ABSTRACT
Despite the health, societal, and economic benefits of immunization, many countries focus primarily on childhood immunizations and lack robust policies and sufficient resources for immunizations that can benefit populations across the life course. While the benefits of childhood vaccination are well documented, there is limited evidence on the financial and social return on investment that policymakers can use to inform decisions around administering a life-course immunization program. We developed a cost-benefit model from a societal perspective to evaluate the inclusion of 5 vaccines across the life course in Colombia's national immunization program. This model estimated a return of US$1.3 per US$1.0 invested in the first 2 decades, increasing to US$3.9 after 60 years. Primary benefits were productivity gains, followed by fiscal savings and household averted expenditure on health care. Furthermore, vulnerable households are predicted to receive 3.2 times greater income protection than formally employed households under a life-course immunization program. Consequently, there is a potential to reduce Colombia's income inequality and poverty rate by increasing access to immunization for all ages.
ABSTRACT
Resumo O objetivo desta pesquisa é analisar a organização do sistema de saúde do Haiti, entre 2010 e 2020, com base no Postulado de Coerência proposto por Mário Testa. O estudo utilizou fontes públicas que foram compiladas e codificadas com auxílio do software QSR NVivo 10.0.641.0, para posterior análise crítica de conteúdo. Os resultados revelaram que o manejo de infecções sexualmente transmissíveis (IST) constituía a maior oferta de serviços, porém de forma fragmentada, sendo que as principais causas de morbimortalidade eram as doenças isquêmicas do coração e demais doenças cardiovasculares, devido a uma transição epidemiológica não identificada como problema prioritário no país. Destaca-se que a eletricidade irregular, a falta de equipamentos para fornecer água e instalações sanitárias, nas instituições de saúde, despontaram como questões estruturais a serem enfrentadas. Identificou-se que doadores contribuíram com mais da metade das despesas em saúde em 2010-2019, evidenciando uma dependência de financiamento externo. Conclui-se que a situação de contínua instabilidade política afeta significativamente o desempenho e a melhoria do sistema de saúde haitiano, mas a colaboração efetiva entre os atores identificados pode aportar mudanças significativas.
Abstract This research aims to analyze the organization of Haiti's health system between 2010 and 2020, based on the Postulate of Coherence proposed by Mário Testa. The study used public sources compiled and coded with the help of the QSR NVivo 10.0.641.0 software, for subsequent critical content analysis. The results revealed that the management of sexually transmitted infections (STIs) were the largest range of services, but in a fragmented manner, with the main causes of morbidity and mortality being ischemic heart disease and other cardiovascular diseases, due to an unidentified epidemiological transition as a priority problem in the country. It is noteworthy that irregular electricity, the lack of equipment to supply water and sanitary facilities in health institutions emerged as structural issues to be faced. It was identified that donors contributed more than half of health expenses in 2010-2019, highlighting a dependence on external financing. It is concluded that the situation of continued political instability significantly affects the performance and improvement of the Haitian health system, but effective collaboration between the identified actors can bring about significant changes.
ABSTRACT
Fair process is instrumental to implementing and sustaining health financing reforms. Ensuring a fair process during the design and adoption phases can garner political capital and secure a sense of citizens' ownership. This will prove useful when reforms are contested before benefits are yet to be fully materialized. Since many well devised health financing reforms are vulnerable to being dismantled after a few years of being launched, fair process should play a more strategic role in the implementation and evaluation phases when policies get challenged and reformulated to reflect the changing political and socioeconomic landscapes and to better manage early evidence on performance.
Subject(s)
Health Care Reform , Healthcare Financing , HumansABSTRACT
O investimento financeiro desempenha um papel fundamental no combate ao HIV, sendo essencial no financiamento de programas de prevenção, como campanhas de conscientização pública, distribuição de preservativos, testagem, tratamento e pesquisas. Sem investimento adequado, as taxas de infecção podem aumentar e as pessoas que vivem com HIV podem não ter acesso aos tratamentos e serviços de que precisam. Este estudo tem como objetivo analisar sobre o aumento de investimento na área da vigilância epidemiológica relativa ao combate a Infecções Sexualmente Transmissíveis (IST's) com um olhar para o vírus da imunodeficiência humana HIV, no município de Ji- Paraná no período de 2019 a 2022. Adotou-se como metodologia uma pesquisa elaborada de forma quantitativa, de caráter exploratório, por meio de uma análise de dados dos registros públicos epidemiológicos e também dos investimentos no fundo municipal de saúde publicados no portal de transparência do município de Ji-Paraná. O seguinte estudo possibilitou a análise dos investimentos realizados no fundo municipal de saúde para a realização de ações voltadas para o controle, diagnósticos e tratamento da Human Immuno Deficiency Virus (HIV) que teve influência direta na diminuição dos casos registrados pelo portal do Sistema de Informações de Agravos de Notificação (SINAN) no período de 2019 a 2020. Conclui-se que o investimento em saúde pública para o combate ao HIV/AIDS é fundamental e pode ser um grande desafio financeiro para os municípios, especialmente em tempos de crise econômica e escassez de recursos, a alocação de recursos adequados para programas de prevenção, tratamento, cuidados de saúde, serviços de apoio, pesquisa e monitoramento pode ajudar a reduzir a incidência de novos casos de HIV e garantir que as pessoas que vivem com HIV recebam o suporte necessário para gerenciar sua condição.
