Rural Health Care in Bolivia*

ABSTRACT: Eighty percent of Bolivians live in rural areas. However, because of a lack of resources and an urban / curative health sector orientation, rural primary health care services are woefully inadequate. Consequently, Bolivia has the worst health conditions of any of the Latin American countries. The broader factors which underlie Bolivia's poor health conditions, such as the low standard of living and impediments to socioeconomic development, are reviewed. Rural primary health programs are hampered by a lack of local support, overdependence on central and distant Ministry of Health supervisory staff, a lack of strong national political support for rural primary health care programs, the absence of public sector support for social programs, and a lack of appropriately trained health providers who are comfortable in the rural sociocultural mileu of community-oriented primary health care. The experience of Andean Rural Health Care is briefly described, and the potential contribution of private organizations working with local communities and with the Ministry of Health is addressed. The most viable option for improving rural primary health care in Bolivia is the census-based community-oriented approach.     

An evaluation of subsidized rural primary care programs: II. The environmental contexts

The placement of subsidized primary care programs in rural communities has been an important aspect of national health policy over the last decade. Using survey and secondary data from programs in over 700 counties in the United States, it was found that while about one-fourth of all counties with some rural populations have been affected by these programs, certain environmental factors are associated with more or less likelihood of placement. High levels of need and low levels of health care resources are positively associated with the presence of a program. States with health policy climates supportive of reimbursement and broader staffing of primary care programs also contained programs in a higher proportion of their rural counties. The effects of decreased federal funding, increased state responsibility, and the precarious market conditions for primary care programs are discussed with emphasis on the mechanisms for developing favorable climates for these programs.     

Can managed health care help manage health care-associated infections?

Managed-care organizations have a unique opportunity, still largely unrealized, to collaborate with health-care providers and epidemiologists to prevent health care-associated infections. Several attributes make these organizations logical collaborators for infection control programs: they have responsibility for defined populations of enrollees and for their overall health, including preventive care; they possess unique data resources about their members and their care; and they are able to make systemwide changes in care. Health care-associated infections merit the attention and effort of managed-care organizations because these infections are common, incur substantial illness and costs, and can be effectively prevented by using methods that are unevenly applied in different health-care settings. Both national and local discussions will be required to enable the most effective and efficient collaborations between managed care organizations and health-care epidemiologists. It will be important to articulate clear goals and standards that can be readily understood and widely adopted.     

妇幼保健机构委托工作经费的管理现状及对策研究

国家妇幼保健机构大量的业务工作是在各级地方妇幼保健机构和有关部门的协作、参与下在全国组织实施的,其中部分工作需要直接委托地方妇幼保健机构和有关部门协助完成,为保证委托工作的顺利完成,并按照国家相关规定合理使用委托工作经费。     

The curious conversion of Empire Blue Cross

The for-profit conversion of Empire Blue Cross in New York challenges the case law and conventional policy wisdom that financial assets from formerly nonprofit organizations should be used to endow independent charitable foundations. The appropriation of Empire's assets by state government itself, and their subsequent deployment to subsidize health care institutions and repay political obligations, changes the conversion process from one that pits nonprofits against for-profits to one that pits private, nonprofit organizations against public-sector programs in the competition for new financial resources.     

Activities of the Centers for Disease Control in AIDS Education

The aim of the Centers for Disease Control (CDC) is to educate individuals about protecting themselves from becoming infected with HIV because there is no vaccine or therapy; this approach can be effective in controlling the epidemic. An estimated 1-1.5 million Americans are infected with HIV; the people are largely asymptomatic. The educational programs are designed to modify behaviors that affect the spread of HIV; namely, sexual intercourse with an infected person, using needles an infected person has used, or having a baby while infected with the virus. Within the Public Health Service, CDC has an AIDS prevention program that includes information and education programs directed toward the general public, school and college-age youth, persons at increased risk for infection, and health workers. 1 group at risk is teenagers because of their behaviors in sexual activity and drug use. Since 1987, the CDC school health program has been carried out by the Office of School Health and Special Projects, Division of Health Education. The program includes working with 15 state and 12 local departments of education in areas with a high cumulative incidence of AIDS. Additionally, national AIDS education training centers have been established to help personnel plan and implement programs; 15 national private section organizations help schools provide effective AIDS education. Educational resources also are developed and disseminated by CDC, such as a computerized bibliography and guidelines for education. National working meetings about AIDS education have been held by CDC for private, local, state, and national departments and organizations.     

Increasing the involvement of national and regional racial and ethnic minority organizations in HIV information and education.

