Retos para los sistemas sanitarios de Latinoamérica: ¿qué puede aprenderse de la experiencia europea?

ORIGINAL Resumen Este artículo compara los retos de los sistemas sanitarios latinoamericanos y la experiencia en Europa. El marco conceptual se centra en cuatro funciones: a) generar recursos; b) producir intervenciones; c) financiar, y d) «ejercer rectoría». Es a este nivel donde los actores pueden influir sobre el desempeño del sistema. Se identifican cinco retos para Latinoamérica: a) extender (prepago y solidaridad) la protección financiera; b) estabilizar en el tiempo dicha protección para épocas de crisis; c) equilibrar los recursos coherentemente con la capacidad de financiar servicios, d) aumentar la eficiencia ubicativa y técni-ca al producir servicios, y e) mejorar la función de rectoría de las demás funciones en los sectores público y privado (el más difícil y más importante reto hoy para los sistemas latinoamericanos). Se analiza luego la experiencia de reforma en Europa, presentando: a) experiencias sobre protección financiera en los sistemas tipo Beveridge y Bismarck; b) estabilidad en tiempos de crisis refrendada recientemente (Oeste) y con graves obstáculos (Este); c) el esfuerzo por equilibrar camas hospitalarias y profesionales sanitarios combinando regulación e incentivos; d) un aumento de la eficiencia en la producción de servicios priorizando más expresamente, dando voz a los pacientes, descentralizando la gestión y con incentivos de mercado, y e) una mejora de la rectoría no regulando menos sino mejor (y en algunos casos, más). Tres áreas de la experiencia europea sobresalen: a) combinar solidaridad con sostenibilidad financiera; b) introducir mesuradamente incentivos de mercado pero manteniendo un claro papel rector del Estado, y c) adoptar innovaciones en la organizacíon y producción de servicios. Pese a las dificultades metodológicas, la convergencia de los retos y las «soluciones» adoptadas justifica este análisis, pero las enseñanzas deben contemplarse desde cada contexto nacional. Un futuro artículo abordará las lecciones ofrecidas por las reformas de los sistemas latinoamericanos a las reformas europeas. Palabras clave: Sistemas sanitarios. Reformas. Latinoamé-rica. Europa. Retos. Lecciones. Comparación. Abstract This article compares the challenges of health systems in Latin America and the experience in Europe. The framework is the analysis of four functions: a) to generate resources; b) to produce activities; c) to finance, and d) to exercise stewardship. It is at this level where actors can influence health system responsiveness. Five challenges are identified in Latin America: a) to extend (prepayment and solidarity) financial protection; b) to stabilise that protection for crisis times; c) to equilibrate resources in accordance to capacity for financing services; d) to increase efficiency (technical and of placement) to produce services, and e) to improve the stewardship function in public and private sectors (the most important and difficult challenge LatinAmerican systems have nowadays). The experience of reform in Europe is analysed, showing: a) experiences about financial protection in Beveridge and Bismarck systems; b) stability in crisis times, recently confirm (West) and with important obstacles (East); c) efforts to equilibrate hospital beds and health care professionals, combining regulation and incentives; d) increase of efficiency in services production, with more express prioritisation, empowering patients, decentralising management and with market incentives, and e) improvement of stewardship with better (not less, sometimes even more) regulation. Three areas of European experience stand out: a) to combine solidarity with financial sustainability; b) to introduce market incentives in a measured way, but maintaining a clear stewardship role for the state, and c) to adopt innovations in organising and producing services. In spite of methodological difficulties, convergence of challenges and adopted solutions justify this analysis, but learning must be seen in each national context. A future article will analyse lessons offered by reform in Latin-American systems for European reforms

Promoting Universal Financial Protection: Evidence from Seven Low- and Middle-Income Countries on Factors Facilitating or Hindering Progress.

Although universal health coverage (UHC) is a global health policy priority, there remains limited evidence on UHC reforms in low- and middle-income countries (LMICs). This paper provides an overview of key insights from case studies in this thematic series, undertaken in seven LMICs (Costa Rica, Georgia, India, Malawi, Nigeria, Tanzania, and Thailand) at very different stages in the transition to UHC.These studies highlight the importance of increasing pre-payment funding through tax funding and sometimes mandatory insurance contributions when trying to improve financial protection by reducing out-of-pocket payments. Increased tax funding is particularly important if efforts are being made to extend financial protection to those outside formal-sector employment, raising questions about the value of pursuing contributory insurance schemes for this group. The prioritisation of insurance scheme coverage for civil servants in the first instance in some LMICs also raises questions about the most appropriate use of limited government funds.The diverse reforms in these countries provide some insights into experiences with policies targeted at the poor compared with universalist reform approaches. Countries that have made the greatest progress to UHC, such as Costa Rica and Thailand, made an explicit commitment to ensuring financial protection and access to needed care for the entire population as soon as possible, while this was not necessarily the case in countries adopting targeted reforms. There also tends to be less fragmentation in funding pools in countries adopting a universalist rather than targeting approach. Apart from limiting cross-subsidies, fragmentation of pools has contributed to differential benefit packages, leading to inequities in access to needed care and financial protection across population groups; once such differentials are entrenched, they are difficult to overcome. Capacity constraints, particularly in purchasing organisations, are a pervasive problem in LMICs. The case studies also highlighted the critical role of high-level political leadership in pursuing UHC policies and citizen support in sustaining these policies.This series demonstrates the value of promoting greater sharing of experiences on UHC reforms across LMICs. It also identifies key areas of future research on health care financing in LMICs that would support progress towards UHC

