Ingrid Vargas

Integrated health care networks in Latin America: toward a conceptual framework for analysis

Las inequidades e ineficiencias de los sistemas de salud de America Latina motivaron algunas reformas, concentradas en las ultimas dos decadas, particularmente en el financiamiento y el suministro de la atencion sanitaria. Este trabajo se enfoca en la introduccion de redes integradas de atencion sanitaria (RIAS) en varios paises de America Latina y los ubica en el contexto internacional. La descripcion y el analisis de las RIAS, ya fueran regionales o de afiliacion, resaltan el debate actual sobre sus posibles beneficios y riesgos. El impacto de las RIAS -en terminos del mejoramiento del acceso a la atencion sanitaria o de la promocion de la eficiencia y la equidad en los sistemas de salud- se ha evaluado en muy pocas oportunidades. Para contribuir al tema, se propone un marco conceptual abarcador para el analisis del desempeno de las RIAS, que trata el proceso interno y los factores externos considerados criticos para alcanzar sus objetivos intermedios y finales.

Barriers in access to healthcare in countries with different health systems. A cross-sectional study in municipalities of central Colombia and north-eastern Brazil

There are few comprehensive studies available on barriers encountered from the initial seeking of healthcare through to the resolution of the health problem; in other words, on access in its broad domain. For Colombia and Brazil, countries with different healthcare systems but common stated principles, there have been no such analyses to date. This paper compares factors that influence access in its broad domain in two municipalities of each country, by means of a cross-sectional study based on a survey of a multistage probability sample of people who had had at least one health problem within the last three months (2163 in Colombia and 2155 in Brazil). The results reveal important barriers to healthcare access in both samples, with notable differences between and within countries, once differences in sociodemographic characteristics and health needs are accounted for. In the Colombian study areas, the greatest barriers were encountered in initial access to healthcare and in resolving the problem, and similarly when entering the health service in the Brazilian study areas. Differences can also be detected in the use of services: in Colombia greater geographical and economic barriers and the need for authorization from insurers are more relevant, whereas in Brazil, it is the limited availability of health centres, doctors and drugs that leads to longer waiting times. There are also differences according to enrolment status and insurance scheme in Colombia, and between areas in Brazil. The barriers appear to be related to the Colombian systems segmented, non-universal nature, and to the involvement of insurance companies, and to chronic underfunding of the public system in Brazil. Further research is required, but the results obtained reveal critical points to be tackled by health policies in both countries.

Inequities in access to health care in different health systems: a study in municipalities of central Colombia and north-eastern Brazil.

IntroductionHealth system reforms are undertaken with the aim of improving equity of access to health care. Their impact is generally analyzed based on health care utilization, without distinguishing between levels of care. This study aims to analyze inequities in access to the continuum of care in municipalities of Brazil and Colombia.MethodsA cross-sectional study was conducted based on a survey of a multistage probability sample of people who had had at least one health problem in the prior three months (2,163 in Colombia and 2,167 in Brazil). The outcome variables were dichotomous variables on the utilization of curative and preventive services. The main independent variables were income, being the holder of a private health plan and, in Colombia, type of insurance scheme of the General System of Social Security in Health (SGSSS). For each country, the prevalence of the outcome variables was calculated overall and stratified by levels of per capita income, SGSSS insurance schemes and private health plan. Prevalence ratios were computed by means of Poisson regression models with robust variance, controlling for health care need.ResultsThere are inequities in favor of individuals of a higher socioeconomic status: in Colombia, in the three different care levels (primary, outpatient secondary and emergency care) and preventive activities; and in Brazil, in the use of outpatient secondary care services and preventive activities, whilst lower-income individuals make greater use of the primary care services. In both countries, inequity in the use of outpatient secondary care is more pronounced than in the other care levels. Income in both countries, insurance scheme enrollment in Colombia and holding a private health plan in Brazil all contribute to the presence of inequities in utilization.ConclusionsTwenty years after the introduction of reforms implemented to improve equity in access to health care, inequities, defined in terms of unequal use for equal need, are still present in both countries. The design of the health systems appears to determine access to the health services: two insurance schemes in Colombia with different benefits packages and a segmented system in Brazil, with a significant private component.

