Social determinants of health and the health system of Mozambique : Towards a comprehensive analysis of health inequalities

The present thesis aims to give a critical overview of the health care and health inequalities for the Mozambican case. The thesis is divided into four articles, two of them are quantitative articles analysing data from the Mozambican household budget survey, while the other two articles employ different methodologies: a systematic review and data source mapping. Findings show that in Mozambique, despite the overall health status has improved over time, women, children, elders and the population living in rural areas of the country are left behind in the progress to attain better health. Structural factors are the major drivers of health inequalities and people’s access to basic services and material conditions, although crucial, are not the main causes of health inequalities in Mozambique. Another key finding is that a comprehensive view of the health system based in primary health care is fundamental for addressing health care inequalities. In Sub-Saharan Africa, the access to and quality of primary health care is mainly determined by the social position, rather than by the need, and health care inequalities persist over time. These results allow drawing conclusions for the improvement of the equity in the access to quality care in Mozambique. In the country, 70% of Mozambicans use healthcare services when having a health need, and despite there are no differences in the direct payments for the public sector visits, significant socio-economic and geographical inequalities were found for women and men in the access to and quality of care received. Finally, this thesis highlights the important information gaps that exists in the national health information system to monitor health equity in MozambiqueAquesta tesi té com a objectiu oferir una visió crítica de les desigualtats sanitàries i de salut per al cas de Moçambic. La tesi es divideix en quatre articles, dos d'ells són articles quantitatius que analitzen dades de l'enquesta sobre el pressupost familiar de Moçambic, mentre que els altres dos articles fan servir diferents metodologies: una revisió sistemàtica i un mapeig de fonts de dades. Els resultats mostren que a Moçambic, malgrat que l'estat general de salut ha millorat amb el temps, les dones, els nens, els ancians i la població que viu a les zones rurals del país es queden enrere en el progrés per aconseguir una millor salut. Els factors estructurals són els principals impulsors de les desigualtats en salut i l'accés als serveis bàsics i les condicions materials, tot i que són crucials, no són les principals causes de les desigualtats en salut a Moçambic. Una altra troballa clau és que una visió integral del sistema de salut basada en l'atenció primària de salut és fonamental per abordar les desigualtats en l'atenció de la salut. A l'Àfrica Subsahariana, l'accés i la qualitat de l'atenció primària de salut es determina principalment per la posició social, més que per la necessitat, i les desigualtats en l'atenció de la salut persisteixen al llarg del temps. Aquests resultats permeten extreure conclusions per a la millora de l'equitat en l'accés a l'atenció de qualitat a Moçambic. Al país, el 70% dels moçambiquesos fan servir els serveis de salut quan tenen una necessitat i, tot i que no hi ha diferències en els pagaments directes per a les visites al sector públic, es van trobar desigualtats socioeconòmiques i geogràfiques significatives per a les dones i els homes en l'accés i la qualitat de l'atenció rebuda. Finalment, aquesta tesi ressalta importants llacunes d'informació que hi ha en el sistema nacional d'informació de salut per a l'avaluació de l'equitat en salut a Moçambi

Commodification of health care systems: The Catalan case

Commodification of the public healthcare system has been a growing process in recent decades, especially in universal healthcare systems and in high-income countries like Spain.  There are substantial differences in the healthcare systems of each autonomous region of Spain, among which Catalonia is characterized by having a mixed healthcare system with complex partnerships and interactions between the public and private healthcare sectors.  Using a narrative review approach, this article addresses various aspects of the Catalan healthcare system, characterizing the privatization and commodification of health processes in Catalonia from a historical perspective with particular attention to recent legislative changes and austerity measures.  The article approximates, the eventual effects that commodification and austerity measures will have on the health of the population and on the structure, accessibility, effectiveness, equity and quality of healthcare services.</p

Beyond access to basic services: Perspectives on the social determinants of health in Mozambique

