Equity, governance and financing after health care reform: lessons from Mexico

Assessing the interactions of people and policy-makers in social participation for health: an inventory of participatory governance measures from a rapid systematic literature review

Social participation, also termed stakeholder voice, is an important component of health system governance. Increased interactions between the community and policy makers could facilitate a more responsive health system that targets the needs of the community better. Recently, the World Health Organization (WHO) published a handbook on social participation that identified five key themes for ministries of health to consider when engaging the input of the community. In this rapid systematic literature review, we aimed to identify quantitative and qualitative measures that have been used to assess aspects of social participation involving people and policy makers. We identified 172 measures from 48 studies from countries in all six WHO regions. These measures were categorized by all five themes from the handbook on social participation and these measures are linked to 27 concepts. This rapid review found that the focus of measures is largely on the existence of participation-be it by the general population or specific vulnerable groups-rather than on the quality of their participation. The measures in this inventory may be useful for ministries of health and other key stakeholders to use when developing methods to assess and encourage social participation in their context.

Understanding service reorganisation in the Irish health & social care system from 1998 to 2020: lessons for reform and transformation

Background: Given policy drives for integrated care and other reforms requiring service reorganisation this study analyses service reorganisation in the Irish health and social care system from 1998 to 2020 with the aim of identifying lessons for reform implementation and system learning generally. Methods: A mixed-method, co-designed study of three distinct datasets through in a policy document analysis, a thematic analysis of interviews with elite respondents, and a formal review of the international literature, sets the Irish reorganisation story in the context of services and system reorganisation elsewhere. This approach is apt given the complexity involved. Results: We find repeated policy declarations for forms of integrated care from the early 1990s in Ireland. These have not resulted in effective change across the system due to political, organisational and implementation failures. We identify poor clarity and commitment to policy and process, weak change management and resourcing, and reluctance from within the system to change established ways of working, cultures and allegiances. Given its narrative approach and identification of key lessons, this study is of use to policy makers, researchers and practitioners, clinical and managerial. It forms part of a bigger project of evidence building for the implementation of Sláintecare, Ireland’s 10-year health system reform programme. Conclusions: The paper captures important lessons for regionalisation of services delivery and other reorganisations in service-based systems more generally. We find evidence of a negative policy/implementation/practice cycle repeatedly missing opportunities for reform. Learning to break this cycle is essential for implementing Sláintecare and other complex reorganisational health reforms generally.

Determining Core Components in Accreditation of Limited Surgery Facilities in Iran

Background:

Limited surgery facilities, or day-care centers, have been expanding in recent years with the approach of reducing the number of patients referred to hospitals for treatment in relation to limited and ambulatory surgeries. This study was conducted to perform a comparative review of accreditation models for limited surgery facilities of selected countries and to obtain expert opinions in the field of policymaking and accreditation in Iran.

Materials and Methods:

This applied and qualitative study was carried out by a comparative method in 2019. The accreditation standards of limited surgery facilities in nine selected countries/states were assessed. Semi-structured interviews were then held with 25 Iranian experts in policymaking as well as accreditation authorities.

Results:

Evaluation of the core components of accreditation standards for limited surgery facilities in selected countries showed that the main concepts of care and treatment, human resource management, patient safety, drug management, patient education, health information management, quality improvement, service recipient rights, infection prevention and control, physical structure, management and leadership, and general facilities were among the key recurring concepts in all models. In the study of factors affecting the accreditation model of limited surgery facilities in Iran, 5 main topics and 43 subtopics were identified.

Conclusion:

Although the current assessment model of limited surgery facilities is an appropriate tool for evaluation, it still needs to be improved because of the uncertainty of evaluation model, training of accreditors and the content of standards.