Financial investment plays a fundamental role in the fight against HIV, being essential in financing prevention programs, such as public awareness campaigns, condom distribution, testing, treatment, and research. Without adequate investment, infection rates can increase and people living with HIV may not have access to the trea- tments and services they need. This study aims to analyze the increase in investment in the area of epidemiological surveillance related to the fight against Sexually Transmitted Infections (STIs) with a focus on the Human Immunodeficiency Virus (HIV) in the mu- nicipality of Ji-Paraná from 2019 to 2022. A quantitative exploratory research methodo- logy was adopted, through an analysis of data from public epidemiological records and also investments in the municipal health fund published on the transparency portal of the municipality of Ji-Paraná. This study enabled the analysis of investments made in the municipal health fund for actions aimed at the control, diagnosis, and treatment of the Human Immuno Deficiency Virus (HIV), which had a direct influence on the decrease in cases recorded by the Notification of Aggravations Information System (SINAN) portal from 2019 to 2020. It is concluded that public health investment for the fight against HIV/AIDS is essential and can be a significant financial challenge for municipalities, especially in times of economic crisis and resource scarcity. Adequate allocation of re- sources for prevention programs, treatment, healthcare, support services, research, and monitoring can help reduce the incidence of new HIV cases and ensure that people living with HIV receive the necessary support to manage their condition. KEYWORDS: AIDS/HIV; Public Health; Financing.
La inversión financiera juega un papel fundamental en la lucha contra el VIH, siendo esencial para el financiamiento de programas de prevención, como campañas de concientización pública, distribución de preservativos, pruebas, tratamiento e investi- gaciones. Sin una inversión adecuada, las tasas de infección pueden aumentar y las per- sonas que viven con VIH pueden no tener acceso a los tratamientos y servicios que nece- sitan. Este estudio tiene como objetivo analizar el aumento de la inversión en el área de la vigilancia epidemiológica en relación a la lucha contra las Infecciones de Transmisión Sexual (ITS), con un enfoque en el virus de la inmunodeficiencia humana VIH, en el municipio de Ji-Paraná en el período de 2019 a 2022. Se adoptó como metodología una investigación elaborada de forma cuantitativa, de carácter exploratorio, a través de un análisis de datos de registros públicos epidemiológicos y también de las inversiones en el fondo municipal de salud publicadas en el portal de transparencia del municipio de Ji- Paraná. Este estudio permitió el análisis de las inversiones realizadas en el fondo munici- pal de salud para llevar a cabo acciones enfocadas en el control, diagnóstico y tratamiento del Virus de Inmunodeficiencia Humana (VIH), lo que tuvo una influencia directa en la disminución de los casos registrados por el portal del Sistema de Información de Agravios de Notificación (SINAN) en el período de 2019 a 2020. Se concluye que la inversión en salud pública para la lucha contra el VIH/SIDA es fundamental y puede ser un gran de- safío financiero para los municipios, especialmente en tiempos de crisis económica y es- casez de recursos, la asignación de recursos adecuados para programas de prevención, tratamiento, cuidado de la salud, servicios de apoyo, investigación y monitoreo puede ayudar a reducir la incidencia de nuevos casos de VIH y garantizar que las personas que viven con VIH reciban el apoyo necesario para manejar su condición.
ABSTRACT
Resumo Neste artigo, aprofunda-se a discussão crítica às políticas adotadas pelo governo Bolsonaro em relação à saúde pública, particularmente no que tange ao financiamento em geral, ao enfrentamento da pandemia e ao primeiro ano de implantação do novo modelo de "financiamento" para a Atenção Primária à Saúde (APS). A análise evidencia o acirramento da legitimidade restrita do regime político, assumida por políticas ultraneoliberais e pelo neofascismo do governo Bolsonaro. Estas formas de dominação - política e econômica - engendram uma conjuntura interna que visa remodelar a acumulação de capital na saúde pública via APS por meio de mecanismos "operacionais" burocráticos sutis de desconstrução da universidade do "financiamento". Na primeira parte, discute-se a abrangência da crise tripla do capital - sanitária, econômica e ecológica - e sua relação orgânica com o Estado no capitalismo dependente brasileiro, abrindo espaço para o crescimento da restrição do regime político endossado pela ascensão do neofascismo. Na segunda parte, aborda-se a escalada do desfinanciamento do Sistema Único de Saúde (SUS) em plena crise de covid-19 e os efeitos da implementação do modelo de financiamento da APS, evidenciando a continuidade do processo de valorização de um "SUS operacional" em detrimento do seu princípio de universalidade como dimensão neofascista do governo Bolsonaro.
