Cristianne Maria Famer Rocha, Silvia Helena De Bortoli Cassiani
In recent decades, health care networks in diff erent parts of the world have incorporated new forms of social organization that involve extensive use of technology to produce and disseminate information and are based on the autonomous, non-hierarchical and decentralized cooperation and collaboration of those within these networks. In Latin American countries, Nursing Networks were created in the 2000s on the initiative of professionals seeking to exchange knowledge and experiences. Over time this initiative gained ground with the support and leadership of the Regional Council for Nursing and Health Technicians of the Pan American Health Organization (PAHO) and, in 2007 and, in 2007, the 1 st International Nursing Network Conference was held in Toledo (Spain), during the 9 th Ibero-American Conference of the Latin American Association of Nursing Schools (ALADEFE). These networks operate as a communication strategy, stimulating cohesion and cooperation between nurses interested in developing nursing care, management, research, information and education with a view to supporting the advancement of the profession and help countries achieve universal health care coverage and access to health services. There are currently around 25 International Nursing Networks in the Americas, which together form Rede EnfAmericas and consist of more than 3000 nurses in Latin America. Information on each of these networks is available at: http://www.
The Government of Lao PDR has formulated a National Growth and Poverty Eradication Strategy (NGPES) that links sustainable economic growth, human development, reduced vulnerability and poverty alleviation; and addresses the key issues of public sector governance and public sector management. Implementation of the overall strategy focuses on rural Districts and relies on decentralized authority and beneficiary participation. Health services are a vital component of the NGPES, which reiterates the Government’s commitment to achieving the Millennium Development Goals (MDGs) and identifies improved access, equity, quality and strengthening the health workforce as key goals. Ministry of Health (MOH) supported by the World Bank (WB) is implementing the Health Services Improvement Project-Additional Financing (HSIP-AF) with the objective to increase utilization and quality of health services, particularly for the poor women and children in rural areas. The consultations with ethnic groups during project implementation is necessary in order to assess whether the design of the HSIP-AF is succeeding in responding to the needs for MNCH services of ethnic groups in project provinces, understand the extent to which free delivery, and outreach activities impact health seeking behaviour of pregnant women and new-born children from ethnic groups and ascertain based on the result of such consultations, broad community support to project activities. The principle of SWOT Analysis was adapted in the consultation methodology. The Consultations however, indicated that ethnic communities were not fully informed of and understood project benefits available to them and requirements for participation. Communication is often particular problematic in areas with language barriers. A higher degree of inclusion in terms of community participation in the identification of problems and ways of solving them would demand bottomup implementation mechanisms and more flexibility to adapt project activities and supplied resources to local needs. The health service providers should preferably be female and members of local communities in order to overcome cultural and language barriers.
Ingrid Sperre Saunes, Anna Sagan, Ingrid Sperre Saunes
Norways five million inhabitants are spread over nearly four hundred thousand square kilometres, making it one of the most sparsely populated countries in Europe. It has enjoyed several decades of high growth, following the start of oil production in early 1970s, and is now one of the richest countries per head in the world. Overall, Norways population enjoys good health status; life expectancy of 81.53 years is above the EU average of 80.14, and the gap between overall life expectancy and healthy life years is around half the of EU average. The health care system is semi decentralized. The responsibility for specialist care lies with the state (administered by four Regional Health Authorities) and the municipalities are responsible for primary care. Although health care expenditure is only 9.4% of Norways GDP (placing it on the 16th place in the WHO European region), given Norways very high value of GDP per capita, its health expenditure per head is higher than in most countries. Public sources account for over 85% of total health expenditure; the majority of private health financing comes from households out-of-pocket payments.The number of practitioners in most health personnel groups, including physicians and nurses, has been increasing in the last few decades and the number of health care personnel per 100 000 inhabitants is high compared to other EU countries. However, long waiting times for elective care continue to be a problem and are cause of dissatisfaction among the patients. The focus of health care reforms has seen shifts over the past four decades. During the 1970s the focus was on equality and increasing geographical access to health care services; during the 1980s reforms aimed at achieving cost containment and decentralizing health care services; during the 1990s the focus was on efficiency. Since the beginning of the millennium the emphasis has been given to structural changes in the delivery and organization of health care and to policies intended to empower patients and users. The past few years have seen efforts to improve coordination between health care providers, as well as an increased attention towards quality of care and patient safety issues. Overall, comparing mortality rates amenable to medical intervention suggests that Norway is among the better performing European countries. Despite having one of the highest densities of physicians in Europe, though, Norway still struggles to ensure geographical and social equity in access to health care.
