Health sector reform in Brazil: a case study of inequity.

Health sector reform in Brazil built the Unified Health System according to a dense body of administrative instruments for organizing decentralized service networks and institutionalizing a complex decision-making arena. This article focuses on the equity in health care services. Equity is defined as a principle governing distributive functions designed to reduce or offset socially unjust inequalities, and it is applied to evaluate the distribution of financial resources and the use of health services. Even though in the Constitution the term "equity" refers to equal opportunity of access for equal needs, the implemented policies have not guaranteed these rights. Underfunding, fiscal stress, and lack of priorities for the sector have contributed to a progressive deterioration of health care services, with continuing regressive tax collection and unequal distribution of financial resources among regions. The data suggest that despite regulatory measures to increase efficiency and reduce inequalities, delivery of health care services remains extremely unequal across the country. People in lower income groups experience more difficulties in getting access to health services. Utilization rates vary greatly by type of service among income groups, positions in the labor market, and levels of education.     

Inequalities in access to health care in Hungary

'Crisis' in health care systems has become a widely discussed issue in the last 10 years. The claim for change is argued from various points of view, and according to manifold interests throughout the industrialized world. However, the present tensions of the national health service system of Hungary can be looked upon only partially in the broader terms of some 'world-phenomenon'. There are a great number of similar features, there is the great importance of temporal co-incidence, but the roots seem totally different in several respects. The paper focuses on those structural processes (historical, as well, as current), that have lead to increasing tensions and a dysfunctional working of the system, that shape the social inequalities of access to it. The main form of deeper structural tensions is the widening gap between needs and the conditions to meet them. This paper analyzes the consequences of the double pressure put on the system at its start after the war. The rapid extension of legal entitlements for free medical care was not followed by a similar extension of available resources for developing the institutions and services of the health care system. The long-term priorities given to forced industrialization and, later, to other spheres of production led to a chronic situation of 'residual' handling of various spheres of communual consumption and to the infrastructure, including programmes of health care, the pressure of rapid extension of rights and permanent scarcity of the resources has lead to a chronic shortage, overuse and 'substitutional, temporary solutions'.(ABSTRACT TRUNCATED AT 250 WORDS)     

Access of Roma to sexual and reproductive health services: qualitative findings from Albania, Bulgaria and Macedonia

The purpose of this study was to explore access of Roma in South-Eastern Europe to sexual and reproductive health services. We conducted 7 focus group discussions with a total of 58 participants from Roma communities in Albania, Bulgaria and Macedonia. Our study revealed a number of barriers for Roma when accessing sexual and reproductive health services. Among the most important were the overall lack of financial resources, requests by health care providers for informal payments, lack of health insurance and geographical barriers. Health systems in the region seem to have failed to provide financial protection and equitable services to one of the most vulnerable groups of society. There is also a need for overcoming racial discrimination, improving awareness and information and addressing gender inequalities.     

Equity and resource allocation in health care: Dialogue between Islam and Christianity

Inequities in health and health care are one of the greatest challenges facing the international community today. This problem raises serious questions for health care planners, politicians and ethicists alike. The major world religions can play an important role in this discussion. Therefore, interreligious dialogue on this topic between ethicists and health care professionals is of increasing relevance and urgency. This article gives an overview on the positions of Islam and Christianity on equity and the distribution of resources in health care. It has been written in close collaboration and constant dialogue between the two authors coming from the two religions. Although there is no specific concept for the modern term equity in either of the two religions, several areas of agreement have been identified: All human beings share the same values and status, which constitutes the basis for an equitable distribution of rights and benefits. Special provisions need to be made for the most needy and disadvantaged. The obligation to provide equitable health services extends beyond national and religious boundaries. Several areas require intensified research and further dialogue: the relationship between the individual and the community interms of rights and responsibilities, how to operationalize the moral duty to decrease global inequalities in health, and the understanding and interpretation of human rights in regard to social services. This revised version was published online in July 2006 with corrections to the Cover Date.     

