Frederico C. Guanais

Transforming Global Health by Improving the Science of Scale-Up.

In its report Global Health 2035, the Commission on Investing in Health proposed that health investments can reduce mortality in nearly all low- and middle-income countries to very low levels, thereby averting 10 million deaths per year from 2035 onward. Many of these gains could be achieved through scale-up of existing technologies and health services. A key instrument to close this gap is policy and implementation research (PIR) that aims to produce generalizable evidence on what works to implement successful interventions at scale. Rigorously designed PIR promotes global learning and local accountability. Much greater national and global investments in PIR capacity will be required to enable the scaling of effective approaches and to prevent the recycling of failed ideas. Sample questions for the PIR research agenda include how to close the gap in the delivery of essential services to the poor, which population interventions for non-communicable diseases are most applicable in different contexts, and how to engage non-state actors in equitable provision of health services in the context of universal health coverage.

Gaps In Primary Care And Health System Performance In Six Latin American And Caribbean Countries

The rapid demographic and epidemiological transitions occurring in Latin America and the Caribbean have led to high levels of noncommunicable diseases in the region. In addition to reduced risk factors for chronic conditions, a strong health system for managing chronic conditions is vital. This study assessed the extent to which populations in six Latin American and Caribbean countries receive high-quality primary care, and it examined the relationship between experiences with care and perceptions of health system performance. We applied a validated survey on access, use, and satisfaction with health care services to nationally representative samples of the populations of Brazil, Colombia, El Salvador, Jamaica, Mexico, and Panama. Respondents reported considerable gaps in the ways in which primary care is organized, financed, and delivered. Nearly half reported using the emergency department for a condition they considered treatable in a primary care setting. Reports of more primary care problems were associated with worse perceptions of health system performance and quality and less receipt of preventive care. Urgent attention to primary care performance is required as the regions population continues to age at an unprecedented rate.

Understanding public perception of the need for major change in Latin American healthcare systems

The opinions and experiences of the public regarding health services are valuable insights into identifying opportunities to improve healthcare systems. We analyzed the 2012-2013 Public Opinion Health Policy Survey carried out in Brazil (n = 1486), Colombia (n = 1485), El Salvador (n = 1460), Jamaica (n = 1480), México (n = 1492) and Panama (n = 1475). In these countries between 82 and 96% of participants perceived that their health systems needed fundamental changes. The most frequent barrier to access to healthcare was lack of the primary medical home, difficulties in obtaining medical care during the weekends and financial barriers. Type of health insurance and challenges in obtaining medical care during the weekends were associated with an increased opinion for the need for fundamental changes in healthcare systems, whereas having a primary medical home showed a protective effect. Focusing on tackling organizational and financial barriers and ensuring access to a primary medical home should be placed on the agenda of Latin American countries.

Patient-centered primary care and self-rated health in 6 Latin American and Caribbean countries: Analysis of a public opinion cross-sectional survey