Responding to the facts that (a) the AIDS epidemic is occurring among black and Hispanic populations disproportionately to their percentage of the U.S. population and (b) effective human immunodeficiency virus (HIV) prevention programs are racially, ethnically, and culturally relevant and sensitive, CDC in 1988 initiated a 5-year grant program for HIV prevention efforts by national racial and ethnic minority organizations and regional consortia of racial and ethnic minority organizations. A total of 33 organizations received first-year funds. Of the 32 grants that are ongoing, 15 primarily target blacks, 12 Hispanics, 4 Native Americans and Alaskan Natives, and 1 Asian Americans and Pacific Islanders. Some grants are for more than one racial or ethnic population. Programs may be categorized as (a) education programs within national non-AIDS organizations and their respective affiliate networks to increase their understanding, support, and community out-reach for HIV prevention; for example, National Urban League, Inc.; (b) programs providing specific HIV prevention expertise and technical assistance to community-based and other organizations; for example, National Minority AIDS Council; (c) HIV prevention programs emphasizing communications and media; for example, Hispanic Designers, Inc; and (d) prevention programs targeted to a specific racial or ethnic group within a geographic area; for example, Midwest Hispanic AIDS Coalition. As a result of these grants, substantial resources are being invested in prevention programs developed by and for racial and ethnic minorities. Other overall benefits include an expanded foundation of organizations to address AIDS and other health problems affecting these populations, strengthened interrelationships among HIV-focused and broader-based minority organizations, and extensive collaboration of private sector organizations with Federal and State public health and education agencies.     

Primary health care and public policy

The health problems of Ecuador are similar to those in other developing countries where the standard of living is low, and housing and sanitation are inadequate. Women, children, and those living in rural areas are those most severely affected. National policy has been to attempt to increase access to health care in rural areas through the construction of new facilities and the appointment of highly paid medical staff. However, little attention was paid to sociocultural factors, which caused the peasantry to reject the medical care system, or to problems of internal efficiency which inhibited utilization. Since the 1970s various national and international organizations have attempted to implement primary health care (PHC) through the use of trained community health workers (CHWs). The primary problems faced by the CHWs were shortages of medicines and supplies, an almost total lack of supervision, and lack of transportation available to take staff to isolated villages. The poor supervision is blamed for the 17% drop out rate among CHWs since 1980. Independent PHC programs have also been established in Ecuador by voluntary organizations. These work best when coordinated with governmental programs, in order to allow monitoring and to avoid the duplication of services. Problems with the establishment of PHC programs in Ecuador will continue, as the government has no clear cut policy, and difficulties financing on a broad national scale. Other problems include the absence of effective supervision and logistical support for even small pilot programs, and inconsistencies in the training and role definition for CHWs. These problems need to be met in the implementation of a national PHC policy.     

Planning and politics of resource allocation for primary health care: Promotion of meaningful national policy

Securing resources for primary health care (PHC) involves consideration of the entire health sector: the higher levels of the health service as well as the primary level, and the private and/or social security sub-sectors as well as the government service. Reshaping resource distribution is less a redistribution of existing resources than the allocation of new resources in accordance with PHC priorities. In this the planning of future current costs is a crucial element and requires a budgetary system that identifies expenditures by geographical area and level of care. Resources should be allocated geographically to reduce health care inequalities through the provision of an appropriate mix of different levels of care. Central resource planning and local health care programming (with ‘dialogue’ between the two) should be the basic planning division of labour, which largely resolves the so-called topdown /bottom-up dichotomy. The private medical sub-sector exerts economic, ideological and political influences on the public health service. Compulsory health insurance schemes can have some similar effects. Success of a PHC policy requires that governments adopt a holistic approach to the health sector.The allocation of health care resources on the bases of need and equity, as opposed to demand, is a political decision. The establishment of a national PHC policy backed up by adequate resources involves a specific politico-technical exercise with four components: research, planning, policy formulation, and government policy decision-making. The resource planning method, based on social epidemiology, is contrasted with conventional health planning methods, based on epidemiology. The articulation of these two approaches is discussed in terms of WHO's Managerial Process for National Health Development.Examples are quoted from Zimbabwe.     

Ensuring quality preventive care: the Texas Department of Health's Put Prevention into Practice initiative.