Access of Roma to sexual and reproductive health services: Qualitative findings from Albania,Bulgaria and Macedonia

Abstract

The purpose of this study was to explore access of Roma in South-Eastern Europe to sexual and reproductive health services. We conducted 7 focus group discussions with a total of 58 participants from Roma communities in Albania, Bulgaria and Macedonia. Our study revealed a number of barriers for Roma when accessing sexual and reproductive health services. Among the most important were the overall lack of financial resources, requests by health care providers for informal payments, lack of health insurance and geographical barriers. Health systems in the region seem to have failed to provide financial protection and equitable services to one of the most vulnerable groups of society. There is also a need for overcoming racial discrimination, improving awareness and information and addressing gender inequalities.     

Using social health insurance to meet policy goals

Social health insurance, with contributions based on incomes and access to services on need is being considered as an option for health care finance in many countries. The argument in this paper starts from the premise that the choice of health care financing mechanisms should start with a clear focus on policy goals, with different options judged against the extent to which these are met. These are likely to include objectives of access to care for those in need, quality of care, incentives for efficient provision and cost control. Different systems will meet the objectives of mobilising resources, providing insurance against risk and redistribution resources to differing extents. It is argued that a particular problem in health care finance is shifting rights to resources over time. It is also important to be clear about the distinction between affordability of and payment mechanisms for health care. The choice of funding mechanisms may have little effect on other policy goals, such as economic development. However, they may differ in the degree to which they allow specific health policy goals to be met. Different mechanisms for collecting and managing funds, and for paying for services are discussed. The paper concludes with concerns that too much emphasis is placed on structures and not how they work, that a lack of cost control may be a serious risk in developing social health insurance and that it is important to have clear mechanisms for setting priorities if policy goals are to be met.     

A framework for assessing the performance of health systems

Health systems vary widely in performance, and countries with similar levels of income, education and health expenditure differ in their ability to attain key health goals. This paper proposes a framework to advance the understanding of health system performance. A first step is to define the boundaries of the health system, based on the concept of health action. Health action is defined as any set of activities whose primary intent is to improve or maintain health. Within these boundaries, the concept of performance is centred around three fundamental goals: improving health, enhancing responsiveness to the expectations of the population, and assuring fairness of financial contribution. Improving health means both increasing the average health status and reducing health inequalities. Responsiveness includes two major components: (a) respect for persons (including dignity, confidentiality and autonomy of individuals and families to decide about their own health); and (b) client orientation (including prompt attention, access to social support networks during care, quality of basic amenities and choice of provider). Fairness of financial contribution means that every household pays a fair share of the total health bill for a country (which may mean that very poor households pay nothing at all). This implies that everyone is protected from financial risks due to health care. The measurement of performance relates goal attainment to the resources available. Variation in performance is a function of the way in which the health system organizes four key functions: stewardship (a broader concept than regulation); financing (including revenue collection, fund pooling and purchasing); service provision (for personal and non-personal health services); and resource generation (including personnel, facilities and knowledge). By investigating these four functions and how they combine, it is possible not only to understand the proximate determinants of health system performance, but also to contemplate major policy challenges.     

Organization of ambulatory care provision: a critical determinant of health system performance in developing countries

Success in the provision of ambulatory personal health services, i.e. providing individuals with treatment for acute illness and preventive health care on an ambulatory basis, is the most significant contributor to the health care system's performance in most developing countries. Ambulatory personal health care has the potential to contribute the largest immediate gains in health status in populations, especially for the poor. At present, such health care accounts for the largest share of the total health expenditure in most lower income countries. It frequently comprises the largest share of the financial burden on households associated with health care consumption, which is typically regressively distributed. The "organization" of ambulatory personal health services is a critical determinant of the health system's performance which, at present, is poorly understood and insufficiently considered in policies and programmes for reforming health care systems. This article begins with a brief analysis of the importance of ambulatory care in the overall health system performance and this is followed by a summary of the inadequate global data on ambulatory care organization. It then defines the concept of "macro organization of health care" at a system level. Outlined also is a framework for analysing the organization of health care services and the major pathways through which the organization of ambulatory personal health care services can affect system performance. Examples of recent policy interventions to influence primary care organization--both government and nongovernmental providers and market structure--are reviewed. It is argued that the characteristics of health care markets in developing countries and of most primary care goods result in relatively diverse and competitive environments for ambulatory care services, compared with other types of health care. Therefore, governments will be required to use a variety of approaches beyond direct public provision of services to improve performance. To do this wisely, much better information on ambulatory care organization is needed, as well as more experience with diverse approaches to improve performance.     

