Management commitments and primary care: another lesson from Costa Rica for the world?

(In)Equity and Primary Health Care: The Case of Costa Rica and Panama

The 1970s marked a significant opportunity for improving primary health care globally. Yet, political will and widescale investment to achieve "health for all" vastly diverged in countries across the Americas in the decades that followed. Distinct ideologies and models of health care emerged following commitments to social investment, equity, and community participation at Alma-Ata. In the 1970s, Costa Rica scaled up its national health system and increased broad social investment. In Panama, the establishment of the Ministry of Health in 1969 coincided with broad state investment in primary health care, yet the emergence of neoliberal models based on efficiency and privatization in the decades that followed undermined efforts toward health equity. Models of state-sanctioned investment and policies diverged in their framing of ideas about the right to health, characterized by broad social investment in Costa Rica addressing the structural factors of ill health versus financing stratified health systems and select biomedical interventions in Panama. These case studies describe the historical, political, economic, and social dimensions that account for the distinct framing of ideas about right to health and health equity and enabled Costa Rica to diverge as a country with one of the most effective health systems in the region.

In defence of a single body of clinical and public health, medical ethics

BACKGROUND

Since some form of dual clinical/public health practice is desirable, this paper explains why their ethics should be combined to influence medical practice and explores a way to achieve that.

MAIN TEXT

In our attempt to merge clinical and public health ethics, we empirically compared the individual and collective health consequences of two illustrative lists of medical and public health ethical tenets and discussed their reciprocal relevance to praxis. The studied codes share four principles, namely, 1. respect for individual/collective rights and the patient's autonomy; 2. cultural respect and treatment that upholds the patient's dignity; 3. honestly informed consent; and 4. confidentiality of information. However, they also shed light on the strengths and deficiencies of each other's tenets. Designing a combined clinical and public health code requires fleshing out three similar principles, namely, beneficence, medical and public health engagement in favour of health equality, and community and individual participation; and adopting three stand-alone principles, namely, professional excellence, non-maleficence, and scientific excellence. Finally, we suggest that eco-biopsychosocial and patient-centred care delivery and dual clinical/public health practice should become a doctor's moral obligation. We propose to call ethics based on non-maleficence, beneficence, autonomy, and justice - the values upon which, according to Pellegrino and Thomasma, the others are grounded and that physicians and ethicists use to resolve ethical dilemmas - "neo-Hippocratic". The neo- prefix is justified by the adjunct of a distributive dimension (justice) to traditional Hippocratic ethics.

CONCLUSION

Ethical codes ought to be constantly updated. The above values do not escape the rule. We have formulated them to feed discussions in health services and medical associations. Not only are these values fragmentary and in progress, but they have no universal ambition: they are applicable to the dilemmas of modern Western medicine only, not Ayurvedic or Shamanic medicine, because each professional culture has its own philosophical rationale. Efforts to combine clinical and public health ethics whilst resolving medical dilemmas can reasonably be expected to call upon the physician's professional identity because they are intellectual challenges to be associated with case management.

Objectives, methods, and results in critical health systems and policy research: evaluating the healthcare market

BACKGROUND

Since the 1980s, markets have turned increasingly to intangible goods - healthcare, education, the arts, and justice. Over 40 years, the authors investigated healthcare commoditisation to produce policy knowledge relevant to patients, physicians, health professionals, and taxpayers. This paper revisits their objectives, methods, and results to enlighten healthcare policy design and research.

MAIN TEXT

This paper meta-analyses the authors' research that evaluated the markets impact on healthcare and professional culture and investigated how they influenced patients' timely access to quality care and physicians' working conditions. Based on these findings, they explored the political economic of healthcare. In low-income countries the analysed research showed that, through loans and cooperation, multilateral agencies restricted the function of public services to disease control, with subsequent catastrophic reductions in access to care, health de-medicalisation, increased avoidable mortality, and failure to attain the narrow MDGs in Africa. The pro-market reforms enacted in middle-income countries entailed the purchaser-provider split, privatisation of healthcare pre-financing, and government contracting of health finance management to private insurance companies. To establish the materiality of a cause-and-effect relationship, the authors compared the efficiency of Latin American national health systems according to whether or not they were pro-market and complied with international policy standards. While pro-market health economists acknowledge that no market can offer equitable access to healthcare without effective regulation and control, the authors showed that both regulation and control were severely constrained in Asia by governance and medical secrecy issues. In high-income countries they questioned the interest for population health of healthcare insurance companies, whilst comparing access to care and health expenditures in the European Union vs. the U.S., the Netherlands, and Switzerland. They demonstrated that commoditising healthcare increases mortality and suffering amenable to care considerably and carries professional, cultural, and ethical risks for doctors and health professionals. Pro-market policies systems cause health systems inefficiency, inequity in access to care and strain professionals' ethics.