Abstract This article deepens the critical discussion about the policies of the Bolsonaro government regarding public health, particularly regarding the general financing, the confrontation of the pandemic, and the first year of implementation of the new financing model for Primary Health Care (PHC). The analysis evidences the aggravation of the restrict legitimacy of the political regime, assumed by ultra-neoliberal policies and by the neofascism of the Bolsonaro government. These forms of domination - political and economic - produce an internal conjuncture that seeks to remodel the capital accumulation in public health by PHC by subtle bureaucratic "operational" mechanisms of deconstruction of financing universality. In the first part, the coverage of the triple crisis of the capital - sanitary, economic and ecological - and its organic relationship to the State in the Brazilian dependent capitalism is discussed, opening space to the increase of the restriction of the political regime endorsed by the ascension of the neofascism. In the second part, the increase of the de-financing of the Unified Health System (SUS) right in the middle of the covid-19 crisis and the effects of the implementation of the financing model of the PHC, evidencing the continuity of the process of valuing an "operational SUS" in detriment of its universality principle as a neofascist dimension of Bolsonaro's government.
Subject(s)
Humans , Male , Female , Politics , Primary Health Care , State , Healthcare Financing , COVID-19 , Unified Health System , Adaptation, Psychological , FascismABSTRACT
Resumo Descreve a evolução da estrutura e resultados da Atenção Primária à Saúde (APS) no Brasil, entre 2008 e 2019. Foram calculadas a mediana de variáveis como: despesa per capita em APS por habitante coberto, cobertura da APS e as taxas de mortalidade e internações por condições sensíveis à atenção primária (CSAP) de 5.565 municípios brasileiros estratificados segundo porte populacional e quintil do Índice Brasileiro de Privação (IBP) e analisada a tendência mediana no período. Houve aumento de 12% na mediana da despesa em APS. A cobertura da APS expandiu, sendo que 3.168 municípios apresentaram 100% de cobertura em 2019, contra 2.632 em 2008. A mediana das taxas de mortalidade e internações por CSAP aumentou 0,2% e diminuiu 44,9% respectivamente. A despesa em APS foi menor nos municípios com maior privação socioeconômica. Quanto maior o porte populacional e melhores as condições socioeconômicas dos municípios, menor a cobertura da APS. Quanto maior a privação socioeconômica dos municípios, maiores foram as medianas das taxas de mortalidade por CSAP. Este estudo demonstrou que a evolução da APS foi heterogênea e está associada tanto ao porte populacional como às condições socioeconômicas dos municípios.
Abstract This paper describes the structure and results of Primary Health Care (PHC) in Brazil between 2008 and 2019. The medians of the following variables were calculated: PHC spending per inhabitant covered, PHC coverage, and rates of mortality and hospitalizations due to primary care sensitive conditions (PCSC), in 5,565 Brazilian municipalities stratified according to population size and quintile of the Brazilian Deprivation Index (IBP), and the median trend in the period was analyzed. There was a 12% increase in median PHC spending. PHC coverage expanded, with 3,168 municipalities presenting 100% coverage in 2019, compared to 2,632 in 2008. The median rates of PCSC mortality and hospitalizations increased 0.2% and decreased 44.9%, respectively. PHC spending was lower in municipalities with greater socioeconomic deprivation. The bigger the population and the better the socioeconomic conditions were in the municipalities, the lower the PHC coverage. The greater the socioeconomic deprivation was in the municipalities, the higher the median PCSC mortality rates. This study showed that the evolution of PHC was heterogeneous and is associated both with the population size and with the socioeconomic conditions of the municipalities.
ABSTRACT
Esta es la segunda parte de un artículo sobre la búsqueda de financiamiento para un proyecto de investigación. Todo proyecto de investigación requiere una fuente de financiamiento para poder ser llevado adelante. La búsqueda de fondos es una tarea que lleva tiempo y esfuerzo con una baja tasa de éxito. Compartimos algunos consejos que podrían ayudar a aumentar esa tasa de éxito en relación con: 1) cómo reconocer la necesidad de búsqueda de una fuente de financiamiento externo, 2) de dónde provienen los fondos, 3) qué gastos se pueden financiar habitualmente con los fondos y 4) cómo mejorar la escritura y la presentación a una convocatoria. (AU)
This is the second part of our series on searching funds for a research plan. Every research proposal requires a source of funding to be carried out. Looking for funds is a time and effort consuming task with a low success rate. We share some tips that may help to improve that success rate related to (1) how to recognize the need of an external funding source, (2) where the funds are coming from, (3) what costs can be funded and (4) how to improve a proposal writing and submission. (AU)
Subject(s)
Humans , Research Financing , Support of Research , Research Design/trends , Research Support as Topic/methods , Writing , Financing, OrganizedABSTRACT
RESUMO O objetivo deste artigo é o de analisar o financiamento federal do Sistema Único de Saúde (SUS) para o enfrentamento da pandemia da Covid-19 em 2020 e durante o primeiro quadrimestre de 2021 - períodos caracterizados como da primeira e da segunda ondas. Realizou-se pesquisa documental com levantamento de dados disponíveis em sítios eletrônicos oficiais. A pandemia se instalou no Brasil em fevereiro de 2020, no contexto do subfinanciamento crônico do SUS, que se aprofundou com o estrangulamento de dotações verificado a partir da Emenda Constitucional 95/2016, que definiu o teto das despesas primárias e o congelamento do piso federal do SUS até 2036, no mesmo valor do piso de 2017. Essa medida constitucional viabilizou o aprofundamento da política de austeridade fiscal pela via da redução das despesas primárias e da dívida pública em relação ao Produto Interno Bruto. Tais objetivos condicionaram também o financiamento federal para o combate à pandemia da Covid-19 em 2020 e 2021, cuja execução orçamentária e financeira pode ser caracterizada como reativa e retardatária. Essa forma de execução comprometeu o atendimento das necessidades de saúde da população, além de prejudicar a gestão do SUS nas esferas de governo subnacionais.