In the current public health arena, assurance of quality clinical preventive services to all populations will be possible only if collaborations are nurtured between public health and the private sector health care delivery systems. This article explores key preventive health programs that serve as the historical context for the evolution of the Texas Department of Health-Put Prevention Into Practice (TDH-PPIP) initiative, outlines documented barriers to implementation of preventive services in primary care, and reviews national public health programs launched to reduce these barriers. Lastly, a discussion regarding the joint responsibilities of the public health and the private sector professionals in assuring quality preventive services to all populations is initiated. Collaborative efforts, such as the TDH-PPIP, initiative improve the availability and quality of clinical preventive services and, thus, result in significant advances in the public health goal of ensuring conditions in which people can be healthy.     

Promoting the private sector: a review of developing country trends

Two questions are addressed in this article: (i) How can itbe ensured that private sector resources promote national healthgoals? and; (ii) What can be learnt from the private sectorto enhance operations in the public sector? There is a surprisingdegree of private sector activity in both the finai icing andprovision of services, despite the fact that few countries haveadopted wide-reaching privatization programmes. In some countriespressure upon government budgets for health has led to privatesector expansion - in others rapid income growth accompaniedby increased demand for health care is a causal factor. A number of problems related to private for-profit providersare evident; often quoted are supplier-induced demand and excessiveinvestment in high technology equipment, the equity implicationsof private health care, and the availability of manpower forthe public sector. Governments have tried to tackle these problemsthrough a range of innovative interventions, however littleproper evaluation of these policies has been carried out. Whilesuch problems are less likely to arise with the private, not-for-profitsector, the financial sustainability of their activities ismore worrying. There is also a need to define more clearly therelationships between governments and not-for-profit organizations. The paper considers market-oriented reforms in industrializedcountries, and their implications for the health sector in developingcountries. The measures taken in industrialized countries appearto be of limited direct applicability in developing countries,due to factors such as the sparse coverage of health facilitiesin the latter. However the principles on which the reforms arebased are relevant, in particular the need for greater transparencyin the activities of public and private sector providers andin the use of con tracting out services. Finally it is suggestedthat too much research in this area has focused on defendingone or other side of the privatization debate. Not enough workhas considered the health sector as a whole, and the complicatedinteractions between public and private sectors as providers,buyers, financ ing agents and regulators of health care services.     

A new era for health services research?

The suggestion that health services research is now on the threshold of a new era of importance is a commonplace theme in selected forums. Concern over escalating costs and quality assurance in the health care industry have inspired government, business, insurers, and health care organizations to search for answers in health services research. Those who expect a new era of assessment and accountability will be disappointed, however, if certain key conditions, such as financial resources, multidisciplinary cooperation, significant new training programs, and unified action on national and state public interest research agendas, are not satisfied.     

THE HEALTH EFFECTS OF THE INTERNATIONAL TRANSFER OF MEDICAL TECHNOLOGY

The rapid international transfer of medical technologies to the developing countries is in progress, promoting a “high technology” model of medicine mat is reflected in the structure of hospitals and university faculties, and medical education and practice. The resulting growth of specialties and sub-specialties in hospitals may inhibit the development of appropriate, village-based primary care services. Postgraduate medical education programs donated by the United States, Australia or Europe may disregard the vital issues of provision of universal primary care and local control of health services, and train doctors to devote resources to high technology urban models of care. Medical graduates emigrate to industrial countries because they find no “market” for their services in villages, where needs are the greatest. Bilateral foreign aid programs, WHO sponsored projects, multinational corporate transactions and medical missions and education have been important sources of technology transfer. While a national pharmacopoeia requires only 200 drugs, with 17 basic drugs in village clinics, most patients are denied suitable drug therapy because of inadequate primary care and the inappropriate transfer and promotion of over 4000 drugs that are expensive, incompletely tested in local conditions, or toxic. The deficiency in basic health services means only about 4 million of the 80 million children born each year in Africa, most of Latin America and South East Asia are effectively immunised with available vaccines. There are some apparently successful examples of appropriate health systems, based on the principles of universal access to primary care by health workers, and a national referral system to secondary and tertiary care. Effective monitoring of technology transfer and the development of appropriate health services involves important roles for the WHO and greater international co-operation among community health workers.     

Lack of national primary care organization partnerships with community groups to promote health care reform

Coalitions are necessary for successful political change. Few national primary care provider organizations partner with community, consumer, or labor organizations, and very few do so to promote policy on access to health care. Many of these provider organizations do work on health care access policy issues and do work in partnership with a variety of organizations, suggesting that community-provider partnerships may be a promising but overlooked strategy for promoting health care reform.     

