PERSPECTIVE: Health Economic Interests at NIMH and NIDA to Improve Delivery of Behavioral Health Services.

BACKGROUND: Effective financing mechanisms are essential to ensuring that people can access and utilize effective treatments and services. Financing mechanisms are needed not only to pay for the delivery of those treatments and services, but also ancillary costs, while also keeping care affordable. AIMS: This article highlights key areas of the interest of the National Institute of Mental Health (NIMH) and the National Institute on Drug Abuse (NIDA) in supporting applied health economics and health care financing research. Specifically, this article discusses the long-range impact of NIH's earlier investments in applied health economics research, and NIH's ongoing efforts to communicate its interests in health economics research. We discuss the 2023 NIMH-NIDA-sponsored health economics conference, and the ideas presented there for developing and assessing innovative behavioral health care financing models; three of the presented papers were recently published in the Journal of Mental Health Policy and Economics. METHODS: We describe the history and impact of NIMH- and NIDA-sponsored economic research and identify current research interests as identified in the NIMH and NIDA Strategic Plans and recent funding announcements. We examine themes presented at the NIMH-NIDA Health Economics conference. The conference included over 300 participants from 20 countries, from six continents. RESULTS: The topics highlighted at the conference highlight the ways in which NIH-funded research has promoted the development of innovative health care financing methods, both from the supply side (e.g., providers and payers) and demand side (e.g., service users and families). Invited speakers discussed the findings from NIH-supported research in the topic areas of payment and financing, behavioral economics and social determinants of health. Keynote speakers highlighted emerging topics in the field, including the economics of health equity, biases in mental health models in health care, and value-based insurance design. DISCUSSION: We demonstrate a resurgence of and explicit interest in health economics and policy research at NIMH and NIDA. However, more work is needed in order to design funding mechanisms that fully provide access to and facilitate use of effective evidence-based practices to improve mental health outcomes. For example, it is important that policy and health economic research projects include decision makers who will be the end users of data and study results, to ensure that results can be meaningfully put into practice. IMPLICATIONS FOR HEALTH CARE: Designing effective and efficient funding mechanisms can help ensure that service users have access to effective treatments and that clinicians and provider organizations are adequately compensated for their work. IMPLICATIONS FOR HEALTH POLICIES: Federal, state, and local policies, as well as policies of payers and health care organizations, can influence the type of care that is supported and incentivized. IMPLICATIONS FOR FURTHER RESEARCH: As demonstrated by the research interests as outlined in their respective Strategic Plans and funding announcements, NIMH and NIDA continue to fund health economic and policy research that aims to improve health care access, quality and outcomes for people with or at risk of developing behavioral health conditions in the US and around the world.

Integrating Depression and Alcohol Use Care Into Primary Care in Low- and Middle-Income Countries: A Meta-Analysis.

OBJECTIVE: Evaluation of the effectiveness of integration of depression and alcohol use disorder care into primary health care in low- and middle-income countries (LMICs) is limited. The authors aimed to quantify the effectiveness of integrating mental health care into primary care by examining depression and alcohol use disorder outcomes. The study updates a previous systematic review summarizing research on care integration in LMICs. METHODS: Following PRISMA guidelines, the authors included studies from the previous review and studies published from 2017 to 2020 that included adults with alcohol use disorder or depression. Studies were evaluated for type of integration model with the typology developed previously. A meta-analysis using a random-effects model to assess effectiveness of integrated interventions was conducted. Meta-regression analyses to examine the impact of study characteristics on depression and alcohol use disorder outcomes were conducted. RESULTS: In total, 49 new articles were identified, and 74 articles from the previous and current studies met inclusion criteria for the meta-analysis. Overall random effect sizes were 0.28 (95% CI=0.22-0.35) and 0.17 (95% CI=0.11-0.24) for studies targeting care integration for depression or for alcohol use disorder, respectively, into primary care in LMICs. High heterogeneity within and among studies was observed. No significant association was found between country income level and depression and alcohol use outcomes. However, differences in effect sizes between types of integration model were statistically significant (p<0.001). CONCLUSIONS: Integration of mental health care into primary health care in LMICs was found to improve depression and alcohol use disorder outcomes. This evidence should be considered when designing interventions to improve mental health screening and treatment in LMICs.