Background Despite the substantial attention to primary care (PC), few studies have addressed the relationship between patients’ experience with PC and their health status in low-and middle-income countries. This study aimed to (1) test the association between overall patient-centered PC experience (OPCE) and self-rated health (SRH) and (2) identify specific features of patient-centered PC associated with better SRH (i.e., excellent or very good SRH) in 6 Latin American and Caribbean countries. Methods and findings We conducted a secondary analysis of a 2013 public opinion cross-sectional survey on perceptions and experiences with healthcare systems in Brazil, Colombia, El Salvador, Jamaica, Mexico, and Panama; the data were nationally representative for urban populations. We analyzed 9 features of patient-centered PC. We calculated OPCE score as the arithmetic mean of the PC features. OPCE score ranged from 0 to 1, where 0 meant that the participant did not have any of the 9 patient-centered PC experiences, while 1 meant that he/she reported having all these experiences. After testing for interaction on the additive scale, we analyzed countries pooled for aim 1, with an interaction term for Mexico, and each country separately for aim 2. We used multiple Poisson regression models double-weighted by survey and inverse probability weights to deal with the survey design and missing data. The study included 6,100 participants. The percentage of participants with excellent or very good SRH ranged from 29.5% in Mexico to 52.4% in Jamaica. OPCE was associated with reporting excellent or very good SRH in all countries: adjusting for socio-demographic and health covariates, patients with an OPCE score of 1 in Brazil, Colombia, El Salvador, Jamaica, and Panama were more likely to report excellent or very good SRH than those with a score of 0 (adjusted prevalence ratio [aPR] 1.61, 95% CI 1.37–1.90, p < 0.001); in Mexico, this association was even stronger (aPR 4.27, 95% CI 2.34–7.81, p < 0.001). The specific features of patient-centered PC associated with better SRH differed by country. The perception that PC providers solve most health problems was associated with excellent or very good SRH in Colombia (aPR 1.38, 95% CI 1.01–1.91, p = 0.046) and Jamaica (aPR 1.21, 95% CI 1.02–1.43, p = 0.030). Having a provider who knows relevant medical history was positively associated with better SRH in Mexico (aPR 1.47, 95% CI 1.03–2.12, p = 0.036) but was negatively associated with better SRH in Brazil (aPR 0.71, 95% CI 0.56–0.89, p = 0.003). Finally, easy contact with PC facility (Mexico: aPR 1.35, 95% CI 1.04–1.74, p = 0.023), coordination of care (Mexico: aPR 1.53, 95% CI 1.19–1.98, p = 0.001), and opportunity to ask questions (Brazil: aPR 1.42, 95% CI 1.11–1.83, p = 0.006) were each associated with better SRH. The main study limitation consists in the analysis being of cross-sectional data, which does not allow making causal inferences or identifying the direction of the association between the variables. Conclusions Overall, a higher OPCE score was associated with better SRH in these 6 Latin American and Caribbean countries; associations between specific characteristics of patient-centered PC and SRH differed by country. The findings underscore the importance of high-quality, patient-centered PC as a path to improved population health.

Desde el paciente: Experiencias de la atención primaria de salud en América Latina y el Caribe

En la region de America Latina y Caribe (ALC), la mayoria de los paises buscan reformar sus sistemas de salud para lograr la cobertura universal y mejorar la eficiencia de sus gastos sanitarios, al tiempo que cumplen con las expectativas cada vez mayores de los ciudadanos acerca de la calidad de la atencion. El papel de la atencion primaria de salud (APS) destaca como clave para lograr esos objetivos de forma integrada. Por ello, el Banco Interamericano de Desarrollo llevo a cabo, entre 2012 y 2014, la Encuesta sobre Acceso, Experiencia y Coordinacion de la Atencion Primaria de Salud en America Latina y el Caribe, en poblaciones adultas de Colombia, Mexico, Brasil, El Salvador, Panama y Jamaica, buscando contribuir al diseno de politicas publicas de salud, y considerando especialmente el punto de vista de los pacientes. Los dos primeros capitulos del presente libro presentan el contexto y desafios de los sistemas de salud de la region y describen el marco conceptual y la metodologia del estudio. Los capitulos tres al ocho tratan, por separado, de cada uno de los seis paises estudiados, con resultados sobre las experiencias de los pacientes con la atencion primaria de salud y su integracion con los demas niveles de atencion. El capitulo nueve cierra el libro con un analisis comparativo entre los seis paises de ALC y extiende la comparacion a 11 paises de altos ingresos de la OCDE, donde se evidencian las brechas persistentes en los indicadores de acceso, experiencia y coordinacion en la APS entre los paises de ALC y los de la OCDE. Un analisis multivariado con los 17 paises demuestra que los principales atributos observados de la APS estan directamente vinculados a las percepciones de los pacientes acerca de la necesidad de cambios fundamentales en los sistemas de salud y de la calidad de los servicios utilizados.