Equidad y reformas de los sistemas de salud en Latinoamérica

The aim of any health care system is to help improve the peoples health, and to do so as efficiently as possible. In order to improve the efficiency and equity of health services provision, many countries around the world have implemented reforms, including several Latin American nations. However similar the objectives may appear, the various ways societies implement such reforms reflect different values and concepts. This article analyzes the egalitarian and neoliberal values underlying different concepts of equity in health care. The authors develop criteria to interpret selected health services funding and provision strategies in Latin American health system reforms. These criteria are then applied to health care financing and delivery policies under the reforms currently being implemented in Colombia and Costa Rica.

Perception of the Ecuadorian population living in Barcelona regarding access to health services

ObjectivesTo analyse the factors that influence access to health services from the point of view of the Ecuadorian population living in Barcelona.MethodsA qualitative, descriptive and phenomenological study was carried out by semi-structured individual interviews on a sample of Ecuadorians (18) with maximum variation in age, sex, time since arrival and administrative status. The analysis was conducted according to Colaizzi’s method. The study area was Barcelona.ResultsAccess was considered to be easy for personal health-care card (PHC) holders. However, interviewees identified few factors that facilitated access related to the Ecuadorian population (PHC holder, language, social networks) and the health system (free care, opening hours). In contrast, a number of hindering factors related to both the Ecuadorian population (insufficient knowledge of the system, problems with the documentation in obtaining the PHC, working conditions) and to the system itself (information availability, resources, organisation, attitude of staff) were also identified.ConclusionsAlthough access was perceived as easy, the Ecuadorian population has to overcome a number of barriers to obtain care. These obstacles may have consequences on immigrants’ health and on the efficiency of the system.

Changes in Access to Health Services of the Immigrant and Native-Born Population in Spain in the Context of Economic Crisis †

Aim: To analyze changes in access to health care and its determinants in the immigrant and native-born populations in Spain, before and during the economic crisis. Methods: Comparative analysis of two iterations of the Spanish National Health Survey (2006 and 2012). Outcome variables were: unmet need and use of different healthcare levels; explanatory variables: need, predisposing and enabling factors. Multivariate models were performed (1) to compare outcome variables in each group between years, (2) to compare outcome variables between both groups within each year, and (3) to determine the factors associated with health service use for each group and year. Results: unmet healthcare needs decreased in 2012 compared to 2006; the use of health services remained constant, with some changes worth highlighting, such as the decline in general practitioner visits among autochthons and a narrowed gap in specialist visits between the two populations. The factors associated with health service use in 2006 remained constant in 2012. Conclusion: Access to healthcare did not worsen, possibly due to the fact that, until 2012, the national health system may have cushioned the deterioration of social determinants as a consequence of the financial crisis. Further studies are necessary to evaluate the effects of health policy responses to the crisis after 2012.

Do existing mechanisms contribute to improvements in care coordination across levels of care in health services networks? Opinions of the health personnel in Colombia and Brazil

BackgroundThe fragmentation of healthcare provision has given rise to a wide range of interventions within organizations to improve coordination across levels of care, primarily in high income countries but also in some middle and low-income countries. The aim is to analyze the use of coordination mechanisms in healthcare networks and its implications for the delivery of health care. This is studied from the perspective of health personnel in two countries with different health systems, Colombia and Brazil.MethodsA qualitative, exploratory and descriptive-interpretative study was conducted, based on a case study of healthcare networks in two municipalities in each country. Individual semi-structured interviews were conducted with a three stage theoretical sample of a) health (112) and administrative (66) professionals of different care levels, and b) managers of providers (42) and insurers (14). A thematic content analysis was conducted, segmented by cases, informant groups and themes.ResultsThe results show that care coordination mechanisms are poorly implemented in general. However, the results are marginally better in certain segments of the Colombian networks analyzed (ambulatory centres with primary and secondary care co-location owned by or tied to the contributory scheme insurers, and public providers of the subsidized scheme); and in the network of the state capital in Brazil. Professionals point to numerous problems in the use of existing mechanisms, such as the insufficient recording of information in referral forms, low frequency and level of participation in shared clinical sessions, low adherence to the few available clinical guidelines and the lack of or inadequate referral of patients by the patient referral centres, particularly in the Brazilian networks. The absence or limited use of care coordination mechanisms leads, according to informants, to the inadequate follow-up of patients, interruptions in care and duplication of tests. Professionals use informal strategies to try to overcome these limitations.ConclusionsThe results indicate not only the limited implementation of mechanisms for coordination across care levels, but also a limited use of existing mechanisms in the healthcare networks analyzed. This has a negative impact on coordination, efficiency and quality of care. Organizational changes are required in the networks and healthcare systems to address these problems.