Qualitative analysis of governance trends after health system reforms in Latin America: lessons from Mexico

OBJECTIVE

Health policies in Latin America are centered on the democratization of health. Since 2003, during the last generation of reforms, health systems in this region have promoted governance strategies for better agreements between governments, institutions, and civil society. In this context, we develop an evaluative research to identify trends and evidence of governance after health care reforms in six regions of Mexico.

METHODS

Evaluative research was developed with a retrospective design based on qualitative analysis. Primary data were obtained from 189 semi-structured interviews with purposively selected health care professionals and key informants. Secondary data were extracted from a selection of 95 official documents on results of the reform project at the national level, national health policies, and lines of action for good governance. Data processing and analysis were performed using ATLAS.ti and PolicyMaker.

RESULTS

A list of main strengths and weaknesses is presented as evidence of health system governance. Accountability at the federal level remains prescriptive; in the regions, a system of accountability and transparency in the allocation of resources and in terms of health democratization strategies is still absent.

CONCLUSION

Social protection and decentralization schemes are strategies that have allowed for improvements with a proactive role of users and civil society. Regarding challenges, there are still low levels of governance and difficulties in the effective conduct of programs and reform strategies together with a lack of precision in the rules and roles of the different actors of the health system.

Growing Pains at Hospitals: Opportunities and Issues of Service Expansion in Maximum Care

PURPOSE

Due to the demographic change morbidity raises the demand for medical hospital services as well as a need for medical specialization, while economic and human resources are diminishing. Unlike other industries hospitals do not have sufficient data and adequate models to relate growing demands and increasing performance to growth in staff capacity and to increase in staff competences.

METHOD

Based on huge medical data sample covering the years from 2010 to 2014 with more than 150,000 operations of the Department for Anesthesiology at the University Hospital Muenster, Germany, comparisons are drawn between the development of medical services and the development of personnel capacity and expertise.

RESULTS

The numbers of surgical operations increased by 21% and "skin incision to closure" time by 17%. Simultaneously, personnel capacity grew by 16% largely resting upon recruiting first-time employees. Expertise measured as "years of professional experience" dwindled from 10 years to 5.4 years on average and staff turnover accelerated.

CONCLUSION

Static benchmark data collected at fixed reference dates do not sufficiently reflect the nexus between capacity and competence and do not reflect the dynamic changes in a hospital's requirements for expertise and specialization, at all. Staff turnover leads to a loss of experience, which jeopardizes patient safety and hampers medical specialization. In consequence of the dramatic shortage of medical specialists, drop-off rates must be reduced and retention rates must be increased. To that end, working conditions need to be fundamentally converted for a multigeneration, multicultural, and increasingly female workforce.

[Sustainability focus in the health plans of the autonomous communities: sustainable development as an opportunity]

OBJECTIVE

To determine the degree to which the health plans of the autonomous communities focus on the usual three dimensions of sustainability: economic, social and environmental, both in the general level of discourse and in the different areas of intervention.

METHOD

A qualitative study was conducted through content analysis of a large sample of documents. The specific methodology was analysis of symbolic and operational sensitivity in a sample of eleven health plans of the Spanish state.

RESULTS

Social aspects, such as social determinants or vulnerable groups, are receiving increasing attention from the health planner, although there is room to strengthen attention to environmental issues and to provide specific interventions in economic terms.

CONCLUSIONS

The analysis demonstrates the incipient state of health plans as strategic planning documents that integrate economic, social and environmental aspects and contribute to the sustainability of the different health systems of the country.