ABSTRACT The purpose of this article is to analyze the federal funding of the Unified Health System (SUS) to fight the COVID-19 pandemic in 2020 and during the first four months of 2021 - periods characterized as the first and second waves. Documentary research was carried out, with data available on official websites. The pandemic took hold in Brazil in February 2020, in the context of the chronic underfunding of SUS, which deepened with the strangulation of appropriations verified from the Constitutional Amendment 95/2016, which defined the ceiling on primary expenditure and the freezing of the federal floor of SUS until 2036, at the same value as the 2017 floor. This constitutional measure made it possible to deepen the fiscal austerity policy by reducing primary expenditure and public debt in relation to the Gross Domestic Product. These goals also conditioned federal funding to combat the COVID-19 pandemic in 2020 and 2021, whose budget and financial execution can be characterized as reactive and delayed. This form of execution compromised meeting the health needs of the population, in addition to harming the management of SUS in subnational government spheres.
ABSTRACT
BACKGROUND: The leading emerging markets of Brazil, Russia, India, China and South Africa (BRICS) are increasingly shaping the landscape of the global health sector demand and supply for medical goods and services. BRICS' share of global health spending and future projections will play a prominent role during the 2020s. The purpose of the current research was to examine the decades-long underlying historical trends in BRICS countries' health spending and explore these data as the grounds for reliable forecasting of their health expenditures up to 2030. METHODS: BRICS' health spending data spanning 1995-2017 were extracted from the Institute for Health Metrics and Evaluation (IHME) Financing Global Health 2019 database. Total health expenditure, government, prepaid private and out-of-pocket spending per capita and gross domestic product (GDP) share of total health spending were forecasted for 2018-2030. Autoregressive integrated moving average (ARIMA) models were used to obtain future projections based on time series analysis. RESULTS: Per capita health spending in 2030 is projected to be as follows: Brazil, $1767 (95% prediction interval [PI] 1615, 1977); Russia, $1933 (95% PI 1549, 2317); India, $468 (95% PI 400.4, 535); China, $1707 (95% PI 1079, 2334); South Africa, $1379 (95% PI 755, 2004). Health spending as a percentage of GDP in 2030 is projected as follows: Brazil, 8.4% (95% PI 7.5, 9.4); Russia, 5.2% (95% PI 4.5, 5.9); India, 3.5% (95% PI 2.9%, 4.1%); China, 5.9% (95% PI 4.9, 7.0); South Africa, 10.4% (95% PI 5.5, 15.3). CONCLUSIONS: All BRICS countries show a long-term trend towards increasing their per capita spending in terms of purchasing power parity (PPP). India and Russia are highly likely to maintain stable total health spending as a percentage of GDP until 2030. China, as a major driver of global economic growth, will be able to significantly expand its investment in the health sector across an array of indicators. Brazil is the only large nation whose health expenditure as a percentage of GDP is about to contract substantially during the third decade of the twenty-first century. The steepest curve of increased per capita spending until 2030 seems to be attributable to India, while Russia should achieve the highest values in absolute terms. Health policy implications of long-term trends in health spending indicate the need for health technology assessment dissemination among the BRICS ministries of health and national health insurance funds. Matters of cost-effective allocation of limited resources will remain a core challenge in 2030 as well.
