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.     

The impact of new vaccine introduction on the coverage of existing vaccines: A cross-national,multivariable analysis

Background

A surge of new and underutilized vaccine introductions into national immunization programmes has called into question the effect of new vaccine introduction on immunization and health systems. In particular, countries deciding whether to introduce a new or underutilized vaccine into their routine immunization programme may query possible effects on the delivery and coverage of existing vaccines. Using coverage of diphtheria–tetanus–pertussis (DTP) vaccine as a proxy for immunization system performance, this study aims to test whether new vaccine introduction into national immunization programs was associated with changes in coverage of three doses of DTP vaccine among infants.

Methods and findings

DTP3 vaccine coverage was analyzed in 187 countries during 1999–2009 using multivariable cross-national mixed-effect longitudinal models. Controlling for other possible determinants of DTP3 coverage at the national level these models found minimal association between the introduction of Hepatitis-, Haemophilus influenzae type b-, and rotavirus-containing vaccines and DTP3 coverage. Instead, frequent and sometimes large fluctuations in coverage are associated with other development and health systems variables, including the presence of armed conflict, coverage of antenatal care services, infant mortality, the percent of health expenditures that are private and total health expenditures per capita.

Conclusions

Introductions of new vaccines did not affect national coverage of DTP3 vaccine in the countries studied. Introductions of other new vaccines and multiple vaccine introductions should be monitored for immunization and health systems impacts.     

Responding to diversity: an exploratory study of migrant health policies in Europe

There has been growing international attention to migrant health, reflecting recognition of the need for health systems to adapt to increasingly diverse populations. However, reports from health policy experts in 25 European countries suggest that by 2009 only eleven countries had established national policies to improve migrant health that go beyond migrants' statutory or legal entitlement to care. The objective of this paper is to compare and contrast the content of these policies and analyse their strengths and limitations. The analysis suggests that most of the national policies target either migrants or more established ethnic minorities. Countries should address the diverse needs of both groups and could learn from "intercultural" health care policies in Ireland and, in the past, the Netherlands. Policies in several countries prioritise specific diseases or conditions, but these differ and it is not clear whether they accurately reflect real differences in need among countries. Policy initiatives typically involve training health workers, providing interpreter services and/or 'cultural mediators', adapting organizational culture, improving data collection and providing information to migrants on health problems and services. A few countries stand out for their quest to increase migrants' health literacy and their participation in the development and implementation of policy. Progressive migrant health policies are not always sustainable as they can be undermined or even reversed when political contexts change. The analysis of migrant health policies in Europe is still in its infancy and there is an urgent need to monitor the implementation and evaluate the effectiveness of these diverse policies.     

An innovative approach to public health research: the case of a new center in Mexico.

This paper presents the conceptual and organizational elements that have guided the development of the Center for Public Health Research (CPHR) in Mexico. The CPHR was established in August 1984, in the midst of the most profound health care reform in Mexico in the last 40 years. The reform has included, among other measures, a Constitutional amendment recognizing the social right to health care, an energetic effort to decentralize the system so that each state will run its own services, an ambitious drive to extend primary health care coverage to all the population, and a strong promotion of research as the basis for strategic planning and for the development of standards of care. The creation of the CPHR is a response to the need for a firm base of epidemiologic and health systems research in Mexico. This need arises from the increasing complexity of the country's organizational arrangements for health care. In addition, the patterns of morbidity and mortality are also becoming more intricate, as Mexico is experiencing an epidemiologic transition whereby chronic diseases, mental ailments, and accidents are on the rise even as the incidence of infectious diseases and malnutrition continues to be high. As a unit of the Ministry of Health, the CPHR must strike a balance between relevance to decision making and excellence in the strict adherence to the norms of scientific research. To do so, it has developed a conceptual framework based on a tridimensional matrix. The dimensions of the matrix include substantive areas (i.e., the phenomena to be researched), knowledge areas (i.e., the disciplines pertinent to public health), and methodological areas (i.e., the methods to be applied in each project). The intersection of these dimensions produces different configurations of "research modules" that can be adapted to changing priorities. Current priorities of the CPHR include epidemiologic studies of the emerging conditions in the transition, migration and health, child survival, social organization and primary health care, health systems management, quality of care, and the development of information systems and quantitative models for public health research. Research projects are undertaken in a matrix type of organization in which academic departments are structured according to problems rather than disciplines. The analysis of Mexico's Center for Public Health Research may contribute to similar endeavors in other countries and also to the wider development of comparative studies on research organizations.     

