Key issues in public health surveillance for the 1990s.

In this paper, we have proposed a wider scope for public health surveillance in order to incorporate demographic and health-system monitoring, along with activities conventionally associated with epidemiologic surveillance. This new conception stems, in turn, from a revised definition of public health, which describes, not a sector of activity or a type of health service, but a level of aggregation based on the population at large. In our review of the ideas that lead to the institutionalization of health surveillance, we have stressed the broad concepts developed by such pioneers as Graunt and Petty. Their original concepts emerged from their active concerns for the public's health at a time when no scientific theory of contagion was available, let alone any knowledge about how to treat persons for the major diseases. Later on, largely as the result of impressive advances in biomedical knowledge, public health surveillance tended to specialize and to concentrate predominantly on disease outbreaks and on salient adverse health conditions. Health surveillance became closely associated with epidemiologic surveillance, which in turn became associated with the ability to respond promptly to adverse health outcomes. Recently, we have witnessed a gradual broadening of both the concepts and the practice of health surveillance. Paradoxically, the new currents tend to recapture some of the spirit and scope of the early definitions, prompted perhaps by grave historical parallels--we face newly emerging health problems for which we have no clear-cut solutions. If one element needs to be stressed to promote the objectives of health surveillance today, it is that we need the ability to anticipate health outcomes and not just respond to them. This, in turn, requires that we give more weight to the surveillance of risk factors and that we increase our understanding of the complex causal interrelationships that link exposure to risk factors--including behavioral, life-style, and environmental ones--with adverse health conditions and disability. Needless to say, the first and foremost aim of health care--and modern surveillance is one of the tools needed to achieve this aim--is to promote the well-being of individuals while improving their health.

First contact, simplified technology, or risk anticipation? Defining primary health care.

PIP: Elements important to defining primary health care (PHC) are discussed, with examples from Latin American countries. Topics are identified as follows: the origins and dilemmas of PHC, conflicting PHC values and practices, organizational changes and PHC, health care reforms and examples from Latin America, and the implications for medical education. The new paradigm for medical education and practice is in the classic Kuhn tradition. A paradigm for health care is an ideological model about the form, content, and organization of health care. There are rules that prescribe in a normative way how resources should be combined to produce health services. The current dominant paradigm is that of curative medicine, and the PHC paradigm assumes that a diversified health care team uses modern technology and resources to actively anticipate health damage and promote well being. The key word is anticipatory. As a consequence secondary care also needs to be redefined as actually treating the illness or damage itself. Organizations must be changed to establish this model. Contrasting primary, anticipatory health care with technical, curative medicine has been discussed over at least the past 150 years. An important development was the new model for developing countries which was a result of a Makerere, Kenya symposium on the Medicine of Poverty. The Western model of physicians acting independently and in a highly specialized fashion to address each patient's complaints was considered inappropriate. The concern must be for training and supervising auxiliaries, designing cost-effective systems, and a practice mode limited to what can actually be provided to the population. How to adapt this to existing medical systems was left undetermined. In 1978 with the WHO drive for health for all, there emerged different conceptions and models of PHC. Conceptually, PHC is realized when services are directed to identifying and modifying risk factors at the collective level, where the health team anticipates and prevents problems through active programming and community participation, and in secondary care, the doctors wait for the ill patient. Level of care and type of contact are subordinate to PHC. 1st contact and 1st level facilities are responsible for PHC, although secondary interventions (prenatal care) are handled. The best technology should be evaluated in terms of the capacity to anticipate severe, irreversible, or fatal damage. Simplified technology is not primitive technology.^ieng

Balancing relevance and excellence: organizational responses to link research with decision making.

Research faces the challenge of balancing relevance to decision making and excellence in the strict adherence to the norms of scientific inquiry. This paper examines the organizational responses that can be undertaken to promote integration of these potentially conflicting goals. We posit that there seem to be structural barriers to effective communication between researchers and decision makers, such as differences in priorities, time management, language, means of communication, integration of findings and definition of the final product of research. These barriers must be overcome through solutions aimed at the organization of research. In this respect, there are three possible models to approach the tension between excellence and relevance: academic subordination, segregation and integration. Only the latter makes it possible to reconcile the advantages of proximity to decision making with the procedures to assure academic quality. In addition to organizational design and institutional development, a strategy to promote research must include a set of incentives to prevent the 'internal brain drain', that is, the tendency of researchers to move to managerial positions. There are four guiding principles to address this problem: parallel careers, academic autonomy, administrative sacrifice and inverted incentives. The complexities of health problems demand that we create new organizational formulas to finally balance relevance and excellence in research.

