Is the Colombian health system reform improving the performance of public hospitals in Bogotá?

Many countries are experimenting with public hospital reform - both increasing the managerial autonomy with which hospitals conduct their affairs, and separating 'purchaser' and 'provider' sides of the health system, thus increasing the degree of market pressure brought to bear on hospitals. Evidence suggesting that such reform will improve hospital performance is weak. From a theoretical perspective, it is not clear why public hospitals should be expected to behave like firms and seek to maximize profits as this model requires. Empirically, there is very slight evidence that such reforms may improve efficiency, and reason to be concerned about their equity implications. In Colombia, an ambitious reform programme includes among its measures the attempt to universalize a segmented health system, the creation of a purchaser-provider split and the transformation of public hospitals into 'autonomous state entities'. By design, the Colombian reform programme avoids the forces that produce equity losses in other developing countries. This paper reports the results of a study that has tried to track hospital performance in other dimensions in the post-reform period in Bogotá. Trends in hospital inputs, production and productivity, quality and patient satisfaction are presented, and qualitative data based on interviews with hospital workers are analyzed. The evidence we have been able to collect is capable of providing only a partial response to the study question. There is some evidence of increased activity and productivity and sustained quality despite declining staffing levels. Qualitative data suggest that hospital workers have noticed considerable changes, which include greater responsiveness to patients but also a heavier administrative burden. It is difficult to attribute specific causality to all of the changes measured and this reflects the inherent difficulty of judging the effects of large-scale reform programmes as well as weaknesses and gaps in the data available.     

A first insight on the population structure of Mycobacterium tuberculosis complex as studied by spoligotyping and MIRU-VNTRs in Bogotá, Colombia

With an incidence of 25.6/100,000 in 2008, tuberculosis (TB) remains an important public health problem in Colombia. In this study, a total of 152 Mycobacterium tuberculosis complex strains isolated in Bogotá, Colombia between years 1995 and 2007 were genotyped by spoligotyping and 12-loci MIRU-VNTRs. The various spoligotyping-based genotypic lineages in our sample were: Latin American & Mediterranean (LAM) n = 75, 49.34%; Haarlem, n = 38, 25.0%; ill-defined T group, n = 21, 13.82%; S family, n = 5, 3.29%; X clade, n = 2, 1.32%; Beijing, n = 1, 0.65%, while strains with unknown signatures (n = 10) represented 6.58% of isolates. Using spoligotyping as a first molecular marker and MIRU-VNTRs as second marker, we obtained 102 single patterns and 14 clustered patterns (n = 52 strains from 49 patients, 2–8 strains per cluster). The MIRU-VNTRs patterns corresponded to 50 MITs for 109 strains and 43 orphan patterns. The most frequent patterns were MIT190 (n = 12), MIT45 (n = 10), and MIT25 (n = 9). The Hunter & Gaston discriminatory index (HGDI) of both methodologies used together showed a value of 0.992. In our setting, the HGDI of five loci subset (MIRU10, 16, 23, 26 and 40) contributed most to the discriminatory power of 12-loci format used (HGDI = 0.977). The lineage distribution of M. tuberculosis showed that more than 3/4 of strains in Bogotá are commonly found in Latin America, Caribbean, and Europe. This observation might reflect the shared post-Columbus history of Colombia and its Latin-American neighbors as well as strains brought in by 20th century immigrants from Europe. We also demonstrate the usefulness of MIRU-VNTR to detect suspected links among patients and polyclonal infections.     

Are data on the uptake of disability benefits a useful addition to census data in describing population health care needs?

OBJECTIVE: To determine if administrative data relating to the uptake of disability benefits held by government departments in Northern Ireland are fair and unbiased indicators of relative need for health care and therefore a useful addition to census data. METHOD: This is an ecological study of the 566 electoral wards in Northern Ireland. The variation in uptake of a health-related benefit (Disability Living Allowance) was regressed against three other indicators of health (limiting long-term illness, mortality and the numbers of patients admitted to hospital). All the indicators had been indirectly standardised by age and sex. The unstandardised residuals from this model were regressed against the social and geographical factors, namely area deprivation score, religious denominational composition and urban/rural dwelling to see if they influenced benefit uptake above and beyond any association with ill health. RESULTS: The health factors alone explained 77.2% of the variation in benefit uptake, with limiting long-term illness being the major determinant; however, even after controlling for differences in health status, benefit uptake was shown to be higher in more urban areas and in areas that had a greater proportion of Catholics. Area deprivation was not associated with benefit uptake once health differences had been controlled for. CONCLUSION: Administrative data on disability benefits can undoubtedly provide useful additional information for describing the levels of relative disadvantage or ill health of areas. However, because they also reflect variations in uptake, which appears to be confounded by social and geographical factors, we would urge caution when they are used to identify priority areas or to allocate resources.     

