Primary health care as a tool to promote equity and sustainability; a review of Latin American and Caribbean literature.

Primary health care (PHC) has increased in global relevance as it has been demonstrated to be a useful strategy to promote community access to health services. Multilateral organizations and national governments have reached a consensus regarding the basic principles of PHC, but the application of these varies from country to country due to the particularities of local health systems.This article aims to review and summarize PHC strategies and the configuration of health networks in Latin American and Caribbean countries.The review was carried out using keywords in at least 9 databases. Papers in languages other than English, Portuguese, and Spanish were excluded, while non-refereed articles and regional gray literature were incorporated. As a result, 1,146 papers were identified. After three instances of analysis, 142 articles were selected for this investigation. Data were analyzed according to an analysis by theme.The evidence collected on health reforms in the region reflects the need to intensify care strategies supported by PHC and care networks. These must be resilient to changes in the population's needs and must be able to adapt to contexts of epidemiological accumulation.

Reducing the equity gap in child health care and health system reforms in Latin America.

BACKGROUND: During the first decade of the current century, Latin American countries have shown high and consistent economic growth rates, increasing per capita GDP and reducing poverty. Social indicators improved in even the poorest and least equitable countries in the region. In terms of health care results, marked advances were made in infant mortality rates. OBJECTIVE: The aim of this paper is to identify if decreasing poverty rates in Latin America and the Caribbean during the first decade of the century have had an effect on health inequality, specifically by reducing the health care equity gap and, if so, whether that trend and its effects were distributed evenly at the sub-national level. METHODS: Basic statistical tools were applied to national and sub-national administrative data for eleven Latin American countries (Argentina, Belize, Bolivia, Brazil, Colombia, Dominican Republic, El Salvador, Mexico, Nicaragua, Peru, and Uruguay) to compare the evolution of a set of social determinants with a classic health care outcome, such infant mortality) during the period 1995-2012. This document proposes a set of indicators to analyze relative evolution of results and convergence to equity, and to discuss general trends in health care reforms across the region. RESULTS: The document shows a correspondence between poverty reduction, and improvement of health care indicators at a regional level, though national differences persist. In some cases, like Brazil and Peru, the reduction in infant mortality rates is coupled with significant movements towards health equity. This trend is different in Bolivia, where the drop in poverty is not followed by better outcomes in poor departments. At the same, results are not necessarily linked to health systems organization and/or specific reforms. For instance, both Brazil and Peru pursue in applying decentralized solutions, although the incentive mechanisms are quite different: the former has a supply side structure at the public provision level while the latter has implemented mixed payment systems. CONCLUSION: While some of the same instruments and measures of effectiveness in health care reforms appear across the region, specific impact evaluations should be performed. To reduce the equity gap in Latin America requires not only major improvements in social determinants but also the design and implementation of sound institutional policy and more robust regulatory frameworks (institutional determinants) so that more resources yield better practices.

América Latina y el Caribe. Equidad y calidad frente al desafío de la segmentación

Por primera vez en la historia reciente somos testigos de cómo los sistemas de salud ocupan un lugar central en la agenda política. Ello ocurre bajo las peores circunstancias: una epidemia global que golpea a todos los países, sobre la cual, en un principio, no había información suficiente sobre cómo combatirla efectivamente. Intentando identificar aprendizajes y oportunidades de la adversidad, propongo esbozar algunos elementos que contribuyan al debate sobre cómo fortalecer la capacidad de respuesta de los esquemas de cobertura en salud de América Latina y el Caribe ante estos fenómenos que ponen a prueba la capacidad de las redes de atención sanitaria y desnudan las limitaciones de los mecanismos de protección financiera. La segmentación sistémica solo permite una respuesta equitativa y de calidad para la pandemia, si la coordinación entre las partes involucra todas las dimensiones del modelo organizacional, particularmente vigilancia epidemiológica, funcionamiento en red y gestión de la información.