Career preferences and perceptions of the medical labor market among Mexican interns.

This paper examines the relationship between choice of career and perception of the medical labor market, as well as the effects of social origin, type of medical school, and place of internship. The data are derived from a survey of interns which was conducted in Mexico during 1978, when a substantial proportion of physicians was unemployed or underemployed. Career preferences were operationalized in terms of type of activity (general practice or specialty), site (ambulatory or hospital) and institution (public assistance, social security or private). Perceptions of the medical labor market were measured as an 'objective' feasibility perception and a 'subjective' opportunity assessment. Additionally, composite indices of career preferences and perceptions were constructed in order to take account of two integrated career patterns: dominant (or majority preference) vs alternative (or minority preference). Analysis of the data consistently revealed that perception of the medical labor market had a much stronger impact on preference for alternative than for dominant career patterns. Whereas social origin had no effect on career preference, type of medical school and place of internship exhibited a statistical interaction with career preference, suggesting that certain structural conditions of the medical school and the teaching hospitals led to preference for alternative rather than dominant careers. The implications of the findings are discussed with regard to health manpower policy, to conceptions of rational career choice and to the professional status of medicine in Mexico.

Comprehensive policy analysis for health system reform.

This article presents the results of a comprehensive approach to policy analysis that may serve as an input for health system reform. The comprehensive character of this effort stems from the attempt to combine, in a coherent framework, various analytical tools that have been developed recently, such as measurement of the burden of disease, cost-effectiveness analysis to integrate packages of essential interventions, national health accounts, assessment of system performance, consumer surveys, and political mapping. These tools were all applied in a study that was carried out in Mexico from August 1993 through September 1994. After explaining the logic of the study, the paper summarizes the findings and recommendations under five headings that shape the form of reform: the problems, the principles, the purposes, the proposals, and the protagonists. Rather than describing these various elements in detail, the paper focuses on the strategic aspects, which are most relevant to other countries currently planning or implementing reform initiatives. The article concludes that, under the current wave of international interest in health system reform, it is necessary to establish a mechanism for shared learning at the global level. Only in this way will it be possible to reproduce the analytical skills and accumulate the body of evidence that health systems require for their sustained improvement.

Dimensions of health system reform.

During recent years there has been a growth of worldwide interest in health system reform. Countries at all levels of economic development are engaged in a creative search for better ways of organizing and financing health care, while promoting the goals of equity, effectiveness, and efficiency. Together with economic, political, and ideological reasons, this search has been fueled by the need to find answers to the complexities posed by the epidemiologic transition, whereby many nations are facing the simultaneous burdens of old, unresolved problems and new, emerging challenges. In order to better understand reform attempts, it is necessary to develop a clear conception of the object of reform: the health system. This paper presents the health system as a set of relationships among five major groups of actors: the health care providers, the population, the state as a collective mediator, the organizations that generate resources, and the other sectors that produce services with health effects. The relationships among providers, population, and the state form the basis for a typology of health care modalities. The type and number of modalities present in a country make it possible to characterize its health system. In the last part, the paper proposes that health system reform operates at four policy levels: systemic, which deals with the institutional arrangements for regulation, financing, and delivery of services; programmatic, which specifies the priorities of the system, by defining a universal package of health care interventions; organizational, which is concerned with the actual production of services by focusing on issues of quality assurance and technical efficiency; and instrumental, which generates the institutional intelligence for improving system performance through information, research, technological innovation, and human resource development. The dimensions of reform offer a repertoire of policy options, which need to be enriched by cross-national comparison of experiences and rigorous social experimentation. Maybe then reform will be a more systematic effort, and nations will be better able to learn from each other.

Corporatism and health care: a comparison of Sweden and Mexico.

