Improving mental and neurological health research in Latin America: a qualitative study

Background  

Research evidence is essential to inform policies, interventions and programs, and yet research activities in mental and neurological (MN) health have been largely neglected, particularly in low- and middle-income countries. Many challenges have been identified in the production and utilization of research evidence in Latin American countries, and more work is needed to overcome this disadvantageous situation. This study aims to address the situation by identifying initiatives that could improve MN health research activities and implementation of their results in the Latin American region.     

Decentralization of the health sector in Latin America

This paper analyzes the Latin American experience of decentralizing health services within the context of health reform. We examine the meaning of the term decentralization and discuss the various modalities of this concept: geographical, institutional and functional. The objectives that, in general, these objectives have not been achieved. After reviewing the literature and drawing on our own fieldwork, we conclude that in many instances the Latin American decentralization programs have produced results opposite to those intended, i.e., these programs have increased inequality and the cost of services and have reduced efficiency and quality of care.We point out that existing information is insufficient to determine with exactitude whether the failure of decentralization is due to the selection of inappropriate policies or to failures in the implementation process. Decentralization is a complex political process, policy makers should decide on the modality of decentralization they wish to implement, estimate the costs, identify the potential obstacles that could surface during the implementation phase and provide solutions. We conclude by suggesting that the multilateral banks have erred by pressing governments to improvise the implementation of decentralization programs without taking into account the different historical, political and socioeconomic contexts.     

The health and economic impact of dengue in Latin America

In the last two decades, all countries in the tropical regions of Latin America have experienced marked increases in the incidence of both classic dengue and dengue hemorrhagic fever. Major risk factors for the occurrence of dengue in the region, as well as some regional peculiarities in its clinical expression, such as the extensive involvement of older age groups, have been defined. While little information exists on the economic impact of dengue in the region in terms of disease burden, the estimated loss associated with the disease is on the same order of magnitude as tuberculosis, sexually transmitted diseases (excluding HIV/AIDS), Chagas disease, leishmaniasis, or intestinal helminths. Therefore, similar priority should be given in the allocation of resources for dengue research and control. Data on cost-efficacy and cost-benefit analysis of dengue control programs in Latin America are scarce; however, the cost per DALY averted by control programs during endemic periods appears low, as compared to other mosquito-borne diseases like yellow fever, leishmaniasis, or malaria. Additionally, the cost-benefit ratio of the control programs has proven to be positive.     

Family health care spending in Latin America

Household budget data from surveys in six Latin American countries, 1966-75, are used to estimate income elasticities of private health care spending. For ten cities in five countries the elasticity is constant at 1.5; for metropolitan, other urban, and rural areas of Brazil it is constant at 1.17. The Brazilian data also show 30 percent higher spending in small than in large cities, and 50 percent higher in the countryside. These results are consistent with supposing that private care is a luxury compared to public care, and that more is spent on the former when the latter is not available. Geographic differences may be exaggerated by differences in payment mechanisms, since reported out-of-pocket expenditure is not net of public reimbursement. Different components of spending such as drugs and hospitalization show very different behavior from the total.     

Backsliding on a key health investment in Latin America and the Caribbean: the case of breastfeeding promotion