Dentistry and distributive justice

There is a growing concern in most countries to address the problem of inequities in health-care within the context of financial restraints on the public purse and the realities of health professions that are influenced strongly by the economic priorities of free-market economies. Dental professionals, like other health professionals, are well aware that the public expects oral health-related services that are effective, accessible, available and affordable. Yet, there is remarkably little reference in the literature to the theories of distributive justice that might offer guidance on how an equitable oral health service could be achieved. This paper considers three prominent theories of distributive justice--libertarianism, egalitarianism and contractarianism--within the controversial context of basic care and quality of life. The discussion leads towards a socially responsible, egalitarian perspective on prevention augmented by a social contract for curative care with the aim of providing maximum benefit to the least advantaged in society.     

An analysis of the role of health care in reducing socioeconomic inequalities in health: the case of the Netherlands.

The aim of this article is to analyze the role of the health care system in reducing socioeconomic inequalities in health in countries with good access to health services, using the Dutch example. In the past, health care has contributed substantially to reducing a number of health problems in the population, paticularly health problems leading to mortality. Data on trends in mortality from selected conditions by socioeconomic group show that both higher and lower socioeconomic groups have profited from these mortality reductions, probably because of largely equal access to essential health car services, and that absolute inequalities in mortality from these conditions have declined notably. The current situation is still one of largely equal financial access to health care services, with relatively small differences between socioeconomic groups in health care utilization, after adjustment for differences in prevalence of health problems. There is no evidence that inequalities in health care utilization contribute to a widening of socioeconomic inequalities in health. Financing of the health care system, however, is slightly regressive, and out-of-pocket payments contribute to the poor financial situation of the chronically ill. For the future, three possible contributions of the health care system to reducing socioeconomic inequalities in health are described: preservation of equal access to high-quality health care; development of specific care packages for lower socioeconomic groups; promotion and support of intersectoral activities.     

Decentralization and human resource management in the health sector: a case study (1996-1998) from Nampula province, Mozambique

Despite political, cultural and geographical diversity, health care reforms implemented in many developing countries share a number of common features regarding management and structural issues. Decentralization of decision-making from the central authority to local and provincial levels is generally regarded in the literature to be an important way of achieving a more equitable distribution of health care and better management practices, aligned with local priorities and needs. However, in the absence of clear guidelines, continuous monitoring and an adequate supply of financial and human resources, decentralization processes are more likely to have a low impact on the process of health care reform and can, to a certain extent, provoke inequalities between regions in the same country. This qualitative study in Nampula province, Mozambique, was conducted to assess the impact of decentralization, through an analysis of the viewpoints of provincial health managers regarding their perceptions of the process, particularly with regard to the management of basic and elementary nurses. Secondary data from Nampula provincial reports and documents from the Mozambican Health Ministry were also reviewed and comparisons made with the experiences of other developing countries.     

Poor medicine for poor people? Assessing the impact of neoliberal reform on health care equity in a post-socialist context

Abstract

Driven in part by a resurgent interest in social inequality and health, and in part by increasing scrutiny of the social and health consequences of neoliberal economic reform, principles of health equity and social justice, the centerpieces of the Health for All strategy drafted at Alma Ata in 1978, are once again at center stage in global public health debates. Whether and how equity in access to health care can be maintained in a context of market-based health sector reform has not been systematically addressed, particularly from the perspective of local communities. This paper will explore how health reform affects health care in post-socialist Mongolia. Through a mixed-methods household-based study of low-to-middle income communities in urban and rural Mongolia we find that despite explicit and concerted efforts to reduce inequities, the reform system is unable to provide equitable health care either vertically or horizontally. Emphasis on privatization of the secondary and tertiary sectors of the system, coupled with deployment of universally-accessible, but from a clinical standpoint, limited, version of essential primary care, produces a fragmented system. Particularly for the vulnerable poor, access to services beyond the primary care system is compromised by financial, opportunity, and informational cost barriers. This research suggests that new models of health reform are needed that will effectively bridge the growing gaps between public and private resources, primary and secondary and/or tertiary care, and clinical and public health services.     

