General theory of paradigms in health.

In Costa Rica, three sequential health paradigms have been identified over the last 50 years. The first began to develop during the 40's and has been called that of the deficiency diseases, since with a diachronic approach it placed excessive emphasis on malnutrition. The second began in 1970 and it is known as that of the infectious diseases, since through a holistic or synchronic approach, it underlined the importance of infections in high rates of morbidity and mortality. The third and last is the paradigm of the chronic diseases, it appeared in the 80's and is presently in process, doing battle with the chronic ailments, life styles, and environment, and it also utilizes a holistic approach. The recognition of these three paradigms has permitted Costa Rica a rapid advance in improving the health of its population, to the point that with a per capita outlay of $130 (US dollars), it has indices similar to those of the industrialized nations. This particular experience could be useful for other less-developed countries that are still applying the paradigm of the deficiency diseases.

PIP: Costa Rica's health care experience is explained in terms of 3 sequential paradigms. The 1st malnutrition paradigm (1940-69) considers the causes of ill health as poverty, ignorance, exploitation, and food shortages. The problems are malnutrition, parasitosis, infectious diseases, high mortality, high rates of hospitalization, and requiring health and hospital based services. The strategies were to improve diet through food distribution, create nutrition departments within the Ministries of Health, increase the number of doctors and nurses, and politicize medicine. Socialism was the model and economic growth and industrialization were seen as prerequisites. Curative medicine was practiced. The attitude was hopelessness is being able to solve problems and acceptance of the status quo. The 2nd infectious disease paradigm (the 1970s) focused the causes as infectious diseases, intestinal parasitosis, unwanted pregnancy, low birth weight, artificial feeding, and limited health services supply, which were given priority. Primary health care for all and health sector reform were some of the strategies. Healthier families were thought to contribute more to economic and social development. Full health services were promoted and the politicization of medicine was reduced. The attitude changed to one of being able to solve one's own problems. The National Health System began to evolve based on a holistic approach where the environment and the life cycle were integrated. Implementation of the national framework was replicated at the regional and local levels; institutions and programs were integrated in a synchronic approach so that the effects of infection, malnutrition, and fertility on human growth and development were considered. Infant mortality dropped by 70%, and infectious diseases were eliminated or greatly reduced. The 3rd chronic disease paradigm (1980s) assumes the causes to be unwanted children, insufficient prenatal and maternity care, inadequate environmental conditions, inadequate life style, and social pathology. The approach is holistic. The philosophical base is the development of individual responsibility and efficient use of science and technology; health contributes to democracy and peace. Prevention, cure, and rehabilitation are equal. The application to other countries must consider that there are more technological options but fewer resources. Rigid and dogmatic plans will not work.

[Social and population policy. Considerations on efficiency and equity]. / Politica social y de poblacion. Consideraciones sobre eficiencia y equidad.

PIP: It is generally accepted that modern governments have a series of obligations and responsibilities to their citizens, and that the modern state should institutionalize its responses to social demands of its citizens in its social policy. Social policy should assure the production of public goods, defined as goods available to all society and distributed equally to all members, whose consumption does not deprive any other individual of similar consumption. Private goods by contrast are those whose benefits are consumed by an individual without providing any benefit to others. Many goods fall between the 2 categories and share characteristics of each. The state should finance and subsidize goods that generate social benefits and should establish rules of operation for the private sector. 2 goals of government participation are that it be efficient and just. Efficiency means that it is clearly oriented to production of public goods, or to the public component of goods that are a mixture of public and private, and that it does not interfere with the "social efficiency" that results from the free development of private institutions. Justice implies equity and equality of opportunities for citizens to promote their personal goals. The specific cases of education and health care demonstrate that efficiency and redistribution may conflict. Although primary and secondary education are recognized as a social good that produces greater social benefits than university education, investment in higher education is frequently greater than that in primary and secondary education, with severe distributive biases. Following the focus of the classic theory of welfare, health expenditures should be concentrated on preventive interventions, increasing the availability of potable water and sanitary facilities, providing basic health services to the least favored groups, and similar actions. But institutionalized medicine in Mexico strongly favors curative services, typically devoting 2% or less of health budgets to prevention. Family planning in Mexico, through subsidies and government participation, is also conceived as a public good. But marked inequalities are observed in the results of Mexico's family planning program in rural and urban areas. Contraceptive coverage in rural areas is only slightly over half that of urban areas, and the decline of rural total fertility rates has amounted to only 2.5 children per woman vs. 4.5 for the nation as a whole. The implications of the differences are disturbing. If current fertility trends continue, the rural growth rate will be 2.3%/year, accentuating rural-urban socioeconomic differentials. As in the cases of health and education, a review is needed of the degree to which population policy is leading to regressive situations counter to the original aims of government intervention.^ieng

[Comment on "La Calidad de Atencion en la Provision de Servicios Clinicos" of Juan Diaz and Hans Halbe]. / Comentario a "La Calidad de Atencion en la Provision de Servicios Clinicos" de Juan Diaz y Hans Halbe.