Open access
Healthcare Policy and Management
Primary Care and Health Outcomes
Health Systems, Economic Evaluations, Quality of Life
In a wide-ranging look at many aspects of health care financing and delivery, the concepts of glasnost and perestroika are used as a framework for presenting ideas from the American system that may have value for European health care planners. These include more uniform approaches to data collection and cost reporting, patient outcome studies, evaluation of service and access standards, publication of information, quality assurance review, decentralization and independent institutions, prepaid group practice, demonstrations and experiments, and managed competition. Suggestions are offered for making health care systems on both sides of the Atlantic more manageable, efficient, and responsive.
Open access
Healthcare Policy and Management
Health Systems, Economic Evaluations, Quality of Life
Hans Okkels Birk, Karsten Vrangbæk, Andreas Rudkjøbing, Allan Krasnik · 7 authors
Denmark has a tradition of a decentralized health system. However, during recent years, reforms and policy initiatives have gradually centralized the health system in different ways. The structural reform of 2007 merged the old counties into fewer bigger regions, and the old municipalities likewise. The hospital structure is undergoing similar reforms, with fewer, bigger and more specialized hospitals. Furthermore, a more centralized approach to planning and regulation has been taking place over recent years. This is evident in the new national planning of medical specialties as well as the establishment of a nationwide accreditation system, the Danish Healthcare Quality Programme, which sets national standards for health system providers in Denmark. Efforts have also been made to ensure coherent patient pathways - at the moment for cancer and heart disease - that are similar nationwide. These efforts also aim at improving intersectoral cooperation. Financially, recent years have seen the introduction of a higher degree of activity-based financing in the public health sector, combined with the traditional global budgeting.A number of challenges remain in the Danish health care system. The consequences of the recent reforms and centralization initiatives are yet to be fully evaluated. Before this happens, a full overview of what future reforms should target is not possible. Denmark continues to lag behind the other Nordic countries in regards to some health indicators, such as life expectancy. A number of risk factors may be the cause of this: alcohol intake and obesity continue to be problems, whereas smoking habits are improving. The level of socioeconomic inequalities in health also continues to be a challenge. The organization of the Danish health care system will have to take a number of challenges into account in the future. These include changes in disease patterns, with an ageing population with chronic and long-term diseases; ensuring sufficient staffing; and deciding how to improve public health initiatives that target prevention of diseases and favour health improvements.