Subject(s)
Health Expenditures , Healthcare Financing , Brazil , China , Health Policy , Humans , India , South AfricaABSTRACT
RESUMEN El financiamiento es una función fundamental que contribuye al propósito que tienen los sistemas de salud de mejorar el estado de salud de la población. Esta función se concreta en la recaudación de fondos, su mancomunación y asignación, y en ella se diferencian las fuentes y los usos de los recursos, especialmente en cuanto al carácter público o privado y a la forma como se cubren los costos de los servicios de salud. En este artículo se presenta una mirada de largo plazo sobre el financiamiento de la salud en Colombia, identificando los antecedentes y la evolución a partir de la reforma de 1993. Se identifican cuatro momentos en esta evolución: I. incremento significativo de recursos, al momento de expedir las Leyes 60 y 100 de 1993; II. contención fiscal, en el marco de la crisis de 1998 y 1999; III. mayor esfuerzo fiscal, especialmente a partir de 2010, y IV. sustitución de fuentes, de cotizaciones a impuestos generales, que se inició en 2012. Se evidencia un desarrollo importante de la función de financiamiento, con un fortalecimiento a partir de la Administradora de los Recursos del Sistema (ADRES), la reducción en la dependencia de las cotizaciones, el proceso de igualación per cápita entre regímenes de aseguramiento, y un mayor aporte de impuestos generales para buscar el equilibrio del sistema. Todo ello implica mantener el predominio público y garantizar la protección financiera en salud.
ABSTRACT Financing is a fundamental function that contributes to the purpose of health systems to improve the health status of the population. This function takes the form of fundraising, pooling and allocation, and it differentiates the sources and uses of resources, especially in terms of their public or private nature and the way in which health costs are covered. This article presents a long-term view of health financing in Colombia, identifying the background and evolution since the 1993 reform. Four moments in this evolution are identified: I. significant increase in resources, at the time of issuing Laws 60 and 100 of 1993; II. fiscal containment, in the context of the 1998 and 1999 crisis; IV. greater fiscal effort, especially since 2010, and V. substitution of sources, from contributions to general taxes, which began in 2012. An important development of the financing function is evident, with a strengthening of the System's Resources Administrator (ADRES), a reduction in the dependence on contributions, the process of equalization of the capita among insurance regimes, and a greater contribution of general taxes to seek the balance of the system, all of which implies maintaining public predominance and guaranteeing financial protection in health.
ABSTRACT
RESUMO O objetivo do artigo foi descrever a resiliência do gasto governamental com Ações e Serviços Públicos de Saúde (ASPS) no Brasil durante a pandemia da Covid-19 em 2020. Demonstra-se que o desenvolvimento do setor público de saúde contemporâneo foi baseado no federalismo cooperativo. Nesse contexto, a participação municipal no financiamento foi consolidada em torno do pacto da vinculação orçamentária entre os níveis da federação (governo central, estados e municípios). Com base nos indicadores do Sistema de Informação sobre Orçamento Público de Saúde (Siops)/DataSUS/Ministério da Saúde, descrevem-se o Índice de Vinculação Orçamentária e a resiliência da amostra de 87 municípios com elevada disponibilidade orçamentária. Expõe-se que o governo central retirou o apoio à expansão das despesas com ASPS, estabilizando a alocação de seus recursos por meio do veto à vinculação orçamentária. A mudança de orientação federal transferiu o ônus da expansão do financiamento aos governos municipais e estaduais nas últimas décadas. Conclui-se que a estabilização das despesas federais foi compensada pelo crescimento da vinculação do orçamento municipal com as ASPS. Durante o primeiro ciclo da pandemia da Covid-19, a vinculação orçamentária foi crucial para a expansão do financiamento das ASPS na maioria dos municípios da amostra, possibilitando a condição resiliente.
ABSTRACT This paper aimed to describe the resilience of the Federal Government's fund of Public Health Actions and Services (ASPS) in Brazil during the 2020 COVID-19 pandemic. It shows that the development of the contemporary public health sector was based on cooperative federalism. In this context, municipal participation in financing was consolidated around the constitutional agreement of budget binding between the levels of the Brazilian federation (Central Government, states, and municipalities). The Budget Binding Index (BBI) and the resilience of the sample of 87 municipalities with a high budget are described from the Public Health Budget Information System (SIOPS) indicators, available at DataSUS/Ministry of Health. The paper shows that the central government withdrew its support for increased ASPS expenditure in the last decade, stabilizing the allocation of its resources through the veto on budget binding. The change in federal orientation shifted the burden of expanding financing to municipal and state governments. The paper concludes that the increase in municipal expenditures offset the stabilization of federal expenditures. Budget binding was crucial to the resilience of ASPS funding in most municipalities in the sample during the first cycle of the COVID-19 pandemic.
ABSTRACT
This article presents an exploratory model to classify public attitudes towards health systems financing and organization. It comprises 5 factors (pay-as-you-use, solidarity, willingness to contribute, mixed financing, and public provision) measured by 17 indicators, selected through Exploratory Structural Equation Modeling (ESEM) applied to a sample of Chilean adults. Based on this model, cluster analysis proposed 2 groups: "Taxes-public" and "Insurance-choice," representing 47% and 53% of interviewees, respectively. The results show differences between groups concerning the evaluation of both health care providers and insurers. The second cluster tends to evaluate them more harshly, showing less willingness to contribute further, less solidarity, more agreement with the current financing arrangement in terms of the mixture and its insurance (as opposed to purchasing of service based on health problems), and more support for choice of provider. These results highlight the need to consider people's attitudes in the public discussion of health systems financing.