For the first time in recent history, we are witnessing health systems taking center stage on the political agenda. This is happening under the worst circumstances: a global epidemic that is hitting all countries, about which, at the beginning, there was not enough information on how to fight it effectively. To identify lessons learned and opportunities from adversity, I propose to outline some elements to contribute to the debate on how to strengthen the response capacity of health coverage schemes in Latin America and the Caribbean to these phenomena that test the capacity of health care networks and expose the limitations of financial protection mechanisms. Systemic segmentation only allows an equitable and quality response to the pandemic if the coordination between the parties involves all the dimensions of the organizational model, particularly epidemiological surveillance, networking and information management.

Understanding inequities in health and health systems in Latin America and the Caribbean: a thematic series.

Latin America, with its culturally and ethnically diverse populations, its burgeoning economies, high levels of violence, growing political instability, and its striking levels of inequality, is a region that is difficult to define and to understand. The region's health systems are deeply fragmented and segmented, which poses great challenges related to the provision of quality of care and overall equity levels in health and in Latin American society at large. Market, social, and political forces continue to push towards the poorly regulated privatization of public health care in many countries within the region, in detriment of public healthcare services where management capacities are limited.In this first collection of papers, we showcase how the region has tackled, with different levels of success, the incorporation of innovative health system reforms aimed at strengthening governance, participation, and the response to the growing epidemiological and demographic demands of its diverse population. We are delighted that this Special Collection will remain open to house future papers from Latin America and the Caribbean. The region has important experiences and lessons to share with the world. We look forward to learning more about how researchers and practitioners continue to experiment and innovate in their struggle to reach equity in health for all. This thematic series is a platform where the region's lessons and approaches can be shared with the global community of Health Policy and Systems Researchers.

Understanding the implications of the Sustainable Development Goals for health policy and systems research: results of a research priority setting exercise.

BACKGROUND: Given the paradigmatic shift represented by the Sustainable Development Goals (SDGs) as compared to the Millennium Development Goals - in particular their broad and interconnected nature - a new set of health policy and systems research (HPSR) priorities are needed to inform strategies to address these interconnected goals. OBJECTIVES: To identify high priority HPSR questions linked to the achievement of the Sustainable Development Goals. METHODS: We focused on three themes that we considered to be central to achieving the health related SDGs: (i) Protecting and promoting access to health services through systems of social protection (ii) Strengthening multisectoral collaborations for health and (iii) Developing more participatory and accountable institutions. We conducted 54 semi-structured interviews and two focus group discussions to investigate policy-maker perspectives on evidence needs. We also conducted an overview of literature reviews in each theme. Information from these sub-studies was extracted into a matrix of possible research questions and developed into three domain-specific lists of 30-36 potential priority questions. Topic experts from the global research community then refined and ranked the proposed questions through an online platform. A final webinar on each theme sought feedback on findings. RESULTS: Policy-makers continue to demand HPSR for many well-established issues such as health financing, human resources for health, and service delivery. In terms of service delivery, policy-makers wanted to know how best to strengthen primary health care and community-based systems. In the themes of social protection and multisectoral collaboration, prioritized questions had a strong emphasis on issues of practical implementation. For participatory and accountable institutions, the two priority questions focused on political factors affecting the adoption of accountability measures, as well as health worker reactions to such measures. CONCLUSIONS: To achieve the SDGs, there is a continuing need for research in some already well established areas of HPSR as well as key areas highlighted by decision-makers. Identifying appropriate conceptual frameworks as well as typologies of examples may be a prerequisite for answering some of the substantive policymaker questions. In addition, implementation research engaging non-traditional stakeholders outside of the health sector will be critical.

[Cost-effectiveness of screening for colorectal cancer in Argentina.] / Costo-efectivided de las pruebas de tamizaje del cáncer colorectal en la Argentina.

International evidence show that screening for colorectal cancer is cost-effective; however, in Argentina is unknown. OBJECTIVE: The study shows the results of a cost-effectiveness evaluation based on two alternative mechanisms: annual faecal immunochemical testing (FIT), and colonoscopy every ten years in Argentina. METHODS: The study develops a Mar- kov model in ten stages, based on information provided by the INC, prior literature review and on-line questionnaires to physicians enrolled in the four major scientific societies related to cancer. Cost information arrived from the Na- tional Superintendence of Social Health Insurances and a sample of managers in social and private insurance schemes. RESULTS: The most cost-effective strategy consisted annual FIT, in comparison no intervention and colonoscopy every 10 years. The incremental cost effectiveness ratio (ICER) of FIT versus no intervention was of 980.5 pesos per QALY The findings were robust to deterministic sensitivity analysis. CONCLUSIONS: We confirmed that screening for CRC is a cost-effective intervention. Whereas the CCR is one of the leading causes of mortality in Argentina, these results support the widespread use of screening for CRC using anual FIT which proves to be highly cost effective for the country.