year as Switzerland's Federal Office of Public Health (FOPH) announces the annual round of health insurance premium increases, this nation of 7.5 million people lets out a collective groan. Last year, the pain was greater than usual. Concerned about the depletion of cash reserves insurers' coffers, the FOPH allowed rises of up to 14.6% for basic insurance premiums depending on the canton. That hurt. Since 1999 the Swiss have seen health insurance costs rise by 50%, according to the FOPH. From 2008-2009, the price hike was significant enough to cut 0.1% from rising household disposable income. Nadia Bouchardy does not need an announcement to know that a sizeable portion of her family's income is being spent on health. Married to an ambulance driver with two young daughters, the family has an annual income of 90 000 Swiss francs (US$ 83 000) before taxes and insurances. year around 10 500 Swiss francs (US$ 9700) or 12.5% of their income goes on health insurance and extra expenses such as dental care. Last year, Bouchardy, who is aged 41, had an operation and had to pay 10% of the costs of the operation, medicine and her stay hospital. (In out-of-pocket expenses are capped to ensure families do not suffer what is termed catastrophic expenses). We are not very happy with the health insurance system Switzerland, she says. Every year we pay more and we get less. The lists with items that are not covered anymore by the health insurance gets longer. Some items like glasses or basic medicine are not fully covered, so we have to pay these costs out of our non-health budget. So far we are lucky we have not been forced to borrow money order to pay the health bill. The Bouchardy family represents how middle-income Switzerland is being squeezed financially. They earn too much to benefit from the health subsidy received by households that spend more than about 8% of their income on premiums (the level of subsidy depends on the canton). Some 40% of households receive the subsidy--either through a lower premium or tax rebate--which is the government's mechanism for preventing the cost of insurance from unfairly disadvantaging low-income families. Professor Alberto Holly, of the University of Lausanne, is an expert Switzerland's health financing system. He points to a system that is envied for its universal coverage, its equity, standard of care and lack of waiting lists. of the strengths of the Swiss system is equity with respect to health risk and patient ratio. No one is penalized for age, gender or medical history. However, it is not totally equitable and is regressive respect to income, he says. Under the Swiss constitution, the Federal Government is responsible for managing the health insurance but has limited responsibility terms of health policy. Instead, this energetically democratic country has a decentralized system which the 26 cantons are autonomous and choose how to organize their own health care. results a wide disparity terms of insurance premiums, which are usually paid by householders, not employers. [ILLUSTRATION OMITTED] Since 1996, it has been illegal not to have basic health insurance Switzerland. There are 82 not-for-profit insurers that offer policies costing around 350 Swiss francs (US$ 325) a month per adult. No one can be turned away under this scheme, known as LAMal. Further, some 44 companies offer complementary forms of insurance, which allow benefits such as dental treatment and access to luxurious hospitals, and these companies are free to choose clients according to their risk profile. One characteristic of Switzerland's health-financing system is its expense. This is not an efficient system, says Holly, in that it has not been possible to control costs. The result is that Switzerland has the third most expensive medical system the world. …
Respected chair persons and members of the Indian Psychiatric Society (IPS), I am extremely happy and privileged to be here at the 59th Annual Conference, before an enlightened gathering to preside over the prestigious IPS. It is a rare honour and it shall be my endeavour to prove myself worthy of being chosen for this prestigious and highly coveted honour among the psychiatrists. I know my limitations but I am also aware of the great role that can be played by our society and I make bold to place before you many of my experiences in the field to exhort my fellow psychiatrists that we have a great responsibility ahead. From what I have observed during these years of my active practice, I have no doubt in my mind that the psychiatry as a profession is slowly gaining ground and in the years to come it will play an effective role in disabusing the minds of the public of their wrong and ill conceived notions. I shall endeavour my best with the cooperation and support of all my fellow psychiatrists. There were quite a few topics that I short listed for my presidential address. Finally, I zeroed in on this topic titled “MAKING PSYCHIATRY A HOUSEHOLD WORD” as I feel the art and science of psychiatry has a great deal to offer society apart from treating the “crazy people”. To make that contribution, psychiatrists must continue to tackle society's most pressing problems and also raise the visibility of psychiatry and its perceived relevance to solving a wide range of personal, social and family problems. The image of psychiatry has been tarnished in the eyes of common man, thanks to the battering that the profession has received at the hands of the media, not to mention the apathy of the policy makers. Here is an example to prove my point. At the recently held conference at Jaipur, I was walking outside the convention center when I heard two young women talking to each other. One said to the other: “My God!!!