RESUMEN
The US healthcare systems is struggling to keep pace with increasing demand, as the burden faced by providers and healthcare organizations expands. While care delivery models continue to evolve in the post-reform era, many barriers stemming from capacity constraints, regulation, shortages of manpower and, misallocation of resources persist. In this paper, we provide an analysis of unmet demand in the US system healthcare system. We contribute a deep dive of the literature to elucidate the reasons for which imbalanced and unmet demand, including the heavy use of the emergency department for non-emergent conditions, continues to burden healthcare organizations. We use these findings to motivate recommendations about how to address critical shortcomings in order to better address the needs of patients with both emergent and non-emergent conditions.
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Servicio de Urgencia en Hospital/estadística & datos numéricos , Necesidades y Demandas de Servicios de Salud/normas , Aceptación de la Atención de Salud/estadística & datos numéricos , Servicio de Urgencia en Hospital/organización & administración , Reforma de la Atención de Salud/normas , Reforma de la Atención de Salud/estadística & datos numéricos , Necesidades y Demandas de Servicios de Salud/estadística & datos numéricos , Humanos , Patient Protection and Affordable Care Act/organización & administración , Patient Protection and Affordable Care Act/estadística & datos numéricosRESUMEN
BACKGROUND: This study examines the expansion of health insurance coverage in Massachusetts under state health reform as a natural experiment to investigate whether expanded insurance coverage reduced the likelihood of advanced stage colorectal cancer (CRC) and breast cancer (BCA) diagnosis. METHODS: Our study populations include CRC or BCA patients aged 50-64 years observed in the Massachusetts Cancer Registry and Surveillance Epidemiology and End Results (SEER) registries for 2001-2013. We use difference-in-differences regression models to estimate changes in the likelihood of advanced stage diagnosis after Massachusetts health reform, relative to comparison states without expanded coverage (Connecticut, New Jersey, Georgia, Kentucky, and Michigan). RESULTS: We find some suggestive evidence of a decline in the proportion of advanced stage CRC cases. Approximately half of the CRC patients in Massachusetts and control states were diagnosed at advanced stages pre reform; there was a 2 percentage-point increase in this proportion across control states and slight decline in Massachusetts post reform. Adjusted difference-in-difference estimates suggest a 3.4 percentage-point (P=0.005) or 7% decline, relative to Massachusetts baseline, in the likelihood of advanced stage diagnosis after the reform in Massachusetts, though this result is sensitive to years included in the analysis. We did not find a significant effect of reform on BCA stage at diagnosis. CONCLUSIONS: The decline in the likelihood of advanced stage CRC diagnosis after Massachusetts health reform may suggest improvements in access to health care and CRC screening. Similar declines were not observed for BCA, perhaps due to established BCA-specific safety-net programs.
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Neoplasias de la Mama/diagnóstico , Neoplasias de la Mama/patología , Neoplasias Colorrectales/diagnóstico , Neoplasias Colorrectales/patología , Reforma de la Atención de Salud/estadística & datos numéricos , Detección Precoz del Cáncer/estadística & datos numéricos , Femenino , Humanos , Cobertura del Seguro/estadística & datos numéricos , Seguro de Salud/estadística & datos numéricos , Masculino , Massachusetts/epidemiología , Persona de Mediana Edad , Estadificación de Neoplasias , Programa de VERFRESUMEN
Health inequalities are marked in Chile. To address this situation, a health reform was implemented in 2005 that guarantees acute myocardial infarction (AMI) health care for the entire population. We evaluated if the health reform changed AMI early and long-term survival rates by hospital provider (public/private) using a longitudinal population-based study of patients ≥15 years with a first AMI in Chile between 2002 and 2011. Time trends and early (within 28 days) and long-term (29-365 days) survival by age were assessed. We identified 59,557 patients: median age of 64 years; 68.9% men; 83.2% treated at public hospitals; 74.4% with public insurance. Early and long-term case-fatality was higher at public hospitals (14.6% vs 9.3%; P < .001 and 5.8% vs 3.3%; P < .001, respectively). There was a higher annual increase for early and long-term survival in public hospitals, 0.008 percentage points (95% CI: 0.006, 0.009; P < .0001) and 0.03 (0.002, 0.003; P < .0001), than in private hospitals, 0.0002 (95% CI: -0.0001, 0.005; P = .10) and 0.002 (95% CI: 0.0007, 0.003; P = .004), respectively. Being served at public hospitals affected early and long-term survival, especially in patients <70 years: hazard ratio was 2.01 (95% CI: 1.77, 2.28) and 3.11 (2.41, 4.01), respectively. Therefore, even if inequalities persist, there was a higher increase in early and long-term survival in public versus private hospitals.