Assessing Latin America's Progress Toward Achieving Universal Health Coverage.

Two commonly used metrics for assessing progress toward universal health coverage involve assessing citizens' rights to health care and counting the number of people who are in a financial protection scheme that safeguards them from high health care payments. On these metrics most countries in Latin America have already "reached" universal health coverage. Neither metric indicates, however, whether a country has achieved universal health coverage in the now commonly accepted sense of the term: that everyone--irrespective of their ability to pay--gets the health services they need without suffering undue financial hardship. We operationalized a framework proposed by the World Bank and the World Health Organization to monitor progress under this definition and then constructed an overall index of universal health coverage achievement. We applied the approach using data from 112 household surveys from 1990 to 2013 for all twenty Latin American countries. No country has achieved a perfect universal health coverage score, but some countries (including those with more integrated health systems) fare better than others. All countries except one improved in overall universal health coverage over the time period analyzed.

The drivers of facility-based immunization performance and costs. An application to Moldova.

OBJECTIVE: This paper identifies factors that affect the cost and performance of the routine immunization program in Moldova through an analysis of facility-based data collected as part of a multi-country costing and financing study of routine immunization (EPIC). METHODS: A nationally representative sample of health care facilities (50) was selected through multi-stage, stratified random sampling. Data on inputs, unit prices and facility outputs were collected during October 3rd 2012-January 14th 2013 using a pre-tested structured questionnaire. Ordinary least square (OLS) regression analysis was performed to determine factors affecting facility outputs (number of doses administered and fully immunized children) and explaining variation in total facility costs. RESULTS: The study found that the number of working hours, vaccine wastage rates, and whether or not a doctor worked at a facility (among other factors) were positively and significantly associated with output levels. In addition, the level of output, price of inputs and share of the population with university education were significantly associated with higher facility costs. A 1% increase in fully immunized child would increase total cost by 0.7%. CONCLUSIONS: Few costing studies of primary health care services in developing countries evaluate the drivers of performance and cost. This exercise attempted to fill this knowledge gap and helped to identify organizational and managerial factors at a primary care district and national level that could be addressed by improved program management aimed at improved performance.

Necesidades y acceso a los servicios de salud de la población adolescente en el norte argentino / Adolescents in northern Argentina: needs and cccess to health services

INTRODUCCION: Los/as adolescentes tienen bajos indicadores de morbimortalidad. Sin embargo, presentan problemáticas particulares que pueden condicionar su desarrollo saludable y que deben ser analizadas, ya que se trata de una población prioritaria desde la prevención sanitaria y con larga expectativa de vida.OBJETIVOS: Conocer la situación de salud/enfermedad de los/asadolescentes en el norte argentino. Identificar sus necesidades realesy percibidas, así como las barreras de acceso a los servicios de salud,particularmente en materia de salud sexual, adicciones, alimentacióny suicidio. METODOS: El estudio incluyó los siguientes pasos: 1) revisiónde bibliografía y normativa sobre salud adolescente; 2) mapeo de actores y entrevistas a referentes locales; 3) aplicación de una encuesta autoadministrada a adolescentes de escuelas públicas en seis provincias argentinas; 4) análisis cuanticualitativo de las encuestas y entrevistas. RESULTADOS: Aunque la percepción y las dolencias correspondieron a perfiles de baja necesidad, del total de adolescentes que consignaron problemas de salud, sólo la mitad consultó al sistema, y la mayoría dijo que prefería recurrir a su entorno cercano (padres, amigos). Las preocupaciones adolescentes no estuvieron vinculadas necesariamente con el estado de salud, sino con planteosy problemas emergentes de su edad. Más allá de las barreras geográficas,se observaron limitaciones institucionales y familiares querestringen el vínculo entre el sistema de salud y los/as adolescentes.CONCLUSIONES: Los resultados muestran espacios vacantes departicipación (del sistema y del entorno familiar, comunitario y escolar) para que los requerimientos de información y atención de los/as adolescentes se traduzcan en demandas y en un mejor acceso.