PIP: Rather than a commentary on a specific article, this work contains reflections on the concept of quality in provision of family planning services and its possible use to deflect family planning efforts. Quality is a difficult concept to define precisely. Applied to family planning, it may be defined as the totality of attributes possessed by a program that does not place impediments in the way of comfortable adoption of a contraceptive method. Another definition of quality, achievable only by a long list of ideal characteristics which are often expensive and sometimes unattainable, has been and continues to be used by enemies of family planning to slow its diffusion; they hold that if perfect quality is not offered, it is better to offer nothing. A specific tactic of this group is to oppose the quantity of services with their quality. The hard-fought campaign to discredit the measurement of concrete goals and results is part of this strategy. But it is apparent that without a reasonably satisfactory quality of service, no program would achieve significant growth. People would not continue to come, and in growing numbers, to a program where they received poor quality service. Each goal, each statistic, each percentage represents human problems confronted and resolved by programs and personnel. Profamilia has become 1 of the largest nongovernmental family planning organizations. Profamilia has always paid attention to the quality of its services and has conducted numerous studies to assess results and identify shortcomings. The high percentage of positive results attests to the quality of Profamilia programs. In an age of scarce resources and tight budgets, the objective of family planning programs is to provide an austere but acceptable quality of attention so that the quantity of services will be sufficient to meet demand. Program elements that have a real cost without offering a measurable benefit should be avoided. Another problem is that integrated programs that aim to combine family planning with maternal-child health or other services often end by neglecting the family planning component. Profamilia believes that good information should be provided with services, but it is limited to what is needed for proper and safe use of each method. And integration is not presently needed to disguise or dress up family planning programs. It is justifiable only when for political reasons there is no alternative or when it can provide other resources to subsidize family planning programs.^ieng

The impact of service delivery frequency on family planning program output and efficiency.

Operations research is the study of factors that can be controlled by program administrators. Among such factors is the frequency of performing program activities. The present experiment, conducted in Lima, Peru during 1985-86, tested the impact of holding family planning post sessions once per month, twice per month, and weekly. Frequency was shown to have a major impact on program outputs, costs, and cost-effectiveness. Depending on the indicator, sessions held twice per month produced between 1.5 and 2.1 times the output of those conducted once per month. Weekly sessions produced between 1.3 and 1.6 times the output of those held twice per month. At an output level of nearly 11,200 visits per year, twice-per-month sessions were estimated to be 7-38 percent more cost-effective, depending on the indicator, than once-per-month sessions, and 6-28 percent more cost-effective than weekly sessions.

PIP: Operations research is the study of factors that can be controlled by program administrators. One of these factors is the frequency of performing program activities. The operational variable is the frequency of having clinical sessions in medical back-up posts in a community-based distribution (CBD) program in Lima, Peru. The study covered 42 posts in urban marginal areas of Lima. 3 performing frequencies were compared: 1) once a month; 2) twice a month; and 3) weekly. A randomized block design was used. The study lasted 12 months--from August, 1985-July, 1986. 3 output indicators were chosen: 1) effectiveness; 2) efficiency; and 3) cost-effectiveness. Outputs include program acceptors, total visits, IUD insertions, sessions and family planning (FP) visits. The once-per-month posts finished 98% of scheduled sessions while the twice-a-month and weekly sessions finished 97% and 96%, respectively. Mean duration of the clinic sessions held by the monthly and twice-monthly posts was 2.9 hours (s.d.=.84 and .73, respectively). Mean duration for the weekly group was 2.8 hours (s.d.=.67). About 73% of the FP talks scheduled for the monthly post were really accomplished compared to 66% for the twice-monthly and weekly groups. The 42 posts held 1136 clinic sessions during the year and had 11,196 visits, including 5371 FP visits. 1705 women accepted a FP method at the posts. 77% were IUD takers; 15% chose pills; and 8% accepted barrier methods. There were 4768 IUD visits. There were 414 pill visits and 18% barrier method visits. About 89% of all FP visits were IUD-related. 87% of all IUD insertions were referred by CBD workers and 5% by supervisors. There were 2954 total visits in monthly posts; 3501 in twice-monthly; and 5641 in weekly posts. Output went up linearly with session frequency, but in lesser proportion than the rise in the number of sessions held. Differences are statistically significant for all outputs. Twice-a-month posts had 1.5-2.1 times the output of once-a-month posts; weekly posts had about 1.3-1.6 times the output as twice-a-month posts, depending on the variable chosen. With output level of nearly 11,200 visits per year, twice-a-month sessions were estimated to be 7-38% more cost-effective than once-a-month sessions; 6-28% more cost-effective than weekly sessions.

Private sector joins family planning effort.