Scaling Up Science-Based Care for Depression and Unhealthy Alcohol Use in Colombia: An Implementation Science Project.

BACKGROUND: Mental disorders are a major cause of the global burden of disease and significantly contribute to disability and death. This challenge is particularly evident in low- and middle-income countries (LMICs), where >85% of the world's population live. Latin America is one region comprising LMICs where the burden of mental disorders is high and the availability of mental health services is low. This is particularly evident in Colombia, a country with a long-standing history of violence and associated mental health problems. METHODS: This article describes the design of a multisite implementation science project, "Scaling Up Science-Based Mental Health Interventions in Latin America" (also known as the DIADA project), that is being conducted in six primary care systems in Colombia. This project, funded via a cooperative agreement from the National Institute of Mental Health, seeks to implement and assess the impact of a new model for promoting widespread access to mental health care for depression and unhealthy alcohol use within primary care settings and building an infrastructure to support research capacity and sustainability of the new service delivery model in Colombia. This care model centrally harnesses mobile health technology to increase the reach of science-based mental health care for depression and unhealthy alcohol use. RESULTS: This initiative offers great promise to increase capacity for providing and sustaining evidence-based treatment for depression and unhealthy alcohol use in Colombia. NEXT STEPS: This project may inform models of care that can extend to other regions of Latin America or other LMICs.

Global mental health and the DIADA project.

The DIADA project, understood as a mental healthcare implementation experience in the context of a middle-income country like Colombia, promotes a necessary discussion about its role in the global mental health framework. The following article outlines the main points by which this relationship occurs, understanding how the project contributes to global mental health and, at the same time, how global mental health nurtures the development of this project. It reflects on aspects like the systematic screening of patients with mental illness, the use of technology in health, the adoption of a collaborative model, the investigation on implementation, a collaborative learning and the Colombian healthcare system. These are all key aspects when interpreting the feedback cycle between the individual and the global. The analysis of these components shows how collaborative learning is a central axis in the growth of global mental health: from the incorporation of methodologies, implementation of models, assessment of outcomes and, finally, the dissemination of results to local, regional and international stakeholders.

Access barriers, self-recognition, and recognition of depression and unhealthy alcohol use: A qualitative study.

INTRODUCTION: Access to healthcare services involves a complex dynamic, where mental health conditions are especially disadvantaged, due to multiple factors related to the context and the involved stakeholders. However, a characterisation of this phenomenon has not been carried out in Colombia, and this motivates the present study. OBJECTIVES: The objective of this study was to explore the causes that affect access to health services for depression and unhealthy alcohol use in Colombia, according to various stakeholders involved in the care process. METHODS: In-depth interviews and focus groups were conducted with health professionals, administrative professionals, users, and representatives of community health organisations in five primary and secondary-level institutions in three regions of Colombia. Subsequently, to describe access to healthcare for depression and unhealthy alcohol use, excerpts from the interviews and focus groups were coded through content analysis, expert consensus, and grounded theory. Five categories of analysis were created: education and knowledge of the health condition, stigma, lack of training of health professionals, culture, and structure or organisational factors. RESULTS: We characterised the barriers to a lack of illness recognition that affected access to care for depression or unhealthy alcohol use according to users, healthcare professionals and administrative staff from five primary and secondary care centres in Colombia. The groups identified that lack of recognition of depression was related to low education and knowledge about this condition within the population, stigma, and lack of training of health professionals, as well as to culture. For unhealthy alcohol use, the participants identified that low education and knowledge about this condition, lack of training of healthcare professionals, and culture affected its recognition, and therefore, healthcare access. Neither structural nor organisational factors seemed to play a role in the recognition or self-recognition of these conditions. CONCLUSIONS: This study provides essential information for the search for factors that undermine access to mental health in the Colombian context. Likewise, it promotes the generation of hypotheses that can lead to the development and implementation of tools to improve care in the field of mental illness.

Addressing harmful alcohol use in primary care in Colombia: Understanding the sociocultural context.

