Health Reform in the Midst of a Social and Political Crisis in Chile, 2019-2020.

The protests in Chile in October 2019 raised the issue of health reform to the public agenda again. This article reviews some of the explanations for why there was a widespread protest, including the expectations of continued progress, the emergence of a "fear-based populism" and the decline in legitimacy of most social and political actors. Using the theories of Kingdon to explain how reforms are placed on the political agenda, we describe how the protests raised health reform as a problem to be addressed, discuss the tendency toward consensus on policy options by technical health reform advocates, and examine the uncertain political processes that would be necessary for a consensus reform to be adopted and implemented. A lesson for reformers is the need to pay attention to growing signs of popular resentment over failures of health reforms to address accumulating problems and to try to address them with urgency to avoid populist crises.

Restructuring Health Reform, Mexican Style.

Mexico's health system is undergoing major restructuring by the administration of President Andrés Manuel López Obrador (known as AMLO) starting in December 2018. The government has eliminated the 2003 health reform (Seguro Popular) from national laws and government agencies and is returning Mexico to a centralized health system with integrated public financing and delivery and reduced private participation. This article looks at the political drivers of Mexico's restructuring reform. Three main ethical principles are identified as the foundation for the government's health system vision: universality, free services, and anti-corruption. The article then compares what existed under Seguro Popular with the new system under the Instituto de Salud para el Bienestar (INSABI), which began on 1 January 2020. The analysis uses the five policy levers that shape health system performance: financing, payment, organization, regulation, and persuasion. The article concludes with five lessons about the reform process in Mexico. First, undoing past reforms is much easier than implementing a new system. Second, the AMLO government's restructuring emerged more from broad ethical principles than detailed technical analyses, with limited plans for evaluation. Third, the overarching values of the AMLO government reflect a pro-statist and anti-market bias, swimming against the global flow of health policy trends to include the private sector in reforming health systems. Fourth, the experiences in Mexico show that path dependence does not always work as expected in policy reform. Finally, the debate of Seguro Popular versus INSABI shows the influence of personality politics and polarization.

Misallocation of Demand and the Persistent Non-emergent Use of the Emergency Department Post-Healthcare Reform.

The US healthcare systems is struggling to keep pace with increasing demand, as the burden faced by providers and healthcare organizations expands. While care delivery models continue to evolve in the post-reform era, many barriers stemming from capacity constraints, regulation, shortages of manpower and, misallocation of resources persist. In this paper, we provide an analysis of unmet demand in the US system healthcare system. We contribute a deep dive of the literature to elucidate the reasons for which imbalanced and unmet demand, including the heavy use of the emergency department for non-emergent conditions, continues to burden healthcare organizations. We use these findings to motivate recommendations about how to address critical shortcomings in order to better address the needs of patients with both emergent and non-emergent conditions.

[Progress in the development of healthcare human resources in Peru and their importance in the quality of care]. / Avances en el desarrollo de los recursos humanos en salud en el Perú y su importancia en la calidad de atención.

Healthcare Human Resources (HHR) are key for the success of any health system; its development and performance are fundamental to ensure quality care. Despite this reality, HHR are often absent from health reform processes. In Peru, in the last 30 years, there have been several reforms that have included, to a greater or lesser extent, improvements in HHR policies aimed at providing a better quality of care to the population. This article seeks to make a brief analysis of the advances in the field of management and development of human resources in the healthcare sector in recent years, highlighting their importance in the quality of care. Through considerable effort, we would achieve competent, equitably-distributed HHR committed to delivering quality care to all individuals.

Los Recursos Humanos en Salud (RHUS) son pilar clave en el éxito de todo sistema de salud, su desarrollo y desempeño son fundamental para garantizar una atención de calidad. A pesar de esta realidad, los RHUS suelen estar ausentes en procesos de reforma sanitaria. En el Perú, en los últimos 30 años, se han dado diversas reformas que han incluido en mayor o menor medida, mejoras en las políticas de RHUS con la finalidad de brindar una mejor calidad de atención a la población. Este artículo busca hacer un breve análisis de los avances en el campo de la gestión y desarrollo de los Recursos humanos en el Sector Salud en los últimos años, destacando su importancia en la calidad de atención. De hacer esfuerzos suficientes en este campo, lograríamos RHUS competentes, distribuidos de forma equitativa y comprometidos con entregar atención de calidad a todos los individuos.

