Giuliano Russo

Negotiating markets for health: an exploration of physicians’ engagement in dual practice in three African capital cities

Scarce evidence exists on the features, determinants and implications of physicians’ dual practice, especially in resource-poor settings. This study considered dual practice patterns in three African cities and the respective markets for physician services, with the objective of understanding the influence of local determinants on the practice. Forty-eight semi-structured qualitative interviews were conducted in the three cities to understand features of the practice and the respective markets. A survey was carried out in a sample of 331 physicians to explore their characteristics and decisions to work in public and private sectors. Descriptive analysis and inferential statistics were employed to explore differences in physicians’ engagement in dual practice across the three locations. Different forms of dual practice were found to exist in the three cities, with public physicians engaging in private practice outside but also inside public facilities, in regulated as well as unregulated ways. Thirty-four per cent of the respondents indicated that they worked in public practice only, and 11% that they engaged exclusively in private practice. The remaining 55% indicated that they engaged in some form of dual practice, 31% ‘outside’ public facilities, 8% ‘inside’ and 16% both ‘outside’ and ‘inside’. Local health system governance and the structure of the markets for physician services were linked to the forms of dual practice found in each location, and to their prevalence. Our analysis suggests that physicians’ decisions to engage in dual practice are influenced by supply and demand factors, but also by how clearly separated public and private markets are. Where it is possible to provide little-regulated services within public infrastructure, less incentive seems to exist to engage in the formal private sector, with equity and efficiency implications for service provision. The study shows the value of analysing health markets to understand physicians’ engagement in professional activities, and contributes to an evidence base for its regulation.

What influences national and foreign physicians’ geographic distribution? An analysis of medical doctors’ residence location in Portugal

BackgroundThe debate over physicians’ geographical distribution has attracted the attention of the economic and public health literature over the last forty years. Nonetheless, it is still to date unclear what influences physicians’ location, and whether foreign physicians contribute to fill the geographical gaps left by national doctors in any given country. The present research sets out to investigate the current distribution of national and international physicians in Portugal, with the objective to understand its determinants and provide an evidence base for policy-makers to identify policies to influence it.MethodsA cross-sectional study of physicians currently registered in Portugal was conducted to describe the population and explore the association of physician residence patterns with relevant personal and municipality characteristics. Data from the Portuguese Medical Council on physicians’ residence and characteristics were analysed, as well as data from the National Institute of Statistics on municipalities’ population, living standards and health care network. Descriptive statistics, chi-square tests, negative binomial and logistic regression modelling were applied to determine: (a) municipality characteristics predicting Portuguese and International physicians’ geographical distribution, and; (b) doctors’ characteristics that could increase the odds of residing outside the country’s metropolitan areas.ResultsThere were 39,473 physicians in Portugal in 2008, 51.1% of whom male, and 40.2% between 41 and 55 years of age. They were predominantly Portuguese (90.5%), with Spanish, Brazilian and African nationalities also represented. Population, Population’s Purchasing Power, Nurses per capita and Municipality Development Index (MDI) were the municipality characteristics displaying the strongest association with national physicians’ location. For foreign physicians, the MDI was not statistically significant, while municipalities’ foreign population applying for residence appeared to be an additional positive factor in their location decisions. In general, being foreigner and male resulted to be the physician characteristics increasing the odds of residing outside the metropolitan areas. However, among the internationals, older doctors were more likely to reside outside metropolitan areas. Being Spanish or Brazilian (but not of African origin) was found to increase the odds of being based outside the Lisbon and Oporto metropolitan areas.ConclusionsThe present study showed the relevance of studying one country’s physician population to understand the factors driving national and international doctors’ location decisions. A more nuanced understanding of national and foreign doctors’ location appears to be needed to design more effective policies to reduce the imbalance of medical services across geographical areas.

Brazil-Africa technical cooperation in health: what’s its relevance to the post-Busan debate on ‘aid effectiveness’?