Harmful alcohol use is a public health problem worldwide, contributing to an estimated 5.1% of the global burden of illness. Screening and addressing at-risk drinking in primary care settings is an empirically supported health care intervention strategy to help reduce the burden of alcohol-use problems. In preparation for introducing screening and treatment for at-risk drinking in primary care clinics in Colombia, we conducted interviews with clinicians, clinic administrators, patients, and participants in Alcoholics Anonymous. Interviews were conducted within the framework of the Detección y Atención Integral de Depresión y Abuso de Alcohol en Atención Primaria (DIADA, [Detection and Integrated Care for Depression and Alcohol Use in Primary Care] www.project-diada.org) research project, and its qualitative phase that consisted of the collection of data from 15 focus groups, 6 interviews and field observations in 5 regional settings. All participants provided informed consent to participate in this research. Findings revealed the association of harmful alcohol use with a culture of consumption, within which it is learned and socially accepted practice. Recognition of harmful alcohol consumption includes a social context that influences its screening, diagnosis and prevention. The discussion highlights how, despite the existence of institutional strategies in healthcare settings and the awareness of the importance of at-risk drinking among health personnel, the recognition of the harmful use of alcohol as a pathology should be embedded in an understanding of historical, social and cultural dimensions that may affect different identification and care scenarios.

Characterizing the perceived stigma towards mental health in the early implementation of an integrated services model in primary care in Colombia. A qualitative analysis.

BACKGROUND: Stigma is a sociocultural barrier to accessing mental health services and prevents individuals with mental health disorders from receiving mental health care. The Ministry of Health and Social Protection of Colombia acknowledges that a great number of people with mental disorders do not seek medical aid due to stigma. OBJECTIVES: Characterise the perceived stigma towards mental health among the stakeholders involved in the early implementation of the DIADA project [Detección y Atención Integral de Depresión y Abuso de Alcohol en Atención Primaria (Detection and Integrated Care for Depression and Alcohol Use in Primary Care)]. Explore whether the implementation of this model can decrease stigma. Describe the impact of the implementation on the lives of patients and medical practice. MATERIALS AND METHODS: Eighteen stakeholders (7 patients, 5 physicians and 6 administrative staff) were interviewed and a secondary data analysis of 24 interview transcripts was conducted using a rapid analysis technique. RESULTS: The main effects of stigma towards mental health disorders included refusing medical attention, ignoring illness, shame and labelling. Half of the stakeholders reported that the implementation of mental health care in primary care could decrease stigma. All of the stakeholders said that the implementation had a positive impact. CONCLUSIONS: The perceived stigma was characterised as social and aesthetic in nature. Communication and awareness about mental health is improving, which could facilitate access to mental health treatment and strengthen the doctor-patient relationship. Culture is important for understanding stigma towards mental health in the population studied.

Patterns of digital information and communication technology use among patients at primary health care centres in Colombia: Phase I of the DIADA project.

OBJECTIVE: Assess the prevalence and types of digital technology use, as well as the extent to which patients use the internet and mobile devises. Evaluate the socioeconomic characteristics of patients and the possible relation to patterns of technology use in Colombia. Understand the nature of patient technology use in primary care for finding medical information. METHODS: A survey was applied to adult patients who attended primary health care centers systems in 6 Colombian cities. The survey inquired about demographic characteristics, insurance, access to services, cell phone use, internet access, and the use of such technology to access health-related services and information. Data was collected and managed using REDCap. Summary statistics on each survey item were calculated and the differences between discrete variables were analyzed using chi-square. Multivariate analyses were performed using logistic regression analysis for binary dependent variables. RESULTS: A total of 1580 patients were surveyed across the six study sites. 93% of the patients reported they have a cell phone. Patients from urban healthcare centers showed a higher use of the Internet on their phone than less urban settings. Around half of the surveyed patients reported Internet use (49.7%). Among Internet users, 65% of participants use the Internet looking for health care information. Around one-third of patients use cellphones to arrange clinic visits. Around 24% of participants answered positively for both Whooley's questions. Of those who screened positive on the Whooley questions, 43% reported being moderately anxious, 47% reported being very anxious. 51% reported having moderate pain; 52% reported having severe pain. CONCLUSIONS: The patterns of technology use identified in this study are essential for developing future health interventions based on ICT. The design of ICT clinical interventions must take into account the cellphone payment plans, availability of internet connection, advantages, and disadvantages of messenger services, including SMS as a possible alternative to people who do not have smartphones.

