The institutional aspects of health sector reform: whither primary care? [abstract]

In recent years, there has been a great deal of discussion about the need for health sector reform. Most of the general discussions have centred around the need for ensuring equity, efficiency, effectiveness and quality, financial sustainability and intersectoral action and community participation. In practice, however, the large majority of the official efforts have focussed on health finance reform, as the several governments in the region have sought to cope with what has been defined as the health resource gap: that is, the difference between available revenues and rising health costs. In addition, the focus of most reform efforts has largely been on improving the health delivery systems. So far, there has been insufficient attention given to those factors affecting the demand for health and health care. Since one of these factors is likely to be the reform package itself, it is critical to seek to assess and evaluate the impacts of the reforms implemented. In this paper, it will be argued that socio-economic circumstances, as well as particular health finance reforms may be significantly changing the character of the demands for health care. It will be also suggested that to the extent that the inefficiency and ineffectiveness of the primary health care system has negatively contributed to the changing character of health demands, it may be necessary to raise questions about the current locus, viability and strength of the ideals of the primary care approach to health care. In this discussion, case material and data from selected countries in the Caribbean will be presented. (AU)

Health trends in Jamaica: significant progress and a vision for the 21st century

Health trends in Jamaica have improved considerably during the past century. Life expectancy at birth increased from 38 years in 1900 to 72 years in 2000. The crude death and infant mortality rates declined significantly from 35.7 and 174.3 deaths to 5.1 and 24.4 deaths, respectively in the same period. The seven leading causes of death in 1945 were infectious diseases while the main causes of mortality and morbidity are now the chronic non-communicable lifestyles diseases, and injuries. Over the past few decades, considerable progress has been made in controlling vaccine preventable diseases and eliminating poliomyelitis and measles. Rates of infectious syphilis and gonorrhoea have declined significantly in recent years although chlamydia and herpes are common and the HIV/AIDS epidemic is a growing concern. Over the past few decades health expenditure has grown more rapidly in the private health sector than in the public health sector although services in the public sector are provided at significantly lower cost. Jamaica provides good health at low cost. However, more funds are needed to support the public health system. The current health reform process needs to be informed by a better understanding of the factors that have contributed to Jamaica's achievements in health and needs a clear health focus. The Ministry of Health has articulated a vision of health for the 21st century that requires a significant reorientation of health staff as well as empowering people to take responsibility for adopting healthy lifestyles. (AU)

Development of primary health care in Jamaica

The development of primary health care in Jamaica is explored, tracing its early roots to the abolition of the slave trade, the collapse of estate-based services after emancipation and the subsequent establishment of the Island Medical Services in 1875. Most developments in the health sector occurred after World War I in response to the high infectious disease mortality rates. The Rockefeller Foundation was asked to assist with the control of hookworm, tuberculosis, malaria and yaws. Its recommendation led to the growth of public health programmes (eg environmental health, public health nursing, community midwifery) alongside community-based curative services run by hospitals. The most significant period of development occurred in the 1970s when the various vertical programmes were integrated into the current primary care system. Jamaica was integral in the development of the World Health Organization's Alma Ata Declaration on Primary Health Care, tabling the "Jamaican Perspective on Primary Health Care" which set out its goal that all citizens should be within 10 miles walking distance of a primary health care facility. At the close of the twentieth century, the health reform process led to the development of regional health authorities aimed at integrating the management of primary and secondary care under four Regional Boards of Health. This has led to a change in the role of the central Ministry of Health to one of policy-making, health promotion, setting standards, monitoring and evaluation of the quality of health care. (AU)

Towards a framework for examining the interrelationship between health and the economy

There is a general acceptance that productive efficiency cannot increase until health improves, health cannot improve until the standard of living improves, and the standard of living cannot improve until productive efficiency increases. In other words the health status of a country's population and that of its economy are intimately interconnected. Despite this recognition, however, policy formulation for health in many developing countries still seems steeped in the idea that the health sector is primarily a welfare sector. This thesis seeks to elucidate a clearer understanding of this intriguing and potently relevant interrelationship. This is achieved through the development of a schema that illustrates the channels and mechanisms through which health impacts on the economy, and similarly through which the performance of the economy ifluences health outcomes. That schema is used to develop a mathematical model that formally demonstates the dynamic linkages between the health system and the economic system. It was found that this model may allow us to trace changes in the rate of economic growth or decline to demand and supply conditions within the health system. The model could therefor provide a medium through which policy formulation for the health sector and the wider economic system can be better understood (AU)

Reforme de los sistemas de salud en America Latin y el Caribe: situacion y tendencias / Health sector reform in Latin America and the Caribbean: situation and trends