Up to now, the Swedish health care system has been used as a model for comparisons with other developed nations, chiefly in Northern Europe and the United States. This article departs from the mainstream and poses that similarities along the political factor of corporatism warrant a comparative analysis between the Swedish and Mexican cases. The most widely accepted definitions and typologies of corporatism are reviewed. The arena of manpower policy is used to illustrate the effects of alternative modes of interest representation on health care organization. The final aim of this comparative exercise is to enrich the empirical basis required to build a theory about the complex determinants of health care systems. State corporatism has acted in Mexico largely unchecked by geographical interest representation, in contrast with Sweden where centralist and decentralist forces are more balanced. This finding helps to understand why Sweden and Mexico mark extreme points along the health equity continuum. The comparison underscores the need for Sweden to avoid the risk of weakening the equity basis of its health care system as it moves along its current reform. The importance of these transformations go beyond Sweden, since they will undoubtedly offer new models of thinking and acting for the rest of the world.

Structured pluralism: towards an innovative model for health system reform in Latin America.

Health systems throughout the world are searching for better ways of responding to present and future challenges. Latin America is no exception in this innovative process. Health systems in this region have to face a dual challenge: on the one hand, they must deal with a backlog of accumulated problems characteristic of underdeveloped societies; on the other hand, they are already facing a set of emerging problems characteristic of industrialized countries. This paper aims at analyzing the performance of current health systems in Latin America, while proposing an innovative model to promote equity, quality, and efficiency. We first develop a conceptualization of health systems in terms of the relationships between populations and institutions. In order to meet population needs, health systems must perform four basic functions. Two of these-financing and delivery-are conventional functions performed by every health system. The other two have often been carried out only in an implicit way or not at all. These neglected functions are 'modulation' (a broader concept than regulation, which involves setting transparent and fair rules of the game) and 'articulation' (which makes it possible to organize and manage a series of transactions among members of the population, financing agencies, and providers so that resources can flow into the production and consumption of services). Based on this conceptual framework, the paper offers a classification of current health system models in Latin America. The most frequent one, the segmented model, is criticized because it segregates the different social groups into three segments: the ministry of health, the social security institute(s), and the private sector. Each of these is vertically integrated, so that it performs all functions but only for a particular group. As an alternative, we propose a model of 'structured pluralism', which would turn the current system around by organizing it according to functions rather than social groups. In this model, modulation would become the central mission of the ministry of health, which would move out of the direct provision of personal health services. Financing would be the main function of social security institutes, which would be gradually extended to protect the entire population. The articulation function would be made explicit by fostering the establishment of 'organizations for health services articulation', which would perform a series of crucial activities, including the competitive enrollment of populations into health plans in exchange for a risk-adjusted capitation, the specification of explicit packages of benefits or interventions, the organization of networks of providers so as to structure consumer choices, the design and implementation of incentives to providers through payment mechanisms, and the management of quality of care. Finally, the delivery function would be open to pluralism that would be adapted to differential needs of urban and rural populations. After examining the convergence of various reform initiatives towards elements of the structured pluralism model, the paper reviews both the technical instruments and the political strategies for implementing changes. The worldwide health reform movement needs to sustain a systematic sharing of the unique learning opportunity that each reform experience represents.

The New World order and international health.

PIP: New global and national health challenges require a new response. National health situations are increasingly influenced by the international transfer of health risks posed by environmental threats, overuse of resources, international migration, trade in harmful legal products (tobacco), traffic of illicit drugs, and diffusion of potentially inappropriate and costly medical technologies and treatment policies. This situation calls for reform of national health systems, and a natural extension of such reform is reform of the world health system. The first step toward this goal should be to achieve consensus about the essential core functions of international health organizations their division of labor. Currently international health agencies have overlapping mandates and duplicate efforts, and they have neglected the following essential functions: monitoring emerging diseases, setting consumer health standards, providing international coordination to control the transfer of health risks, coordinating research efforts and technological development, designing information systems to facilitate development of national and global health policies, accumulating knowledge about cost-effectiveness of medical technologies and interventions, and creating a process for sharing information about national health system reform. Reform "essentialists" identify the following core functions for international health organizations: surveillance and control of globally-threatening diseases, promotion of research and technological development, development of standards and norms for international certification, protection of international refugees, and assisting vulnerable populations. Others give international health organizations a more expansive role including redistributing resources from rich to poor countries, political advocacy, direct regulation of transnational corporations, and intervention in national health projects. Consensus must be reached to effect reform.^ieng

International health in transition.