PIP: Projects supported by the Directorate for Population (S&T/POP) of the U.S. Agency for International Development and aimed at increasing for-profit private sector involvement in providing family planning services and products are described. Making products commercially available through social-marketing partnerships with the commercial sector, USAID has saved $1.1 million in commodity costs from Brazil, Dominican Republic, Ecuador, Indonesia, and Peru. Active private sector involvement benefits companies, consumers, and donors through increased corporate profits, healthier employees, improved consumer access at lower cost, and the possibility of sustained family planning programs. Moreover, private, for-profit companies will be able to meet service demands over the next 20 years where traditional government and donor agency sources would fail. Using employee surveys and cost-benefit analyses to demonstrate expected financial and health benefits for businesses and work forces, S&T/POP's Technical Information on Population for the Private Sector (TIPPS) project encourages private companies in developing countries to invest in family planning and maternal/child health care for their employees. 36 companies in 9 countries have responded thus far, which examples provided from Peru and Zimbabwe. The Enterprise program's objectives are also to increase the involvement of for-profit companies in delivering family planning services, and to improve the efficiency and effectiveness of private volunteer organizations in providing services. Projects have been started with mines, factories, banks, insurance companies, and parastatals in 27 countries, with examples cited from Ghana and Indonesia. Finally, the Social Marketing for Change project (SOMARC) builds demand and distributes low-cost contraceptives through commercial channels especially to low-income audiences. Partnerships have been initiated with the private sector in 17 developing countries, with examples provided from the Dominican Republic, Liberia and Ecuador. These projects have increased private sector involvement in family planning, thereby promoting service expansion at lower public sector cost.^ieng

Costs of treating diarrhoea in a children's hospital in Mexico City.

The treatment received by children aged under 5 years with diarrhoea was studied in the Hospital Infantil de México (Federico Goméz), Mexico City. The costs of treatment were calculated and estimates were made of how these had changed since the establishment of an oral rehydration unit in the hospital in 1985. The results indicate that drug treatment of outpatients was generally appropriate and inexpensive. In contrast, the cost of drugs for inpatients was considerably higher. The seriousness of the cases justified much of this additional expense for inpatients, but there is evidence that the costs could be reduced further without jeopardizing the quality of the care. Diagnostic tests were relatively expensive, frequently failed to identify diarrhoeal etiology, and their results correlated poorly with the treatment prescribed. The oral rehydration unit resulted in significant savings by causing a 25% fall in the number of inpatients with diarrhoea.

PIP: Treatments of diarrhea in children under 5 by the Hospital Infantil de Mexico (Federico Gomez), Mexico City, in 1983-84 versus 1986 were compared with respect to drugs and laboratory tests, and costs were estimated. An outpatient oral rehydration unit was opened in the emergency room, reducing by 25% numbers of inpatients with diarrhea. Other than increased use of ORS, no changes in hospitalized patients were evident except a trend toward more laboratory tests, and prescription of amoxicillin and chloramphenicol over amikacin. There was little evidence that laboratory tests or antibiotic prescriptions were appropriate in most cases. Only 1 patient had a positive Shigella culture, and those with negative fecal cultures received more antibiotics than those with no cultures taken. Intravenous solutions were used in 85%, while only 17% were dehydrated and 22% had electrolyte imbalances, possibly because as a method of rehydration they require less nursing time than oral solutions. The average patient costs were 1200 pesos for lab tests and 180 pesos for drugs. In addition, prior to hospitalization, many patients had received ineffective or dangerous drugs such as Kaopectate-antibiotic mixtures, intestinal motility agents such as loperamide, Lactobacillus cultures, and iodochlorohydroxyquinoline.

Contraceptive social marketing and community-based distribution systems in Colombia.

Three operations research experiments were carried out in three provinces of Colombia to improve the cost-effectiveness of Profamilia's nonclinic-based programs. The experiments tested: (a) whether a contraceptive social marketing (CSM) strategy can replace a community-based distribution (CBD) program in a high contraceptive use area; (b) if wage incentives for salaried CBD instructors will increase contraceptive sales; and (c) whether a specially equipped information, education, and communication (IEC) team can replace a cadre of rural promoters to expand family planning coverage. All three strategies proved to be effective, but only the CSM system yielded a profit. Despite this, Profamilia discontinued its CSM program soon after the experiment was completed. Unexpected government controls regulating the price and sale of contraceptives in Colombia made the program unprofitable. As a result, family planning agencies are cautioned against replacing CBD programs with CSM. Instead, CBD programs might adopt a more commercial approach to become more efficient.

The high costs of health care in Brazil.

PIP: Most of Brazil's medical and hospital services are delivered through the private sector but are paid for by the government through the National Institute of Medical Care and Social Security (INMAPS). During 1981 and 1982, INMAPS took a number of measures designed to cut costs and improve operation of this system. It has also introduced a number of changes since 1983 directed at cost control. Still, it appears that health costs in Brazil are frequently higher than those in developed countries. This problem has gone hand in hand with substantial expenditures on high technology services that are frequently not needed or that are very costly and benefit relatively few patients. In seeking to confront and ameliorate these problems, what is needed is development of a system or environment that will encourage a more socially efficient use of health services. In this regard it is important to recall that creation of such a system requires a more effective use of prices as signals to physicians, who are the system's decision-makers.^ieng