Health-related quality of life and health literacy among adult primary care patients with subsidized or contributive health insurance in Colombia.

CONTEXT: Colombia passed Law 100 in 1993 with the goal of providing universal health care coverage, and by 2013, over 96% of the Colombian population had health insurance coverage. However, little is known about how health-related quality of life (HRQoL) and health literacy are related among those with the two most common types of health insurance coverage: subsidized (those with lower incomes) and contributory (those with higher incomes) coverage. OBJECTIVES AND METHODS: In the current exploratory investigation, data from adults visiting six primary care clinics in Colombia were analysed to examine the relationship between HRQoL (assessed as problems with mobility, self-care, completing usual activities, pain/discomfort, and anxiety/depression), demographics, the two health insurance types, and health literacy. Analyses also assessed whether, within insurance types, health literacy was related to HRQoL. RESULTS: Results showed that those with contributory health insurance coverage had greater health literacy than those with subsidized coverage, and this was accounted for by differences in education and socioeconomic status. HRQoL did not differ by insurance type. Although lower health literacy was related to worse HRQoL in the overall sample, in subgroup analyses lower health literacy significantly related to worse HRQoL only among those with subsidized health insurance coverage. CONCLUSION: Targeting skills which contribute to health literacy, such as interpreting medical information or filling out forms, may improve HRQoL, particularly in those with subsidized insurance coverage.

A characterisation of social media users within the primary care system in Colombia and predictors of their social media use to understand their health.

INTRODUCTION: Social media use is growing in Latin America and is increasingly being used in innovative ways. This study sought to characterise the profile of social media users, among primary care patients in Colombia, and to assess predictors of their use of social media to search for health and mental health information (searching behaviour). METHODS: As part of a larger scale-up study, we surveyed 1580 patients across six primary care sites in Colombia about their social media use. We used chi-square and Student's t-tests to assess associations between demographic variables, social media use and searching behaviour, and a Chi-square Automatic Interaction Detector (CHAID) analysis to determine predictors of searching behaviour. RESULTS: In total, 44.4% of respondents reported that they were social media users. Of these, 35.7% used social media to search for health-related information and 6.6% used it to search for mental health-related information. While the profile of individuals who used social media to search for health-related information was similar to that of general social media users (the highest use was among women living in urban areas), the presence of mental health symptoms was a more important predictor of using social media to search for mental health-related information than demographic variables. Individuals with moderate-severe symptoms of anxiety reported a significantly higher percentage of searching than individuals without symptoms (12.5% vs. 5.2%). CONCLUSIONS: Given that some individuals with mental health disorders turn to social media to understand their illness, social media could be a successful medium for delivering mental health interventions in Colombia.

Barriers and facilitators to the diagnosis and treatment of depression in primary care in Colombia: Perspectives of providers, healthcare administrators, patients and community representatives.

INTRODUCTION: Depression represents a major disease burden in Colombia. To better understand opportunities to improve access to mental healthcare in Colombia, a research team at Javeriana University conducted formative qualitative research to explore stakeholders' experiences with the integration of mental healthcare into the primary care system. METHODS: The research team conducted 16 focus groups and 4 in-depth interviews with patients, providers, health administrators and representatives of community organisations at five primary care clinics in Colombia, and used thematic analysis to study the data. RESULTS: Themes were organised into barriers and facilitators at the level of patients, providers, organisations and facilities. Barriers to the treatment of depression included stigma, lack of mental health literacy at the patient and provider level, weak links between care levels, and continued need for mental health prioritization at the national level. Facilitators to the management of depression in primary care included patient support systems, strong patient-provider relationships, the targeting of depression interventions and national depression guidelines. DISCUSSION: This study elucidates the barriers to depression care in Colombia, and highlights action items for further integrating depression care into the primary care setting.