Avances en el desarrollo de los recursos humanos en salud en el Perú y su importancia en la calidad de atención / Progress in the development of healthcare human resources in Peru and their importance in the quality of care

RESUMEN Los Recursos Humanos en Salud (RHUS) son pilar clave en el éxito de todo sistema de salud, su desarrollo y desempeño son fundamental para garantizar una atención de calidad. A pesar de esta realidad, los RHUS suelen estar ausentes en procesos de reforma sanitaria. En el Perú, en los últimos 30 años, se han dado diversas reformas que han incluido en mayor o menor medida, mejoras en las políticas de RHUS con la finalidad de brindar una mejor calidad de atención a la población. Este artículo busca hacer un breve análisis de los avances en el campo de la gestión y desarrollo de los Recursos humanos en el Sector Salud en los últimos años, destacando su importancia en la calidad de atención. De hacer esfuerzos suficientes en este campo, lograríamos RHUS competentes, distribuidos de forma equitativa y comprometidos con entregar atención de calidad a todos los individuos.

ABSTRACT Healthcare Human Resources (HHR) are key for the success of any health system; its development and performance are fundamental to ensure quality care. Despite this reality, HHR are often absent from health reform processes. In Peru, in the last 30 years, there have been several reforms that have included, to a greater or lesser extent, improvements in HHR policies aimed at providing a better quality of care to the population. This article seeks to make a brief analysis of the advances in the field of management and development of human resources in the healthcare sector in recent years, highlighting their importance in the quality of care. Through considerable effort, we would achieve competent, equitably-distributed HHR committed to delivering quality care to all individuals.

["ObamaCare": effects for the health reform in Chile]. / Repercusiones de "ObamaCare" para la reforma sanitaria en Chile.

Health care raises structural issues in a democratic society, such as the role assigned to the central government in the management of health risk and the redistributive consequences generated by the implementation of social insurance. These are often cause of strong political controversy. This paper examines the United States of America health reform, popularly known as "ObamaCare". Its three main elements, namely individual mandate, creation of new health insurance exchanges, and the expansion of Medicaid, generated a redistribution of health risks in the insurance market of that country after almost a century of frustrated legislative efforts to guarantee minimum universal coverage. The article proposes that a change of this magnitude in the United States will produce effects in a forthcoming parliamentary discussion on the health reform in Chile, which still maintains a highly deregulated private health system.

Repercusiones de "ObamaCare" para la reforma sanitaria en Chile / "ObamaCare": effects for the health reform in Chile

Health care raises structural issues in a democratic society, such as the role assigned to the central government in the management of health risk and the redistributive consequences generated by the implementation of social insurance. These are often cause of strong political controversy. This paper examines the United States of America health reform, popularly known as "ObamaCare". Its three main elements, namely individual mandate, creation of new health insurance exchanges, and the expansion of Medicaid, generated a redistribution of health risks in the insurance market of that country after almost a century of frustrated legislative efforts to guarantee minimum universal coverage. The article proposes that a change of this magnitude in the United States will produce effects in a forthcoming parliamentary discussion on the health reform in Chile, which still maintains a highly deregulated private health system.

Personal and political histories in the designing of health reform policy in Bolivia.