Evidence on equity, governance and financing after health care reform in Mexico: lessons for Latin American countries

This article includes evidence on equity, governance and health financing outcomes of the Mexican health system. An evaluative research with a cross-sectional design was oriented towards the qualitative and quantitative analysis of financing, governance and equity indicators. Taking into account feasibility, as well as political and technical criteria, seven Mexican states were selected as study populations and an evaluative research was conducted during 2002-2010. The data collection techniques were based on in-depth interviews with key personnel (providers, users and community leaders), consensus technique and document analysis. The qualitative analysis was done with ATLAS TI and POLICY MAKER softwares. The Mexican health system reform has modified dependence at the central level; there is a new equity equation for resources allocation, community leaders and users of services reported the need to improve an effective accountability system at both municipal and state levels. Strategies for equity, governance and financing do not have adequate mechanisms to promote participation from all social actors. Improving this situation is a very important goal in the Mexican health democratization process, in the context of health care reform. Inequality on resources allocation in some regions and catastrophic expenditure for users is unequal in all states, producing more negative effects on states with high social marginalization. Special emphasis is placed on the analysis of the main strengths and weaknesses, as relevant evidences for other Latin American countries which are designing, implementing and evaluating reform strategies in order to achieve equity, good governance and a greater financial protection in health.

Indicadores de gobernanza para el desarrollo de estrategias binacionales deprotección social en la salud de los migrantes

Este artículo presenta resultados de un estudio cuyo principal objetivo fue identificar los actores clave, sus roles, coaliciones y los espacios de interacción para el desarrollo de protección social en la salud de los migrantes. Se identificaron 10 categorías de actores clave para estrategias de salud para emigrantes, así como metas de política y estrategias binacionales de salud con diferentes niveles de factibilidad y efectividad. Un seguro público binacional de salud para emigrantes indocumentados es factible pero requiere una gran inversión y movilización de recursos públicos. Para ello se deberán desarrollar nuevas iniciativas dirigidas a resolver los problemas de equidad y acceso en la salud de los migrantes.

Economic burden to primary informal caregivers of hospitalized older adults in Mexico: a cohort study

BACKGROUND

The burden of out of pocket spending for the Mexican population is high compared to other countries. Even patients insured by social security institutions have to face the cost of health goods, services or nonmedical expenses related to their illness. Primary caregivers, in addition, experience losses in productivity by taking up responsibilities in care giving activities. This situation represents a mayor economic burden in an acute care setting for elderly population. There is evidence that specialized geriatric services could represent lower overall costs in these circumstances and could help reduce these burdens.The aim of this study was to investigate economic burden differences in caregivers of elderly patients comparing two acute care services (Geriatric and Internal Medicine). Specifically, economic costs associated with hospitalization of older adults in these two settings by evaluating health care related out of pocket expenditures (OOPE), non-medical OOPE and indirect costs.

METHODS

A comparative analysis of direct and indirect costs in hospitalised elderly patients (60-year or older) and their primary informal caregivers in two health care settings, using a prospective cohort was performed. Economic burden was measured by out of pocket expenses and indirect costs (productivity lost) due to care giving activities. The analysis included a two-part model, the first one allowing the estimation of the probability of observing any health care related and non-medical OOPE; and the second one, the positive observations or expenditures.

RESULTS

A total of 210 subjects were followed during their hospital stay. Of the total number of subjects 95% reported at least one non-medical OOPE, being daily transportation the most common expense. Regarding medical OOPE, medicines were the most common expense, and the mean numbers of days without income were 4.12 days. Both OOPE and indirect costs were significantly different between type of services, with less overall economic burden to the caregivers of elderly hospitalized in the geriatric unit. The final model showed that type of service and satisfaction had the largest coefficients (-0.68 and 0.662 respectively, p<0.001).

CONCLUSIONS

This study allowed us to identify associated factors of economic burden in elderly hospitalized in acute care units. It opens as well, an issue that should not be overlooked in framing public policies regarding elderly health care.

Avian and pandemic human influenza policy in South-East Asia: the interface between economic and public health imperatives

The aim of this study was to analyse the contemporary policies regarding avian and human pandemic influenza control in three South-East Asia countries: Thailand, Indonesia and Vietnam. An analysis of poultry vaccination policy was used to explore the broader policy of influenza A H5N1 control in the region. The policy of antiviral stockpiling with oseltamivir, a scarce regional resource, was used to explore human pandemic influenza preparedness policy. Several policy analysis theories were applied to analyse the debate on the use of vaccination for poultry and stockpiling of antiviral drugs in each country case study. We conducted a comparative analysis across emergent themes.

