Pierre De Paepe

Chile's Neoliberal Health Reform: An Assessment and a Critique

In spite of serious under-financing during the Pinochet years, Chiles public health system remains the backbone of health provision, responsible for the impressive public health status.

Colombia: In vivo Test of Health Sector Privatization in the Developing World

The reform of the Colombian health sector in 1993 was founded on the internationally advocated paradigm of privatization of health care delivery. Taking into account the lack of empirical evidence for the applicability of this concept to developing countries and the documented experience of failures in other countries, Colombia tried to overcome these problems by a theoretically sound, although complicated, model. Some ten years after the implementation of “Law 100,” a review of the literature shows that the proposed goals of universal coverage and equitable access to high-quality care have not been reached. Despite an explosion in costs and a considerable increase in public and private health expenditure, more than 40 percent of the population is still not covered by health insurance, and access to health care proves uncreasingly difficult. Furthermore, key health indicators and disease control programs have deteriorated. These findings confirm the results in other middle- and low-income countries. The authors suggest the explanation lies in the inefficiency of contracting-out, the weak economic, technical, and political capacity of the Colombian government for regulation and control, and the absence of real participation of the poor in decision-making on (health) policies.

Costa Rica: achievements of a heterodox health policy

Costa Rica is a middle-income country with a strong governmental emphasis on human development. For more than half a century, its health policies have applied the principles of equity and solidarity to strengthen access to care through public services and universal social health insurance. Costa Ricas population measures of health service coverage, health service use, and health status are excellent, and in the Americas, life expectancy in Costa Rica is second only to that in Canada. Many of these outcomes can be linked to the performance of the public health care system. However, the current emphasis of international aid organizations on privatization of health services threatens the accomplishments and universality of the Costa Rican health care system.

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.

Can malaria be controlled where basic health services are not used

Objectiveu2002 To assess the potential of integrating malaria control interventions in underused health services.

International health policy and stagnating maternal mortality: is there a causal link?

Abstract This paper examines why progress towards Millennium Development Goal 5 on maternal health appears to have stagnated in much of the global south. We contend that besides the widely recognised existence of weak health systems, including weak services, low staffing levels, managerial weaknesses, and lack of infrastructure and information, this stagnation relates to the inability of most countries to meet two essential conditions: to develop access to publicly funded, comprehensive health care, and to provide the not-for-profit sector with needed political, technical and financial support. This paper offers a critical perspective on the past 15 years of international health policies as a possible cofactor of high maternal mortality, because of their emphasis on disease control in public health services at the expense of access to comprehensive health care, and failures of contracting out and public–private partnerships in health care. Health care delivery cannot be an issue both of trade and of right. Without policies to make health systems in the global south more publicly-oriented and accountable, the current standards of maternal and child health care are likely to remain poor, and maternal deaths will continue to affect women and their families at an intolerably high level. Résumé Pourquoi les progrès vers lOMD 5 relatif à la santé maternelle semblent-ils stagner dans la plupart des pays du Sud ? Les auteurs de larticle avancent quen plus des faiblesses largement reconnues des systèmes de santé, notamment les déficiences des services, linsuffisante dotation en personnel, les lacunes de la gestion, ainsi que le manque dinfrastructure et dinformation, cette stagnation est due à lincapacité de la plupart des pays à rencontrer deux conditions essentielles : élargir laccès à des soins de santé globaux et financés par lÉtat, et doter le secteur non lucratif dun soutien politique, technique et financier cruellement nécessaire. Larticle propose une perspective critique sur les politiques sanitaires internationales des 15 dernières années comme corrélat possible de la mortalité maternelle élevée, en raison de laccent que ces politiques placent sur la lutte contre les maladies dans les services de santé publique, aux dépens de laccès à des soins de santé globaux, et le manque de recours aux services extérieurs et aux partenariats public-privé dans la santé. Les soins de santé ne peuvent relever à la fois du commerce et du droit à la santé. Sans politiques qui orienteront les systèmes de santé du Sud vers une logique sociale et les rendront plus comptables de leurs activités, les normes actuelles des soins de santé maternelle et infantile risquent de rester médiocres, et les décès maternels continueront de toucher les femmes et leurs familles à un niveau intolérable. Resumen En este artículo se examinan las razones por las que los avances hacia el Objetivo 5 de Desarrollo del Milenio respecto a la salud materna parecen haberse estancado en gran parte del sur global. Argüimos que además de la existencia, ampliamente conocida de sistemas de salud débiles, con servicios deficientes, número reducido de personal, debilidades administrativas y falta de infraestructura e información, este estancamiento está relacionado con la incapacidad de la mayoría de los países para satisfacer dos condiciones esenciales: crear acceso a servicios de atención integral de la salud financiados por el sector público y brindar al sector sin fines de lucro el apoyo político, técnico y financiero que necesita. Este artículo ofrece un punto de vista crítico sobre los últimos 15 años de políticas internacionales de salud como un posible cofactor de las altas tasas de mortalidad materna, debido a su énfasis en el control de enfermedades en servicios de salud pública a expensas del acceso a la atención integral de la salud, así como a los fracasos de subcontratación y alianzas entre los sectores público y privado de salud. La prestación de atención de salud no puede ser un asunto tanto de comercio como de derecho. Sin políticas para lograr que los sistemas de salud del sur estén más orientados hacia el público y sean más responsables, los niveles actuales de atención materno-infantil probablemente continuarán siendo deficientes, y las muertes maternas continuarán afectando intolerablemente a las mujeres y sus familias.

Revisiting health policy and the World Bank in Bolivia

This article analyses the influence of the World Bank on reforms of the health sector in Bolivia during the period 1986–2006, and assesses their impact on the health care delivery system to date. The article examines the transformation of health services undertaken by the current socialist government since 2006. A literature review and interviews with decision-makers critically examine the outcome of reforms on criteria linked to health system integration. The study illustrates that Bolivia applied quite comprehensively the WB recommendations. Among others these included indirect privatization through public health services’ restriction of access to a basic package of care and decentralization with devolution. In consequence, the segmentation and fragmentation of the health system was exacerbated, accessibility and quality of care suffered and health status barely improved. The article attempts to locate the relationship between policy, health care delivery and health systems functioning.

Ecuador's Silent Health Reform

Health sector reform was implemented in many Latin American countries in the 1980s and 1990s, leading to reduced public expenditure on health, limitations on public provision for disease control, and a minimum package of services, with concomitant growth of the private sector. At first sight, Ecuador appeared to follow a different pattern: no formal reform was implemented, despite many plans to reform the Ministry of Health and social health insurance. The authors conducted an in-depth review and analysis of published and gray literature on the Ecuadorian health sector from 1990 onward. They found that although neoliberal reform of the health sector was not openly implemented, many of its typical elements are present: severe reduction of public budgets, “universal” health insurance with limited coverage for targeted groups, and contracting out to private providers. The health sector remains segmented and fragmented, explaining the populations poor health status. The leftist Correa government has prepared an excellent long-term plan to unite services of the Ministry of Health and social security, but implementation is extremely slow. In conclusion, the health sector in Ecuador suffered a “silent” neoliberal reform. President Correas progressive government intends to reverse this, increasing public budgets for health, but hesitates to introduce needed radical changes.

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.

International health and aid policies : the need for alternatives

Objectives: To assess inequity in health care financing and utilisation, its associated socio-economic variables and consequences, with focus on the impact of alternative health financing systems.xa0 ...