…. He's so weird! He really should see one of those psychiatrists who are walking around here.” “That's it!” I thought. “People think you have to be ‘weird’ to see a psychiatrist.” The public tends to view psychiatrists narrowly, associating us chiefly with our expertise in mental illness. In reality, psychiatrists can promote coping and wellness in addition to diagnosing and treating mental illness. Many people today have significant stress in their lives and we all undergo crises and life-stage transitions as a normal part of life. Psychiatrists can help people assess how they are coping with current stresses and develop new skills and strategies. A lot of people find that their stress levels have increased in this era of wars, terrorism and natural disasters. We, as psychiatrists, could do much more to prevent problems by helping people learn to cope and build their resilience. I wondered what it would take to normalize our public image, that set me thinking and I looked into dentistry, which changed the public image of its profession in the 1980s when it teamed up with Colgate toothpaste in a public education campaign that promoted the idea of the dental check-up. This campaign led to major changes not only in the public image of dentistry but also in the very nature and public impact of dental practice. Dentistry moved from a focus on restorative dentistry to an emphasis on preventive dentistry. We have all witnessed the success of this transition. People no longer wait for a toothache to visit the dentist and employers routinely include preventive examinations and cleanings as a dental benefit. I am envisaging a day when people similarly take appointments for a “psychological check-up” akin to a general health check -up and when that day comes one can rest assured that the community has truly embraced our profession. At these check-ups they could address such matters as their stress level, their relationships, how they are caring for their children and ageing parents and health basics such as diet, nutrition, sleep and exercise. In my 30 years of practising psychiatry, I have had a unique vantage point from which to both observe and reflect on, the process whereby psychiatry responds to urgent societal needs and how these needs thus influence the evolution of psychiatry. As I see it, the scope of psychiatric practice is expanding and diversifying into new areas. In short, the stage is set for the public's as well as policymakers and health care payers' full embrace of our field and for the true integration of psychiatry into health care, Only if we make them aware of our scientific knowledge and professional skills. DISABILITY AND MENTAL ILLNESS The burden of mental illness on health and productivity throughout the world has long been profoundly underestimated. Data developed by the massive Global Burden of Disease study conducted by the World Health Organization, the World Bank and Harvard University, reveal that mental illness, including suicide, accounts for over 15 percent of the burden of disease in established market economies, such as the United States. This is more than the disease burden caused by all cancers.[1] This Global Burden of Disease study developed a single measure to allow comparison of the burden of disease across many different disease conditions by including both death and disability. This measure was called Disability Adjusted Life Years (DALYs). DALYs measure lost years of healthy life regardless of whether the years were lost to premature death or disability. The disability component of this measure is weighted for severity of the disability. For example, disability caused by major depression was found to be equivalent to blindness or paraplegia whereas active psychosis seen in schizophrenia produces disability equal to quadriplegia. The World Health Organization's Global Burden of Disease study reported that mental disorders comprise four of the top five sources of premature death and disability in 15-44 year olds in the Western world. Using the DALYs measure, major depression ranked second only to ischemic heart disease in magnitude of disease burden in established market economies. Schizophrenia, bipolar disorder, obsessive-compulsive disorder, panic disorder and post-traumatic stress disorder also contributed significantly to the total burden of illness attributable to mental disorders. The projections show that with the aging of the world population and the conquest of infectious diseases, psychiatric and neurological conditions could increase their share of the total global disease burden by almost half, from 10.5 percent of the total burden to almost 15 percent in 2020. Major depression is the leading cause of disability (measured by the number of years lived with a disabling condition) worldwide among persons age 5 and older. For women throughout the world as well as those in established market economies, depression is the leading cause of DALYs. In established market economies, schizophrenia and bipolar disorder are also among the top 10 causes of DALYs for women. The above stated facts, hopefully will be an eye-opener for all the concerned parties. From our side, we should do all that we can in whichever small way to reduce this enormous disease burden. My presidential address, I hope, will serve as an initiative to formulate ways and means to achieve this objective. IMPEDIMENTS IN MAKING PSYCHIATRY A HOUSEHOLD WORD There have been a lot of impediments in making psychiatry a household word. The main culprits are the age old concept of mind-body dualism and lack of integration of mental health care into primary health