Improving public health system performance through multiorganizational partnerships

Public health activities in the United States are delivered through multiple public and private organizations that vary widely in their resources, missions, and operations. Without strong coordination mechanisms, these delivery arrangements may perpetuate large gaps, inequities, and inefficiencies in public health activities. We examined evidence and uncertainties concerning the use of partnerships to improve the performance of the public health system, with a special focus on partnerships between public health agencies and health care organizations. We found that the types of partnerships likely to have the largest and most direct effects on population health are among the most difficult, and therefore least prevalent, forms of collaboration. High opportunity costs and weak and diffuse participation incentives hinder partnerships that focus on expanding effective prevention programs and policies. Targeted policy actions and leadership strategies are required to illuminate and enhance partnership incentives.     

Challenges and opportunities for personal selling

Health care organizations are beginning to use sales forces in much the same way as traditional for-profit organizations have used selling programs in the past. However, numerous challenges to the implementation of selling in the health care industry have yet to be overcome. The authors report viewpoints expressed by administrators in a national survey of health care organizations.     

A vision for older adults and health promotion

Our rapidly aging population is expected to place heavy demands on all segments of society, particularly the health care resources needed to attend to health concerns associated with aging. Is this a looming crisis, as some predict, or a challenge to use resources more wisely and to help older adults and their caregivers share in the responsibility for health promotion and chronic disease self-management activities? Community-based organizations serving older adults are uniquely positioned to augment health care providers' health promotion counseling activities and to bridge the gap between the research and practice of health promotion in older adults. They already play a crucial role by providing appropriate health promotion education, screening and referral, service planning, and reinforcement to facilitate self-care activities and behavior changes that promote healthy aging. By increasing teamwork across the network of services for the aging, the health sector, public and private organizations, and academe, there is a great opportunity to enhance the health and well-being of all older Americans.     

Commentary on Gurewich et Al, "comparative performance of community health centers and other usual sources of primary care": community health centers: valuable partners for state medicaid programs

Community health centers are well positioned to bring needed primary care to populations experiencing the most acute health disparities. Health centers already care for 1 in 7 Medicaid beneficiaries and 1 in 5 low-income, uninsured individuals. And they generate $24 billion in annual savings to the entire health care system, including $6 billion for Medicaid programs. Health center patients are distinctly different from patients of other providers, and successfully meet the challenges associated with serving those who have special needs that require more time and resources to address. For this reason, health centers provide a much more comprehensive array of services, both health care and services that facilitate access to care, compared to private practice physicians. With more beneficiaries joining the Medicaid rolls under health reform, and the limited number of providers available to serve the most complex, hard-to-reach, and underserved patients, health centers will play an increasingly important partnership role with state Medicaid programs. Continued investments are necessary to effectively serve at-risk patients.     

Gaining strategic advantages through partnerships with public health departments

Public health officials have advocated in public health and public policy journals for collaboration with private sector health care organizations for nearly a decade. There has been little written in the management literature on this topic, however. There are several important areas in which public health departments have expertise that could be valuable to private sector health care organizations, including health maintenance organizations (HMOs). These include the delivery of services in some geographic areas and to some special populations, provision of preventive and health promotion services to HMO members, performance of epidemiology services, assistance in accreditation, and repair of the damaged image of HMOs. HMOs and local health departments in many parts of the country are already entering into contracts for these purposes. Such partnerships between HMOs and local health departments can improve the health of the members of HMO plans and contribute to improving the health of the community.     

Canada Deserves a National Health System

A defining — some would say peculiar — feature about Canada and Canadians is the strong position that we give social programs within our national identity. FORUM presents an essay by Dr. Thomas Noseworthy based on an address to the annual meeting of the Association of Canadian Medical Colleges in April 1996. In it, Dr. Noseworthy calls for a national health system. He sees the federal government retaining an important role in preserving medicare and, in fact, strengthening its powers in maintaining national consistency and standards. Dr. Noseworthy's views are contrary to the governmental decentralization and devolution of powers occurring across the country. In a “point/counterpoint” exchange on this issue, we have invited commentaries from three experts. Raisa Deber leads off by noting that while a national health system may be desirable, constitutional provisions would be an obstacle. Governments, says Deber, have an inherent conflict of interest between their responsibility for maintaining the health care system and their desire to shift costs. Michael Rachlis reminds us that medicare fulfills important economic as well as social objectives. It helps to support Canada's business competitiveness among other nations. The problem, says Rachlis, is that public financing of health care does not ensure an efficient delivery system. Michael Walker offers some reality orientation. He observes that Canada's health care system is based upon ten public insurance schemes with widely different attributes. While he supports a minimum standard of health care across the country, citizens should be able to purchase private medical insurance and have access to a parallel private health care delivery system. Ultimately, this debate is about who should control social programs: the provinces or the federal government?We'll let you, the readers, decide. — RRS