Economic crisis and access to care: Cuba's health care system since the collapse of the Soviet Union.

This article explores the effects on access to health care in Cuba of the severe economic crisis that followed the collapse of the Soviet Union and the monetary and market reforms adopted to confront it. Economic crises undermine health and well-being. Widespread scarcities and self-seeking attitudes fostered by monetary and market relations could result in differential access to health services and resources, but the authors found no evidence of such differential access in Cuba. While Cubans generally complain about many shortages, including shortages of health services and resources before the economic recovery began in 1995, no interviewees reported systemic shortages or unequal access to health care services or resources; interviewees were particularly happy with their primary care services. These findings are consistent with official health care statistics, which show that, while secondary and tertiary care suffered in the early years of the crisis because of interruptions in access to medical technologies, primary care services expanded unabated, resulting in improved health outcomes. The combined effects of the well-functioning universal and equitable health care system in place before the crisis, the government's steadfast support for the system, and the network of social solidarity based on grassroots organizations mitigated the corrosive effects of monetary and market relations in the context of severe scarcities and an intensified U.S. embargo against the Cuban people.     

Equity in health in unequal societies: meeting health needs in contexts of social change.

The paper explores the implications for health policy of the segmentation of society into social groups with very different levels of income and wealth. Discourses on equity in health are presently dominated by a debate between 'European' and 'American' models of health delivery. This has led to a focus on ideal outcomes rather than practical options for organising and financing health services in poor countries undergoing rapid change. The paper argues for a more explicit acknowledgement of the dynamic character of health development and the political nature of the negotiations regarding the use of government powers. Unregulated markets for health care are neither equitable nor efficient. Government must play a role in supporting the organisation of health services used by different social groups. Countries with low levels of inequality may be able to provide universal access to relatively sophisticated health services. Otherwise, governments need to operate within a segmented system. This means the negotiation of strategies to reduce the burden of sickness and premature death, whilst meeting the needs of different social groups. The discussion is organised in terms of the powers of government to require individuals and institutions to transfer resources for social uses, enforce regulations and generate and disseminate information. The paper concludes that governments committed to equity-enhancing health development need to increase their capacity to facilitate coalition building and manage change. It proposes an international public health legal framework that might include a definition of minimum standards for certain health services, to be underwritten by national and international financial commitments.     

What does 'access to health care' mean?

Facilitating access is concerned with helping people to command appropriate health care resources in order to preserve or improve their health. Access is a complex concept and at least four aspects require evaluation. If services are available and there is an adequate supply of services, then the opportunity to obtain health care exists, and a population may 'have access' to services. The extent to which a population 'gains access' also depends on financial, organisational and social or cultural barriers that limit the utilisation of services. Thus access measured in terms of utilisation is dependent on the affordability, physical accessibility and acceptability of services and not merely adequacy of supply. Services available must be relevant and effective if the population is to 'gain access to satisfactory health outcomes'. The availability of services, and barriers to access, have to be considered in the context of the differing perspectives, health needs and material and cultural settings of diverse groups in society. Equity of access may be measured in terms of the availability, utilisation or outcomes of services. Both horizontal and vertical dimensions of equity require consideration.     

Protecting resources for primary health care under fiscal federalism: options for resource allocation

The introduction of fiscal federalism or decentralization of functions to lower levels of government is a reform not done primarily with health sector concerns. A major concern for the health sector is that devolution of expenditure responsibilities to sub-national levels of government can adversely affect the equitable distribution of financial resources across local jurisdictions. Since the adoption of fiscal federalism in South Africa, progress towards achieving a more equitable distribution of public sector health resources (financial) has slowed down considerably. This study attempts to identify appropriate resource allocation mechanisms under the current South African fiscal federal system that could be employed to promote equity in primary health care (PHC) allocations across provinces and districts. The study uses data from interviews with government officials involved in the budgeting and resource allocation process for PHC, literature on fiscal federalism and literature on international experience to inform analysis and recommendations. The results from the study identify historical incremental budgeting, weak managerial capacity at lower levels of government, poor accounting of PHC expenditure, and lack of protection for PHC funds as constraints to the realization of a more equitable distribution of PHC allocations. Based on interview data, no one resource allocation mechanism received unanimous support from stakeholders. However, the study highlights the particularly high level of autonomy enjoyed by provincial governments with regards to decision making for allocations to health and PHC services as the major constraint to achieving a more equitable distribution of PHC resources. The national government needs to have more involvement in decision making for resource allocation to PHC services if significant progress towards equity is to be achieved.     