Subject(s)
Insurance Carriers , Medical Assistance , Adult , Attitude , Chile , Government Programs , HumansABSTRACT
Purpose: In an effort to transition toward universal health coverage (UHC), Jamaica abolished user fees at all public health facilities in 2008. We aimed to determine the extent of out-of-pocket payments (OPPs) and the other cost barriers to UHC among patients with sickle cell disease (SCD). Methods: Patients presenting to the Sickle Cell Unit in Kingston, Jamaica, for routine care between October 2019 and August 2020 were consecutively recruited and interviewed about their latest hospitalization within the previous 4 weeks. Parents or guardians completed the questionnaire on behalf of pediatric patients. The questionnaire included the Patient Satisfaction Questionnaire Short Form (PSQ)-18 and the health module of the Jamaica Survey of Living Conditions. Results: There were 103 patients with ages ranging from 7 months to 56 years (51.5% female, 60.2% public hospitalizations, and 54.4% pediatric). The modal income (J$6200-$11,999 per week) was similar to the minimum wage and 48.5% lived in overcrowded households. Government drug-subsidy cards were owned by 39.8%. OPPs were made by 19.4% of persons for items and tests that were unavailable at public facilities. There were no costs reported by 69.6%, who visited public pharmacies. Similarly, the cost of admission to public hospitals was free for 95.4% of subjects. Using public transportation, private hospitalization, and having more disease complications were predictive of a perception that health care is unaffordable. Conclusion: Most SCD subjects reported no expense with public hospitalizations; however, approximately one in five reported OPPs. Efforts are needed to increase the availability of subsidized items, and the use of drug-subsidy cards, to improve UHC.
ABSTRACT
OBJECTIVE: To assess the relationship between out-of-pocket (OOP) payments and primary health care quality in six low-income countries: Afghanistan, the Democratic Republic of the Congo (DRC), Haiti, Nepal, Senegal and Tanzania. METHODS: We examined the association between OOP payments and quality of care during antenatal care and sick child care visits using Service Provision Assessments data. We defined four process quality outcomes from observations of clinical care: visit duration, history-taking items asked, exam items performed, and counselling items delivered. The outcome is the total amount paid for services. We used multilevel models to test the relationship between OOP payments and each quality measure in public, private non-profit and private for-profit facilities controlling for patient, provider, and facility characteristics. RESULTS: Across the six countries, an average of 42% of the 29 677 observed clients paid for their visit. In the adjusted models, OOP payments were positively associated with the visit duration during sick child visits, with history-taking and exam items during antenatal care visits, and with counselling in private for-profit facilities for both visit types. These associations were strong particularly in Afghanistan, the DRC and Haiti; for example, a high-quality antenatal care visit in the DRC would cost approximately USD 1.12 more than a visit with median quality. CONCLUSION: Provider effort was associated with higher OOP payments for sick child and antenatal care services in the six countries studied. While many families are already spending high amounts on care, they must often spend even more to receive higher quality care.
Subject(s)
Health Expenditures , Prenatal Care/economics , Primary Health Care/economics , Quality of Health Care/economics , Afghanistan , Cross-Sectional Studies , Democratic Republic of the Congo , Female , Haiti , Humans , Nepal , Poverty , Senegal , TanzaniaABSTRACT
BACKGROUND: Understanding health financing reforms and means is key to evaluate how maternal health has improved. Problems related to health financing policies are contributing to inadequate quality of care and inequitable use of healthcare by pregnant women, resulting in poor maternal health outcomes. The purpose of the study was to measure socioeconomic and health financing related inequality in maternal mortality in Colombia as well as identifying potential epicenters of this inequality. METHODS: The data used was obtained from National Information of Social Protection (Sispro), the Department of Planning and National Statistics Department. Maternal mortality ratios were calculated by health insurance scheme and disaggregated by health spending per capita quintiles to allow for closer examination of inequality. The Slope Index of Inequality and Concentration Index were estimated to express absolute and relative inequality. We conducted interviews with key informants involved in the implementation of health financing and maternal health policies. RESULTS: The main finding shows inequality in maternal mortality across regions and in particular in the subsidized health insurance. The contributory health insurance scheme is closing gaps over time, but inequality in the subsidized scheme is significantly widening, which impacts the severity of overall measurements of inequality. 20% of territories with the lowest health spending per capita have reached 35% of maternal mortality, and it such rates are worsening. This means that there is a marginal exclusion in which most of maternal deaths still occur in the regions with lowest resources. CONCLUSIONS: Beyond the key issues in health financing, issues of quality of care must be addressed. The country must define its own approach to financing for maternal health coverage given its unique situation and starting point. Potential policy implications that emerged are: i) afro-Colombian, indigenous, poorer and migrant women must be put at the center of the maternal health care services; ii) better skills, Reproductive, Maternal, Newborn and Child Health RMNCH training and health worker retention strategies and training in rural, insular and remote geographical areas; ii) a better understanding of provider payment mechanisms and the incentives that influence provider behaviors; and iv) inequality prompt calls for a targeted approach, whereby care is directed toward the most disadvantaged regions.
