A Comparative Case Study: Does the Organization of Primary Health Care in Brazil and Turkey Contribute to Reducing Disparities in Access to Care?

Brazil and Turkey are among the few high-middle-income countries that explicitly chose to strengthen their primary health care (PHC) systems as the centerpiece of much broader health system reforms aiming to narrow inequities in access to care. This comparative case study reviews the organization of Brazil and Turkey's PHC systems to derive lessons that can apply to other countries that may consider reforming the organization of PHC systems as a way to address health inequities. The analysis uses the Flagship Framework to investigate how the organization of PHC delivery in Brazil and Turkey can lead to measurable improvements in access to care. It compares (1) the degree of decentralization in PHC service delivery responsibilities, (2) the use of multi-professional PHC teams, and (3) patient impanelment strategies. The comparative analysis offers three important lessons. First, changes in the organization of PHC systems can contribute to observable improvements in the level and distribution of health outcomes, but organizational strategies do not guarantee eliminating disparities in access. Second, PHC systems can operate in health systems with varying degrees of decentralization, but the level of decentralization may influence implementation. Third, relying on multi-professional PHC teams that serve geographically empaneled populations can improve equitable access to care, but course corrections may be needed to address evolving health demands.

Health system stewardship of National Health Ministries in the WHO European region: concepts, functions and assessment framework.

OBJECTIVES: To propose an operational framework for assessing the completeness and consistency of the stewardship function of national health ministries. METHODS: The authors carried out a purposive and multidisciplinary review of the literature and derived an operational framework through iterative discussions and participatory methods. The results of the literature review were compared to the authors' observations of stewardship in action and key functions were matched with case examples from Europe and North America. RESULTS: The operational framework relates six functions of stewardship with national contexts, values and ultimate goals pursued by health systems: to define the vision for health and strategy to achieve better health; to exert influence across all sectors for better health; to govern the health system in a way that is consistent with prevailing values; to ensure that system design is aligned with health system goals; to better leverage available legal and regulatory instruments; and to compile, disseminate and apply intelligence. CONCLUSIONS: Challenges in the implementation of stewardship relate to: limitations to the role of health ministries; and to governance, operational and change implementation issues. The framework proposed seems flexible enough to help assess the health system stewardship function; however it should be further tested in practice.

Exposure to indoor air pollution from household energy use in rural China: the interactions of technology, behavior, and knowledge in health risk management.

Indoor air pollution (IAP) from household use of biomass and coal is a leading environmental health risk in many developing nations. Much of the initial research on household energy technology overlooked the complex interactions of technological, behavioral, economic, and infrastructural factors that determine the success of environmental health interventions. Consequently, despite enormous interest in reducing the large and inequitable risks associated with household energy use in international development and global health, there is limited empirical research to form the basis for design and delivery of effective interventions. We used data from four poor provinces in China (Gansu, Guizhou, Inner Mongolia, and Shaanxi) to examine the linkages among technology, user knowledge and behavior, and access and infrastructure in exposure to IAP from household energy use. We conclude that broad health risk education is insufficient for successful risk mitigation when exposure behaviors are closely linked to day-to-day activities of households such as cooking and heating, or have other welfare implications, and hence cannot be simply stopped. Rather, there should be emphasis on the economic and infrastructure determinants of access to technology, as well as the details of behaviors that affect exposure. Better understanding of technology-behavior interface would also allow designing technological interventions that account for, and are robust to, behavioral factors or to provide individuals and households with alternative behaviors. Based on the analysis, we present technological and behavioral interventions for these four Chinese provinces.

Patterns of household concentrations of multiple indoor air pollutants in China.

Most previous studies on indoor air pollution from household use of solid fuels have used either indirect proxies for human exposure or measurements of individual pollutants at a single point, as indicators of (exposure to) the mixture of pollutants in solid fuel smoke. A heterogeneous relationship among pollutant-location pairs should be expected because specific fuel-stove technology and combustion and dispersion conditions such as temperature, moisture, and air flow are likely to affect the emissions and dispersion of the various pollutants differently. We report on a study for monitoring multiple pollutants--including respirable particles (RPM), carbon monoxide, sulfur dioxide, fluoride, and arsenic--at four points inside homes that used coal and/or biomass fuels in Guizhou and Shaanxi provinces of China. All pollutants exhibited large variability in emissions and spatial dispersion within and between provinces and were generally poorly correlated. RPM, followed by SO2, was generally higher than common health-based guidelines/standards and provided sufficient resolution for assessing variations within and between households in both provinces. Indoor heating played an important role in the level and spatial patterns of pollution inside homes, possibly to an extent more important than cooking. The findings indicate the need for monitoring of RPM and selected other pollutants in longer-term health studies, with focus on both cooking and living/sleeping areas.

Geographical, spatial, and temporal distributions of multiple indoor air pollutants in four Chinese provinces.

Exposure to indoor air pollution from household energy use depends on fuel, stove, housing characteristics, and stove use behavior. We monitored three important indoor air pollutants-respirable particles (RPM), carbon monoxide (CO), and sulfur dioxide (SO2)-for a total of 457 household-days in four poor provinces in China (Gansu, 129 household-days; Guizhou, 127 household-days; Inner Mongolia, 65 household-days; and Shaanxi, 136 household-days), in two time intervals during the heating season to investigate spatial and temporal patterns of pollution. The two provinces where biomass is the primary fuel (Inner Mongolia and Gansu) had the highest RPM concentrations (719 microg/m3 in the single cooking/living/bedroom in Inner Mongolia in December and 351-661 microg/m3 in different rooms and months in Gansu); lower RPM concentration were observed in the primarily coal-burning provinces of Guizhou and Shaanxi (202-352 microg/m3 and 187-361 microg/m3 in different rooms and months in Guizhou and Shaanxi, respectively). Inner Mongolia and Gansu also had higher CO concentrations (7.4 ppm in the single cooking/living/bedroom in Inner Mongolia in December and 4.8-11.3 ppm in different rooms and months in Gansu). Among the two primarily coal-burning provinces, Guizhou had lower concentrations of CO than Shaanxi (1.2-1.8 ppm in Guizhou vs 2.0-13.3 ppm in different rooms and months in Shaanxi). In the two coal-burning provinces, SO2 concentrations were substantially higher in Shaanxi than in Guizhou. Relative concentrations in different rooms and provinces indicate that in the northern provinces heating is an important source of exposure to indoor pollutants from energy use. Day-to-day variability of concentrations within individual households, although substantial, was smaller than variation across households. The implications of the findings for designing environmental health interventions in each province are discussed.

Reshaping health care in Latin America: A comparative analysis of health care reform in Argentina, Brazil, and Mexico

This book presents empirical evidence on this contentious and highly politicized issue. Uniquely, it integrates qualitative and quantitative analyses of health care reforms at various stages of implementation in three countries of Latin America. The book sheds light on important issues pertaining to accessibility and equity and, in its approach, sets precedents and provides guidelines for further comparative work on health care reform. In many countries of the world, including Canada, arguments are made for a private-public mix in the financing and provision of health services. Proponents claim that such a mix would improve both access and quality of health care. Opponents counter that it would create a two-tiered system, narrowing the range of options available to the lower socioeconomic segments of society and ultimately harming the equitable delivery of quality health care.