The political context of social inequalities and health.

This analysis reflects on the importance of political parties, and the policies they implement when in government, in determining the level of equalities/inequalities in a society, the extent of the welfare state (including the level of health care coverage by the state), the employment/unemployment rate, and the level of population health. The study looks at the impact of the major political traditions in the advanced OECD countries during the golden years of capitalism (1945-1980)--social democratic, Christian democratic, liberal, and ex-fascist--in four areas: (1) the main determinants of income inequalities; (2) levels of public expenditures and health care benefits coverage; (3) public support of services to families; and (4) the level of population health as measured by infant mortality. The results indicate that political traditions more committed to redistributive policies (both economic and social) and full-employment policies, such as the social democratic parties, were generally more successful in improving the health of populations. The erroneous assumption of a conflict between social equity and economic efficiency is also discussed. The study aims at filling a void in the growing health and social inequalities literature, which rarely touches on the importance of political forces in influencing inequalities.     

The welfare state, class, and gender.

If we compare the welfare state countries with others, from the point of view of both health and health services, the crisis concerns primarily the second group of countries. Nevertheless, difficulties arise also for welfare state policies. The problem is how to respond to neoconservative attacks on social and health rights, and how to change the bureaucratic and medicalized bias of the welfare state. The "golden era" of social insurance and health services, conceived as free access to funds to cope with all the growing needs of the population, is over. Limitations, controls, and priorities have to be established. In Italy and similar countries, the tendency is toward restricting health care for those who have greater needs, cutting funds for prevention, and creating greater inequalities. It is clear that the state must intervene to reduce social inequalities, but at the same time some existing differences (sexual, cultural, ethnic) have an intrinsic value that must be recognized. A policy of free-choice welfare is useful, and has nothing to do with the selective measures that are being introduced. Moreover, a key point has become the relationship between class and gender. The working class continues to be exploited, but new phenomena arise, connected with production and social reproduction and not limited to this sphere. It is true that gender includes social classes, but no social class may represent both sexes, or different ethnic groups, or gender itself.     

Selected myths guiding the Reagan Administration's health policies

This article analyzes four major assumptions that guide the Reagan Administration's health policies: 1) the Administration received an overwhelming popular mandate to reduce the federal role in the U.S. health sector; 2) the size and growth of federal social (including health) expenditures are contributing to the current economic recession; 3) the costs to business of federally imposed health and safety regulations have contributed to making the U.S. economy less competitive; and 4) market intervention is intrinsically more efficient than government intervention in regulating the costs and distribution of health resources. Based on these assumptions, the main characteristics of the Reagan Administration's health policies have been 1) a reduction of federal health expenditures and, very much in particular, expenditures to the poor, handicapped, and elderly; 2) a weakening of federal health and safety regulations to protect workers, consumers, and the environment; and 3) the further privatization and commodification of medical services. This article shows that there is no evidence to support the assumptions on which these policies are based. Quite to the contrary, all available evidence shows the opposite: 1) the majority of Americans want an expansion of federal health expenditures and a strengthening of federal health regulation; 2) U.S. government expenditures and regulations are much more limited than those of other countries whose economies are performing more satisfactorily; and 3) those countries with larger government interventions have more efficient health care systems than the American one, where the "free market" forces are primarily responsible for the allocation of resources. Thus, major Reagan Administration health policies are based on myth rather than reality.     

Progress towards the achievement of MDG4 in the Commonwealth of Independent States: uncertain data, clear priorities