Relationship between the sociodemographic characteristics of participants in the DIADA project and the rate of compliance with follow-up assessments in the initial stage of the intervention.

OBJECTIVE: Analyse the relationship between the sociodemographic profile of the DIADA study participants and the rate of compliance with the follow-up assessments in the early stage of this project's intervention for depression and unhealthy alcohol use offered within primary care. METHODS: A non-experimental quantitative analysis was conducted. The sociodemographic data of DIADA [Detección y Atención Integral de Depresión y Abuso de Alcohol en Atención Primaria (Detection and Integrated Care for Depression and Alcohol Use in Primary Care)] study participants had been previously collected. At the time of the evaluation (September 12, 2019), only the participants who had been in the project for a minimum of 3 months were included. By using univariate (Chi-squared) analyses, we studied the association between participants' sociodemographic profile and their rate of compliance with the first follow-up assessment at 3 months after study initiation. RESULTS: At the date of the evaluation, 584 adult participants were identified, of which 389 had been involved in the project for more than 3 months. From the participants included, 320 performed the first follow-up, while 69 did not. The compliance rate to the first follow-up was 82.3% (95 % [CI] 78.1%-86%) and was not affected by: site location, age, sex, civil status, level of education, use of smartphone, PHQ9 score (measuring depression symptomatology) or AUDIT score (measuring harmful alcohol use). Participants who do not use a smartphone, from rural areas and with a lower socioeconomic status, tended to show higher compliance rates. Statistically significant associations were found; participants with lower job stability and a lack of access to the Internet showed higher compliance rates to the early initial follow-up assessment. CONCLUSIONS: The compliance rate was high and generally constant in spite of the variability of the sociodemographic profiles of the participants, although several sub-groups of participants showed particularly high rates of compliance. These findings may suggest that integrating mental health into primary care allows the structural and financial barriers that hinder access to health in Colombia to be broken down by raising awareness about mental illnesses, their high prevalence and the importance of timely and accessible medical management.

Workshop on Implementation Science and Digital Therapeutics for Behavioral Health.

Digital therapeutics can overcome many of the barriers to translation of evidence-based treatment for substance use, mental health, and other behavioral health conditions. Delivered via nearly ubiquitous platforms such as the web, smartphone applications, text messaging, and videoconferencing, digital therapeutics can transcend the time and geographic boundaries of traditional clinical settings so that individuals can access care when and where they need it. There is strong empirical support for digital therapeutic approaches for behavioral health, yet implementation science with regard to scaling use of digital therapeutics for behavioral health is still in its early stages. In this paper, we summarize the proceedings of a day-long workshop, "Implementation Science and Digital Therapeutics," sponsored and hosted by the Center for Technology and Behavioral Health at Dartmouth College. The Center for Technology and Behavioral Health is an interdisciplinary P30 Center of Excellence funded by the National Institute on Drug Abuse, with the mission of promoting state-of-the-technology and state-of-the-science for the development, evaluation, and sustainable implementation of digital therapeutic approaches for substance use and related conditions. Workshop presentations were grounded in current models of implementation science. Directions and opportunities for collaborative implementation science research to promote broad adoption of digital therapeutics for behavioral health are offered.

The effectiveness and cost-effectiveness of integrating mental health services in primary care in low- and middle-income countries: systematic review.

AIMS AND METHOD: This systematic review examines the effectiveness and cost-effectiveness of behavioural health integration into primary healthcare in the management of depression and unhealthy alcohol use in low- and middle-income countries. Following PRISMA guidelines, this review included research that studied patients aged ≥18 years with unhealthy alcohol use and/or depression of any clinical severity. An exploration of the models of integration was used to characterise a typology of behavioural health integration specific for low- and middle-income countries. RESULTS: Fifty-eight articles met inclusion criteria. Studies evidenced increased effectiveness of integrated care over treatment as usual for both conditions. The economic evaluations found increased direct health costs but cost-effective estimates. The included studies used six distinct behavioural health integration models. CLINICAL IMPLICATIONS: Behavioural health integration may yield improved health outcomes, although it may require additional resources. The proposed typology can assist decision-makers to advance the implementation of integrated models.