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Reforma de la Atención de Salud/estadística & datos numéricos , Disparidades en el Estado de Salud , Hospitales Privados/estadística & datos numéricos , Hospitales Públicos/estadística & datos numéricos , Infarto del Miocardio/mortalidad , Distribución por Edad , Anciano , Anciano de 80 o más Años , Chile/epidemiología , Femenino , Humanos , Estimación de Kaplan-Meier , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Distribución por SexoRESUMEN
OBJECTIVE:: To analyze the process of design and implementation of AUGE. MATERIALS AND METHODS:: Literature review of pre-reform background, architecture design and implementation process of reform AUGE and complementary interviews to eight informants involved in its development. RESULTS:: The assessment of health equity was a key element in pre-reform, there are four fundamental dimensions in the design, and the implementation has nine phases. CONCLUSION:: The results show AUGE strengthening public health by investing in equipment for cost-effective treatments, and also through clinical guidelines that standardize and guide the management of health professionals with patients.
Asunto(s)
Reforma de la Atención de Salud , Cobertura Universal del Seguro de Salud , Chile , Costos de la Atención en Salud/estadística & datos numéricos , Reforma de la Atención de Salud/economía , Reforma de la Atención de Salud/legislación & jurisprudencia , Reforma de la Atención de Salud/estadística & datos numéricos , Prioridades en Salud , Servicios de Salud/tendencias , Accesibilidad a los Servicios de Salud , Humanos , Cobertura Universal del Seguro de Salud/economía , Cobertura Universal del Seguro de Salud/legislación & jurisprudencia , Cobertura Universal del Seguro de Salud/estadística & datos numéricosRESUMEN
Resumen: Objetivo: Analizar el proceso de diseño e implementación del Acceso Universal con Garantías Explícitas (AUGE). Material y métodos: Revisión de bibliografía sobre antecedentes prerreforma, arquitectura de diseño y proceso de implementación de la reforma AUGE y, complementariamente, entrevistas a ocho informantes involucrados en su desarrollo. Resultados: La valoración de la equidad en la salud fue un elemento clave prerreforma; existen cuatro dimensiones fundamentales en el diseño y nueve fases en la implementación. Conclusión: Los resultados del AUGE muestran un fortalecimiento en la salud pública por la inversión en equipamiento para tratamientos costo-efectivos; también por las guías clínicas que estandarizan y orientan la gestión de los profesionales de la salud con los pacientes.
Abstract: Objective: To analyze the process of design and implementation of AUGE. Materials and methods: Literature review of pre-reform background, architecture design and implementation process of reform AUGE and complementary interviews to eight informants involved in its development. Results: The assessment of health equity was a key element in pre-reform, there are four fundamental dimensions in the design, and the implementation has nine phases. Conclusion: The results show AUGE strengthening public health by investing in equipment for cost-effective treatments, and also through clinical guidelines that standardize and guide the management of health professionals with patients.