Data on under five mortality in the twelve countries of the Commonwealth of Independent States show important fluctuations over time due to variations in quality of data, definitions of neonatal deaths and methods of mortality estimation. Despite the uncertainties regarding mortality trends, the analysis of health and social information from different sources offers clues to identify priority areas and key strategic directions for accelerating the achievement of the 4^th Millennium Development Goal. Neonatal deaths represent from 40% to over 50% of under five deaths in all these countries. Maternal mortality was above 50 per 100,000 in 2005, despite the good coverage with antenatal care and births assisted by skilled birth attendants. The scanty information on quality of perinatal care indicates widespread substandard care at all levels. Stunting in children under five is above 10% in ten out of twelve countries and coexists with emerging overweight. Exclusivity and duration of breastfeeding fall short of what is recommended. There are important inequalities in child and maternal mortality, malnutrition and access and use of health services within countries. Taken as a whole, the available information clearly indicates that priority should be given to improvement of the health of women in reproductive age and of the quality of perinatal care, including the establishment of reliable data collection systems. To achieve this, action will need to focus on strengthening the capacity of the health system to improve the technical content of service provision, and on improving access and appropriate use of services by the most disadvantaged groups. The involvement of other sectors will be necessary to improve reproductive health and nutrition at community level and to tackle inequity. Comparisons between countries with similar socioeconomic background but different health policies seem to indicate that gradual progression towards universal coverage with essential health care through a national health insurance system is associated with larger reduction of child mortality than troubled transition towards a privatized and unregulated health system.     

“Enticing case study” or “celebrated anomaly”? Policy learning from the Cuban health system

Cuba is regarded as having achieved very good health outcomes for its level of economic development. It has adopted policies and programs that focus on prevention, universal access to healthcare, a strong primary care system, the integration of health in all policies, and public participation in health. It has also established a strong and accessible system of medical education and provides substantial medical aid and support to other countries. Why then, it may be asked, has the Cuban experience not had greater influence on health policies and reforms elsewhere? This article, based on a literature review and new primary sources, analyzes various factors highlighted in the policy transfer literature to explain this. It also notes other factors that have created greater awareness of Cuban health achievements in some countries and which provide a basis for learning lessons from its policies.     

The Commission on the Social Determinants of Health: reinventing health promotion for the twenty-first century?

This paper describes the work of the Commission on the Social Determinants of Health, established by WHO in 2005 and considers the potential for this Commission to contribute to a reinvention of health promotion for the twenty-first century. It argues that the Commission can do this by reinforcing the move that health promotion has been making since the 1980s to be less concerned with behaviour change and more concerned with creating the conditions in which health and well-being flourish. Specific contributions the Commission will make are: providing a vision of the moral importance and feasibility of a more equitable world; positioning health promotion as a task for the whole of the economy through action within the government sector and through assessment of the health equity impact of the corporate sector and neo-liberalism; through its Knowledge Networks, providing a much stronger evidence base than has previously been available on the social determinants of health and health equity including the actions and policies that are most likely to promote health and equity; providing a focus for the further growth of a global social movement advocating for health equity within and between countries; contributing to the reform of WHO and other international health agencies so that all programmes are built to take comprehensive action in communities and nationally to tackle the underlying causes of disease; adding legitimacy to moves to re-orientate health care systems to a focus on health promotion and population health.     

Political and welfare state determinants of infant and child health indicators: an analysis of wealthy countries

Economic indicators such as income inequality are gaining attention as putative determinants of population health. On the other hand, we are just beginning to explore the health impact on population health of political and welfare state variables such as political orientation of government or type of medical care coverage. To determine the socially structured impact of political and welfare state variables on low birth weight rate, infant mortality rate, and under-five mortality rate, we conducted an ecological study with unbalanced time-series data from 19 wealthy OECD countries for the years from 1960 to 1994. Among the political/welfare state variables, total public medical coverage was the most significant predictor of the mortality outcomes. The low birth weight rate was more sensitive to political predictors such as percentage of vote obtained by social democratic or labor parties. Overall, political and welfare state variables (including indicators of health policies) are associated with infant and child health indicators. While a strong medical care system seems crucial to some population health outcomes (e.g., the infant mortality rate), other population health outcomes might be impacted by social policies enacted by parties supporting strong welfare states (the low birth weight rate). Our investigation suggests that strong political will that advocates for more egalitarian welfare policies, including public medical services, is important in maintaining and improving the nation's health.     

Regulating private health insurance to serve the public interest: policy issues for developing countries

Private health insurance plays a large and increasing role around the world. This paper reviews international experiences and shows that private health insurance is significant in countries with widely different income levels and health system structures. It contrasts trends in private health insurance expansion across regions and highlights countries with particularly important experiences of private coverage. It then discusses the regulatory approaches and policies that can structure private health insurance markets in ways that mobilize resources for health care, promote financial risk protection, protect consumers and reduce inequities. The paper argues that policy makers need to confront the role that private health insurance will play in their health systems and regulate the sector appropriately so that it serves public goals of universal coverage and equity.     