CONCLUSION

Policy research methodologies benefit from being inductive, as health services and systems evaluations, and population health studies are prerequisites to challenge official discourse and to explore the historical, economic, sociocultural, and political determinants of public policies.

Neo-Hippocratic healthcare policies: professional or industrial healthcare delivery? A choice for doctors, patients, and their organisations

BACKGROUND

Ethical medical practice requires managing health services to promote professionalism and secure accessibility to care. Commercially financed and industrially managed services strain the physicians' clinical autonomy and ethics because the industry's profitability depends on commercial, clinical standardisation. Private insurance companies also reduce access to care whilst fragmenting and segmenting health systems. Against this background, given the powerful, symbolic significance of their common voice, physicians' and patients' organisations could effectively leverage together political parties and employers' organisations to promote policies favouring access to professional care.

MAIN TEXT

To provide a foundation for negotiations between physicians' and patients' organisations, we propose policy principles derived from an analysis of rights-holders and duty-bearers' stakes, i.e., patients, physicians and health professionals, and taxpayers. Their concerns are scrutinised from the standpoints of public health and right to health. Illustrated with post-WWII European policies, these principles are formulated as inputs for tentative action-research. The paper also identifies potential stumbling blocks for collective doctor/patient negotiations based on the authors' personal experience. The patients' concerns are care accessibility, quality, and price. Those of physicians and other professionals are problem-solving capacity, autonomy, intellectual progress, ethics, work environment, and revenue. The majority of taxpayers have an interest in taxes being progressive and public spending on health regressive. Mutual aid associations tend to under-estimate the physician's role in delivering care. Physicians' organisations often disregard the mission of financing care and its impact on healthcare quality.

CONCLUSION

The proposed physicians-patients' alliance could promote policies in tune with professional ethics, prevent European policies' putting industrial concerns above suffering and death, bar care financing from the ambit of international trade treaties, and foster international cooperation policies consistent with the principles that inspire the design of healthcare policies at home and so reduce international migration. To be credible partners in this alliance, physicians' associations should promote a public health culture amongst their members and a team culture in healthcare services. To promote a universal health system, patients' organisations should strive to represent universal health interests rather than those of patients with specific diseases, ethnic groups, or social classes.

[Validity and consistency of the entries in the Health Care Network's patient records for the use of services by the elderly]

The scope of this article is to verify the validity and consistency of entries in medical records and self-reporting about the use of the health services by elderly users of the Health Care Network. It involved a cross-sectional, population-based observational study. Entries in medical, dental, home visit, referral to the secondary sector and hospitalization appointment records for the years 2015 and 2016 were evaluated. The concordance percentage, Kappa coefficient, sensitivity, specificity and predictive values for each item were also analyzed. The highest concordance percentage (81.93%) with a significant Kappa coefficient (p = 0.03) was for hospitalization. The dentistry appointments revealed a higher Kappa coefficient (k = 0.271) with significance of p=0.01. The analyses showed high specificity in the hospitalization records (83%), and a greater sensitivity for home visits (74%). Positive predictive values were low for hospitalization (8%), and negative predictive values were low for medical appointments (17%). The low concordance between the use of the self-reported health service and entries in medical records highlight one of the possible causes of the fragmentation in continuity of care.

[Factors associated with preventive health services search among Brazilian adults: National Health Survey, 2013]

The objective of this article is to examine factors associated with preventive health services search among Brazilian adults. Sample included adults participants from the National Health Survey (2013), that had reported any health service search in prior 15 days, categorized into "treatment/diagnosis" or "preventive" service. Exploratory variables included sex, age, race, marital status, education, household situation, private health plan enrolment and time of FHS enrolment. Associations were verified by prevalence ratios (PR), estimated using robust Poisson regression, considering complexity of sampling parameters. Final sample included 32,377 individuals, 12,94% have searched "preventive" services. Preventive search was more often among women and less often among the older adults, those not living with partner, with less education. Having private health plan was associated with less preventive services search. FHS enrolment were not associated with preventive search. By conclusion, although some efforts and the importance of preventive actions, most of individuals search for treatment services.

Primary Health Care That Works: The Costa Rican Experience

Long considered a paragon among low- and middle-income countries in its provision of primary health care, Costa Rica reformed its primary health care system in 1994 using a model that, despite its success, has been generally understudied: basic integrated health care teams. This case study provides a detailed description of Costa Rica's innovative implementation of four critical service delivery reforms and explains how those reforms supported the provision of the four essential functions of primary health care: first-contact access, coordination, continuity, and comprehensiveness. As countries around the world pursue high-quality universal health coverage to attain the Sustainable Development Goals, Costa Rica's experiences provide valuable lessons about both the types of primary health care reforms needed and potential mechanisms through which these reforms can be successfully implemented.