The system of informal caregiving as inequality

In our setting, it is families, not the health and social services, who play the greatest role in providing continuous care to persons in need of such services. Informal health care poses two key questions with regard to the issue of equity: differences in the burdens borne by men and women, which contribute to gender inequality and, depending on their educational and socio-economic level, inequities in their ability to choose and gain access to needed resources and support services, thus contributing to social class inequalities. Distributing the burden of caregiving between men and women, and between the family and the state, constitutes a crucial debate in public health. This study analyzes the concept and characteristics of informal care, provides data on its dimensions in our setting, and analyzes the profile of caregivers, as well as the work they do and the impact it has on their lives. Finally, it presents currently existing models and support strategies for informal caregivers. It is largely women who assume the principal role of providing informal care, undertaking the most difficult and demanding tasks and dedicating the largest share of their time to them. As a result, women bear an elevated cost in their lives in terms of health, quality of life, access to employment and professional development, social relations, availability of time for themselves, and economic repercussions. Unemployed, under-educated women from the least privileged social classes constitute the largest group of informal caregivers in our country. Any policies aimed at supporting those who provide such care should keep in mind the unequal point from which they start and be evaluated in terms of their impact on gender and social class inequality.     

Solutions to tackle the mental health consequences of the economic recession: A qualitative study integrating primary health care users and professionals’ perspectives

This qualitative study explores solutions proposed by primary health care users and professionals to address the consequences of the economic recession and austerity measures on populations' mental health and delivery of care in Portugal. Qualitative data were collected in three primary health care centres in the Lisbon Metropolitan Area. Five focus groups with 26 users and semistructured interviews with 27 health professionals were conducted. Interviews were audio-recorded, transcribed verbatim and underwent thematic analysis.Solutions proposed by users focused on improvements in accessibility and management of services, socioeconomic and living conditions, human resources for health, and investment in mental health. Health professionals focused on improvements in integration and articulation of services, infrastructure and structural barriers to primary care, recruitment and retention of human resources, and socioeconomic and living conditions. The themes from both groups were integrated and organized into three axes for action: 1) increasing investment and reversing austerity measures in health and social sectors; 2) coordination and integration of mental health care; and 3) tackling the social determinants of mental health.The findings provide an assessment of the needs and priorities set by primary health care users and professionals, reflecting their contextspecific experiences. These complementary perspectives highlight the need for inter-sectoral efforts in policy-making to improve delivery of care and to mitigate social inequalities in health across the Portuguese population.     

Information, communication and equitable access to health care: a conceptual note

This conceptual paper addresses the health policy goal of equitable access to health care from a perspective that highlights the role of choice. It sketches a framework around the three access dimensions availability, affordability, and acceptability. The "degree of fit" with respect to each of these dimensions between the health system and individuals or communities plays a role in determining the level of access to health services by outlining the existing choice set. Yet it is the degree of informedness about the choices that ultimately determines access to health services. Access is therefore defined as the freedom to utilize. The paper focuses on information and its properties, which cut across the dimensions of access. It is argued that equity-oriented health policy should stimulate communicative action in order to empower individuals and communities by expanding their subjective choice sets.     

Strong general health care systems: a prerequisite to reach global tuberculosis control targets

We argue that tuberculosis control cannot reach its proposed global targets without investment in an adequate network of accessible, effective and comprehensive health services. Lessons from the past are reviewed. They underscore that passive case-detection and adequate case management is the central technical strategy for tuberculosis control. There is no compelling evidence to support active case-detection in the general population. We elaborate on why a strong health care system is a prerequisite in the framework of case-detection and treatment. The necessity to improve quality and accessibility of general health services for ensuring early detection and subsequent cure is demonstrated. It is argued why the need for strong public health care system becomes even more eminent in the light of the tuberculosis/HIV dual epidemics and of the rapid growth of unregulated private-for-profit services. We finally examine the financial gaps for tuberculosis control and discuss the need for allocating more resources to the strengthening of general health care systems.