The world is ageing: a pact of social solidarity is an imperative

Abstract This text presents the key topics, which guided the discussions about demographic change and the resultant public health implications. With the ageing of the societies, the health problems of the elderly put pressure on health and social security systems. With regard to work and social wellbeing, there are three important sub-topics: the labor market and the elderly; social security and questions related to shelter for the aged population. The ageing process normally occurs in good health conditions unless there is disease. In addition, the scientific and technological achievements in the health area allow for a better quality of life for the elderly. This is why preventive strategies over the lifespan turned more important for meeting today's challenges and increasingly those of tomorrow. As refers to innovation and markets, longevity creates numberless opportunities especially in terms of new products and markets. On the other hand, the term "productive ageing" has been widely used for defining the increasing trend towards a life style in an ageing society. Finally we will approach the topic ageing and development showing that the demographic shift is already one of the most urgent global problems, being addressed by public policies both in the developed and developing countries.     

Health research systems: promoting health equity or economic competitiveness?

International collaborative health research is justifiably expected to help reduce global health inequities. Investment in health policy and systems research in developing countries is essential to this process but, currently, funding for international research is mainly channelled towards the development of new medical interventions. This imbalance is largely due to research legislation and policies used in high-income countries. These policies have increasingly led these countries to invest in health research aimed at boosting national economic competitiveness rather than reducing health inequities. In the United States of America and the United Kingdom of Great Britain and Northern Ireland, the regulation of research has encouraged a model that: leads to products that can be commercialized; targets health needs that can be met by profitable, high-technology products; has the licensing of new products as its endpoint; and does not entail significant research capacity strengthening in other countries. Accordingly, investment in international research is directed towards pharmaceutical trials and product development public-private partnerships for neglected diseases. This diverts funding away from research that is needed to implement existing interventions and to strengthen health systems, i.e. health policy and systems research. Governments must restructure their research laws and policies to increase this essential research in developing countries.     

The political context of social inequalities and health

This analysis reflects on the importance of political parties, and the policies they implement when in government, in determining the level of equalities/inequalities in a society, the extent of the welfare state (including the level of health care coverage by the state), the employment/unemployment rate, and the level of population health. The study looks at the impact of the major political traditions in the advanced OECD countries during the golden years of capitalism (1945-1980) -- social democratic, Christian democratic, liberal, and ex-fascist -- in four areas: (1) the main determinants of income inequalities, such as the overall distribution of income derived from capital versus labor, wage dispersion in the labor force, the redistributive effect of the welfare state, and the levels and types of employment/ unemployment; (2) levels of public expenditures and health care benefits coverage; (3) public support of services to families, such as child care and domiciliary care; and (4) the level of population health as measured by infant mortality rates. The results indicate that political traditions more committed to redistributive policies (both economic and social) and full-employment policies, such as the social democratic parties, were generally more successful in improving the health of populations, such as reducing infant mortality. The erroneous assumption of a conflict between social equity and economic efficiency, as in the liberal tradition, is also discussed. The study aims at filling a void in the growing health and social inequalities literature, which rarely touches on the importance of political forces in influencing inequalities. The data used in the study are largely from OECD health data for 1997 and 1998; the OECD statistical services; the comparative welfare state data set assembled by Huber, Ragin and Stephens; and the US Bureau of Labor Statistics.     

Why do health labour market forces matter?

Human resources for health have been recognized as essential to the development of responsive and effective health systems. Low- and middle-income countries seeking to achieve universal health coverage face human resource constraints – whether in the form of health worker shortages, maldistribution of workers or poor worker performance – that seriously undermine their ability to achieve well-functioning health systems. Although much has been written about the human resource crisis in the health sector, labour economic frameworks have seldom been applied to analyse the situation and little is known or understood about the operation of labour markets in low- and middle-income countries. Traditional approaches to addressing human resource constraints have focused on workforce planning: estimating health workforce requirements based on a country’s epidemiological and demographic profile and scaling up education and training capacities to narrow the gap between the “needed” number of health workers and the existing number. However, this approach neglects other important factors that influence human resource capacity, including labour market dynamics and the behavioural responses and preferences of the health workers themselves. This paper describes how labour market analysis can contribute to a better understanding of the factors behind human resource constraints in the health sector and to a more effective design of policies and interventions to address them. The premise is that a better understanding of the impact of health policies on health labour markets, and subsequently on the employment conditions of health workers, would be helpful in identifying an effective strategy towards the progressive attainment of universal health coverage.     

