Walter Flores

Universal Health Coverage Anchored in the Right to Health

This editorial was published in the Bulletin of the World Health Organization [© 2013 Bulletin of the World Health Organization] and the definite version is available at: http://www.who.int/bulletin/volumes/91/1/12-115808/en/

An evidence-based approach to benchmarking the fairness of health-sector reform in developing countries

The Benchmarks of Fairness instrument is an evidence-based policy tool developed in generic form in 2000 for evaluating the effects of health-system reforms on equity, efficiency and accountability. By integrating measures of these effects on the central goal of fairness, the approach fills a gap that has hampered reform efforts for more than two decades. Over the past three years, projects in developing countries on three continents have adapted the generic version of these benchmarks for use at both national and subnational levels. Interdisciplinary teams of managers, providers, academics and advocates agree on the relevant criteria for assessing components of fairness and, depending on which aspects of reform they wish to evaluate, select appropriate indicators that rely on accessible information; they also agree on scoring rules for evaluating the diverse changes in the indicators. In contrast to a comprehensive index that aggregates all measured changes into a single evaluation or rank, the pattern of changes revealed by the benchmarks is used to inform policy deliberation aboutwhich aspects of the reforms have been successfully implemented, and it also allows for improvements to be made in the reforms. This approach permits useful evidence about reform to be gathered in settings where existing information is underused and where there is a weak information infrastructure. Brief descriptions of early results from Cameroon, Ecuador, Guatemala, Thailand and Zambia demonstrate that the method can produce results that are useful for policy and reveal the variety of purposes to which the approach can be put. Collaboration across sites can yield a catalogue of indicators that will facilitate further work.

Synergies and tensions between universal health coverage and global health security: why we need a second ‘Maximizing Positive Synergies’ initiative

A kind of courtship is going on between proponents of universal health coverage (UHC) and proponents of global health security (GHS). In our opinion, efforts to make progress on the path to UHC and efforts to improve GHS can be synergistic, but are not self-evidently so. Making this partnership work will require careful thinking and planning. Several comments on ‘lessons from Ebola’ highlight the potential of UHC as a way to improve GHS.1 Simon Rushton, Louis Lillywhite and Bhimsen Devkota argue that the “[p]romotion of health security therefore entails ensuring that effective health systems exist before a crisis, are sustained during and after conflict and disaster, and are at all times accessible to the population.”1 Rob Yates, Ranu Dhillon and Ravi Rannan-Eliya remind us that several epidemics of global concern ‘occurred in settings without universal health coverage where health systems were unable to perform effective public health functions’.1 In a reaction to these ‘lessons from Ebola’, and a preview to the G7 summit in Ise-Shima of May 2016, Gavin Yamey argued that a way to make the case for UHC more compelling ‘could be to link UHC to the worldwide concern about pandemics in the wake of the Ebola crisis’,2 and he encouraged Japan—a longstanding proponent of UHC and GHS—to ‘rouse the G7 nations into action on universal health coverage’.2 Japan indeed promoted UHC and GHS, as an ‘inseparable couple’,3 and the ‘G7 Ise-Shima Vision for Global Health’ outcome document highlights both.4 ### Not a new attempt to create an alliance The present courtship is not new. The 2007 World Health Report, on ‘A safer future: global public health security in the 21st century’,5 highlighted the importance of strong health systems to enhance GHS. Without using the expression UHC, this report tried to tie efforts to make progress towards UHC into …

Providers’ perspectives on inbound medical tourism in Central America and the Caribbean: factors driving and inhibiting sector development and their health equity implications