Asunto(s)
Humanos , Reforma de la Atención de Salud/economía , Reforma de la Atención de Salud/legislación & jurisprudencia , Reforma de la Atención de Salud/estadística & datos numéricos , Cobertura Universal del Seguro de Salud/economía , Cobertura Universal del Seguro de Salud/legislación & jurisprudencia , Cobertura Universal del Seguro de Salud/estadística & datos numéricos , Chile , Costos de la Atención en Salud/estadística & datos numéricos , Prioridades en Salud , Servicios de Salud/tendencias , Accesibilidad a los Servicios de SaludAsunto(s)
Atención a la Salud/economía , Seguro de Salud , Patient Protection and Affordable Care Act , Atención a la Salud/estadística & datos numéricos , Reforma de la Atención de Salud/estadística & datos numéricos , Humanos , Seguro de Salud/clasificación , Seguro de Salud/economía , Patient Protection and Affordable Care Act/estadística & datos numéricos , Estados UnidosRESUMEN
OBJECTIVES: To assess health coverage among Mexicans with US migration experience, before and after the implementation of Mexico's universal health care program, Seguro Popular. METHODS: I used data from the 2000 and 2010 Mexican Censuses to generate nationally representative estimates of health coverage among working-age Mexicans by migrant status. RESULTS: In 2000, before the implementation of Seguro Popular, 56% of Mexicans aged 15 to 60 years with no recent US migrations were uninsured compared with 80% of recently returned migrants. By 2010, the proportion uninsured declined from 56% to 35% (-38%) among nonmigrants and from 80% to 54% (-33%) among return migrants. CONCLUSIONS: Seguro Popular has increased health coverage among Mexican return migrants, but they remain substantially underinsured. A creative and multifaceted approach likely will be needed to address Mexican immigrants' health care needs.
Asunto(s)
Reforma de la Atención de Salud/estadística & datos numéricos , Americanos Mexicanos , Migrantes/estadística & datos numéricos , Cobertura Universal del Seguro de Salud/estadística & datos numéricos , Adolescente , Adulto , Femenino , Humanos , Masculino , México , Persona de Mediana Edad , Estados Unidos , Adulto JovenRESUMEN
BACKGROUND: Patients with venous thromboembolism (VTE) require access to comprehensive physician and pharmacy benefits to prevent recurrence and hemorrhage. Before 2006, Massachusetts provided these benefits through a program restricted to safety net hospitals called Free Care. Providing portable health insurance through Massachusetts health reform could improve outcomes for uninsured with VTE but its cost-effectiveness is unknown. METHODS AND RESULTS: We constructed a Markov decision analysis model comparing our conceptualization of the Massachusetts health reform (health reform strategy) to no health reform strategy for a patient beginning warfarin for new episode of VTE. In the model, a patient may develop recurrent VTE or develop hemorrhage or stop warfarin after 6 months if no event occurs. To measure effectiveness, we analyzed laboratory data from Boston Medical Center, the largest safety net hospital in Massachusetts. Specifically, we measured the probability of having a subtherapeutic warfarin level for patients newly insured compared with those on Free Care prereform adjusting for secular trends. To calculate inpatient costs, we used the Health Care Utilization Project. We then calculated the incremental cost-effectiveness ratio for the health reform strategy adjusted to 2014 USD per quality-adjusted life-year (QALY) and performed sensitivity analyses. The health reform strategy cost less and gained more QALYs than the no health reform strategy. Our result was most sensitive to the odds that Health Reform protected against a subtherapeutic warfarin level, the cost of Health Reform, and the percentage of total health care costs attributable to VTE in Massachusetts. CONCLUSION: The health reform strategy cost less and was more effective than the no health reform strategy for patients with VTE.