Implementing Technology-Supported Care for Depression and Alcohol Use Disorder in Primary Care in Colombia: Preliminary Findings.

OBJECTIVE: Depression and alcohol use disorder are among the most common causes of disability and death worldwide. Health care systems are seeking ways to leverage technology to screen, evaluate, and treat these conditions, because workforce interventions alone, particularly in low- and middle-income countries, are insufficient. This article reports data from the first year of implementation of a technology-supported, systematic approach to identify and care for persons with these disorders in primary care in Colombia. METHODS: A care process that includes waiting room kiosks to screen primary care patients, decision support tablets to guide doctors in diagnosis and treatment, and access to digital therapeutics as a treatment option was implemented in two primary care clinics, one urban and one in a small town. The project collected data on the number of people screened, diagnosed, and engaged in the research and their demographic characteristics. RESULTS: In the first year, 2,656 individuals were screened for depression and unhealthy alcohol use in the two clinics. Primary care doctors increased the percentage of patients diagnosed as having depression and alcohol use disorder from next to 0% to 17% and 2%, respectively. CONCLUSIONS: Early experience with implementing technology-supported screening and decision support for depression and alcohol use disorder into the workflow of busy primary care clinics in Colombia indicates that this care model is feasible and leads to dramatically higher rates of diagnoses of these conditions. Diagnosis in these settings appeared to be easier for depression than for alcohol use disorder.

Perspectives, Experiences, and Practices in the Use of Digital Information Technologies in the Management of Depression and Alcohol Use Disorder in Health Care Systems in Colombia.

Digital information technologies are increasingly used in the treatment of mental health disorders. Through this qualitative study, researchers illuminated perspectives, experiences, and practices among diverse stakeholders in the use of digital information technologies in the management of depression and alcohol use disorders in Colombia. In-depth interviews and focus groups were conducted in five primary care institutions across Colombia. Thematic analysis was used to analyze the data. The use of technology in the treatment of mental health disorders can facilitate the evaluation and diagnosis, treatment, and promotion and prevention of mental health disorders, as well as multiple nonmental health applications in the primary care setting. Potential barriers to the use of technology in this setting include challenges of digital literacy, access to technology, confidentiality, and financing. This study can inform the implementation of digital information technologies in the care of depression and problematic alcohol use within health care systems in Colombia.

Addressing Severe Mental Illness Rehabilitation in Colombia, Costa Rica, and Peru.

Many Latin American countries face the challenge of caring for a growing number of people with severe mental illnesses while promoting deinstitutionalization and community-based care. This article presents an overview of current policies that aim to reform the mental health care system and advance the employment of people with disabilities in Colombia, Costa Rica, and Peru. The authors conducted a thematic analysis by using public records and semistructured interviews with stakeholders. The authors found evidence of supported employment programs for vulnerable populations, including people with disabilities, but found that the programs did not include people with severe mental illnesses. Five relevant themes were found to hamper progress in psychiatric vocational rehabilitation services: rigid labor markets, insufficient advocacy, public subsidies that create conflicting incentives, lack of deinstitutionalized models, and lack of reimbursement for evidence-based psychiatric rehabilitation interventions. Policy reforms in these countries have promoted the use of medical interventions to treat people with severe mental illnesses but not the use of evidence-based rehabilitation programs to facilitate community integration and functional recovery. Because these countries have other supported employment programs for people with nonpsychiatric disabilities, they are well positioned to pilot individual placement and support to accelerate full community integration among individuals with severe mental illnesses.

Assessing the Integration of Behavioral Health Services in Primary Care in Colombia.

Integration of behavioral health care into primary care can improve health and economic outcomes. This study adapted the Behavioral Health Integration in Medical Care (BHIMC) index to the Colombian context and assessed the baseline level of behavioral health integration in a sample of primary care organizations. The BHIMC was able to detect the capacity to provide integrated behavioral care in Colombian settings. Results indicate a minimal to partial integration level across all sites, and that it is possible to measure the degree of integrated care capacity and identify improvement areas for better behavioral health care provision.

Prioritization of strategies to approach the judicialization of health in Latin America and the Caribbean.

