Overcoming social segregation in health care in Latin America.

Latin America continues to segregate different social groups into separate health-system segments, including two separate public sector blocks: a well resourced social security for salaried workers and their families and a Ministry of Health serving poor and vulnerable people with low standards of quality and needing a frequently impoverishing payment at point of service. This segregation shows Latin America's longstanding economic and social inequality, cemented by an economic framework that predicted that economic growth would lead to rapid formalisation of the economy. Today, the institutional setup that organises the social segregation in health care is perceived, despite improved life expectancy and other advances, as a barrier to fulfilling the right to health, embodied in the legislation of many Latin American countries. This Series paper outlines four phases in the history of Latin American countries that explain the roots of segmentation in health care and describe three paths taken by countries seeking to overcome it: unification of the funds used to finance both social security and Ministry of Health services (one public payer); free choice of provider or insurer; and expansion of services to poor people and the non-salaried population by making explicit the health-care benefits to which all citizens are entitled.

Implementation research: towards universal health coverage with more doctors in Brazil

Objective: To evaluate the implementation of a programme to provide primary care physicians for remote and deprived populations in Brazil. Methods: The Mais Médicos (More Doctors) programme was launched in July 2013 with public calls to recruit physicians for priority areas. Other strategies were to increase primary care infrastructure investments and to provide more places at medical schools. We conducted a quasi-experimental, before-and-after evaluation of the implementation of the programme in 1708 municipalities with populations living in extreme poverty and in remote border areas. We compared physician density, primary care coverage and avoidable hospitalizations in municipalities enrolled (n = 1450) and not enrolled (n = 258) in the programme. Data extracted from health information systems and Ministry of Health publications were analysed. Findings: By September 2015, 4917 physicians had been added to the 16 524 physicians already in place in municipalities with remote and deprived populations. The number of municipalities with ≥ 1.0 physician per 1000 inhabitants doubled from 163 in 2013 to 348 in 2015. Primary care coverage in enrolled municipalities (based on 3000 inhabitants per primary care team) increased from 77.9% in 2012 to 86.3% in 2015. Avoidable hospitalizations in enrolled municipalities decreased from 44.9% in 2012 to 41.2% in 2015, but remained unchanged in control municipalities. We also documented higher infrastructure investments in enrolled municipalities and an increase in the number of medical school places over the study period. Conclusion: Other countries having shortages of physicians could benefit from the lessons of Brazil’s programme towards achieving universal right to health.

Vigilancia de obitos infantis em sistemas locais de saude: avaliacao da autopsia verbal e das informacoes de agentes de saude / Surveillance of infant deaths in local health systems: assessment of verbal autopsies and of information collected by community health agents

Conhecer os eventos vitais de uma populaçao e de fundamental importancia para combater a morbimortalidade e melhorar as condicoes de vida. Contudo, no Brasil, os sistemas de informacao de saude tem-se mostrado ineficientes. No presente estudo, realizado em tres municipios do Estado do Ceara (Quixada, Icapui e Jucas), com boa cobertura de servicos de atencao primaria a saude, foram investigados, atraves de um instrumento epidemiologico denominado autopsia verbal, 215 obitos de criancas menores de 1 ano de idade, representando 90 por cento do total dos obitos em 1993 e 1994. Foram averiguadas as caracteristicas socioeconomicas, cuidados e higiene, estado nutricional, o processo de doenca, assistencia e morte, a causa basica do obito e o funcionamento do sistema de informacao sobre mortalidade e do sistema de informacao de agentes de saude. Segundo a autopsia verbal, 39 por cento dos obitos tiveram como causa basica a diarreia, seguida da prematuridade (17 por cento) e infeccao respiratoria aguda (10 por cento); 49 por cento das criancas morreram no domicilio, embora 79 por cento das familias tenham procurado os servicos de saude no decorrer da doenca fatal, sugerindo uma baixa efetividade na identificacao e no tratamento de lactentes com doencas graves. Em 84 por cento dos casos, a familia procurou a rezadeira. Os agentes de saude foram procurados em 29 por cento dos casos, embora tenham notificado 78 por cento dos obitos investigados. A concordancia estatistica entre diagnostico dos agentes de saude para a causa basica do obito e autopsia verbal foi boa para a diarreia, regular para outras causas, e fraca para a infeccao respiratoria aguda. A incorporacao da autopsia verbal a rotina dos servicos de atencao primaria a saude do Estado propiciaria informacoes valiosas para as equipes locais de saude e geraria uma consciencia critica que favorece a reducao da mortalidade infantil

Knowing the vital statistics of a population is fundamental in controlling morbidity and mortality and improving living conditions. In Brazil, however, the available health information systems do not provide reliable vital statistics. This study was carried out in Quixadá, Icapuí, and Jucás, three municipalities in the state of Ceará that had good coverage by primary health care services. The study used an epidemiological instrument known as a "verbal autopsy" and investigated 215 (90%) of the 237 deaths of children younger than 1 year identified in 1993 and 1994 in the three communities. We investigated socioeconomic characteristics; sanitary conditions; nutritional status; the course of illness, health care, and death; the cause of death; and the operation of the national mortality information system and of the community health agents system. According to the verbal autopsies, diarrhea was the cause of death in 39% of the cases, followed by premature birth (17%), and acute respiratory infections (10%). Even though 79% of the families had sought formal health care services during the child's illness, 49% of the infants had died at home. This suggests limited effectiveness in the identification and treatment of sick infants. In 84% of the cases the family sought help from folk healers. Although community health agents reported 78% of the deaths, only 29% of the families had sought help from the agents during the children's illnesses. In terms of the statistical agreement between the information on the cause of death provided by community health agents and by the verbal autopsies, the agreement was good for diarrhea, intermediate for other causes, and low for acute respiratory infections. Making verbal autopsy a routine part of primary health care services in Ceará would provide invaluable information for local health care teams and would raise a critical consciousness fostering a reduction in infant mortality.