Asunto(s)
Anticoagulantes/administración & dosificación , Pacientes no Asegurados/estadística & datos numéricos , Tromboembolia Venosa/prevención & control , Warfarina/administración & dosificación , Anticoagulantes/efectos adversos , Anticoagulantes/economía , Análisis Costo-Beneficio , Reforma de la Atención de Salud/economía , Reforma de la Atención de Salud/estadística & datos numéricos , Hemorragia/inducido químicamente , Hospitalización/economía , Humanos , Cadenas de Markov , Massachusetts , Modelos Econométricos , Años de Vida Ajustados por Calidad de Vida , Proveedores de Redes de Seguridad/estadística & datos numéricos , Tromboembolia Venosa/mortalidad , Warfarina/efectos adversos , Warfarina/economíaRESUMEN
OBJECTIVE: Evaluative research projects for identifying good practice have been postponed regarding health system reform. This study was thus aimed at identifying health governance and social protection indicators. METHODS: This study involved evaluative research regarding the health system for the uninsured part of the population in six Mexican states. The primary data was obtained from in-depth interviews with key players from the participating states; official statistics and the results of a macro-project concerned with Mexican health and governance reform and policy was used for secondary. Atlas Ti and Policy Maker software were used for processing and analysing the data. RESULTS: A list of strengths and weaknesses was presented as evidence of health system governance. Accountability at federal level (even though not lacking) was of a prescriptive nature and a system of accountability and transparency regarding the assignment of resources and strategies for the democratisation of health in the states and municipalities was still lacking. CONCLUSIONS: All six states had low levels of governance and experienced difficulty in conducting effective reform programmes and strategies involving a lack of precision regarding the rules and roles adopted by different health system actors.
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Reforma de la Atención de Salud/organización & administración , Programas Nacionales de Salud/organización & administración , Indicadores de Calidad de la Atención de Salud/estadística & datos numéricos , Bienestar Social , Reforma de la Atención de Salud/estadística & datos numéricos , Humanos , América Latina , México , Programas Nacionales de Salud/estadística & datos numéricos , Evaluación de Programas y Proyectos de Salud , Investigación Cualitativa , Estudios RetrospectivosRESUMEN
Maintained dedication to primary care has fostered a public health delivery system with exceptional outcomes in Costa Rica. For more than a decade, management commitments have been part of Costa Rican health reform. We assessed the effect of the Costa Rican management commitments on access and quality of care and on compliance with their intended objectives. We constructed seven hypotheses on opinions of primary care providers. Through a mixed qualitative and quantitative approach, we tested these hypotheses and interpreted the research findings. Management commitments consume an excessive proportion of consultation time, inflate recordkeeping, reduce comprehensiveness in primary care consultations, and induce a disproportionate consumption of hospital emergency services. Their formulation relies on norms in need of optimization, their control on unreliable sources. They also affect professionalism. In Costa Rica, management commitments negatively affect access and quality of care and pose a threat to the public service delivery system. The failures of this pay-for-performance-like initiative in an otherwise well-performing health system cast doubts on the appropriateness of pay-for-performance for health systems strengthening in less advanced environments.