OBJECTIVE: To describe strategies that contribute to the comprehensive approach to the judicialization of health in countries of Latin America and the Caribbean. METHODS: A search was structured to identify articles presenting strategies to approach the judicialization of health. A survey was designed, which included actors of the health system and judiciary sector. We prioritized the strategies qualified by more than the 50.0% of the participants as "very relevant". Strategies were categorized according to: governance, provision of services, human resources, information systems, financing, and medical products. RESULTS: We included 64 studies, which identified 50 strategies, related to the sub-functions and components of health systems. Of the 165 people who answered the survey, 80.0% were aged 35-64 years. The distribution of men and women was homogeneous. Half of the respondents were from Colombia (20.0%), Uruguay (16.9%), and Argentina (12.7%). We prioritized strategies that addressed aspects of generation of useful scientific evidence for decision making according to the health needs of the population, empowerment for the society, and creating spaces for discussion of measures of inclusion or exclusion of health technologies. The executive and judiciary decision makers prioritized questions that dealt with strategies that would ensure accountability. CONCLUSIONS: The results of this study contribute to the identification of effective strategies to approach the phenomenon of judicialization of health, guaranteeing the right to health. OBJETIVO: Describir estrategias que contribuyan al abordaje integral de la judicialización de la salud en países de América Latina y El Caribe. MÉTODOS: Se estructuró una búsqueda para identificar artículos que presentaran estrategias para el abordaje de la judicialización en salud. Se diseñó una encuesta, en donde se incluyeron actores del sistema de salud y del sector judicial. Se priorizaron las estrategias calificadas por más del 50,0% de los participantes como "muy relevantes". Se categorizaron las estrategias según: gobernanza, prestación de servicios, recursos humanos, sistemas de información, financiación y productos médicos. RESULTADOS: Se incluyeron 64 estudios en los cuales se identificaron 50 estrategias, relacionadas con las sub-funciones y componentes de los sistemas de salud. De las 165 personas que respondieron la encuesta, el 80,0% tenían entre 35-64 años. La distribución de hombres y mujeres fue homogénea. La mitad de los respondientes fue de Colombia (20,0%), Uruguay (16,9%) y Argentina (12,7%). Se priorizaron mayormente las estrategias que abordaron los aspectos de generación de evidencia científica útil para toma de decisión según las necesidades de salud de la población, el empoderamiento para la sociedad, y la generación de espacios de discusión de las medidas de inclusión o exclusión de tecnologías de salud. Los tomadores de decisión de la rama ejecutiva y judicial priorizaron las preguntas que abordaron las estrategias que garantizaran la rendición de cuentas. CONCLUSIONES: Los resultados de este estudio contribuyen a la identificación de estrategias efectivas para el abordaje del fenómeno de la judicialización en salud, garantizando el derecho a la salud.

Public participation in decision-making on the coverage of new antivirals for hepatitis C.

Purpose - New hepatitis C medicines such as sofosbuvir underline the need to balance considerations of innovation, clinical evidence, budget impact and equity in health priority-setting. The purpose of this paper is to examine the role of public participation in addressing these considerations. Design/methodology/approach - The paper employs a comparative case study approach. It explores the experience of four countries - Brazil, England, South Korea and the USA - in making coverage decisions about the antiviral sofosbuvir and involving the public and patients in these decision-making processes. Findings - Issues emerging from public participation ac tivities include the role of the universal right to health in Brazil, the balance between innovation and budget impact in England, the effect of unethical medical practices on public perception in South Korea and the legitimacy of priority-setting processes in the USA. Providing policymakers are receptive to these issues, public participation activities may be re-conceptualized as processes that illuminate policy problems relevant to a particular context, thereby promoting an agenda-setting role for the public. Originality/value - The paper offers an empirical analysis of public involvement in the case of sofosbuvir, where the relevant considerations that bear on priority-setting decisions have been particularly stark. The perspectives that emerge suggest that public participation contributes to raising attention to issues that need to be addressed by policymakers. Public participation activities can thus contribute to setting policy agendas, even if that is not their explicit purpose. However, the actualization of this contribution is contingent on the receptiveness of policymakers.