic research. The global movement toward evidence-based healthcare practice is thus timely and necessary. In order to provide a foundation for evidence-based practice that will demonstrate quality, efficiency, effectiveness and community acceptability, employers must address both infrastructure and educational needs. Educators must be responsive to changes in the organisation and funding of care. Also both groups must work collaboratively toward ensuring dissemination of research information that will make a difference to patient and community outcomes. The key to success is ongoing communication between employers, educators, practitioners in the field, community members and professional organisations so that research findings can be analysed in simple language that increases utility and that provides a forum for valuing information from all sources.     

The role of public health in providing primary care for the medically underserved

Strategies designed to meet the health care needs of Americans should include the issues of access as well as financing. And primary care and clinical preventive services should receive as much national attention as acute care and long-term care. The public health system at the Federal, State, and local levels with its mandate to assure conditions in which people can be healthy must also be incorporated into the national debate. Publicly funded infrastructures for delivering primary health care have become a significant element of assuring access at the community level. This paper examines the expanding role of public health in assuring access to the delivery of primary health care and clinical preventive services to vulnerable populations within the larger issue of who should have access to care and how it should be made available. Special attention is paid to the part played by the Health Resources and Services Administration (HRSA) of the Public Health Service, which, in the Federal fiscal year that began on October 1, 1989, administered some $1.8 billion worth of programs for health care of targeted populations and for the support of training in the health professions.     

Improving performance using indicators. Recent experiences in the United States, the United Kingdom, and Australia.

This article describes recent national performance improvement initiatives in the United States, United Kingdom, and Australia. This comparison is of particular interest because each of these three countries faces similar challenges in delivering health care and improving health. Each has elevated a focus on safety and quality improvement to a national level. Marked differences in the organization and financing of health care across these three countries provide a unique opportunity to compare and contrast approaches. Drawing on the experience of the authors in each of the three countries and publicly available data sources about specific national initiatives, we describe the national context for improvement and outline recent performance improvement initiatives and emerging issues and challenges. Similarities and differences in the current evolution of national performance initiatives are described and conclusions are drawn about challenges that all three countries face, particularly in terms of developing meaningful sets of national indicators of health system performance. The challenges for future work include the importance of information infrastructure, the paucity of accurate and accessible clinical data, the need for effective performance measurement processes at a local level to capture useful data, and the tensions of balancing accountability and improvement agendas for measurement.     

Taking care of the sick and scared: a local response in pandemic preparedness

Virtually all health care operations, including public health, are undertaken only at a local or regional level. Large-scale infectious disease emergencies, such as SARS or pandemic influenza, will be recognized and managed at a local level. The creation of the Public Health Agency of Canada (PHAC) was an important step in strengthening public health capacity. However, we need adequate operational capacity in local public health departments to have a strong public health system. Local public health takes an integral role in the preparation for and management of infectious disease emergencies. Local public health departments and regional public health infrastructures must be positioned to both maintain core functions and to lead and support health sector response to emergencies. The local establishment of a flexible and sustainable emergency management system must address the need to: integrate health care and first responders; provide all-hazards tools for managing a crisis at the frontline; rank service priorities and provide surge resources; and provide accurate information on a timely basis. Only the leaders within the local or regional health care facilities and organizations can develop workable plans to deliver health care. PHAC must ensure and support the local public health infrastructure and local emergency preparedness. Without this support, there will be consequences for local response to major public health emergencies.     

Assessment of the epidemiologic capacity in state and territorial health departments--United States, 2001

Epidemiology is essential for the detection, control, and prevention of major health problems. Described as the foundation of all public health functions, epidemiology provides information needed to perform the 10 essential public health services. One of the national health objectives for 2010 calls for increases in the proportion of tribal, state, and local public health agencies that provide or ensure comprehensive epidemiology services to support essential public health services (objective 23-14). Although national infectious disease capacity has been assessed, no comprehensive national assessment of epidemiologic capacity has been conducted. To assess core epidemiology and infectious disease capacity of public health departments, the Council of State and Territorial Epidemiologists (CSTE) surveyed state and territorial health departments in November 2001, immediately before the release of approximately 1 billion dollars in federal funding to state health departments for terrorism and public health emergency preparedness. This report summarizes the results of that survey, which indicate that the national epidemiology infrastructure in state and local health departments is far below optimal capacity and that approximately 42% of epidemiologists working in public health have no formal epidemiologic training. Although recent terrorism preparedness initiatives have improved capacity in infectious disease epidemiology, increased resources are needed to build epidemiologic capacity necessary to address the major causes of morbidity and mortality.     