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Atención a la Salud/organización & administración , Países en Desarrollo , Programas Controlados de Atención en Salud/organización & administración , Programas Nacionales de Salud/organización & administración , Atención Primaria de Salud/organización & administración , Actitud del Personal de Salud , Costa Rica , Atención a la Salud/estadística & datos numéricos , Servicio de Urgencia en Hospital/organización & administración , Servicio de Urgencia en Hospital/estadística & datos numéricos , Reforma de la Atención de Salud/organización & administración , Reforma de la Atención de Salud/estadística & datos numéricos , Humanos , Programas Nacionales de Salud/estadística & datos numéricos , Atención Primaria de Salud/estadística & datos numéricos , Calidad de la Atención de Salud/organización & administración , Calidad de la Atención de Salud/estadística & datos numéricos , Derivación y Consulta/organización & administración , Derivación y Consulta/estadística & datos numéricos , Revisión de Utilización de RecursosRESUMEN
Prevention of mother-to-child transmission of HIV was added to standard antenatal care (ANC) in 2000 for Colombians enrolled in the two national health insurance schemes, the 'subsidized regime' (covering poor citizens) and the 'contributory regime' (covering salaried citizens with incomes above the poverty threshold), which jointly covered 80% of the total Colombian population as of 2007. This article examines integration of HIV testing in ANC through the relationship between ordering an HIV test with the type of health insurance, including lack of health insurance, using data from the nationally representative 2005 Colombia Demographic and Health Survey. Overall, health-care providers ordered an HIV test for only 35% of the women attending ANC. We regressed the order of an HIV test during ANC on health systems characteristics (type of insurance and type of ANC provider), women's characteristics (age, wealth, educational attainment, month of pregnancy at first antenatal visit, HIV knowledge, urban vs. rural residence and sub-region of residence) and children's characteristics (birth order and birth year). Women enrolled in the subsidized regime were significantly less likely to be offered and receive an HIV test in ANC than women without any health insurance (adjusted odds ratio = 0.820, P < 0.001), when controlling for the other independent variables. Wealth, urban residence, birth year of the child and the type of health-care provider seen during the ANC visit were significantly associated with providers ordering an HIV test for a woman (all P < 0.05). Our findings suggest that enrolment in the subsidized regime reduced access to HIV testing in ANC. Additional research is needed to elucidate the mechanisms through which the potential effect of health insurance coverage on HIV testing in ANC occurs and to examine whether enrolment in the subsidized regime has affected access to other essential health services.
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Serodiagnóstico del SIDA/estadística & datos numéricos , Reforma de la Atención de Salud , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Programas Nacionales de Salud/estadística & datos numéricos , Atención Prenatal/estadística & datos numéricos , Adolescente , Adulto , Colombia/epidemiología , Femenino , Infecciones por VIH/prevención & control , Reforma de la Atención de Salud/organización & administración , Reforma de la Atención de Salud/estadística & datos numéricos , Accesibilidad a los Servicios de Salud/organización & administración , Humanos , Transmisión Vertical de Enfermedad Infecciosa/prevención & control , Persona de Mediana Edad , Programas Nacionales de Salud/organización & administración , Pobreza/estadística & datos numéricos , Embarazo , Atención Prenatal/organización & administración , Factores Socioeconómicos , Adulto JovenRESUMEN
OBJECTIVES: We examined the impact of expanding health insurance coverage on socioeconomic disparities in total and cardiovascular disease mortality from 1998 to 2007 in Colombia. METHODS: We used Poisson regression to analyze data from mortality registries (633 905 deaths) linked to population census data. We used the relative index of inequality to compare disparities in mortality by education between periods of moderate increase (1998-2002) and accelerated increase (2003-2007) in health insurance coverage. RESULTS: Disparities in mortality by education widened over time. Among men, the relative index of inequality increased from 2.59 (95% confidence interval [CI] = 2.52, 2.67) in 1998-2002 to 3.07 (95% CI = 2.99, 3.15) in 2003-2007, and among women, from 2.86 (95% CI = 2.77, 2.95) to 3.12 (95% CI = 3.03, 3.21), respectively. Disparities increased yearly by 11% in men and 4% in women in 1998-2002, whereas they increased by 1% in men per year and remained stable among women in 2003-2007. CONCLUSIONS: Mortality disparities widened significantly less during the period of increased health insurance coverage than the period of no coverage change. Although expanding coverage did not eliminate disparities, it may contribute to curbing future widening of disparities.