Subject(s)
Delivery of Health Care/organization & administration , Healthcare Disparities/economics , Maternal Health Services/organization & administration , Maternal Mortality/trends , Socioeconomic Factors , Adolescent , Adult , Colombia/epidemiology , Delivery of Health Care/economics , Delivery of Health Care/standards , Female , Humans , Insurance, Health/economics , Maternal Health , Maternal Health Services/economics , Maternal Health Services/standards , Middle Aged , Rural Population , Young AdultABSTRACT
Resumo Em 2019, o governo brasileiro lançou uma nova política para a Atenção Primária à Saúde (APS) no Sistema Único de Saúde (SUS). Chamada de "Previne Brasil", a política modificou o financiamento da APS para municípios. No lugar de habitantes e de equipes de Estratégia Saúde da Família (ESF), as transferências intergovernamentais passaram a ser calculadas a partir do número de pessoas cadastradas em serviços de APS e de resultados alcançados sobre um grupo selecionado de indicadores. As mudanças terão um conjunto de impactos para o SUS e para a saúde da população que precisaram ser identificados e monitorados. Neste artigo, discute-se os possíveis efeitos da nova política a partir de uma breve análise de contexto sobre tendências globais de financiamento de sistemas de saúde e de remuneração por serviços de saúde, bem como dos avanços, desafios e ameaças à APS e ao SUS. Com base na análise realizada, entende-se que a nova política parece ter objetivo restritivo, que deve limitar a universalidade, aumentar as distorções no financiamento e induzir a focalização de ações da APS no SUS, contribuindo para a reversão de conquistas históricas na redução das desigualdades na saúde no Brasil.
Abstract In 2019, the Brazilian government launched a new Primary Health Care (PHC) policy for the Unified Health System (SUS). Called "PrevineBrasil", the policy changed the PHC funding for municipalities. Instead of inhabitants and Family Health Strategy (ESF) teams, intergovernmental transfers are calculated from the number of people registered in PHC services and the results achieved in a selected group of indicators. The changes will have a set of impacts for the SUS and the health of the population, which must be observed and monitored. In this paper, possible effects of the new policy are discussed from a brief context analysis of global trends in health systems financing and health services' remuneration models, as well as on the advances, challenges, and threats to PHC and the SUS. Based on the analysis, the new policy seems to have a restrictive purpose, which should limit universality, increase distortions in financing and induce the focus of PHC actions on the SUS, contributing to the reversal of historic achievements in reducing health inequalities in Brazil.
Subject(s)
Humans , Primary Health Care/economics , Healthcare Financing , National Health Programs/economics , Primary Health Care/statistics & numerical data , Reimbursement, Incentive/economics , Brazil , Capitation Fee , Family Health , Health Expenditures , Health Care Reform/economics , Healthcare Disparities/economics , Health Plan Implementation/economics , Health PolicyABSTRACT
Introduction: Although economic crises are common in low/middle-income countries (LMICs), the evidence of their impact on health systems is still scant. We conducted a comparative case study of Maranhão and São Paulo, two unevenly developed states in Brazil, to explore the health financing and system performance changes brought in by its 2014-2015 economic recession. Methods: Drawing from economic and health system research literature, we designed a conceptual framework exploring the links between macroeconomic factors, labour markets, demand and supply of health services and system performance. We used data from the National Health Accounts and National Household Sample Survey to examine changes in Brazil's health spending over the 2010-2018 period. Data from the National Agency of Supplementary Health database and the public health budget information system were employed to compare and contrast health financing and system performance of São Paulo and Maranhão. Results: Our analysis shows that Brazil's macroeconomic conditions deteriorated across the board after 2015-2016, with São Paulo's economy experiencing a wider setback than Maranhão's. We showed how public health expenditures flattened, while private health insurance expenditures increased due to the recession. Public financing patterns differed across the two states, as health funding in Maranhão continued to grow after the crisis years, as it was propped up by transfers to local governments. While public sector staff and beds per capita in Maranhão were not affected by the crisis, a decrease in public physicians was observed in São Paulo. Conclusion: Our case study suggests that in a complex heterogeneous system, economic recessions reverberate unequally across its parts, as the effects are mediated by private spending, structure of the market and adjustments in public financing. Policies aimed at mitigating the effects of recessions in LMICs will need to take such differences into account.