Development and testing of indicators to measure coordination of clinical information and management across levels of care

BackgroundCoordination across levels of care is becoming increasingly important due to rapid advances in technology, high specialisation and changes in the organization of healthcare services; to date, however, the development of indicators to evaluate coordination has been limited. The aim of this study is to develop and test a set of indicators to comprehensively evaluate clinical coordination across levels of care.MethodsA systematic review of literature was conducted to identify indicators of clinical coordination across levels of care. These indicators were analysed to identify attributes of coordination and classified accordingly. They were then discussed within an expert team and adapted or newly developed, and their relevance, scientific soundness and feasibility were examined. The indicators were tested in three healthcare areas of the Catalan health system.Results52 indicators were identified addressing 11 attributes of clinical coordination across levels of care. The final set consisted of 21 output indicators. Clinical information transfer is evaluated based on information flow (4) and the adequacy of shared information (3). Clinical management coordination indicators evaluate care coherence through diagnostic testing (2) and medication (1), provision of care at the most appropriate level (2), completion of diagnostic process (1), follow-up after hospital discharge (4) and accessibility across levels of care (4). The application of indicators showed differences in the degree of clinical coordination depending on the attribute and area.ConclusionA set of rigorous and scientifically sound measures of clinical coordination across levels of care were developed based on a literature review and discussion with experts. This set of indicators comprehensively address the different attributes of clinical coordination in main transitions across levels of care. It could be employed to identify areas in which health services can be improved, as well as to measure the effect of efforts to improve clinical coordination in healthcare organizations.

Health professional perceptions regarding healthcare provision to immigrants in Catalonia

ObjectivesTo analyse health personnel perceptions regarding the provision of care to immigrant population.MethodsAn exploratory and descriptive qualitative study was carried out by means of semi-structured individual interviews and focus groups to a theoretical sample of informants: Healthcare managers (19) and health professionals (46) from primary and secondary care. Narrative content analysis was conducted, segmented by informants’ groups and themes. The area of study was five regions (comarcas) of Catalonia (Spain).ResultsHaving to provide healthcare to immigrants generates feelings of distress, overload and exhaustion in health professionals, particularly in primary care personnel. However, problems faced in providing care were identified both by professionals and managers. Communication barriers emerged as the main problem. Other problems were attributed to specific characteristics of immigrants, their inappropriate use of services and professionals’ attitudes. Structural and organizational deficiencies of the health system also emerged.ConclusionsFor health professionals in Catalonia to provide care of quality to immigrants, interventions that reduce communication barriers and improve their cultural competences are requested. In addition, structural changes are needed to adapt the Catalonian health care system to the new circumstances.

Barriers to healthcare coordination in market-based and decentralized public health systems: a qualitative study in healthcare networks of Colombia and Brazil.

Although integrated healthcare networks (IHNs) are promoted in Latin America in response to health system fragmentation, few analyses on the coordination of care across levels in these networks have been conducted in the region. The aim is to analyse the existence of healthcare coordination across levels of care and the factors influencing it from the health personnel’ perspective in healthcare networks of two countries with different health systems: Colombia, with a social security system based on managed competition and Brazil, with a decentralized national health system. A qualitative, exploratory and descriptive–interpretative study was conducted, based on a case study of healthcare networks in four municipalities. Individual semi-structured interviews were conducted with a three stage theoretical sample of (a) health (112) and administrative (66) professionals of different care levels, and (b) managers of providers (42) and insurers (14). A thematic content analysis was conducted, segmented by cases, informant groups and themes. The results reveal poor clinical information transfer between healthcare levels in all networks analysed, with added deficiencies in Brazil in the coordination of access and clinical management. The obstacles to care coordination are related to the organization of both the health system and the healthcare networks. In the health system, there is the existence of economic incentives to compete (exacerbated in Brazil by partisan political interests), the fragmentation and instability of networks in Colombia and weak planning and evaluation in Brazil. In the healthcare networks, there are inadequate working conditions (temporary and/or part-time contracts) which hinder the use of coordination mechanisms, and inadequate professional training for implementing a healthcare model in which primary care should act as coordinator in patient care. Reforms are needed in these health systems and networks in order to modify incentives, strengthen the state planning and supervision functions and improve professional working conditions and skills.