BackgroundBrazil is rapidly becoming an influential player in development cooperation, also thanks to its high-visibility health projects in Africa and Latin America. The 4th High-level Forum on Aid Effectiveness held in Busan in late 2011 marked a change in the way development cooperation is conceptualised. The present paper explores the issue of emerging donors’ contribution to the post-Busan debate on aid effectiveness by looking at Brazil’s health cooperation projects in Portuguese-speaking Africa.DebateWe first consider Brazil’s health technical cooperation within the country’s wider cooperation programme, aiming to identify its key characteristics, claimed principles and values, and analysing how these translate into concrete projects in Portuguese-speaking African countries. Then we discuss the extent to which the Busan conference has changed the way development cooperation is conceptualised, and how Brazil’s technical cooperation health projects fit within the new framework.SummaryWe conclude that, by adopting new concepts on health cooperation and challenging established paradigms - in particular on health systems and HIV/AIDS fight - the Brazilian health experience has already contributed to shape the emerging consensus on development effectiveness. However, its impact on the field is still largely unscrutinised, and its projects seem to only selectively comply with some of the shared principles agreed upon in Busan. Although Brazilian cooperation is still a model in the making, not immune from contradictions and shortcomings, it should be seen as enriching the debate on development principles, thus offering alternative solutions to advance the discourse on cooperation effectiveness in health.

Connecting the dots on health inequalities – a systematic review on the social determinants of health in Portugal

IntroductionHealth inequalities are recognised as a public health issue worldwide, but only a few countries have developed national strategies to monitor and reduce them. Despite its considerable health inequalities, Portugal seems to lack a systematic strategy to tackle them, possibly due to the absence of organised evidence on the issue. We performed a systematic review that aimed to describe the available evidence on social inequalities in health in Portugal, in order to contribute towards a comprehensive and focused strategy to tackle them.MethodsWe followed the PRISMA guidelines and searched Scopus, Web of Science and PubMed for studies that looked at the association between a measure of socioeconomic status and a health outcome in the Portuguese resident population since the year 2000. We excluded health behaviours and healthcare use from our search. We performed a qualitative description of the results.ResultsSeventy-one publications were selected, all reporting observational analyses, most of them using cross-sectional data. These publications showed strong evidence for health inequalities related to education and gender, chiefly for obesity, self-rated health and mental health.ConclusionsAnalysis of the eligible publications showed that current research does not seem to have consistently covered the link between health and key Portuguese social problems. A strategy focusing on the monitoring of most prevalent diseases, most determining socioeconomic factors and vulnerable populations would be crucial to guide academic research in a country in which health inequalities are so ubiquitous and deeply rooted.RegistrationThis systematic review is not registered.

Implications of dual practice for universal health coverage.

Abstract Making progress towards universal health coverage (UHC) requires that health workers are adequate in numbers, prepared for their jobs and motivated to perform. In establishing the best ways to develop the health workforce, relatively little attention has been paid to the trends and implications of dual practice – concurrent employment in public and private sectors. We review recent research on dual practice for its potential to guide staffing policies in relation to UHC. Many studies describe the characteristics and correlates of dual practice and speculate about impacts, but there is very little evidence that is directly relevant to policy-makers. No studies have evaluated the impact of policies on the characteristics of dual practice or implications for UHC. We address this lack and call for case studies of policy interventions on dual practice in different contexts. Such research requires investment in better data collection and greater determination on the part of researchers, research funding bodies and national research councils to overcome the difficulties of researching sensitive topics of health systems functions.