Demographic profile of the Xavánte Indian population in Sangradouro-Volta Grande, Mato Grosso

This paper analyzes the demographic profile of the Xavánte population at the Sangradouro-Volta Grande Indigenous Reserve in Mato Grosso, Brazil, from 1993 to 1997. The survey included annual censuses and vital statistics from 7 Xavánte villages. Permanent contact with Brazilian national society, established in the 1940s and 50s, caused a population drop due to epidemics and clashes. In 1995 there were 825 individuals in the community. The crude birth rate (57.7/1,000) and death rate (9.1/1,000) were higher than the national averages. The majority (56%) of the population is under 15 years of age (median: 13 years) and the infant mortality rate is high (87.1 per thousand live births), probably resulting from precarious sanitary conditions in the villages. Other results included the persistence of polygyny; low levels of migration; a dynamic of splits and formation of new villages; traditional housing patterns maintained in the old villages and abandoned in the new ones. The recent demographic recovery in the data from Sangradouro-Volta Grande is similar to that observed in the Pimentel Barbosa community. The study highlights the importance of systematically collecting and analyzing demographic data from indigenous populations.     

Provider barriers and facilitators to screening for intimate partner violence in Bogotá, Colombia

We conducted interviews with 27 health care personnel in Bogotá, Colombia, to examine provider barriers and facilitators to screening for intimate partner violence (IPV). We used systematic qualitative analysis to identify the range and consistency of beliefs. We found that respondents did not routinely screen for IPV. Providers listed numerous barriers to screening. Ways to improve screening included increased clinician training, installing systematic IPV screening, providing patient education, and implementing health care setting interventions. Improving the care for IPV survivors will involve translating health care personnel preferred solutions into more systematic IPV screening interventions.     

Hand Washing Among School Children in Bogotá, Colombia

Objectives. We assessed hand-washing behaviors and intentions among school children in Bogotá, Colombia, to help identify and overcome barriers to proper hygiene practices.Methods. Data on hand-washing behavior and intentions and individual and contextual factors were collected from 2042 sixth- through eighth-grade students in 25 schools in Bogotá via anonymous questionnaires. A member of the school administration or teaching staff completed a questionnaire about the school environment. Site inspections of bathroom facilities were conducted.Results. Only 33.6% of the sample reported always or very often washing hands with soap and clean water before eating and after using the toilet. About 7% of students reported regular access to soap and clean water at school. A high level of perceived control was the strongest predictor of positive hand-washing intentions (adjusted odds ratio [AOR] = 6.0; 95% confidence interval [CI] = 4.8, 7.5). Students with proper hand-washing behavior were less likely to report previous-month gastrointestinal symptoms (OR = 0.8; 95% CI = 0.6, 0.9) or previous-year school absenteeism (OR = 0.7; 95% CI = 0.6, 0.9).Conclusions. Scarcity of adequate facilities in most schools in Bogotá prevents children from adopting proper hygienic behavior and thwarts health promotion efforts. The current renovation program of public schools in Bogotá provides a unique opportunity to meet the challenges of providing a supportive environment for adoption of healthy behaviors.Remarkable improvements have been made in the past century in the fight against communicable diseases, yet a significant amount of mortality and morbidity worldwide can still be attributed to these conditions.¹ Respiratory infections and diarrheal diseases—the 2 leading causes of disease burden globally—are responsible for half of all child deaths each year.¹ The burden of communicable disease remains predominantly acute in developing regions of the world,² and children remain particularly vulnerable.³Recent estimates in Colombia indicate that acute respiratory and intestinal infections are the main cause of mortality among children aged 1 to 4 years, the second leading cause of death among girls aged 5 to 14 years, and the third leading cause of infant mortality.⁴ According to a recent national household survey in Colombia, 14.1% and 9.6% of children younger than 5 years had experienced diarrhea or an acute respiratory infection, respectively, in the 2 weeks before the survey.⁴Despite much evidence supporting the effectiveness of measures such as vaccination,^5,6 improvement in sanitary conditions,^3,6 and basic hygiene practices^3–7 in controlling communicable diseases, many developing nations have yet to achieve effective vaccination coverage⁶ and remain plagued with poor sanitary conditions. Basic personal hygiene behaviors, such as hand washing, are still not widely practiced.⁷Diverse health behavior and social marketing theories have been applied in the design and implementation of behavioral change interventions that promote infection-control practices.^8,9 The theory of reasoned action and planned behavior,^10,11 for example, suggests that a person''s behavior is determined by her or his intention to perform the behavior. Intention, in turn, is a function of the person''s attitudes toward the behavior, beliefs concerning benefits or harms of adopting or not adopting the behavior, subjective norms and normative beliefs, and perceived control over the opportunities, resources, and skills necessary to perform the behavior.^9,10 More recently, ecological approaches have been incorporated into behavioral theories to disentangle independent effects of individual and contextual factors on health behavior.¹² The underlying premise of such models is a bidirectional relation between environmental modifications and behavioral change.^12,13Bearing in mind that school children have been consistently implicated in the spread of communicable diseases¹⁴ and that the school has been recognized as a vital setting for health promotion, we assessed the prevalence and individual and contextual determinants of proper hand-washing behavior and positive hand-washing intentions among school children in Bogotá, Colombia.     