Objectives. We examined trends in breastfeeding promotion investments, breastfeeding promotion activities, and breastfeeding duration in Latin America and the Caribbean from the 1980s to the 2000s.Methods. We obtained financial data from the United States Agency for International Development and the International Code Documentation Center, and we obtained breastfeeding promotion data from surveys of breastfeeding coordinators with ministries of health and with the International Baby Food Action Network. We obtained breastfeeding data from nationally representative surveys conducted between 1986 and 2008.Results. Investment in breastfeeding promotion declined in the 2000s relative to earlier years. For all countries, breastfeeding duration increased between the first and last survey. Of the 12 countries represented in the interval when investment in breastfeeding promotion was high, breastfeeding duration decreased in 1 country. Of the 12 countries represented in the interval when investment was low, breastfeeding duration decreased in 3 countries. Nonetheless, the average annual change in breastfeeding duration for the 2 intervals was positive and similar (0.16 months and 0.21 months).Conclusions. Breastfeeding promotion likely resulted in large improvements in breastfeeding. Investments in breastfeeding promotion have declined, but this does not appear to have adversely affected breastfeeding duration.Breastfeeding is one of the best values among investments in child survival, recognized for both the magnitude of its effect on mortality^1,2 and the effectiveness of interventions to promote it.^3,4 Early initiation of breastfeeding reduces neonatal mortality^5,6 (an increasingly important component of infant mortality⁷) and has many other short- and long-term benefits for maternal and child health and child development.^8,9 Failure to promote breastfeeding, coupled with inadequate attention to the safety of replacement formulas, can have serious health consequences.^10,11International concern about declining rates of breastfeeding in the 1970s¹² led national and international health authorities to make a concerted effort to promote breastfeeding.¹³ Many breastfeeding interventions focused on improving health worker training and support for breastfeeding in hospitals because of the perception that these services were not providing skilled support for and environments conducive to breastfeeding. Few evaluations of the impact of these interventions are available, although in Latin America the duration of breastfeeding increased from the 1980s to the 1990s, coinciding with breastfeeding promotion efforts.¹⁴Disentangling the impact of national promotion programs is challenging because traditional epidemiological models do not lend themselves to the analysis of such a relationship. The extent to which public health interventions have the potential to improve behaviors measurable at the national level depends on coverage as well as quality.^15a Both are difficult to measure systematically, and neither has been documented in national programs. However, given the importance of breastfeeding for achieving the Millennium Development Goal related to child survival (goal 4),^15b a better understanding of the relationship between promotion of breastfeeding and changes in breastfeeding is important.We examined trends in breastfeeding promotion investments, trends in breastfeeding promotion activities, and changes in breastfeeding from the 1980s to the 2000s in 19 Latin American and Caribbean nations. We sought to answer 3 questions: (1) What is the evidence that policies and programs in support of breastfeeding were implemented? (2) How have investments in breastfeeding promotion changed over time? (3) How have exclusive breastfeeding and breastfeeding duration changed over the same period?     

Decentralization of health systems in Latin America.

Decentralization is often a major part of health reform policies. However, there have been few attempts to comparatively study the degree of decentralization and the effects of decentralization on equity of allocations to health, so we do not know how best to implement this reform. This article uses an innovative comparative analysis of the "decision space" that was allowed to local municipalities in the health reforms of Bolivia and Chile, two countries that have had several years of experience in implementing decentralization. The studies found that relatively little decision space was allowed to local authorities over key functions of health care systems. The studies also found that central authorities often reduce the decision space in order to direct more resources to health or to restrict local choice over human resources issues. The studies found that more equitable allocations of health funding were achieved through a common equalization fund for the municipalities in Chile and by forcing the assignment to health of a specific percentage of the central government transfers to municipalities in Bolivia.     

Social analysis of collective health in Latin America

During the last 15 years there has been an increasing interest in Latin America to study the collective health conditions as part of and determined by the social, economic and political processes. The present article analyzes the origins of this current of thought, known as Latin American social medicine, and its main theoretical and methodological approach. Since the two basic analytical concepts proposed by this current are 'social class' and 'work process', some examples of concrete studies that employ these are given to highlight the type of study designs used and the knowledge produced     

The reform process and social participation in health in Latin America

Currently, many countries throughout the world are reforming their health services. Even though these reforms differ according to the country's characteristics, they share many policies, one of which is the promotion of social participation in health-related matters. This policy, however, is not new in the field of health service organization. Throughout the last century, individual or collective collaboration between the population and health services has been promoted by several philosophies and concepts with different aims: from the search for collaboration with the general public to broaden public health system coverage to the promotion of the creation of mechanisms that would allow society to exercise control over these services' performance. Nevertheless, for the public to be involved with these services, several factors concerning both the services themselves and the population, need to converge. Although the theoretical frameworks that have encouraged social participation throughout the history of the development of health systems differ considerably, their practical implementation shares many common elements in all periods, from participation as a means of obtaining certain objectives to being an end in itself, as a democratic process. This can also be applied to the current promotion of social participation policies in the context of health care reforms, which are analyzed using Colombia and Brazil as examples.     