Asunto(s)
Reforma de la Atención de Salud/estadística & datos numéricos , Disparidades en el Estado de Salud , Cobertura del Seguro/estadística & datos numéricos , Seguro de Salud/estadística & datos numéricos , Mortalidad , Adulto , Factores de Edad , Colombia/epidemiología , Escolaridad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Factores SexualesRESUMEN
INTRODUCTION: A recent health reform was implemented in Chile (the AUGE reform) with the objective of reducing the socioeconomic gaps to access healthcare. This reform did not seek to eliminate the private insurance system, which coexists with the public one, but to ensure minimum conditions of access to the entire population, at a reasonable cost and with a quality guarantee, to cover an important group of health conditions. This paper's main objective is to enquire what has happened with the use of several healthcare services after the reform was fully implemented. METHODS: Concentration and Horizontal Inequity indices were estimated for the use of general practitioners, specialists, emergency room visits, laboratory and x-ray exams and hospitalization days. The change in such indices (pre and post-reform) was decomposed, following Zhong (2010). A "mean effect" (how these indices would change if the differential use in healthcare services were evenly distributed) and a "distribution effect" (how these indices would change with no change in average use) were obtained. RESULTS: Changes in concentration indices were mainly due to mean effects for all cases, except for specialists (where "distribution effect" prevailed) and hospitalization days (where none of these effects prevailed over others). This implies that by providing more services across socioeconomic groups, less inequality in the use of services was achieved. On the other hand, changes in horizontal inequity indices were due to distribution effects in the case of GP, ER visits and hospitalization days; and due to mean effect in the case of x-rays. In the first three cases indices reduced their pro-poorness implying that after the reform relatively higher socioeconomic groups used these services more (in relation to their needs). In the case of x-rays, increased use was responsible for improving its horizontal inequity index. CONCLUSIONS: The increase in the average use of healthcare services after the AUGE reform has not always led to improved equity in the use of such services in most services. This indicates that there are still barriers to the equitable use of healthcare services (e.g. insufficient medical human resources, financial barriers, capacity constraints, etc.) that have remained after the reform.
Asunto(s)
Servicios de Salud/estadística & datos numéricos , Disparidades en Atención de Salud/estadística & datos numéricos , Adolescente , Adulto , Factores de Edad , Anciano , Niño , Preescolar , Chile/epidemiología , Femenino , Médicos Generales/estadística & datos numéricos , Reforma de la Atención de Salud/estadística & datos numéricos , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Disparidades en Atención de Salud/organización & administración , Hospitalización/estadística & datos numéricos , Humanos , Lactante , Seguro de Salud/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Factores Sexuales , Factores Socioeconómicos , Adulto JovenRESUMEN
Asthma morbidity and mortality have increased in the past two decades; Puerto Rican children have the highest prevalence of asthma in the United States. An asthma admission to PICU is a marker of asthma severity. This study describes the profile of the pediatric population admitted with status asthmaticus during a three year period to PICU at Hospital Episcopal San Lucas. An ambispective cohort chart review of 46 cases was performed; there was a mean average age of 6.2 years, male predominance (70%) and a strong family and personal history of asthma and allergies. 48% were classified as persistent asthmatics, only 19% of these received preventive mediation regimens. 72% of patients were covered under Puerto Rico's Health Care Reform and 28% had private insurance. Of the patients covered by Puerto Rico's Health Care Reform, classified as persistent asthmatics, 79% did not receive preventive treatment medication compared to 46% in private insurance. Background asthma management remains suboptimal in children needing hospitalization. Lack of preventive medication appears to be related to the type of health insurance.
Asunto(s)
Unidades de Cuidados Intensivos/estadística & datos numéricos , Estado Asmático/epidemiología , Antiasmáticos/uso terapéutico , Asma/tratamiento farmacológico , Niño , Preescolar , Estudios de Cohortes , Utilización de Medicamentos/estadística & datos numéricos , Femenino , Adhesión a Directriz/estadística & datos numéricos , Reforma de la Atención de Salud/estadística & datos numéricos , Humanos , Cobertura del Seguro/estadística & datos numéricos , Seguro de Salud/clasificación , Seguro de Salud/estadística & datos numéricos , Masculino , Puerto Rico/epidemiología , Estado Asmático/prevención & controlRESUMEN
In 1993, Colombia carried out a sweeping health reform that sought to dramatically increase health insurance coverage and reduce state involvement in health provision by creating a unitary state-supervised health system in which private entities are the main insurers and health service providers. Using a quantitative comparison of household survey data and an analysis of the content of the reforms, we evaluate the effects of Colombia's health reforms on gender equity. We find that several aspects of these reforms hold promise for greater gender equity, such as the resulting increase in women's health insurance coverage. However, the reforms have not achieved gender equity due to the persistence of fees which discriminate against women and the introduction of a two-tier health system in which women heads of household and the poor are concentrated in a lower quality health system.