Behaviour in therapeutic medical care: evidence from general practitioners in Austria

Aim: The present study examines monetary effects of general practioners’ behaviour in therapeutic medical care to identify sample characteristics that allow differentiating between the individual general practitioner and the basic population. Subjects and methods: Medical services, provided by 3,919 general practitioners in Austria, were operationalized by means of the dependent variable “costs per patient”. Statistical outliers were identified using Chebyshev’s inequality and categorized by investigating bivariate correlations between the dependent variable and the personal characteristics of each physician. Results: Variables that relate to the size of the customer base such as number of consultations (r = 0.385) and office days (r = 0.376), correlate positively with the costs for medical services. By analyzing the portfolio of the general practitioners, we found a correlation of 0.451 between this coefficient and the costs. Statistical outliers feature an average portfolio of 44.5 different services, compared to 30.45 among non-outliers. Laboratory services especially were identified as cost drivers (r = 0.408). Statistical outliers generate at least one laboratory parameter for 44.34% of their patients, opposed to 27.2% within the rest of the sample. Consequently outliers produce higher laboratory costs than their counterparts. Conclusion: We found some evidence that physicians have influence in the provision of their services. Considering entrepreneurial objectives, the extension of the portfolio can increase their profit. Our findings indicate supplier-induced demand for several groups of services. We assume that the effect is consolidated by the fee for service system and could be compensated by adequate reform

Effects of information, education, and communication campaign on a community-based health insurance scheme in Burkina Faso

Objective : The study analysed the effect of Information, Education, and Communication (IEC) campaign activities on the adoption of a community-based health insurance (CHI) scheme in Nouna, Burkina Faso. It also identified the factors that enhanced or limited the campaign's effectiveness. Design : Complementary data collection approaches were used. A survey was conducted with 250 randomly selected household heads, followed by in-depth interviews with 22 purposively selected community leaders, group discussions with the project management team, and field observations. Bivariate analysis and multivariate logistic regression models were used to assess the association between household exposure to campaign and acquisition of knowledge as well as household exposure to campaign and enrolment. Results : The IEC campaign had a positive effect on households’ knowledge about the CHI and to a lesser extent on household enrolment in the scheme. The effectiveness of the IEC strategy was mainly influenced by: 1 frequent and consistent IEC messages from multiple media channels (mass and interpersonal channels), including the radio, a mobile information van, and CHI team, and 2 community heads’ participation in the CHI scheme promotion. Education was the only significantly influential socio-demographic determinant of knowledge and enrolment among household heads. The relatively low effects of the IEC campaign on CHI enrolment are indicative of other important IEC mediating factors, which should be taken into account in future CHI campaign evaluation. Conclusion : The study concludes that an IEC campaign is crucial to improving the understanding of the CHI scheme concept, which is an enabler to enrolment, and should be integrated into scheme designs and evaluations

Gene Expression Dynamics During Bone Healing and Osseointegration

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/141010/1/jper1007.pd

Who uses outpatient healthcare services under Ghana’s health protection scheme and why?

Background: The National Health Insurance Scheme (NHIS) was launched in Ghana in 2003 with the main objective of increasing utilisation to healthcare by making healthcare more affordable. Previous studies on the NHIS have repeatedly highlighted that cost of premiums is one of the major barriers for enrollment. However, despite introducing premium exemptions for pregnant women, older people, children and indigents, many Ghanaians are still not active members of the NHIS. In this paper we investigate why there is limited success of the NHIS in improving access to healthcare in Ghana and whether social exclusion could be one of the limiting barriers. The study explores this by looking at the Social, Political, Economic and Cultural (SPEC) dimensions of social exclusion. Methods: Using logistic regression, the study investigates the determinants of health service utilisation using SPEC variables including other variables. Data was collected from 4050 representative households in five districts in Ghana covering the 3 ecological zones (coastal, forest and savannah) in Ghana. Results: Among 16,200 individuals who responded to the survey, 54 % were insured. Out of the 1349 who sought health care, 64 % were insured and 65 % of them had basic education and 60 % were women. The results from the logistic regressions show health insurance status, education and gender to be the three main determinants of health care utilisation. Overall, a large proportion of the insured who reported ill, sought care from formal health care providers compared to those who had never insured in the scheme. Conclusion: The paper demonstrates that the NHIS presents a workable policy tool for increasing access to healthcare through an emphasis on social health protection. However, affordability is not the only barrier for access to health services. Geographical, social, cultural, informational, political, and other barriers also come into play