INTRODUCTION: Adolescents have low mortality and morbidity rates. However, there are certain problemsconditioning a healthy development which should be analyzed as a priority, from a prevention perspective, for this population with long life expectancy. OBJECTIVES: To know the health/disease status of adolescents in Northern Argentina. To identify real andperceived needs as well as barriers in access to health services, focusing on sexual health, addictions, nutrition and suicide. METHODS: The study included following steps: 1) literature review and survey of current legislation on adolescent health; 2) mapping of actors and interviews with local key informants; 3) self-administered survey to adolescents of public schools in six Argentine provinces; 4) qualitative and quantitative analysis of surveys and interviews. RESULTS: Although perceptions and complaints belonged to low-need profiles, only half of theadolescents reporting health problems used the health system to get information, and most of them said they preferred to talk with parents and friends. Adolescent concerns were notnecessarily related to health status, but to issues of their age group. Apart from geographical barriers, family and institutional reasons were found to limit the relationship between healthsystem and adolescents. CONCLUSIONS: Results show spacesfor participation which should be occupied by the health care system and family, community and school environment, so that information and attention requirements can be reflectedin demands and a better access.

Sociedad Internacional para la Equidad en Salud: [editoriales] / International Society for Equity in Health: [editorial]

La equidad es inherente a todo planeamiento, a toda idea y toda acción política, y puede constituirse como principio y objetivo en sí misma, erigiéndose así como un valor social. Por esta razón, resulta imposible pensar un planteamiento actual de la atención de la salud sin que la misma aparezca como tema prioritario. La equidad en salud es un valor ético, inherentemente normativo, que está basado en el principio de justicia distributiva y en consonancia con los principios de derechos humanos. No obstante, es necesario desterrar la ilusión de que el problema de la equidad en salud puede ser resuelto en el discurso de la ética universal (1)...

Household catastrophic health expenditures: a comparative analysis of twelve Latin American and Caribbean Countries / Gastos catastróficos en salud de los hogares: un análisis comparativo de doce países en América Latina y el Caribe

OBJETIVO: Comparar los patrones de gastos catastróficos en salud en 12 países de América Latina y el Caribe. MATERIAL Y MÉTODOS: Se estimó la prevalencia de gastos catastróficos de manera uniforme para doce países usando encuestas de hogares. Se emplearon dos tipos de indicadores para medir la prevalencia basados en el gasto de bolsillo en salud: a) en relación con una línea de pobreza internacional; y b) en relación con la capacidad de pago del hogar en términos de su propia canasta alimentaria. Se estimaron razones para comparar el nivel de gastos catastróficos entre subgrupos poblacionales definidos por variables económicas y sociales. RESULTADOS: El porcentaje de hogares con gastos catastróficos variaron de 1 a 25 por ciento en los 12 países. En general, la residencia rural, el bajo nivel de ingresos, la presencia de adultos mayores, y la carencia de aseguramiento en salud de los hogares se asocian con mayor propensión a sufrir gastos catastróficos en salud. Sin embargo, existe una marcada heterogeneidad por país. CONCLUSIONES: Los estudios comparativos entre países pueden servir para examinar cómo los sistemas de salud contribuyen a la protección social de los hogares en América Latina.

OBJECTIVE: Compare patterns of catastrophic health expenditures in 12 countries in Latin America and the Caribbean. MATERIAL AND METHODS: Prevalence of catastrophic expenses was estimated uniformly at the household level using household surveys. Two types of prevalence indicators were used based on out-of-pocket health expense: a) relative to an international poverty line, and b) relative to the household's ability to pay net of their food basket. Ratios of catastrophic expenditures were estimated across subgroups defined by economic and social variables. RESULTS: The percent of households with catastrophic health expenditures ranged from 1 to 25 percent in the twelve countries. In general, rural residence, lowest quintile of income, presence of older adults, and lack of health insurance in the household are associated with higher propensity of catastrophic health expenditures. However, there is vast heterogeneity by country. CONCLUSIONS: Cross national studies may serve to examine how health systems contribute to the social protection of Latin American households.