Subject(s)
Economic Recession , Income , Brazil , Financing, Government , Health Expenditures , HumansABSTRACT
Resumo O artigo analisa os retrocessos na Política Nacional de Saúde Mental no período de 2016-2019, com base em estudo das normativas emanadas pelo governo federal e documentos de caráter público, e no estudo dos dados do Ministério da Saúde relativos à rede de saúde mental do Sistema Único de Saúde. Foram avaliados todos os documentos normativos que compõem um conjunto de 'reorientações' da Política, além daqueles que a afetam diretamente, incluindo posicionamentos contrários emitidos por instâncias dos poderes executivo, legislativo e judiciário. A análise indica os primeiros efeitos destas mudanças na Rede de Atenção Psicossocial, como o incentivo à internação psiquiátrica e ao financiamento de comunidades terapêuticas, ações fundamentadas em uma abordagem proibicionista das questões relacionadas ao uso de álcool e outras drogas. A análise dos dados de gestão permite afirmar que há tendência de estagnação do ritmo de implantação de serviços de base comunitária. Este estudo pretende contribuir para uma melhor compreensão sobre os fundamentos e a direção estratégica das mudanças, que implicam retrocesso nas diretrizes da Reforma Psiquiátrica, pretendendo ampliar o debate sobre as formas de resistência ao desmonte da Política Nacional de Saúde Mental.
Abstract The article analyzes the setbacks in the National Mental Health Policy in the period between 2016 and 2019, based on a study of the norms issued by the federal government and documents of a public nature, and on the study of data from the Brazilian Ministry of Health regarding the mental health network of the Unified Health System. All normative documents that make up a set of 'reorientations' of the Policy were evaluated, in addition to those that directly affect it, including opposing positions issued by the executive, legislative and judicial branches. The analysis indicates the first effects of these changes in the Psychosocial Care Network, such as encouraging psychiatric hospitalization and financing for therapeutic communities, actions based on a prohibitionist approach to issues related to the use of alcohol and other drugs. The analysis of the management data allows to affirm that there is a tendency of stagnation in the pace of implantation of community-based services. This study aims to contribute to a better understanding of the fundamentals and the strategic direction of the changes, which imply a setback in the Psychiatric Reform guidelines, aiming to broaden the debate on the forms of resistance to the dismantling of the National Mental Health Policy.
Resumen El artículo analiza el retrocesso de la Política Nacional de Salud Mental en el período 2016-2019, basado en un estudio de las normas emitidas por el gobierno federal y documentos públicos, y en el estudio de datos del Ministerio de Salud brasileño relacionados con la red de salud mental del Sistema de Salud Unificado. Se evaluaron todos los documentos normativos que conforman un conjunto de 'reorientaciones' de la Política, además de los que la afectan directamente, incluidas las posiciones opuestas emitidas por instancias de los poderes ejecutivo, legislativo y judicial. El análisis indica los primeros efectos de estos cambios en la Red de Atención Psicosocial, tales como el incentivo a la hospitalización psiquiátrica y la financiación de comunidades terapéuticas, acciones basadas en un enfoque prohibicionista a cuestiones relacionadas con el uso de alcohol y otras drogas. El análisis de los datos de gestión permite afirmar que existe una tendencia al estancamiento en el ritmo de implantación de los servicios basados en la comunidad. Este estudio tiene como objetivo contribuir a una mejor comprensión de los fundamentos y la dirección estratégica de los cambios, lo que implica un retroceso en las directrices de la Reforma Psiquiátrica, con el objetivo de ampliar el debate sobre las formas de resistencia al desmantelamiento de la Política Nacional de Salud Mental.
Subject(s)
Humans , Primary Health Care , Unified Health System , Mental Health , Health Care Reform , Healthcare Financing , Health PolicyABSTRACT
RESUMO O ensaio analisa os efeitos da política de austeridade sobre o Sistema Único de Saúde (SUS). Dados orçamentários e fiscais indicam que o Novo Regime Fiscal (NRF), criado pela Emenda Constitucional nº 95/2016 (EC 95), transformou o subfinanciamento crônico da saúde em desfinanciamento do SUS. Ademais, o NRF altera as relações entre as dimensões fiscal e social, uma vez que a despesa passa a ser avaliada a partir da pressão que exerce sobre o teto. Particularmente, o sistema de saúde universal se torna um excesso em relação ao limite estabelecido pela EC 95, pois os direitos sociais passam a aparecer como objeto de ajuste à fronteira fiscal, a partir da qual o gasto é tomado como irregular. Será mostrado que tais mudanças já implicam redução do orçamento disponível de saúde.
ABSTRACT The essay analyzes the effects of the austerity policy on the Unified Health System (SUS). Budgetary and fiscal data indicate that the New Tax Regime (NTR), created by Constitutional Amendment nº 95/2016 (CA 95), has transformed chronic underfunding into reduction of the health budget. In addition, the NTR alters the relations between the fiscal and social dimensions, since the expense is now evaluated from the pressure exerted on the cap. Particularly, the universal health care system becomes an excess in relation to the limit established by CA 95, since social rights begin to appear as an object of adjustment to the fiscal frontier, from which the expense is taken as irregular. The article shows that such changes already imply reduction of the available health budget.