Asunto(s)
Reforma de la Atención de Salud/estadística & datos numéricos , Disparidades en Atención de Salud/estadística & datos numéricos , Seguro de Salud/estadística & datos numéricos , Salud de la Mujer , Colombia , Femenino , Humanos , Renta , Masculino , Factores SexualesAsunto(s)
Humanos , Masculino , Femenino , Psiquiatría/clasificación , Psiquiatría/historia , Psiquiatría/métodos , Psiquiatría/normas , Psiquiatría/organización & administración , Psiquiatría/tendencias , Reforma de la Atención de Salud/estadística & datos numéricos , Reforma de la Atención de Salud/legislación & jurisprudencia , Reforma de la Atención de Salud/organización & administración , Servicios de Salud Mental/clasificación , Servicios de Salud Mental/legislación & jurisprudencia , Servicios de Salud Mental/normas , Servicios de Salud Mental/organización & administración , Servicios de Salud Mental/tendencias , Servicios de Salud MentalRESUMEN
The authors analyze the evolution in publications indexed in MEDLINE, LILACS, and Sociological Abstracts concerning health reforms around the world and the determinants of their orientation and distribution from 1990 to 2004. A total of 8,729 publications were selected. The principles of "sustainability" and "quality and effectiveness" were dealt with most frequently, with different patterns of attention, depending on the regions and countries. Of 199 countries, 61% included references as to their health reform processes, with the largest numbers in the United States and the Great Britain. The British and U.S. standards for attention to health reform principles displayed strong influences on the study of health reforms elsewhere. This may limit the scientific visibility of issues like equity, participation, and efficiency.
Asunto(s)
Bibliometría , Reforma de la Atención de Salud/estadística & datos numéricos , Publicaciones Periódicas como Asunto/estadística & datos numéricos , Investigación/estadística & datos numéricos , Reforma de la Atención de Salud/normas , Humanos , Edición , Investigación/tendenciasRESUMEN
Benchmarking of the performance of states, provinces, or districts in a decentralised health system is important for fostering of accountability, monitoring of progress, identification of determinants of success and failure, and creation of a culture of evidence. The Mexican Ministry of Health has, since 2001, used a benchmarking approach based on the WHO concept of effective coverage of an intervention, which is defined as the proportion of potential health gain that could be delivered by the health system to that which is actually delivered. Using data collection systems, including state representative examination surveys, vital registration, and hospital discharge registries, we have monitored the delivery of 14 interventions for 2005-06. Overall effective coverage ranges from 54.0% in Chiapas, a poor state, to 65.1% in the Federal District. Effective coverage for maternal and child health interventions is substantially higher than that for interventions that target other health problems. Effective coverage for the lowest wealth quintile is 52% compared with 61% for the highest quintile. Effective coverage is closely related to public-health spending per head across states; this relation is stronger for interventions that are not related to maternal and child health than those for maternal and child health. Considerable variation also exists in effective coverage at similar amounts of spending. We discuss the implications of these issues for the further development of the Mexican health-information system. Benchmarking of performance by measuring effective coverage encourages decision-makers to focus on quality service provision, not only service availability. The effective coverage calculation is an important device for health-system stewardship. In adopting this approach, other countries should select interventions to be measured on the basis of the criteria of affordability, effect on population health, effect on health inequalities, and capacity to measure the effects of the intervention. The national institutions undertaking this benchmarking must have the mandate, skills, resources, and independence to succeed.