Mapa de actores del sector oncológico en la Argentina / Oncology actors’ map in Argentina

El estudio identifica y caracteriza el mapa de actores del sector oncológico en la Argentina y sus interacciones. Utilizandometodologías cualitativas de investigación (análisis de fuentessecundarias y entrevistas en profundidad a representantesdel Ministerio de Salud y las principales organizaciones de lasociedad civil (OSCs), referentes del sector). Los resultados muestran que la estructura del sistemade salud argentino no proporciona estímulos eficaces a los actores, obstaculizando la implementación de intervenciones relevantes para el control del cáncer. Las obras socialesno cuentan con incentivos para desarrollar actividades deprevención y detección temprana. Por su parte el PAMI (elseguro de la vejez), encuentra limitada su posibilidad dedesarrollar estas acciones, al no tener jurisdicción sobre sufutura población objetivo. Finalmente, el subsector públicoabsorbe los costos de la fragmentación, en un contextodescentralizado con fallas de coordinación y brechas definanciamiento entre provincias.Frente a este panorama, el Programa Nacional de Control de Cáncer pareciera ser una respuesta adecuada. Sin embargo la práctica evidencia retrasos y desafíos deimplementación. Las OSCs buscan incrementar sus alcances y cobranrelevancia en áreas de docencia, campañas y tratamientos, aunque con poca comunicación y articulación con el Estado, y entre ellas. Ante un escenario de creciente incidencia de enfermedades oncológicas, la coordinaciónnación/provincias y público/privado son imprescindibles para alcanzar mayor equidad asignativa y eficiencia en el gerenciamiento.

The study identifies and characterizes oncology actors’ map in Argentina and its interactions using qualitative research techniques (secondary source analysis and in-depth interviews with representatives from the Department of Health and the main civil society organizations (CSOs), benchmarks of the sector). Results show that the Argentine Healthcare system structure does not provide actors with effective incentives, thus hindering the implementation of relevant interventions for cancer control. Health insurers do not have incentives to develop prevention and early detection activities. Besides, PAMI (health insurance for retired people) has no jurisdictionregarding its future target population and therefore, possibilities to develop such activities are limited. Finally, the public subsector takes in fragmentation costs in a decentralized context with coordination defects and financing gaps between provinces. Confronting this panorama, the National Program for Cancer Control seems to be anadequate answer. However, the program put into practice is showing implementation delays and hallenges. CSOs try to increase their scope and become relevant in teaching, campaigns andtreatments, nevertheless with little communication and articulation with the State and among themselves.Facing a scenario of growing incidence of oncologic diseases, nation-provinces and public-private.

[Public financing of health research in five Latin American countries]. / Financiamiento público de la investigación en salud en cinco países de América Latina.

OBJECTIVES: Describe the public subsystems of the national health research systems (SNIS) in five Latin American countries (Argentina, Bolivia, Chile, Paraguay, and Uruguay), emphasizing the types of institutional arrangements in place in each country to promote, develop, and sustain their SNIS, as well as explicit or implicit mechanisms for prioritizing health research projects. METHODS: The bodies responsible for managing the public resources allocated to finance health research projects in the five countries studied were identified. The types of projects financed were then analyzed-using a matrix constructed by area and object of study-, certain characteristics of the principal investigators, and the sums allocated between 2002 and 2006. RESULTS: Only the countries with greater resources or better developed networks of investigators have formal structures for allocating funds with regular calls for proposals and fixed rules. None of them has explicit comprehensive mechanisms for prioritizing health research. Moreover, the health research priorities in the countries vary widely. In this regard, it is significant that problems such as "nutrition and the environment" or "violence and accidents" receive little attention in most countries. The same holds true for a number of public health issues in some countries. In contrast, the research in the "hard sciences" absorbs up to one-third of the total resources for research. CONCLUSIONS: Many questions arise about the ability of these countries to adapt and generate new knowledge, as well as the nearly nonexistent research on social, economic, and cultural determinants, or on health services and systems that have a high impact on groups with limited access to health care. Explicit priorities should be set with stakeholders for the health research agenda, and mechanisms should be adopted for monitoring and following up health research financing by subject and area of study.

