Aseguramiento y cobertura: dos temas criticos en las reformas del sector de la salud / Health insurance and health coverage: two critical issues within the context of health sector reform

The goal of health for all in the year 2000, which was established at Alma Ata more than two decades ago, has led countries in Latin America and the Caribbean to adopt health sector reforms aimed at extending health coverage to each and every individual citizen. Whereas much has come about as a result of reform policies in the way of theory and legislation, in practice the goals that were established are far from attained, and many countries show large gaps in theoretical coverage on the one hand, and true coverage on the other. This is largely due to organizational features and other "endogenous" characteristics of the various countries' health systems, as well as to "exogenous" factors in the political, macroeconomic, social, epidemiologic, and cultural spheres. This document takes a closer look at the different types of health systems that are currently operating in countries of the Region and their impact on sources of health insurance and health coverage for individuals living in those countries. The end of the article focuses on the different strategies adopted by the countries in an effort to extend health coverage, which in some cases involve policies targeting the most vulnerable social groups (AU)

A coding system for diagnosis and management of medical problems - for the purpose of completing group health insurance claim forms

Since 1994, group health insurers in Trinidad and Tobago have been requesting more specific details diagnosis and other services rendered to patients on Health Claim Insurance Forms. The argument put forward by group health insurers is that "Health plans provide coverage on a "per ailment" basis with specified limits applicable to each ailment. It is therefore necessary to know what ailment is being treated to ensure that plan limits are not exceeded". This presented the problem of medical information passing from the doctor to the patient's place of work and then to the insurance company without confidential cover. In cases where the doctor limits the information to protect doctor/patient confidentially, the forms are often returned creating additional work and delay in reimbursement of claims. This is generally frustrating to all parties concerned. In 1984 a coding system was designed for 3 columns on existing forms - diagnosis, type of visit and services rendered - the aim being to provide, through the use of simple codes, specific information while preserving confidentially. Codes number only from 1 to 21 (major systems) with sub-code between the major systems makes it very simple to use. The coding system was accepted by group health carriers in Trinidad and Tobago in 1984 and has been computerized and used for both external and internal business. Doctors (mainly general practitioners and obstetrician-gynaecologists) have been coding with ease, and patients now submit health claim forms without reservations(AU)

Improving financial management of health care in the Caribbean: conceptual and empirical issues

Structural adjustment is reducing the traditional dominant role of the state in the financing and provision of health care. Issues of equity, allocative efficiency, sustainability and clinical freedom are brought into question. This paper examines two models of escalating health costs and discusses the possibilities and limitations of cost sharing mainly health insurance), cost recovery (user fees) and cost containment (privatisation and decentalisation) measures in the health sector. It also explores additional measures to improve financial management in the health sector -- this must be seen as a moral oblication by all rather than a managerial imperative by a few (AU)

Comparative health care financing in St. Lucia, Grenada and Dominica

Presents the findings of a study of health care financing in the English-speaking Caribbean. The initial objective of the study was to explore whether increased support for maternal and child health might be provided through an expansion of social insurance coverage to include health benefits for workers and their dependents and also to find out how countries can adapt the organization, financing and delivery of health services so as to continue to provide primary health care equitably and efficiently, while at the same time providing essential secondary and tertiary level services. Details of the comparative study of the health systems in the three countries in terms of the adequacy of the health care provided at different levels and the real resources with which it is provided. Findings show that the level of health care spending both from public and private sources vary considerably among the islands. Includes statistical data on expenditure on health as well as the findings of a survey of consumers' view on the organization and quality of health care in the islands

The prevalence of health insurance in a Jamaica suburb and its correlations with service utilisation

The prevalence of health insurance in a low-income Jamaican community was determined from a systematic sample of 103 households. A household prevalence for health insurance of 32 per cent was found. Differentials in health service utilisation were more striking for private practitioner services where the highest correlation with coverage was found (r=0.346,p<0.001). A negative correlation with local health centre utilisation was obtained. The level of health insurance coverage in the community and its impact on service utilisation would suggest the possibility of harsh economies in health sector, forcing consumers in low-income groups to seek a buffer for the expenses incurred from needs unmet by the the public services. Part of this favourable prevalence of health insurance may also be due to job-related coverage (AU)

A community demand analysis of health services in suburban Jamaica: focus on Hermitage - August Town

A demand analysis of health services for the Hermitage - August Town community was done in the month of November 1986. This cross-sectional study focussed on the economic variables involved in service utilisation principally household income and health insurance. The Community Health Centre at the Department of Social and Preventive Medicine, University of the West Indies accounted for 51.2 percent of overall demand with University services accounting overall for over 75 percent . The public-to-private demand ratio was 6:1, with health insurance featuring as a major enabling factor towards the use of private services. There is a striking higher rise in the cumulative demand in the very low income group, (household income per capita less than $166.54) compared to the 'higher' income group. This means that the income elasticity of demand for all types of health services decreases as household income rises. The need for development of health services research especially in relation to the economic aspects of health care in Jamaica and for outreach activities aimed at very low income groups is stressed (AU)

Blue Cross in the health care system of Jamaica

Briefly reviews the historical development of the Blue Cross from it initial philosophy of service to one indemnity and experience rating. Comments on the pilot programme operated in St. Catherine, aimed at merging the specialised knowledge and services of hospitals and clinics with private medical practitioners and the nursing homes. States that the objective of Blue Cross is to provide all segments of the population with a voluntary non profit mechanism for obtaining an adequate level of health service effectively and economically. Discusses the new trust of presenting a health care system based on geographical grouping to encourage subscribers to go to participating doctors in specified areas based on working together in groups. Comments on policy proposals with respect to maintenance of positive health delivery system, cost and quality and financing of health care system. Concluded that if reasonable quality and cost health care is to be made available as a right, the social, medical and operational services must be brought into play. Blue Cross with governments help will assist (AU)

Uitgangspunten voor een nieuw beleid gezondheidszorg Suriname met betrekking tot een Algemene Ziektekostenverzekering / Starting points for a new health care policy in Suriname concerning a general health costs insurance

Health is a primary necessity of life, as well as a basic human right. The relationship between patient and doctor should be without hindrance. Health care has to be available for everyone, but the health costs are priceless. A national health insurance could provide in this by way of statutory regulations. For that purpose the costs of medical assistance for all citizens and their joint income should be determined. Then the mutual proportion has to be expressed in percentages. Hence the premium for each income earner is determined. However, medical costs increase faster than the average income. That is why it should also be operated by medical-ethical, financial and organisational standards