While health policies are a major focus in disciplines such as public health and public policy, there is a dearth of work on the histories, social contexts, and personalities behind the development of these policies. This article takes an anthropological approach to the study of a health policy's origins, based on ethnographic research conducted in Bolivia between 2010 and 2012. Bolivia began a process of health care reform in 2006, following the election of Evo Morales Ayma, the country's first indigenous president, and leader of the Movement Toward Socialism (Movimiento al Socialism). Brought into power through the momentum of indigenous social movements, the MAS government platform addressed racism, colonialism, and human rights in a number of major reforms, with a focus on cultural identity and indigeneity. One of the MAS's projects was the design of a new national health policy in 2008 called The Family Community Intercultural Health Policy (Salud Familiar Comunitaria Intercultural). This policy aimed to address major health inequities through primary care in a country that is over 60% indigenous. Methods used were interviews with Bolivian policymakers and other stakeholders, participant observation at health policy conferences and in rural community health programs that served as models for aspects of the policy, and document analysis to identify core premises and ideological areas. I argue that health policies are historical both in their relationship to national contexts and events on a timeline, but also because of the ways they intertwine with participants' personal histories, theoretical frameworks, and reflections on national historical events. By studying the Bolivian policymaking process, and particularly those who helped design the policy, it is possible to understand how and why particular progressive ideas were able to translate into policy. More broadly, this work also suggests how a uniquely anthropological approach to the study of health policy can contribute to other disciplines that focus on policy analysis and policy processes.

Dos clamores das ruas aos rumores no Congresso: uma análise da conjuntura recente da saúde no Brasil / The popular claim and Congress rumors: a recent conjuncture analysis of health in Brazil / De las voces de las calles a los rumores en el Congreso: un análisis de lacoyuntura reciente de salud en Brasil

O processo da Reforma Sanitária Brasileira requer acompanhamento da Política de Saúde. Assim, objetivou-se analisar a conjuntura e as políticas de saúde no Brasil no período de junho/2013 a março/2015. A investigação utilizou pesquisa documental por meio da mídia, programas de candidaturas à presidência e publicações de entidades de saúde para identificar fatos e acontecimentos relevantes a serem categorizados e analisados. Em junho de 2013, a saúde foi apontada como prioridade pelas manifestações de rua, obtendo como resposta institucional o Programa Mais Médicos. Entretanto, a Reforma Sanitária e o SUS não prevaleceram no debate eleitoral das campanhas à presidência, enquanto predominava a influência do setor privado. Aprovações de leis recentes no Congresso Nacional podem indicar assimilação da lógica de Cobertura Universal. Mudanças na política econômica e prioridades governamentais sugerem desmonte das conquistas sociais e apontam a necessidade de rearticulação da sociedade civil em defesa do direito universal à saúde...

The Brazilian Health Reform’s process needs the continuous monitoring of the Health Policy. So, theobjective was to analyze the conjuncture and health policies in Brazil from June/2013 to March/2015. Thestudy used documental research through the media, government programs of the presidential candidatesand health associations’ documents to identify the relevant facts and events for analysis. In June/2013,health was identified as a priority by protests, getting as government response the More Doctors Program.However, the Brazilian Health Reform and the SUS did not preponderate in the electoral debate of thepresidency running, while the private sector had predominant influence. Laws recently passed in Congressmay indicate assimilation of Universal Coverage logic. Changes in economic policy and governmentpriorities suggest regression of social rights and the need for re-articulation of civil society in defense of theuniversal right to health...

El proceso de la Reforma de Salud Brasileña requiere un seguimiento de la política de salud. El objetivofue analizar la coyuntura y las políticas de salud en Brasil, de junio/2013 a marzo/2015. Fue utilizadala investigación documental a través de los medios de comunicación, programas de los candidatos a laPresidencia y publicaciones de las entidades de salud para identificar acontecimientos relevantes paraanálisis. En junio de 2013 la salud fue una prioridad para las manifestaciones, obteniendo como respuestadel gobierno lo Programa Más Médicos. Pero, la Reforma de Salud Brasileña y el SUS no prevalecieron en eldebate electoral de la campaña presidencial, donde el sector privado consiguió la influencia predominante.Recientes leyes aprobadas en el Congreso pueden indicar asimilación de la lógica de la Cobertura Universal.Los cambios en la política económica y prioridades del gobierno sugieren desmantelamiento de lasconquistas sociales y destacan la necesidad de re-articulación de la sociedad civil en defensa del derechouniversal a la salud...

Changes in socioeconomic inequalities in the use of dental care following major healthcare reform in Chile, 2004-2009.