Better education for better health care

In India, all national nutrition programs and activities are carried out by staff at the primary health centers under the leadership of medical officers. A study of 114 of these officers from 80 primary health centers in rural districts of Andhra Pradesh State was undertaken to assess their knowledge and performance, particularly with regard to nutrition and related matters. Scores were expressed in percentages, with under 50% considered poor, 50-75% satisfactory, and over 75% good. The highest score 67.7% was obtained on knowledge of nutrition and related areas, and the lowest, 19.7% was for the participant's awareness of their own job responsibilities. Although overall theoretical knowledge on nutrition and related matters was satisfactory, significant gaps existed. A majority were ignorant as to how many people were covered by their centers and the numbers of staff in different categories, suggesting little attention was being given to planning and implementation of various services. Only 23% were aware of their own responsibilities regarding nutrition, and only 16% mentioned teaching nutrition during their training programs. The conclusion is that the medical education system must be better coordinated with the health care delivery infrastructure. Medical undergraduates need more exposure to Practical aspects of health care in rural communities, managerial aspects of work in primary health centers, and programs with a stronger nutrition component. In addition, refresher courses must be offered, and the problem of overburdening the medical officers must be dealt with.     

Building the infrastructure for primary health care: an overview of vertical and integrated approaches

In the past four decades there has been a succession of different approaches to the development of infrastructure for the delivery of health services. There have been striking similarities among these approaches in both direction and timing in many different countries, particularly in the developing world. While the general trend has been strongly in the direction of a more comprehensive, integrated health infrastructure, there have been important regressions from this path. It is suggested that the recent attention given to the delivery of 'selective' packages of interventions has often diverted energy and resources from the essential task of developing comprehensive, efficient and effective health services. This paper begins with an historical review of trends in the development of health services infrastructure in recent decades. It proceeds to analyse the implications for the organization of health services and for resource allocation when the health services infrastructure is viewed as part of a health system based on primary health care. Finally, we maintain that district health systems based on primary health care provide an excellent practical model for health development, including an appropriate health system infrastructure. Within this model the concerns with accelerating the application of known and effective technologies and the concerns with strengthening of community involvement and intersectoral action for health are both accommodated. The district health system provides a realistic setting for dialogue and planning involving both professionals and non-professionals concerned with health and social development.     

Transforming Chaplaincy: The Emergence of a Healthcare Pastoral Care for a Post-Modern World

This article provides a snap shot of the current position and recent developments in chaplaincy in health care settings particularly in England, Scotland, the United States of America and Australia in order to guide the emerging modernization agenda in the Australian context, and to assist the acceleration of the local adoption of best practice in pastoral care. Over all, the picture is one of change. As hospitals develop to meet new performance expectations services that work within the hospital system, such as chaplaincy and pastoral care, must also adapt. Rather than chaplaincy being discarded as marginal during these changes, recent research evidence supports the inclusion of pastoral care in holistic health care. Demographic changes also mean that pastoral care needs to have an emphasis on spiritual support if it is to respond to patients of other faith traditions or with secular beliefs.     

Assessing Indian public health standards for community health centers: a case study with special reference to essential newborn care services

The main objective of the study is to identify the availability of infrastructure facility, human resources, investigative services, and facility based newborn care services with respect to Indian Public Health Standards (IPHS) at community health centers (CHC) of Bharatpur District of Rajasthan State. Data were collected from service providers at CHC through well structured questionnaire at thirteen CHCs situated at Bharatpur District of Rajasthan State. It was found that infrastructure facilities were available in almost all the CHCs, but shortage of manpower especially specialists was observed. Availability of investigative services was found quite satisfactory except ECG. It was also observed that none of the CHCs have fully equipped facility based newborn care services (including newborn corner and newborn care stabilization unit). As per IPHS suggested in the revised draft (2010) important deficiencies were revealed in the studied CHCs of Bharatpur district and by additional inputs such as recruiting staff, improving infrastructure facilities, CHCs can be upgraded.     

Moving beyond access: achieving equity in state health care reform

The Institute of Medicine's 2003 Unequal Treatment report raised the public's and policymakers' awareness of racial and ethnic health care disparities, but federal policy-makers have implemented few of the report's more than two dozen recommendations. State health care reform efforts, however, are gaining support around the country and have great potential to reduce health care inequality. This paper offers a policy framework to explore how states can move toward eliminating disparities by addressing health care access and quality, state health care infrastructure, patient and community empowerment, state policy infrastructure, and social and community determinants of health.     

The engine or the caboose: health policy in developing countries

A discussion of health policy in developing countries is presented. It argues that developing countries must adopt a progressive approach to health policy which rejects the two-tiered system of public and private health care. However, it also points out that ideology is not sufficient to maintain support. A progressive health system must utilize administrative and social and behavioral sciences to achieve effectiveness and efficiency in health care delivery. It cannot ignore these goals any more than a private health care system can.     