Financiamiento público de la investigación en salud en cinco países de América Latina / Public financing of health research in five Latin American countries

OBJETIVOS: Describir los subsistemas públicos de los Sistemas Nacionales de Investigación en Salud (SNIS) en cinco países de América Latina (Argentina, Bolivia, Chile, Paraguay y Uruguay), con énfasis en los tipos de arreglos institucionales que se observan en cada país para promover, desarrollar y sostener sus SNIS, así como en los mecanismos explícitos o implícitos de priorización de proyectos de investigación en salud. MÉTODOS: Se identificó a los organismos responsables de manejar los recursos públicos destinados a financiar proyectos de investigación en salud en los cinco países estudiados. Luego se analizaron los tipos de proyectos que fueron financiados -utilizando una matriz por área y objeto de estudio-, ciertas características de los investigadores principales y los montos asignados entre 2002 y 2006. RESULTADOS: Solamente los países con mayores recursos o con redes de investigadores más desarrolladas poseen estructuras formales de asignación de fondos, con convocatorias periódicas y reglas estables, y ninguno cuenta con mecanismos explícitos e integrales de priorización para la investigación en salud. A su vez, las prioridades de investigación en salud presentan diferencias importantes entre países. En este sentido, es notorio que ciertos problemas, como "nutrición y medio ambiente" o "violencia y accidentes", reciban escasa atención en la mayoría de los países, al igual que varios temas de salud pública en algunos otros. Contrariamente, la investigación referida a "ciencias básicas" absorbe hasta un tercio de los recursos totales para investigación. CONCLUSIONES: Surgen numerosos interrogantes acerca de la capacidad de estos países para adaptar y generar nuevos conocimientos, y de la casi inexistente investigación sobre condicionantes sociales, económicos y culturales o sobre servicios y sistemas de salud, de alto impacto en grupos con acceso limitado al cuidado de la salud. Es necesario establecer explícitamente las prioridades en la agenda de investigación en salud, en consenso con las partes interesadas, así como incorporar mecanismos de monitoreo y seguimiento por temas y áreas de estudio del financiamiento de la investigación en este campo.

OBJECTIVES: Describe the public subsystems of the national health research systems (SNIS) in five Latin American countries (Argentina, Bolivia, Chile, Paraguay, and Uruguay), emphasizing the types of institutional arrangements in place in each country to promote, develop, and sustain their SNIS, as well as explicit or implicit mechanisms for prioritizing health research projects. METHODS: The bodies responsible for managing the public resources allocated to finance health research projects in the five countries studied were identified. The types of projects financed were then analyzed-using a matrix constructed by area and object of study-, certain characteristics of the principal investigators, and the sums allocated between 2002 and 2006. RESULTS: Only the countries with greater resources or better developed networks of investigators have formal structures for allocating funds with regular calls for proposals and fixed rules. None of them has explicit comprehensive mechanisms for prioritizing health research. Moreover, the health research priorities in the countries vary widely. In this regard, it is significant that problems such as "nutrition and the environment" or "violence and accidents" receive little attention in most countries. The same holds true for a number of public health issues in some countries. In contrast, the research in the "hard sciences" absorbs up to one-third of the total resources for research. CONCLUSIONS: Many questions arise about the ability of these countries to adapt and generate new knowledge, as well as the nearly nonexistent research on social, economic, and cultural determinants, or on health services and systems that have a high impact on groups with limited access to health care. Explicit priorities should be set with stakeholders for the health research agenda, and mechanisms should be adopted for monitoring and following up health research financing by subject and area of study.