In the early 1990s, most Latin American and Caribbean countries were beginning, or planning to begin, health sector reform processes. This paper presents the status and trends of health sector reform at the end of the 1990s. The authors relied on information in 20 health system and services profiles completed by the Pan American Health Organization between August 1998 and October 1999. The analysis, which follows a methodology that had been applied earlier, was organized on two different levels: (1) monitoring the reform processes (dynamics and content) and (2) evaluating their outcomes. In looking at the dynamics of the reform processes, the article examines the content in which they take place and the actors involved in their different phases: inception, design and negotiation, implementation, and evaluation. The description and analysis of the contents of health sector reform inititives are organized into 12 broad thematic areas. Outcomes evaluation was only possible in the eight countries that provided enough pertinent information, and should be viewed as preliminary. Nevertheless, the article does present detailed information on the outcomes of health sector reform in terms of equity, effectiveness and quality, efficiency, sustainability, and societal participation and control. The article also discusses the potential causes and determining factors for the observed outcomes (AU)

Health sector reform in the Republic of Trinidad and Tobago

The Republic of Trinidad and Tobago lies at the southern-most end of the Caribbean chain of islands. The estimated population in 1998 was 1.28 million of whom 27 percent were under 15 years of age and 6.3 percent were 65 or older. The population consists of a rainbow of persons of diverse cultural and ethnic antecedents. The leading causes of mortality and morbidity are heart diseases, neoplasms, diabetes mellitus, and cerebrovascular diseases. Trinidad and Tobago supports its population through petroleum and its downstream industries and from growing manufacturing and tourism sectors (AU)

Hacia una nueva seguridad social en el siglo XXI: sin solidaridad en el financiamiento no habra universalidad / Towards new social security systems in the 21st century: universal coverage is impossible without cohesion in financing

In the countries of Latin America and the Caribbean, social security systems have traditionally been almost exclusively the responsibility of the public sector. These systems have had major shortcomings, such as low coverage rates, unbalanced budgets, inadequate funding, and poor management of resources. In order to solve these problems and face the increased demands associated with demographic and epidemiological transitions, in the 1990s a number of countries began to reform their social security systems. These reforms have been characterized by three fundamental features: a) a search for a closer link between contributions and benefits, in order to better balance income and expenses, b) changes in the public-private composition of the systems that allow a greater private role in the financing and delivery of services, and c) an emphasis on market mechanisms as a way to promote efficiency in applying resources, and leaving to the State a role as a regulator and as a guarantor of basic benefits to groups that, because of their socioeconomic conditions, cannot make certain minimum contributions. This article looks at some of the problems raised by the reforms carried out so far, and the lessons that can be learned from them. The piece also analyzes the relationship between universal coverage and societal unity. In addition, the article suggests that the main challenge with social security reforms is that of moving toward universal systems that sinificantly expand coverage. In order to achieve that, it is necessary to strengthen the mechanisms of cohesion in financing and to improve efficiency by introducing market instruments that do not negatively affect the unitarian character of the financing. The piece concludes that it is necessary to increase coverage; improve management; be concerned about the design of the public-private makeup; identify the responsibilities of the private sector and of the government in financing, provision, and regulation of social security systems; and introduce and strengthen unity mechanisms in financing (AU)

Repensar la proteccion social en salud en America Latina y el Caribe / Rethinking social protection in health in Latin America and the Caribbean

Despite what is written in the constitutions and other basic document mandates of the countries of the Region, exclusion from societal protection in health (SPH) affects an important proportion of the population (at least 20 percent, which represents, in absolute figures, between 80 and 200 million people). These estimates are obtained through a series of theoretical (social security coverage) and practical indicators that encompass structural indicators (poverty, ethnicity, and geographical barriers) as well as process indicators (non-institutional births, compliance with vaccination schedules, and access to basic sanitation). Exclusion levels in a society are affected by the degree of segmentation of the health system. Traditionally, most countries of the Region have had a public, a social security and a private subsystem in health. Lack of attention to the problem has resulted in the formation of a community-based subsystem. The coexistence of many subsystems, along with poor regulation on the part of health authorities, has resulted in high levels of exclusion and inefficient resource allocation within the sector. The organization of social dialogue processes focusing on SPH within the context of health sector reform initiatives in each country is recommended. The process, which should be participatory, should include a full diagnosis of the situation (how many are excluded, who are they, and why, and what mechanisms are the most appropriate for tackling the issue in each country). It should also provide a political and technical feasibility analysis of the most suitable options for each society, and a determination of whether or not conventional subsystems have exhausted their potential. The process should culminate in a program for implementing the specific proposals made in each society, in an effort to maximize SPH (AU)

Las funciones esenciales de la salud publica: un tema emergente en las reformas del sector de la salud / The essential functions of public health: an emerging theme in health sector reforms