The need for a transition towards a new concept of international health is emphasized and a paradigm for making the transition is proposed. The challenge of building a vigorous intellectual and academic tradition of international health which supports its efforts to generate knowledge and leads to its practical application is recognized and addressed. It is argued that the development of such an intellectual field is based on four elements: conceptual base, production base, reproduction base, and utilization base. The Unit for International Studies in Public Health (UISPH) of Mexico is presented as one example of efforts to consolidate an academic tradition in this field.

Primary care and reform of health systems: a framework for the analysis of Latin American experiences.

The article first proposes a framework within which to assess the potential of health sector reforms in Latin America for primary health care (PHC). Two dimensions are recognized: the scope of the reforms, content, and the means of participation that are put into play. This framework is then complemented through a critique of the often-sought but little-analyzed PHC reform strategies of decentralization and health sector integration. The analytical framework is next directed to the financing of health services, a chief aspect of any reform aiming toward PHC. Two facets of health service finance are first distinguished: its formal aspect as a means for economic subsistence and growth, and its substantive aspect as a means to promote the rational use of services and thus improvement of health. Once finance is understood in this microeconomic perspective, the focus shifts to the analysis of health care reforms at the macro, health policy level. The article concludes by positing that PHC is in essence a new health care paradigm, oriented by the values of universality, redistribution, integration, plurality, quality, and efficiency.

[The medical profession in urban areas of Mexico: demographic composition and social origin]. / La profesión médica en las áreas urbanas de México: composición demográfica y origen social.

The medical profession in Mexico has experienced deep changes during the last decades. One of the most prominent has been the rapid growth in the number of physicians, who have tended to concentrate in the urban areas. In order to examine the sources of such increase, this paper analyzes the composition of the medical profession by age, sex, and social origin. The data come from the National Survey of Medical Employment, carried out in 1986, in which 604 physicians from a representative sample of households were interviewed in 16 of the main Mexican cities. The results show that the medical profession in Mexico is marked by a clear predominance of young people, which in turn is a sign of the recent explosion of graduates from medical schools. At the same time, there is a growing proportion of women. In contrast, the social origin of physicians has not experienced major changes, since most of them continue to come from the middle classes. The interpretation of these findings indicates that the growth in the number of physicians has not been due to a diversification of the social base of the profession, but to a greater demand for medical education among the middle classes and women. The changes experienced by the medical profession have a basic significance for the present and the future of health in México.

An innovative approach to public health research: the case of a new center in Mexico.

This paper presents the conceptual and organizational elements that have guided the development of the Center for Public Health Research (CPHR) in Mexico. The CPHR was established in August 1984, in the midst of the most profound health care reform in Mexico in the last 40 years. The reform has included, among other measures, a Constitutional amendment recognizing the social right to health care, an energetic effort to decentralize the system so that each state will run its own services, an ambitious drive to extend primary health care coverage to all the population, and a strong promotion of research as the basis for strategic planning and for the development of standards of care. The creation of the CPHR is a response to the need for a firm base of epidemiologic and health systems research in Mexico. This need arises from the increasing complexity of the country's organizational arrangements for health care. In addition, the patterns of morbidity and mortality are also becoming more intricate, as Mexico is experiencing an epidemiologic transition whereby chronic diseases, mental ailments, and accidents are on the rise even as the incidence of infectious diseases and malnutrition continues to be high. As a unit of the Ministry of Health, the CPHR must strike a balance between relevance to decision making and excellence in the strict adherence to the norms of scientific research. To do so, it has developed a conceptual framework based on a tridimensional matrix. The dimensions of the matrix include substantive areas (i.e., the phenomena to be researched), knowledge areas (i.e., the disciplines pertinent to public health), and methodological areas (i.e., the methods to be applied in each project). The intersection of these dimensions produces different configurations of "research modules" that can be adapted to changing priorities. Current priorities of the CPHR include epidemiologic studies of the emerging conditions in the transition, migration and health, child survival, social organization and primary health care, health systems management, quality of care, and the development of information systems and quantitative models for public health research. Research projects are undertaken in a matrix type of organization in which academic departments are structured according to problems rather than disciplines. The analysis of Mexico's Center for Public Health Research may contribute to similar endeavors in other countries and also to the wider development of comparative studies on research organizations.