Identification of the area of influence of the public basic health care delivery to the elderly population in Viçosa-MG

This study aimed to describe the demographic and epidemiological characteristics of the elderly population, identify the area of influence of basic care in relation to the area of residence of the elderly and the rate of service use, as well as to map the demand according to the geographic location of the Basic Care Unit. The sample comprised 6,964 male and female subjects aged 60 years or more, who sought any of the outpatient public health services between May 2003 and April 2004. From this total, 64.1% were women and 35.9% men. The results show that cardiovascular diseases account for the greater part of medical consultations in the health system, with a mean of 3,576 consultations per year per elderly. Geographic mapping showed the demand for medical consultations in determinate basic care units to be related with the medical specialty available at these units. These results allow identifying the neighborhoods with the highest concentrations of specific diseases, indicating the need for insertion/redistribution of professionals between the basic care units in order to improve the quality of life of the elderly.     

Cross sectional survey of perpetrators,victims, and witnesses of violence in Bogotá, Colombia

OBJECTIVES: To establish the prevalence and distribution of witnesses, victims, and perpetrators of different types of violence in the general population and the proportion of victims consulting health services or reporting the incident to authorities. METHODS: Cross sectional survey of a random sample of 3007 inhabitants between the ages of 15 and 60 in the city of Bogotá, Colombia, in 1997, based on a face to face interview. RESULTS: Age adjusted past year prevalence of witnesses, victims, and perpetrators of physical aggression was 61%, 27%, and 27%, respectively, while lifetime prevalence of witnesses, victims, and perpetrators of assault with a weapon in this population reached 70%, 55%, and 5.8%. Between 11% and 67% of the victims consulted a health service and less than 32% reported the incident to an authority. Those involved in most types of physical violence tended to be young, male, from lower middle social classes, with some degree of secondary education, and single or divorced. CONCLUSIONS: Prevalence of witnesses and victims of violence in this sample appears to be high, while perpetrators constitute a small proportion. Violence is not equally distributed throughout the population suggesting the possibility of identifying a population at higher risk for the development of intervention programmes.     

The increase in occurrence of typhoid fever in Cameroon: overdiagnosis due to misuse of the Widal test?

This study investigates the cause of an apparent increase in occurrence of typhoid fever in Cameroon. The reasons explored include an overdiagnosis of the illness related to poor performance of the Widal test in laboratories and interpretation by prescribers. Questionnaires were used in 1996 to evaluate the use and interpretation of the Widal test, and checklists were used to assess its laboratory performance in 2 of the 10 provinces in Cameroon. The majority of prescribers from 20 health facilities (an average of 76% of the doctors and 61% of the nurses) could detect patients who truly had positive Widal tests and needed treatment. However, an average of 48% of the doctors and 84% of the nurses would treat patients who did not require treatment based on the Widal test result. Patients may therefore be treated unnecessarily. Most (88%) of the visited laboratories performed the Widal rapid slide agglutination test as opposed to the conventional tube agglutination test. About 14% of the laboratories that performed the rapid slide agglutination test had a score above average for each criterion evaluated. Misdiagnosis of typhoid fever leads to unnecessary expenditure and exposure of patients to the side-effects of antibiotics. In addition, misdiagnosis may result in delayed diagnosis and treatment of malaria, and other acute febrile illness.