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Since the 1970s the Member States of the World Health Organization have pledged themselves to the goal of "health for all" and to broadening the coverage, quality, and efficiency of the health care services they provide. In spite of that commitment, there has been little progress in the conceptual understanding and development of indicators to help evaluate the characteristics of the populations with and without coverage, as well as in knowing the relationship between coverage and the characteristics of health care services. Most of the countries of Latin America and the Caribbean are in the process of reforming their health care sectors, and they could benefit from new insight in these areas. To help build that knowledge, this study looked at the population without health care services in the countries of Latin America and the Caribbean, using four indicators: vaccination for poliomyelitis, tuberculosis (BCG) vaccination, prenatal care for pregnant women, and childbirths attended by a health professional. In 1995, out of a total population of 474 million in Latin America and the Caribbean, the number without coverage was a minimum of 40 million, calculated using the indicator of BCG vaccination coverage. Using the indicator for prenatal care, the number of persons without health care coverage was 137 million. By analyzing these four indicators in each country, it is possible to develop health services profiles that would suggest different health sector reform policies. The study also analyzed some characteristics of the structure and coverage of the health systems in 46 countries and territories and their correlation with indicators of result or impact. Five indicators of health care resources were used, along with ten indicators of coverage and seven indicators of result or level of health achieved. A statistically significant association (P = 0.05) was found between the coverage of prenatal care and professionally attended childbirths and the results as measured by rates of infant mortality and maternal mortality.

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This report describes a management information system (MIS) designed by PAHO's Health Systems and Services Division in collaboration with technical experts from a number of different countries. This MIS, a methodology currently used at the institutional or national level in more than 21 countries of the Americas, is a strategic and practical instrument that is easy to apply, interpret, and use, and whose purpose is to facilitate fundamental changes in health management. Based on the management concept that inputs, processes, and outputs are quantifiable, the MIS places special emphasis on health system productivity, an essential condition for achieving health coverage that is both adequate and equitable.

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The objective of this research was to study the relationship between structural characteristics of hospitals (number and types of personnel, size of hospital units, and specialization of services) and health care outcomes, as measured by in-hospital mortality and average weight gain (AWG) in children under 1 year diagnosed with acute diarrheal disease (ADD). The study was carried out at 14 nonprofit acute-care hospitals located in greater Buenos Aires. The units of analysis were 23 pediatric wards (1,718 beds). The study population included 3,434 ADD cases (15.6% of total ward discharges). Various generalized linear models were used in the analysis, and the findings were adjusted according to the patients' age, severity of illness, and nutritional status. The acuteness of the disease investigated was verified. Of the study patients, 80.4% were 6 months old or younger and 40.1% suffered from some nutritional deficiency. According to an analysis of 32% of the cases, age was inversely associated with severity of illness, grade I nutritional deficiency, and in-hospital mortality, and directly associated with AWG. The adjusted case-fatality rates for the wards studied were different. Analysis of the relationship between the structural variables and the outcomes revealed that the number of nurses was inversely related to in-hospital mortality, while ward specialization and professional experience were directly related to AWG. These associations were statistically significant. There was a direct, statistically significant relationship between number of hospital staff and in-hospital mortality. Structural variables measuring the physicians' commitment to the institution, ward size, and hospital size were not found to be related to the outcomes. These findings can provide useful support for decision-making about hospital resource allocation, as well as about hospital organization and management. There is a need for more in-depth study of the relationship between the structure of hospitals and health systems and health care outcomes.

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This article gives a general overview of present local health systems and their possible future. It reviews the background that led the countries of the Americas to make plans to transform their national health systems and points out the key role played by local health systems in this undertaking. In addition to summarizing the basic conditions necessary for setting up a local health system, the authors define these local systems as instruments for decentralization of the State and the expression of democratic action. They consider it an imperative for the 1990s to ensure that the services are improved in terms of equity and quality, democratization and social participation, economic and social development and transformation, and efficiency and use of appropriate technology. Stress is placed on the comprehensive concept of health, well-being, and development, as well as on health promotion by the population itself, while taking into account the responsibilities that correspond to national sector agencies and to local communities.

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