Development of oral health policy in Nigeria: an analysis of the role of context, actors and policy process

BackgroundIn Nigeria, there is a high burden of oral health diseases, poor coordination of health services and human resources for delivery of oral health services. Previous attempts to develop an Oral Health Policy (OHP) to decrease the oral disease burden failed. However, a policy was eventually developed in November 2012. This paper explores the role of contextual factors, actors and the policy process in the development of the OHP and possible reasons why the current approved OHP succeeded.MethodsThe study was undertaken across Nigeria; information gathered through document reviews and in-depth interviews with five groups of purposively selected respondents. Analysis of the policy development process was guided by the policy triangle framework, examining context, policy process and actors involved in the policy development.ResultsThe foremost enabling factor was the yearning among policy actors for a policy, having had four failed attempts. Other factors were the presence of a democratically elected government, a framework for health sector reform instituted by the Federal Ministry of Health (FMOH). The approved OHP went through all stages required for policy development unlike the previous attempts. Three groups of actors played crucial roles in the process, namely academics/researchers, development partners and policy makers. They either had decision making powers or influenced policy through funding or technical ability to generate credible research evidence, all sharing a common interest in developing the OHP. Although evidence was used to inform the development of the policy, the complex interactions between the context and actors facilitated its approval.ConclusionsThe OHP development succeeded through a complex inter-relationship of context, process and actors, clearly illustrating that none of these factors could have, in isolation, catalyzed the policy development. Availability of evidence is necessary but not sufficient for developing policies in this area. Wider socio-political contexts in which actors develop policy can facilitate and/or constrain actors’ roles and interests as well as policy process. These must be taken into consideration at stages of policy development in order to produce policies that will strengthen the health system, especially in low and middle-income countries, where policy processes and influences can be often less than transparent.

Two-tier charging in Maputo Central Hospital: Costs, revenues and effects on equity of access to hospital services

BackgroundSpecial services within public hospitals are becoming increasingly common in low and middle income countries with the stated objective of providing higher comfort services to affluent customers and generating resources for under funded hospitals. In the present study expenditures, outputs and costs are analysed for the Maputo Central Hospital and its Special Clinic with the objective of identifying net resource flows between a system operating two-tier charging, and, ultimately, understanding whether public hospitals can somehow benefit from running Special Clinic operations.MethodsA combination of step-down and bottom-up costing strategies were used to calculate recurrent as well as capital expenses, apportion them to identified cost centres and link costs to selected output measures.ResultsThe results show that cost differences between main hospital and clinic are marked and significant, with the Special Clinics cost per patient and cost per outpatient visit respectively over four times and over thirteen times their equivalent in the main hospital.DiscussionWhile the main hospital cost structure appeared in line with those from similar studies, salary expenditures were found to drive costs in the Special Clinic (73% of total), where capital and drug costs were surprisingly low (2 and 4% respectively). We attributed low capital and drug costs to underestimation by our study owing to difficulties in attributing the use of shared resources and to the Special Clinics outsourcing policy. The large staff expenditure would be explained by higher physician time commitment, economic rents and subsidies to hospital staff. On the whole it was observed that: (a) the flow of capital and human resources was not fully captured by the financial systems in place and stayed largely unaccounted for; (b) because of the little consideration given to capital costs, the main hospital is more likely to be subsidising its Special Clinic operations, rather than the other way around.ConclusionWe conclude that the observed lack of transparency may create scope for an inequitable cross subsidy of private customers by public resources.

Feminization of the medical workforce in low-income settings; findings from surveys in three African capital cities

BackgroundWomen represent an increasingly growing share of the medical workforce in high-income countries, with abundant research focusing on reasons and implications of the phenomenon. Little evidence is available from low- and middle-income countries, which is odd given the possible repercussion this may have for the local supply of medical services and, ultimately, for attaining universal health coverage.MethodsDrawing from secondary analysis of primary survey data, this paper analyses the proportion and characteristics of female physicians in Bissau, Maputo and Praia, with the objective of gaining insights on the extent and features of the feminization of the medical workforce in low- and middle-income settings. We used descriptive statistics, parametric and non-parametric test to compare groups and explore associations between different variables. Zero-inflated and generalized linear models were employed to analyse the number of hours worked in the private and public sector by male and female physicians.Results and discussionWe show that although female physicians do not represent yet the majority of the medical workforce, feminization of the profession is under way in the three locations analysed, as women are presently over-represented in younger age groups. Female doctors distribute unevenly across medical specialties in the three cities and are absent from traditionally male-dominated ones such as surgery, orthopaedics and stomatology. Our data also show that they engage as much as their male peers in private practice, although overall they dedicate fewer hours to the profession, particularly in the public sector.ConclusionsWhile more research is needed to understand how this phenomenon affects rural areas in a broader range of locations, our work shows the value of exploring the differences between female and male physicians’ engagement with the profession in order to anticipate the impact of such feminization on national health systems and workforces in low- and middle-income countries.