care, stigma, psychiatrists themselves, the apathy of the policy makers, failure of Consultation - Liaison psychiatry and media. I will make an attempt to briefly detail what resulted in these hindrances and some plausible solutions to overcome them. MIND-BODY DUALISM The earlier concepts of health glorifying mind-body dualism are bankrupt now and mind-body dualism has an enormous negative impact on our health care system. Because of it, our health care system does not systematically attend to the many psychological risk factors for both morbidity and mortality and it virtually ignores the psychosocial pathways that lead to unnecessary utilization of medical and surgical services. In addition, the psychological impact of a medical illness is not well by the health care is the that many people from a illness have psychological illness. Finally, the share of mental health problems are by primary care take a at some of the of the top health risk factors are diet, suicide, and of the leading causes of death have significant At as much as of all to primary care medical are for problems with a psychological those who with mental health problems and those who or for problems with a psychological component those with such as those with and those with medical one study found that than of had and A number of have that health care the utilization of medical and surgical The of people mental health are for by medical with in mental is a of the of psychological in a wide range of health including both and disease system and and In addition to being these are than across a wide of and including and that mental health can be in primary health care with and on but it is whether this is true of for persons with and mental illness. There is a long of in for persons with mental disorders that would be a single system of care that to medical and mental health services. Many mental health problems are seen as and thus the general health is a natural point for and treating mental health problems. Many also continue to find care for psychiatric problems more when by their primary care The and mental health care in an system also a that common and mental disorders will be and that and among will reduce and common of of The concept of a number of that are at the of health care them are the and A significant is that not be in a highly system of As medical are to be more and they have to to each and to know the and to the of problems that Because with conditions are and to their and they will not be with disabling mental illness will have to with who more and to deal with by and of these problems has but they are not can be to and with mental but this is a and can be to increase the of health care to disabling illness, but this must with many in an of new and practice by of public and is but effective in this objective. the that mental health for ill can be into the general health a and that are on at for the The is for persons with more and disorders. - A Psychiatrists should have been seen as and as an as they are so few in In are only psychiatrists for a population of over of psychiatrists to the of is which is quite Psychiatrists are seen in negative by the of the have been are seen as disease and not are seen as being seen as are seen as a on the most in the are seen as the to as not in and thus could them of their and being a are seen as making a a to their view are seen as not scientific psychiatrists in and are seen as are seen as only and not the have been up over and mental health of of and of including have contributed to these of by help has matters The of and of view has it from the the of psychiatrists themselves, the to formulate and not the focus from negative to and not our have it We of the of mental and disease in the but are not to prevent We of mental health but do not or we do not have or for mental health at the professional or We of well being and on The and do not have psychiatrists as the but are to our We would be to of and for but not in at the to preventive and health strategies. We can be if we are to The community of which is a part would be to allow us to lead if we have for and which are effective and We would have to hands with and community with to long solutions for the population than at a of only those who have extremely and We to be for the mental health needs of the and not only the for It is only that psychiatrists in and psychiatry in general would its place and a - PSYCHIATRY of the to with are and are for the cooperation and for effective is a on the part of some to the place of factors in the of the This be to and conditions that are to observe and or to is that mental health have long had a for The or at was in the many people the field in to their psychological problems. it and such an are to The that be and the of psychiatric The on of or at in many is with and One by many including psychiatrists, is that a will come in that the has a more disorder than the one and that the is on should the for psychiatric the the moved to this is not an the two care This is to the of if the psychiatric The should that lack expertise outside of and with psychiatrists is a that must be over a of the most here is to make but when called for an This reduce by the and allow to up in the psychiatrists have a for diagnosing as or the that they be to have some psychiatric problems of their The is not as many psychiatrists and mental health in make of fellow them or their A general way to many of these is for the to be in and to the of and medical and should that the is a in which the will have the The of with psychological problems in with should be and not The should not be or or that will be as very by the He should also be