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

Citizen engagement in national health insurance in rural western Kenya

Effective citizen engagement is crucial for the success of social health insurance, yet little is known about the mechanisms used to involve citizens in low- and middle-income countries. This paper explores citizen engagement efforts by the National Health Insurance Fund (NHIF) and their impact on health insurance coverage within rural informal worker households in western Kenya. Our study employed a mixed methods design, including a cross-sectional household survey (n = 1773), in-depth household interviews (n = 36), six focus group discussions with community stakeholders and key informant interviews (n = 11) with policymakers. The findings reveal that NHIF is widely recognized, but knowledge of its services, feedback mechanisms and accountability systems is limited. NHIF enrolment among respondents is low (11%). The majority (63%) are aware of NHIF, but only 32% know about the benefit package. There was higher awareness of the benefit package (60%) among those with NHIF compared to those without (28%). Satisfaction with the NHIF benefit package was expressed by only 48% of the insured. Nearly all respondents (93%) are unaware of mechanisms to provide feedback or raise complaints with NHIF. Of those who are aware, the majority (57%) mention visiting NHIF offices for assistance. Most respondents (97%) lack awareness of NHIF's performance reporting mechanisms and express a desire to learn. Negative media reports about NHIF's performance erode trust, contributing to low enrolment and member attrition. Our study underscores the urgency of prioritizing citizen engagement to address low enrolment and attrition rates. We recommend evaluating current citizen engagement procedures to enhance citizen accountability and incorporate their voices. Equally important is the need to build the capacity of health facility staff handling NHIF clients in providing information and addressing complaints. Transparency and information accessibility, including the sharing of performance reports, will foster trust in the insurer. Lastly, standardizing messaging and translations for diverse audiences, particularly rural informal workers, is crucial.

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.

A framework for explaining the role of values in health policy decision-making in Latin America: a critical interpretive synthesis

BACKGROUND

Although values underpin the goals pursued in health systems, including how health systems benefit the population, it is often not clear how values are incorporated into policy decision-making about health systems. The challenge is to encompass social/citizen values, health system goals, and financial realities and to incorporate them into the policy-making process. This is a challenge for all health systems and of particular importance for Latin American (LA) countries. Our objective was to understand how and under what conditions societal values inform decisions about health system financing in LA countries.

METHODS

A critical interpretive synthesis approach was utilised for this work. We searched 17 databases in December 2016 to identify articles written in English, Spanish or Portuguese that focus on values that inform the policy process for health system financing in LA countries at the macro and meso levels. Two reviewers independently screened records and assessed them for inclusion. One researcher conceptually mapped the included articles, created structured summaries of key findings from each, and selected a purposive sample of articles to thematically synthesise the results across the domains of agenda-setting/prioritisation, policy development and implementation.

RESULTS

We identified 5925 references, included 199 papers, and synthesised 68 papers. We identified 116 values and developed a framework to explain how values have been used to inform policy decisions about financing in LA countries. This framework has four categories - (1) goal-related values (i.e. guiding principles of the health system); (2) technical values (those incorporated into the instruments adopted by policy-makers to ensure a sustainable and efficient health system); (3) governance values (those applied in the policy process to ensure a transparent and accountable process of decision-making); and (4) situational values (a broad category of values that represent competing strategies to make decisions in the health systems, their influence varying according to the four factors).

CONCLUSIONS

It is an effort to consolidate and explain how different social values are considered and how they support policy decision-making about health system financing. This can help policy-makers to explicitly incorporate values into the policy process and understand how values are supporting the achievement of policy goals in health system financing.

TRIAL REGISTRATION

The protocol was registered with PROSPERO, ID=CRD42017057049 .

Análise do Seguro Popular de Saúde mexicano: uma revisão integrativa da literatura

RESUMO Esse artigo objetiva analisar a reforma do sistema de saúde mexicano, a partir da implantação do Seguro Popular de Saúde, destacando seu funcionamento, aspectos positivos e negativos. Foi realizada uma revisão integrativa da literatura nas bases Lilacs e SciELO Regional no período de janeiro de 2011 a dezembro de 2018. Foram incluídas publicações que atendiam a três questionamentos: história do sistema de saúde mexicano, seu funcionamento e pontos positivos e negativos do Seguro Popular de Saúde. A literatura aponta que o Seguro Popular surgiu após um processo de reformas neoliberais no sistema de saúde mexicano, consonante com a proposta de Cobertura Universal de Saúde, que visa reduzir o empobrecimento por gastos em saúde na população sem seguridade social. O Seguro Popular oferece menor variedade de diagnósticos e tratamentos do que a seguridade social, menor número de consultas, atendimentos de urgência e medicamentos. Seu maior impacto foi nas populações indígena e rural, mas 20% da população continua descoberta e o atendimento permanece desigual. A análise do Seguro Popular permite inferir possíveis impactos que teriam os planos de saúde acessíveis no cenário brasileiro, acarretando acesso a um elenco menor de procedimentos para a população atualmente coberta pelo Sistema Único de Saúde.

Challenges on the epidemiological and economic burden of diabetes and hypertension in Mexico

OBJECTIVE

To analyze the epidemiological and economic burden of the health services demand due to diabetes and hypertension in Mexico.

METHODS

Evaluation study based on a time series study that had as a universe of study the assured and uninsured population that demands health services from the three main institutions of the Health System in Mexico: The Health Department, the Mexican Institute of Social Security, and Institute of Services and Social Security for State Workers. The financing method was based on instrumentation and consensus techniques for medium case management. In order to estimate the epidemiological changes and financial requirements, a time series of observed cases for diabetes and hypertension 1994–2013 was integrated. Probabilistic models were developed based on the Box-Jenkins technique for the period of 2013–2018 with 95% confidence intervals and p < 0.05.