Neoliberal reforms in health services in Latin America: a critical view from two case studies]

Neoliberal reforms have promoted privatization and decentralization as strategies to improve equity, efficiency, and the quality of health services. In this piece the impact of these reforms in Latin America is critically analyzed, and the impacts of privatization in Colombia and of decentralization in Mexico are detailed. These two cases show that after 10 years of privatization in Colombia and 20 years of decentralization in Mexico the reforms have had the opposite of the desired effect: They have not improved equity, have increased health expenditures, have not increased efficiency, and have not shown a positive impact on quality. Public health programs in Colombia have deteriorated, while decentralization in Mexico has had a very high cost, without achieving the proposed objectives. It is officially accepted that decentralization in Mexico has increased inequity, and that new reforms implemented in 2003 promote vertical programs. Health systems based on regulated competition are not the most suitable ones for Latin America. Latin American countries should improve their health systems in line with the principles stated in the Declaration of Alma Ata and according to their own national experiences.     

Women, household and health in Latin America

Although recent studies have identified some of the links in Latin America between uneven capitalist economic development and health, the impact of development on either the health of women or on household health is still largely unknown. This account identifies several areas of needed research. It focuses on how changing women's roles and patterns of domestic production affect women's reproductive behavior, and the consequences of these changes for the health of women and other members of their households.     

Agricultural occupational health and health education in Latin America and the Caribbean

Agricultural diseases and injuries are major sources of healthconcern in Latin America and the Caribbean. To help alleviatethis situation, health education programs directed at workersat risk have been implemented. This paper discusses the factorsinherent to agricultural work that need to be considered inthe design, planning, implementation, and evaluation of healtheducation activities, such as the characteristics of agriculturalwork and occupational health problems. In addition, it presentsa case study of health promotion for Argentine Hemorrhagic Feverdirected to agricultural workers in the endemic area of thisdisease.     

Determinants of health status and the influence of primary health care services in Latin America, 1990-98

Primary health care (PHC) services have been advocated as a means by which less developed countries may improve the health of their populations even in the face of poverty, low levels of literacy, poor nutrition and other factors that negatively influence health status. Using aggregated data from the World Bank and UNICEF this study examined which factors, both within the health care system and outside of it, are associated with under-5 mortality rates in 22 countries of Latin America and the Caribbean during the 1990s. In a multivariate analysis using generalized estimating equations for repeated measures, five factors were found to be independent predictors of lower under-5 mortality rates (U5MRs). These were vaccination levels, female literacy, the use of oral rehydration therapy, access to safe water and GNP per capita. When the magnitude of these associations were assessed, higher levels of GNP per capita was found to be very weakly associated with lower U5MRs, compared with female literacy and vaccination rates. These findings suggest that government policies which focus only on promoting economic growth, while not making important investments in PHC services, female education and access to safe water are unlikely to see large improvements in health status.     

The continuity of moral reform: Community mental health centers

Contemporary involvement of citizens in the formation of mental health policies continues a long history of influential lay advocates achieving desired reforms. The Community Mental Health Centers Program arose from, and also recognized, the citizens' movement for community care. This legislation mandated and encouraged citizen membership on the governing boards of local centers. The influence of these citizen bodies is seen in the diversity and continuing evolution of the local centers structurally, in orientation and in services provided. Three examples from original field research are provided to illustrate.     

The effect of structural adjustment on health conditions in Latin America and the Caribbean, 1980-2000]

OBJECTIVE: To assess the impact of structural adjustment on health indicators in Latin America and the Caribbean during 1980-2000. METHODS: This was an ecological study. Public spending and per capita gross domestic product (pcGDP) figures were obtained from the World Bank, and life expectancy (LE) and infant mortality (IM) figures were obtained from the World Health Organization. Structural adjustment (government downsizing) was assessed by looking at the change in the amount of spending taken up by the government (or the reduction in public spending) in Latin American and Caribbean countries during 1980-1990. Changes in health indicators were measured in terms of the percentage variation in LE and IM. The variations found in Latin America and the Caribbean were compared to those seen in different groups of countries in other parts of the world during 1980-2000. Pearson's chi squared test was used to explore the associations between the decrease in public spending and health indicators. In order to estimate the health effects of such changes, a multivariate linear regression model was created, with adjustments for pcGDP. RESULTS: A deceleration in the rise of LE and in the decline of IM in Latin America and the Caribbean was noted, especially over the period from 1980 through 1990. Significant associations were observed between health indicators and the change in public spending in all groups of countries included in the study. When adjustments were introduced into the multiple regression model, the only associations that remained were seen in Latin America and the Caribbean. CONCLUSIONS: In the decade of 1980, adjustments in macroeconomic policies had a negative effect on social indicators, specifically those that had to do with health conditions in Latin America and the Caribbean. Such an effect lasted throughout the following decade.