The study found that whilst Indonesia and Vietnam introduced poultry vaccination programmes, Thailand rejected this policy approach. By contrast, all three countries adopted similar strategic policies for antiviral stockpiling in preparation. In relation to highly pathogenic avian influenza, economic imperatives are of critical importance. Whilst Thailand's poultry industry is large and principally an export economy, Vietnam's and Indonesia's are for domestic consumption. The introduction of a poultry vaccination policy in Thailand would have threatened its potential to trade and had a major impact on its economy. Powerful domestic stakeholders in Vietnam and Indonesia, by contrast, were concerned less about international trade and more about maintaining a healthy domestic poultry population. Evidence on vaccination was drawn upon differently depending upon strategic economic positioning either to support or oppose the policy.

With influenza A H5N1 endemic in some countries of the region, these policy differences raise questions around regional coherence of policies and the pursuit of an agreed overarching goal, be that eradication or mitigation. Moreover, whilst economic imperatives have been critically important in guiding policy formulation in the agriculture sector, questions arise regarding whether agriculture sectoral policy is coherent with public health sectoral policy across the region.

Health insurance for undocumented immigrants: opportunities and barriers on the Mexican side of the US border

OBJECTIVE

This article aims to identify opportunities, barriers and challenges in Mexico's policy networks for the development of healthcare programs for undocumented migrants in the USA and their families.

METHODS

We used policy analysis, in-depth interviews and a case study. Key stakeholders at the federal, state and municipal levels in one major migrant-sending state were interviewed. We also conducted an in-depth case study of one community to obtain the perceptions of local health workers, migrant families and local nongovernmental organizations.

RESULTS

Findings identified opportunities and barriers involving the stakeholders, institutions, social interactions and types of relationships necessary for further progress on binational policies. There was wide interest in creating binational health insurance with different degrees of potential involvement by political actors and variation in local actors' willingness to be covered by some type of health insurance scheme.

CONCLUSIONS

The use of the opportunities to overcome barriers depends on the identification of high, medium or low interaction among key stakeholders, integration of coalitions and negotiating skills of all stakeholders involved.

Rebuilding health systems to improve health and promote statebuilding in post-conflict countries: a theoretical framework and research agenda

Violent conflicts claim lives, disrupt livelihoods, and halt delivery of essential services, such as health care and education. Health systems are often devastated in conflicts as health professionals flee, infrastructure is destroyed, and the supply of drugs and supplies is halted. We propose that early reconstruction of a functioning, equitable health system in countries recovering from conflict is an investment with a range of benefits for post-conflict countries. Building on the growing literature about health systems as social and political institutions, we elaborate a logic model that outlines how health systems may contribute not only to improved health status but also potentially to broader statebuilding and enhanced prospects for peace. Specifically, we propose that careful design of the core elements of the health system by national governments and their development partners can promote reliable provision of essential health services while demonstrating a commitment to equity, strengthening government accountability to citizens, and building the capacity of government to manage core social programs. We review the conceptual basis and extant empirical evidence for these mechanisms, identify knowledge gaps, and suggest a research agenda.

Equity and accessibility in health? Out-of-pocket expenditures on health care in middle income countries: evidence from Mexico

This study analyzes the results of a cross-sectional survey which set out to determine the costs to patients of searching for and receiving health care in public and private institutions. The information analyzed was obtained from the study population of the Mexican National Health Survey. The dependent variable was the out-of-pocket users' costs and the independent variables were the insurance conditions, type of institution and income. The empirical findings suggest that there is a need for a more detailed analysis of user costs in middle income countries in general, where the health system is based on social security, public assistance and private institutions. This study shows that the out of pocket costs faced by users are inequitable and fall disproportionately upon socially and economically marginalized populations.