RESULTS

Comparing results from 2013 versus 2018, in the five regions, different incremental trends of 14%–17% in epidemiological changes and 58%-66% in the economic burden for both diseases were observed.

CONCLUSIONS

If the risk factors and the different models of care remained as they currently are in the three institutions analyzed, the financial consequences would be of greater impact for the Mexican Institute of Social Security, following in order of importance the Institute of Services and Social Security for State Workers and lastly the Health Department. The financial needs for both diseases will represent approximately 13%–15% of the total budget allocated to the uninsured population and 15%–17% for the population insured depending on the region.

The community is just a small circle: citizen participation in the free maternal and child healthcare programme of Enugu State, Nigeria

BACKGROUND

There is a gap in knowledge about how citizen participation impacts governance of free healthcare policies for universal health coverage in low- and middle-income countries.

OBJECTIVE

This study provides evidence about how social accountability initiatives influenced revenue generation, pooling and fund management, purchasing and capacity of health facilities implementing the free maternal and child healthcare programme (FMCHP) in Enugu State, Nigeria.

METHODS

The study adopted a descriptive, qualitative case-study design to explore how social accountability influenced implementation of the FMCHP at the state level and in two health districts (Isi-Uzo and Enugu Metropolis) in Enugu State. Data were collected from policymakers (n = 16), providers (n = 16) and health facility committee leaders (n = 12) through in-depth interviews. We also conducted focus-group discussions (n = 4) with 42 service users and document review. Data were analysed using thematic analysis.

RESULTS

It was found that health facility committees (HFCs) have not been involved in the generation of funds, fund management and tracking of spending in FMCHP. The HFCs did not also seem to have increased transparency of benefits and payment of providers. The HFCs emerged as the dominant social accountability initiative in FMCHP but lacked power in the governance of free health services. The HFCs were constrained by weak legal framework, ineffectual FMCHP committees at the state and district levels, restricted financial information disclosure, distrustful relationships with policymakers and providers, weak patient complaint system and low use of service charter.

CONCLUSION

The HFCs have not played a significant role in health financing and service provision in FMCHP. The gaps in HFCs' participation in health financing functions and service delivery need to be considered in the design and implementation of free maternal and child healthcare policies that aim to achieve universal health coverage.

Governance and mental health: contributions for public policy approach

OBJECTIVE

To analyze the conceptualization of the term governance on public mental health programs.

METHODS

In this systematic review, we analyzed the scientific literature published in the international scenario during 15 years (from 2000 to 2015). The databases analyzed were: Medline, CINAHL, PsycINFO and PubMed. Governance and mental health were the descriptors. We included relevant articles according to our subject of study and levels of analysis: (i) the concept of governance in mental health; (ii) process and decision spaces; (iii) strategic and pertinent actors who operate in the functioning of the health system, and (iv) social regulations. We excluded letters to the editor, news articles, comments and case reports, incomplete articles and articles whose approach did not include the object of study of this review.

RESULTS

We have found five conceptualizations of the term governance on mental health in the area of provision policies and service organization. The agents were both those who offer and those who receive the services: we identified several social norms.

CONCLUSIONS

The concept of governance in mental health includes standards of quality and attention centered on the patient, and incorporates the consumers of mental healthcare in the decision-making process.

OBJETIVO

Analizar la conceptualización del término gobernanza en las políticas de salud mental.

MÉTODOS

En esta revisión sistemática se analizó literatura científica publicada en el ámbito internacional durante 15 años (de 2000 hasta 2015). Las bases de datos analizadas fueron: Medline, CINAHL, PsycINFO y PubMed. Los descriptores fueron gobernanza y salud mental. Fueron incluidos artículos relevantes de acuerdo a nuestro objeto de estudio y niveles de análisis: (i) concepto de gobernanza en salud mental; (ii) proceso y espacios de decisión; (iii) actores estratégicos y de interés que intervienen en el funcionamiento del sistema de salud, y (iv) normas sociales. Se excluyeron cartas al editor, noticias, comentarios y reporte de caso, artículos incompletos y artículos que no incluyeran en su abordaje el objeto de estudio de esta revisión.

RESULTADOS

Se reportaron cinco conceptualizaciones del término gobernanza en salud mental en el ámbito de políticas de provisión y organización de servicios. Los actores fueron desde proveedores a usuarios de servicios; se identificaron diversas normas sociales.

CONCLUSIONES

El concepto de gobernanza en salud mental incorpora estándares de calidad y atención centrada en el paciente, e incluye a los usuarios en la toma de decisiones.

Type 2 diabetes and health care costs in Latin America: exploring the need for greater preventive medicine

BACKGROUND

Despite advances in medicine, health systems in Latin America are not coping with the challenges of chronic diseases. Incidence of disease and the economic burdens as a consequence have both increased in recent years. We have chosen Type 2 diabetes as an example to highlight the challenges posed by chronic diseases, in terms of the epidemiological transition and the economic burden of the demand for services to treat such problems.

DISCUSSION

Current health systems are not prepared to respond in a comprehensive manner to all phases of the natural history of the disease. There are new models of universal coverage, but resources and models of care are focused on programs aimed at healing/rehabilitation, and very sparsely at detection/prevention.

SUMMARY

In this scenario, chronic problems have alarmingly increased direct costs (medical care) and indirect costs (temporary disability, permanent disability and premature mortality). If more resources are not assigned to preventive medicine, these trends, in addition to not meeting the needs of the population, will financially collapse health systems and the patients' pockets. This Opinion piece outlines some possible changes that can be implemented to better prepare the health services in Latin American countries.