The social determinants of health have not been studied extensively in low-income contexts, where most studies focus on access to medical care. We undertake a retrospective cross-sectional analysis of the social determinants of health in Mozambique for the 2002-14 period, covering 258,431 observations. The results consistently show that neither better access to health care nor material conditions are related to better health outcomes. Rather, we find that macro factors, proxied by place of residence, are the predominant predictor of health inequalities. A policy implication is that a narrow focus of health policy on selected services is not sufficient to address the current health equity gap

The value of comparative research in major day surgery

Objective: To measure time trends in major day surgery rates according to hospital ownership and other hospital characteristics among the providers of the public healthcare network of Catalonia, Spain. Method: Data from the Statistics of Health Establishments providing Inpatient Care. A generalized linear mixed model with Gaussian response and random intercept and random slopes. Results: The greatest growth in the rate of major day surgery was observed among private for-profit hospitals: 42.9 (SD: 22.5) in 2009 versus 2.7 (SD: 6.7) in 1996. These hospitals exhibited a significant increase in major day surgery compared to public hospitals (coefficient 2; p-value <0.01) Conclusions: The comparative evaluation of hospital performance is a decisive tool to ensure that public resources are used as rationally and efficiently as possible. Resumen: Objetivo: Medir la evolución temporal de la cirugía mayor ambulatoria entre los proveedores de la red sanitaria pública de Cataluña de acuerdo con la titularidad y otras características de los hospitales. Métodos: Con datos provenientes de la Estadística de Establecimientos Sanitarios con Régimen de Internamiento, se realizó un modelo lineal generalizado mixto con respuesta gaussiana y pendiente e intersección aleatorios. Resultados: Se observó que la mayor variación en la tasa de cirugía mayor ambulatoria era para los hospitales privados con fines de lucro: 42,9 (desviación estándar [DE]: 22,5) en 2009 frente a 2,7 (DE: 6,7) en 1996. Estos hospitales tuvieron un aumento significativo de la cirugía mayor ambulatoria en comparación con los hospitales públicos (coeficiente 2; p <0,01). Conclusiones: La evaluación comparativa del desempeño de los hospitales es una herramienta decisiva para garantizar que los recursos públicos se utilizan de la forma más racional y eficiente posible. Keywords: Health services research, Ambulatory surgical procedures, Public Hospitals, Private Hospitals, Palabras clave: Investigación sobre servicios de salud, Procedimientos quirúrgicos ambulatorios, Hospitales públicos, Hospitales privado

From evidence to tailored decision-making: a qualitative research of barriers and facilitating factors for the implementation of non-clinical interventions to reduce unnecessary caesarean section in Romania

Objective To improve understanding of the drivers of the increased caesarean section (CS) rate in Romania and to identify interventions to reverse this trend, as well as barriers and facilitators.Design A formative research study was conducted in Romania between November 2019 and February 2020 by means of in-depth interviews and focus-group discussions. Romanian decision-makers and high-level obstetricians preselected seven non-clinical interventions for consideration. Thematic content analysis was carried out.Participants 88 women and 26 healthcare providers and administrators.Settings Counties with higher and lower CS rates were selected for this research—namely Argeș, Bistrița-Năsăud, Brașov, Ialomița, Iași, Ilfov, Dolj and the capital city of București (Bucharest).Results Women wanted information, education and support. Obstetricians feared malpractice lawsuits; this was identified as a key reason for performing CSs. Most obstetrics and gynaecology physicians would oppose policies of mandatory second opinions, financial measures to equalise payments for vaginal and CS births and goal setting for CS rates. In-service training was identified as a need by obstetricians, midwives and nurses. In addition, relevant structural constraints were identified: perceived lower quality of care for vaginal birth, a lack of obstetricians with expertise in managing complicated vaginal births, a lack of anaesthesiologists and midwives, and family doctors not providing antenatal care. Finally, women expressed the need to ensure their rights to dignified and respectful healthcare through pregnancy and childbirth.Conclusion Consideration of the views, values and preferences of all stakeholders in a multifaceted action tailored to Romanian determinants is critical to address relevant determinants to reduce unnecessary CSs. Further studies should assess the effect of multifaceted interventions