Background Many governments and health care providers worldwide are enthusiastic to develop medical tourism as a service export. Despite the popularity of this policy uptake, there is relatively little known about the specific local factors prospectively motivating and informing development of this sector. Objective To identify common social, economic, and health system factors shaping the development of medical tourism in three Central American and Caribbean countries and their health equity implications. Design In-depth, semi-structured interviews were conducted in Mexico, Guatemala, and Barbados with 150 health system stakeholders. Participants were recruited from private and public sectors working in various fields: trade and economic development, health services delivery, training and administration, and civil society. Transcribed interviews were coded using qualitative data management software, and thematic analysis was used to identify cross-cutting issues regarding the drivers and inhibitors of medical tourism development. Results Four common drivers of medical tourism development were identified: 1) unused capacity in existing private hospitals, 2) international portability of health insurance, vis-a-vis international hospital accreditation, 3) internationally trained physicians as both marketable assets and industry entrepreneurs, and 4) promotion of medical tourism by public export development corporations. Three common inhibitors for the development of the sector were also identified: 1) the high expense of market entry, 2) poor sector-wide planning, and 3) structural socio-economic issues such as insecurity or relatively high business costs and financial risks. Conclusion There are shared factors shaping the development of medical tourism in Central America and the Caribbean that help explain why it is being pursued by many hospitals and governments in the region. Development of the sector is primarily being driven by public investment promotion agencies and the private health sector seeking economic benefits with limited consideration and planning for the health equity concerns medical tourism raises.Background Many governments and health care providers worldwide are enthusiastic to develop medical tourism as a service export. Despite the popularity of this policy uptake, there is relatively little known about the specific local factors prospectively motivating and informing development of this sector. Objective To identify common social, economic, and health system factors shaping the development of medical tourism in three Central American and Caribbean countries and their health equity implications. Design In-depth, semi-structured interviews were conducted in Mexico, Guatemala, and Barbados with 150 health system stakeholders. Participants were recruited from private and public sectors working in various fields: trade and economic development, health services delivery, training and administration, and civil society. Transcribed interviews were coded using qualitative data management software, and thematic analysis was used to identify cross-cutting issues regarding the drivers and inhibitors of medical tourism development. Results Four common drivers of medical tourism development were identified: 1) unused capacity in existing private hospitals, 2) international portability of health insurance, vis-a-vis international hospital accreditation, 3) internationally trained physicians as both marketable assets and industry entrepreneurs, and 4) promotion of medical tourism by public export development corporations. Three common inhibitors for the development of the sector were also identified: 1) the high expense of market entry, 2) poor sector-wide planning, and 3) structural socio-economic issues such as insecurity or relatively high business costs and financial risks. Conclusion There are shared factors shaping the development of medical tourism in Central America and the Caribbean that help explain why it is being pursued by many hospitals and governments in the region. Development of the sector is primarily being driven by public investment promotion agencies and the private health sector seeking economic benefits with limited consideration and planning for the health equity concerns medical tourism raises.

Using information communication technology to identify deficits in rural health care: a mixed-methods evaluation from Guatemala

ABSTRACT Background: In August 2014, the Centre for the Studies of Equity and Governance in Health Systems (CEGSS) in Guatemala launched an online platform, which facilitates complaints about health services via text messages. The aim is to collect, systemise and forward such complaints to relevant institutions, and to create a data pool on perceived deficits of health care in rural Guatemala. Objective: To evaluate if the online platform is an accepted, user-friendly and efficient medium to engage citizens in the reporting of health care deficiencies in Guatemala. Methods: The general study design of this research was a mixed-method approach including a quantitative analysis of complaints received and a qualitative exploration of the attitude of community leaders towards the platform. Results: User statistics showed that a total of N = 228 messages were sent to the platform in the period August 2014–March 2015. The majority of complaints (n = 162, 71%) fell under the ‘lack of drugs, equipment or supplies’ category. The community leaders welcomed the platform, describing it as modern and progressive. Despite feedback mechanisms and methods to respond to complaints not yet being fully developed, many users showed a high intrinsic motivation to use the new tool. Others, however, were restrained by fear of personal consequences and distrust of the state’s judicial system. Access to mobile phones, reception, and phone credit or battery life did not pose major obstacles, but the producing and sending of correctly formatted messages was observed to be difficult. Conclusion: The online platform paired with SMS technology appears to be a viable approach to collect citizens’ complaints in health care and connect citizens with relevant institutions. Further studies should be conducted to quantify follow-up activities and the impact on local health care provision.

False and real, but avoidable, dichotomies.

This letter was published in The Lancet [© 2017 Lancet Publishing Group] and the definitive version is available at : http://doi.org/10.1016/S0140-6736(17)31445-9 The Journals website is at: https://www.sciencedirect.com/science/article/pii/S0140673617314459?via%3Dihub