Sistemas de salud locales: Análisis de la relación entre aseguramiento y mecanismos de contratación y pago en Córdoba, Salta y Tucumán / Local health systems: analysis of the relationship between insurance and contract and payment mechanisms in Cordoba, Salta and Tucuman

INTRODUCCIÓN: Los mecanismos de contratación y pago en salud generan un impacto diverso en la cantidad y calidad de los servicios médicos, en la transferencia de riesgo entre actores y en la eficiencia de la utilización de los recursos. OBJETIVO: Analizar la estructura del mercado de servicios de salud en las provincias de Córdoba, Salta y Tucumán durante los últimos cinco años. MÉTODO: Se consideraron las condiciones socio-económico-sanitarias locales, el marco institucional, la historia de los actores más relevantes del sector y las conductas adquiridas como respuesta a la estructura. La metodología incluyó un mapeo de los actores claves del sector salud cada provincia así como la administración de un cuestionario a una muestra de establecimientos públicos y privados de cada jurisdicción. RESULTADOS: Los ministerios de salud provinciales son los principales financiadores del sistema público de salud y el Instituto Nacional de Servicios Sociales para Jubilados y Pensionados (PAMI) y las obras sociales provinciales lo son del sistema privado. CONCLUSIONES: PAMI tiene una política nacional que lo torna menos flexible para contemplar las particularidades locales, mientras que las obras sociales provinciales se presentan como los actores idiosincrásicos, siendo más permeables a las demandas locales. En la medida en que el PAMI coordine con los ministerios y la obra social provincial, se podría converger a modelos más homogéneos de atención y mecanismos de pago, generando incentivos para una mayor eficiencia en la asignación de recursos y una mayor equidad en salud

INTRODUCTION: The contracting and payment mechanisms in health generate different impact on the quantity and quality of medical services, the transfer of risk among actors and the efficient use of resources. OBJECTIVES: To analyze the market structure of health services in the provinces of Cordoba, Salta and Tucuman during the past five years. We considered the local socioeconomic and health conditions, institutional framework, the history of the most relevant actors, and their behaviour in response to the structure. The methodology included a mapping of key actors in the health sector in each province and the administration of a questionnaire to a sample of local public and private health institutions. RESULTS: The results show that the provincial ministries of health are the primary funders of the public services and the national insurance for retired people (PAMI) and the provincial social insurances are the primary funders of the private system. CONCLUSION: PAMI has a national policy which makes it self less flexible to consider the local particularities,while the provincial social insurances present themselves as idiosyncratic actors, being more receptive to local demands. If PAMI were coordinated with the structure of the local social insurance and the ministries of health, it could beachieved homogeneous models of health care and payment mechanisms, generating incentives for a more efficient resources allocation and equity in health

Iniciativa por los derechos sexuales y reproductivos en las reformas del sector salud. América latina / Initiative for sexual rights and reproductive health sector reforms. Latin America

La Iniciativa por los derechos sexuales y reproductivos en las reformas del sector salud es una iniciativa del Cono Sur liderada por un grupo de defensores de los derechos y la salud sexual y reproductiva de Asia, África y América Latina. El propósito de esta Iniciativa coordinada por el Women.s Health Project, Johannesburgo, Sudáfrica, era reforzar en los activistas y tomadores de decisiones la comprensión del rol que juegan los cambios sociales y económicos globales, y específicamente el rol que juega las reformas del sector salud en facilitar o debilitar los esfuerzos para alcanzar programas y políticas en derechos y salud sexual y reproductiva. Los objetivos específicos de la Iniciativa son . Reforzar la base de conocimiento con respecto al impacto de los cambios macroecon ómicos y de las reformas del sector salud en los derechos y la salud sexual y reproductiva. Iniciativa por los derechos sexuales y reproductivos en las reformas del sector salud 5 . Fortalecer institucionalmente a distintos actores, particularmente las ONGs en el campo de derechos y salud sexual y reproductiva para - Comprender el contexto social y económico que da forma a los derechos y a la salud sexual y reproductiva al igual que a los servicios de salud. - Identificar los factores que facilitan y restringen el desarrollo e implementación de políticas y programas que apoyan los derechos y la salud sexual y reproductiva, e - Identificar ventanas de oportunidad para intervenciones que mejoren los derechos y la salud sexual y reproductiva. . Construir entre los actores de los campos de derechos humanos, salud y desarrollo la comprensión de que los derechos sexuales y reproductivos deben ser incluidos en la agenda de los derechos humanos, la justicia social y la equidad. La primera fase de la Iniciativa de Derechos y Reformas estuvo destinada a reforzar el conocimiento de base con respecto al impacto de la RSS en los derechos y la salud sexual y reproductiva. Los artículos incluidos en e...