Access to medicines by ambulatory health service users in Mexico: an analysis of the national health surveys 1994 to 2006

OBJECTIVE To analyse the medicines prescription, prescription filling, payment expenditure for medicines by ambulatory health service users (HSU) in 2006, and to evaluate its evolution in the last 12 years. MATERIAL AND METHODS Using data from the National Health Surveys in 2006 three binary logistic regression models were constructed to identify the variables associated with the prescription rate, prescription filling and payment for medicines in 2006. The results of access to medicines were compared to the ones from previous National Health Services from 1994 and 2000. RESULTS The type of health service provider was found to be the most important predictors of access to medicines. Although the proportion of HSU obtaining a prescription and paying for drugs has broadly stayed the same as in 1994, the percentage of HSU paying for their prescribed medicines decreased from 70% in 1994 to 42% at Ministry of Health institutions in 2006. CONCLUSION The progress in prescription and population access to medicines has been uneven across health service providers.

Brazil’s engagement in health co-operation: what can it contribute to the global health debate?

Brazil and other emerging powers, such as China and India, are becoming increasingly influential world players. As they expand their global recognition and the associated diplomatic influence and access to markets, these countries are multiplying their development co-operation efforts with low-income countries often located in the southern hemisphere (Kragelund 2008). Within this ‘South–South co-operation’ these so-called ‘emerging donors’ are progressively turning to health interventions as effective foreign policy soft-power tools (Feldbaum and Michaud 2010). In the debate on the relationship between health and foreign policy objectives, it has been argued that the two interact in more than just one way and end up exerting mutual influence (Kickbush 2011). Although the former are often regarded as tools for the latter, public health objectives are also seen as benefiting from foreign policy action, as demonstrated by Brazil’s diplomatic efforts for worldwide tobacco control and access to antiretroviral (ARV) drugs (Lee et al. 2010). However, many take the view that there will always be a tension between global health and foreign policy, and that co-operation projects need to be read through the lenses of foreign policies to understand the potential and limitations of this new form of ‘health diplomacy’ (Feldbaum and Michaud 2010). The tension between foreign policy and development goals is in part reflected in emerging donors’ questioning of the traditional principles of aid effectiveness affirmed in the 2005 Paris Declaration and subsequent Accra Agenda. Such principles of aid effectiveness aimed, among other things, at separating aid from non-aid goals by seeking traditional donors’ commitment to measurable results and sustainability of co-operation projects. In more than one way, the recent Busan High Level Forum on Aid Effectiveness has come to bridge the existing rift between old and new donors, not only by hailing ‘horizontal partnership’ and ‘development cooperation’ instead of vertical aid (Martini et al. 2012) but also by relaxing contentious aid principles like that of alignment to national governments’ policies, and donor harmonization (HLF4 2011). As a result, the new consensus emerging from Busan puts forward a more inclusive model of development cooperation focused on ownership, focus on results, global partnership, transparency and accountability, but based on donors’ differential commitments (Hill et al. 2011, Russo et al 2013). This commentary draws on a study on Brazilian projects in Africa (Russo et al. 2011) and the authors’ direct involvement with Brazilian health co-operation to argue that, although shaped by its foreign policy goals, Brazil’s engagement is contributing to a shift in the discourse on health development co-operation, by offering home-grown examples of health development, by adopting new concepts of health co-operation and by leading unusually bold action on key global health issues. The consideration also emerges that Brazilian health co-operation, being relatively young and still learning its trade, would also benefit from a deeper engagement in the discussion on effectiveness and sustainability of development interventions.