Investing in health systems for universal health coverage in Africa

Background

This study focused on the 47 Member States of the World Health Organization (WHO) African Region. The specific objectives were to prepare a synthesis on the situation of health systems components, to analyse the correlation between the interventions related to the health Millennium Development Goals (MDGs) and some health systems components and to provide overview of four major thrusts for progress towards universal health coverage (UHC).

Methods

The WHO health systems framework and the health-related MDGs were the frame of reference. The data for selected indicators were obtained from the WHO World Health Statistics 2014 and the Global Health Observatory.

Results

African Regions average densities of physicians, nursing and midwifery personnel, dentistry personnel, pharmaceutical personnel, and psychiatrists of 2.6, 12, 0.5, 0.9 and 0.05 per 10 000 population were about five-fold, two-fold, five-fold, five-fold and six-fold lower than global averages.Fifty-six percent of the reporting countries had fewer than 11 health posts per 100 000 population, 88% had fewer than 11 health centres per 100 000 population, 82% had fewer than one district hospital per 100 000 population, 74% had fewer than 0.2 provincial hospitals per 100 000 population, and 79% had fewer than 0.2 tertiary hospitals per 100 000 population.Some 83% of the countries had less than one MRI per one million people and 95% had fewer than one radiotherapy unit per million population. Forty-six percent of the countries had not adopted the recommendation of the International Taskforce on Innovative Financing to spend at least US$ 44 per person per year on health. Some of these gaps in health system components were found to be correlated to coverage gaps in interventions for maternal health (MDG 5), child health (MDG 4) and HIV/AIDS, TB and malaria (MDG 6).

Conclusions

Substantial gaps exist in health systems and access to MDG-related health interventions. It is imperative that countries adopt the 2014 Luanda Commitment on UHC in Africa as their long-term vision and back it with sound policies and plans with clearly engrained road maps for strengthening national health systems and addressing the social determinants of health.

     

Modelling rubella in Europe

The prevention of congenital rubella syndrome (CRS), as a complication of rubella infection during pregnancy, is the main aim of rubella vaccination programmes. However, as vaccination of infants leads to an increase in the average age at which those who were not immunized become infected, certain rubella vaccination programmes can lead to an increase in the incidence of CRS. In this paper we use a mathematical model of the transmission dynamics of rubella virus to investigate the likely impact of different vaccination policies in Europe. The model was able to capture pre- and post-vaccination patterns of infection and prevalence of serological markers under a wide variety of scenarios, suggesting that the model structure and parameter estimates were appropriate. Analytical and numerical results suggest that endemic circulation of rubella is unlikely in Finland, the United Kingdom, The Netherlands, and perhaps Denmark, provided vaccine coverage is uniform across geographical and social groups. In Italy and Germany vaccine coverage in infancy has not been sufficient to interrupt rubella transmission, and continued epidemics of CRS seem probable. It seems unlikely that the immunization programmes in these countries are doing more harm than good, but this may be partly as a result of selective immunization of schoolgirls. Indeed, in both these countries, selective vaccination of schoolgirls with inadequate vaccination histories is likely to be an important mechanism by which CRS incidence is suppressed (unlike the other countries, which have had sufficiently high infant coverage rates to withdraw this option). Reducing inequalities in the uptake of rubella vaccine may bring greater health benefits than increasing the mean level of coverage.     

Evaluations of health interventions in social insurance-based countries: Germany,the Netherlands,and Austria

Health Technology Assessment (HTA) in social insurance-based, or so-called 'Bismarck' health care systems (Germany, Austria, and the Netherlands) has taken a different course than in either taxed-based (Sweden, Norway, United Kingdom, and Spain) or private health care systems (such as the United States). The culture of informed decisions supported by transparent and evidence-based evaluations of health interventions was hindered by the strong professional autonomy and sectoral interests in Germany and Austria for a long time. On the other hand, HTA has a long-standing tradition in the Netherlands. In all three countries sickness funds play an important role in implementing evaluations-as a policy tool-by linking reimbursement to explicit proof of effectiveness in both new and established interventions. This article focuses on the obstacles and opportunities for HTA in Germany, Austria and the Netherlands as countries with insurance-based health care systems.