aware of the of the and than a take it or it I have found that with when I am by and does not medical the can find ways to make to the medical He should with and take the of these It is also to attend medical The of knowledge of one by psychiatrists and can during before such and can lead to the also the with an to the and of with their and AND MENTAL of people with mental disorders has throughout It is by to or or people with mental disorders such as It to and and to and It the public from and to In its most and in and it people of their and with their full in for in from the mind and by of in the of the mental health system in the United from the of an influence on and in the world. In the the public mental illness as a and an of mental illness. were not to as when with of who would have been said to be ill to the professional of the The public was not at mental illness from and and to see only of mental illness. illness great social stigma, with of and a that had scientific of mental illness. the in knowledge not social in comparison with the the public's of mental illness more This was true among those who mental illness to include psychosis view held by of the The also how of those with mental illness by The public was more to an with schizophrenia as mental illness than an with This people with mental disorders truly more some public but the of is The risk of is from those who have who have a mental disorder as well as a There is a small in risk of from with mental disorders if they are with their the risk of is much for a than for a family or who is to the with mental In is very risk of or to a from with an who has a mental Because the is to whether who is has of these or in the natural is to be to this all in the of mental disorders to the total of in society is Because most people should have to from those with mental illness, in its most is of so focus on and One of found that the public's and mental illness and people to from those with mental disorders. of the common with from psychiatric disorders are listed of mental illness of of It is not that psychiatry has a in its to mental illness, but that it has also to address its current of the psychiatry in their There is a of psychiatric on and and a to the are some in psychiatry, which are in minds and a great deal to the in psychiatry. A IN PSYCHIATRY and of and and for and help for mental disorders of all people with mental disorders do not the of mental health is among the many that people from to be in in to or and for mental disorder of is in the public's to for mental health services. to for mental health or has been public held in of the public a to for for with mental such as schizophrenia and than for conditions such as and the public to support for its support the that or would be In the of the to for mental illness is to be The public for mental disorders that for There is no or single to the with mental illness. was to with increased knowledge of mental illness, but the in some ways over the years of mental illness by to knowledge be to public is to that negative mental illness can be by on the and mental to of public education and with persons with mental illness and societal way to is to find causes and effective for mental disorders. this to be of and to are of mental disorders for which has The of an infectious and of led to the of when was to a and with was the was in the developed world. with had been in mental in the before its was no one has the of public these conditions over the and of this disease of its these also a more that the mental health field was when causes and were As were each was from the mental health field to medical For over of was moved to and in and over mental disorders was moved to The of this to is that mental health field over the years the for mental disorders was This the mental health field to by their medical that psychiatry was not part of and that psychiatric practice on and that for disorders them or the mental disorders not only but be by to mental health care only those conditions causes or To point this is not to that in mental health should be should be and The here is to some of the of the the general health and mental health that will continue to effective for mental disorders to be an effective people that mental disorders are not the of or will but are that are to much of the negative to to to be developed and science has much to to the and of As a in public should People should to should more to its most they should more to the that are the of this mental health and mental illness are part of the of health and they are a for all to would be the of the to who to mental illness regardless of from the of has been a in the success of on and AND MENTAL and medical profession have been in in the media. psychiatry and psychiatrists have not been so than the profession has been by media. illness has been the for and which the in the minds of the public mental illness and the the old some of the have psychiatry in extremely Psychiatrists are as who and for the most are not in their of mental illness. as as if is not in the minds of The is not in its of psychiatry and psychiatrists. I an by the which in the on the the no longer as a the Indian Psychiatric to do of that and it a measure of the of the profession of psychiatry in if you to a This of will the most from of psychiatric have been some of mental illness, the and both of which have been into the It is to that these have been well and psychiatrists are in a of will well for the mental health profession and for psychiatrists as a There are no to tackle this It is for all of as psychiatrists, to a to this It is our responsibility to more in the