In the Americas, health sector reforms are facing the challenge of strengthening the steering and leadership role of health authorities. An important part of that role consists of fulfilling the essential public health functions (EPHFs) that are incumbent on all levels of government. For that, it's crucial to improve public health practice, as well as the instruments used to assess the current state of public health practice and the areas where it needs to be strengthened. For that purpose, the Pan American Health Organization has started an initiative called "Public Health in the Americas", with the objective of defining and measuring EPHFs, as a way of improving public health practice and strengthening the leadership provided by health authorities at all levels of government. This article summarizes conceptual and methodological aspects of defining and measuring EPHFs. The article also analyzes the implications that measuring performance on these public health roles, responsibilities, and activities would have for improving public health practice in the Americas (AU)

Iniciativa regional de reforma del sector de la salud en America Latina y el Caribe / The Latin America and Caribbean regional health sector reform initiative

Many countries throughout Latin America and the Caribbean are introducing reforms that can profoundly influence how health services are provided and who receives them. Governments in the region identified the need for a network to support health reform by building capacity in analysis and training, both at the Summit of the Americas in 1994 and the Special Meeting on Health Sector Reform, which was convened in 1995 by an interagency committee of the Pan American Health Organization/World Health Organization, the Inter-American Development Bank, the World Bank, and other multilateral and bilateral agencies. In response, in 1997 the Pan American Health Organization and the United States Agency for the International Development launched the Latin America and Caribbean Regional Health Sector Reform Initiative. The Initiative has approximately US$ 10 million in funding through the year 2002 to support activities in Bolivia, Brazil, the Dominican Republic, Ecuador, El Salvador, Guatemala, Haiti, Honduras, Jamaica, Mexico, Nicaragua, Paraguay, and Peru. Now in its third year of implementation, the Initiative supports regional activities seeking to promote more equitable and effective delivery of basic health services (AU)

Iniciativa regional de reforma del sector de la salud en America Latina y el Caribe / Regional initiative on health care reform in Latin America and the Caribbean

Many countries throughout Latin America and the Caribbean are introducing reforms that can profoundly influence how health services are provided and who receives them. Governments in the region identified the need for a network to support health reform by building capacity in analysis and training, both at the summit of the Americas in 1994 and at the Special Meeting on Health Sector Reform, which was convened in 1995 by an interagency committee of the Pan American Health Organization/World Health Organization, the Inter-American Development Bank, the World Bank, and other multilateral agencies. In response, in 1997, the Pan American Health Organization and the United States Agency for the International development launched the Latin America and Caribbean Health Sector Reform Initiative. The Initiative has approximately US$ 10 million in funding through the year 2002 to support activities in Bolivia, Brazil, the Dominican Republic, Ecuador, El Salvador, Guatemala, Haiti, Honduras, Jamaica, Mexico, Nicaragua, Paraquay, and Peru. Now in its third year of implementation, the Initiative supports regional activities seeking to promote more equitable and effective delivery of basic health services. (AU)

Equity, gender and health policy reform in Latin America and the Caribbean

The recent impetus given to the reform of health and social security policies throughout the Region has given rise to an intense debate on the impact of these policies on equity in health and human development. Up to now, this debate has focused on concerns with respect to geographic location and social stratum, without considering gender. The absence of this concern has resulted in a lack of policies to correct the gender inequities created or exacerbated by health and social security reform that cannot be addressed with the same measures employed to reduce the gaps between socioeconomic strata and geographic regions. This study has two objectives. The first is to call attention to the most significant implications of health and social security reform for gender equity, with specific regard to: (a) the health situation and its determinants; (b) access to, use, and financing of health care; and (c) the contribution/reward ratio for health-related work. The second objective is to propose a series of strategies with the stakeholder participation to identify problems, mobilize resources and institutionalize responses. The study has been divided into four parts. The first discusses the institutional history and mandates of the Pan American Health Organisation that underlie the plan to incorporate the gender perspective into the reform processes. The second briefly outlines the conceptual framework of the proposal. The third indicates some of the most serious implications for gender equity of the most common sectoral reform policies in the Region of the Americas. Finally, the fourth lays out the prinicpal challenges posed by incorporating the gender equity perspective into sectoral reform policies and proposes a pluralistic strategy to document, prevent, and help to elimate gender inequities in health and social security reform (AU)

Annual comprehensive health report year 2000

The report is an effort by the Ministry of Health to document the progress of the health situation and the performance of the health care system in Belize up to the year 1999. The data shows for the past four years Belize is experiencing a transition from communicable to non-communicable diseases. For the third consecutive year, Road Traffic Accidents ranked number one among the ten leading causes of mortality, followed by hypertension, Cerebrovascular Accidents and Diabetes. In 1999, NCD 's contributed to 77.8% of all deaths in the country. The report focuses on general Morbidity and Mortality figures; the response of the Health Systems; National Health Information and Surveillance System; Health Sector Reform; the response to Hurricane Keith; National Achievement of the Ministry of Health; and District Health services. With regards to the communicable diseases and vector control, data is also provided on the programs aimed at reducing malaria and dengue; the duties and activities of the vector control personnel; and the general objectives of the Vector Control program.