The physician's role in health care spending

Physicians must weigh their obligation to provide their patients with the best care possible against their obligation to be good stewards of health care resources. Given the rising cost of health care in the United States and Minnesota, striking the right balance has become more of a challenge. This article describes national and state health care spending trends. It also describes the State of Minnesota's Provider Peer Grouping program and the health plans' total cost of care analyses, two initiatives that are being used to evaluate the cost of care delivered by various provider groups and highlight areas for improvement.     

Designing health care information systems for integrated delivery systems: where we are and where we need to be

A critical step in evolving an integrated delivery system (IDS) is planning, designing, and technologically realizing an efficient, appropriate, and effective infrastructure for developing an integrated network of information systems. The key to meeting this objective philosophically, logically, and physically in the face of rapid advances in computing technology and communication trends is often poorly understood by health providers and managers. The article discusses the concept of a total quality management information system model and illustrates how this sort of thinking can be applied to guide the critical steps that must be undertaken to plan, design, and develop a networked infrastructure of health care information systems that can facilitate information exchange and sharing among multiple health care providers within an IDS.     

Eligibility, the ICF and the UN Convention: Australian perspectives

The UN Convention on the Rights of Persons with Disabilities, in Australia, acts as a philosophical and moral statement and framework guiding integrated and strategic policy across the nation. Broad policy agreement has been reached by governments, and both the government and non-government sectors are developing strategies for implementation or evaluation. There is however a need for a more integrated approach to disability policy and information, reflecting all three components of the Italian project: legislation and a high level philosophical framework and policy guide; a technical framework that can underpin specific policies and programs aiming to achieve the major goals; and , a language and set of tools, relating to both the above, that provide infrastructure for assessment methods and information systems. The International Classification of Functioning, Disability and Health (ICF) is the ideal tool to support the latter two components, consistent with the UN Convention. While the ICF has been used as the basis for national data standards, in population surveys and in the national data collection on disability support services, there is considerable scope for greater use of it, including using all domains of the Activities and Participation and the Environmental Factors component for policy, information and service provision, to advance a disability-inclusive society. Information available from the income support system and from generic services could be enhanced by reference to the ICF components. It would be of significant national value in Australia, especially as a 'continuum of care' is desired, if consistency of concepts and information were expanded across health and social welfare sectors. It would then be possible to obtain consistent data from health, aged care, disability and community services systems about key aspects of health and functioning, building a consolidated picture of access and experience across these sectors. Without attention to all three components of the Italian project and continuing effort to meet the challenges identified in this paper, it will not be possible to determine whether the goals of Australia's National Disability Agreement or the ambitions of the Convention are achieved.     

Investing in health

This article analyses the relationship between health and development. It provides a theoretical foundation of the empirical finding that health and development are positively correlated. Empirical data and recent studies on the relation between health and development are analysed. The theory of development traps is enhanced to explain the feedback loop between these elements. There is a strong empirical correlation between health and development. The higher the gross national product, the higher the life expectancy and the lower the mortality and morbidity. This relation is true for developing as well as for developed countries. It is obvious that economic resources have an impact on the availability of health care resources and consequently on health, but at the same time the health of a population is of strong importance for their economic capability. Thus, health and development are elements of an autocatalytic process. Investments in health care will start a positive spiral of development and health. However, not every investment will yield fruits. They must be efficient and effective, must follow the value system of a society and must invest in the ability of decision makers to deal with complexity and dynamics.     

Challenges for the public in negotiating the health system in the 21st century

This paper addresses the challenges and opportunities that face the public in negotiating the health care system (both medicine and public health) in the 21st century. It addresses three issues: how consumers exercise choice, with special attention to the choice of health care coverage; how patients and communities interact with clinicians and public health professionals; and whether and how the public's “voice” is heard as health policy decisions, at the societal and institutional levels, are made. With respect to each of these issues, the paper describes the current status of public influence and articulates a vision for the future. These three related visions are (1) that empowered, informed, supported consumers make decisions about health plans, clinicians, treatments, and their own behavior; (2) that clinicians and public health professionals, working as partners with patients and communities, are in a position to “standardize the customization of care” so that all aspects of care are tailored to the needs of the individual, family, or community in question and social, economic, and cultural factors are taken into account in the day-to-day practice of medicine and public health; and (3) that the ability and willingness of the public to negotiate and shape the health care environment is supported by an independent infrastructure that permits enhanced public involvement in health policy making and governance. The paper identifies key elements of this vision, discusses challenges to pursuing and achieving each vision, and identifies opportunities that may support the pursuit of the vision.