mental illness. For we should no as the of this can be of you must have seen in the and for public health causes you seen psychiatry in which I think of a when mental illness and the impact that will have on the common I feel that is a and we in are some to that I all members of to the and come more with a and the psychiatry and do all that you can to the image of psychiatry, which is for the public to embrace our IN PSYCHIATRY In this I would briefly some of the success in the field of mental The that come to my mind are the by the psychiatrists in the of the The has a lot of for psychiatry and psychiatrists. This is significant as this of will a long way in making the public more and in psychiatry. The by psychiatrists during the and and the so called in the Indian of and is a in point. a long way in the with the policy and the public I also the of and that is on in the and I also the of all the psychiatrists who have in the community mental illness and to the PSYCHIATRY IN must a with a as its more than psychiatry at the of a of has such a of as psychiatry This of both and is our and we must not up one for the of the other. health must more for Indian and psychiatry do not develop in a but they develop in a social psychiatric of and and to are all on This is not a very for a with its no has the of the and the of mental the way we have in we continue to concepts and these are in our We to on these and a truly to mental from such an will more with ground in of is its and psychological well being of the community for a and of the and we as mental health should that MENTAL I of this has a to a and an which to an of and family community and care or or in the that of mental health care with primary health care into the and of mental illness and into the of and effective and overcome the with mental illness public and Health to effective must be the for people with mental illness as for medical to mental health care should be across including the and to be with and should be to and to an of psychiatrists, to the current and needs of the population I psychiatry as my profession with a lot of and I am very happy I do feel to the way in which psychiatrists are in the society A day should come when we should be to that am a and in are psychiatrists and are psychiatry. This will if we to offer solutions to a wide range of personal, family and pressing social in and and the of in some of our role in We should make the that their health the to their should be on long solutions for the population than at a of only those who are extremely and We should make the community what we are is what our minds are the which the To this the with a the is a the mind is so to it is that we it to the is the medical profession to the with such emphasis on the In this who the of by in the is by and has to a to at the of the mind and all that it has I a day not in when people make appointments for general health check We to be for the mental health needs of the community and not only the for In these of I would to the the that you to see in the we play our role as psychiatrists, I a when psychiatry in general and psychiatrists in would their place and a household word. My to all of you is that each one of you needs to in this of a household one and all IPS.
OBJECTIVE: The results of an evaluative longitudinal study, which identified the effects of health care decentralization on health financing in Mexico, Nicaragua and Peru are presented in this article. METHODS: The methodology had two main phases. In the first, secondary sources of data and documents were analyzed with the following variables: type of decentralization implemented, source of financing, funds for financing, providers, final use of resources, mechanisms for resource allocation. In the second phase, primary data were collected by a survey of key personnel in the health sector. RESULTS: Results of the comparative analysis are presented, showing the changes implemented in the three countries, as well as the strengths and weaknesses of each country in matters of financing and decentralization. CONCLUSIONS: The main financing changes implemented and quantitative trends with respect to the five financing indicators are presented as a methodological tool to implement corrections and adjustments in health financing.
Stephen T. Miller, Roger Vander Zwagg, Melanie Joyner, John W. Runyan
Observations of a publicly-financed system for the medical care of a large number of persons with chronic diseases have been made over seven years. The system combines decentralized, nurse-staffed neighborhood clinics, operated by a public health department, with a central referral clinic for consultations and the management of complicated problems. After seven years in the chronic disease program 55% of 1,004 patients with diagnoses of diabetes mellitus, hypertension, and cardiac diseases were still receiving care, 19% had died, and 26% had been lost to the program. In the seventh year, the mean diastolic blood pressure in hypertensives was 84 mm Hg and the mean serum glucose in diabetics was 203 mg/dl. For the group under care, hospital days/1000/year were 74% of the rate during the year before referral to the program and out-patient visits/1000/year were approximately the same as before referral. However, two-thirds of the visits, formerly made to a public hospital, were now being made to neighborhood clinics. The system appears to be an effective method of providing medical services for persons who formerly used the public hospital as their source of outpatient care.
Open access
Primary Care and Health Outcomes
Chronic Disease Management Strategies
Health Systems, Economic Evaluations, Quality of Life