The study examines changes in the distribution and socioeconomic inequalities of dental care utilization among adults after the major healthcare reform in Chile, 2004-2009. We evaluated the proportion of people who visited the dentist at least once in the previous two years, and the mean number of visits. These outcome variables were stratified by sex, age (20-39, 40-59, 60-63; ≥64 years), educational level (primary, secondary, higher), type of health insurance (public, private, uninsured), and socioeconomic status (quintiles of an asset-index). We also used the concentration index (CIndex) to assess the extent of socioeconomic inequalities in the use of dental care, stratified by age and sex as a proxy for dental care needs. The use of dental care significantly increased between 2004 and 2009, especially in those with public health insurance, with lower educational level and lower socioeconomic status. The CIndex for the total population significantly decreased both for the proportion who used dental care, and also the mean number of visits. Findings suggest that the use of dental care increased and socioeconomic-related inequalities in the utilization of dental care declined after a Major Health Reform, which included universal coverage for some dental cares in Chile. However, efforts to ameliorate these inequalities require an approach that moves beyond a sole focus on rectifying health coverage.

[Social security for health system transformation]. / La seguridad social en la transformación del sistema de salud.

The aim of this article is to present the management and medical components within the public health institutions that can contribute to the transformation of the National Health System (NHS). It is expected that these will have an impact in the extent of the medical coverage and will improve the health care services delivered to the Mexican population. A diagnostic study revealed the existence of fragmentation in the NHS. The health institutions are vertically established and operate under isolated mechanisms of financing and administration. Additionally, it is pointed out the problematic derived from the multiplicity in the public insurance conditions among individuals and the lack of census of the insured population within the institutions. As part of the universalization of health services, it is necessary to integrate the health care system; accordingly, a variety of mechanisms for the partial and total integration are arise, such as the exchange of the health care services and the portability and convergence of the institutions. Particularly, we listed the actions carried out by the Mexican Institute of Social Security for the integration of the NHS such as, the independent management medical areas, diagnosis-related groups (DRG), the performing evaluation of the medical units, and the preventive and curative strategies in the implemented programs. Finally, is dealt some reflections in order to improve the public health care.

The quest for equity in Latin America: a comparative analysis of the health care reforms in Brazil and Colombia.

INTRODUCTION: Brazil and Colombia have pursued extensive reforms of their health care systems in the last couple of decades. The purported goals of such reforms were to improve access, increase efficiency and reduce health inequities. Notwithstanding their common goals, each country sought a very different pathway to achieve them. While Brazil attempted to reestablish a greater level of State control through a public national health system, Colombia embraced market competition under an employer-based social insurance scheme. This work thus aims to shed some light onto why they pursued divergent strategies and what that has meant in terms of health outcomes. METHODS: A critical review of the literature concerning equity frameworks, as well as the health care reforms in Brazil and Colombia was conducted. Then, the shortfall inequality values of crude mortality rate, infant mortality rate, under-five mortality rate, and life expectancy for the period 1960-2005 were calculated for both countries. Subsequently, bivariate and multivariate linear regression analyses were performed and controlled for possibly confounding factors. RESULTS: When controlling for the underlying historical time trend, both countries appear to have experienced a deceleration of the pace of improvements in the years following the reforms, for all the variables analyzed. In the case of Colombia, some of the previous gains in under-five mortality rate and crude mortality rate were, in fact, reversed. CONCLUSIONS: Neither reform seems to have had a decisive positive impact on the health outcomes analyzed for the defined time period of this research. This, in turn, may be a consequence of both internal characteristics of the respective reforms and external factors beyond the direct control of health reformers. Among the internal characteristics: underfunding, unbridled decentralization and inequitable access to care seem to have been the main constraints. Conversely, international economic adversities, high levels of rural and urban violence, along with entrenched income inequalities seem to have accounted for the highest burden among external factors.

The quest for equity in Latin America: a comparative analysis of the health care reforms in Brazil and Colombia

Introduction: Brazil and Colombia have pursued extensive reforms of their health care systems in the last couple of decades. The purported goals of such reforms were to improve access, increase efficiency and reduce health inequities. Notwithstanding their common goals, each country sought a very different pathway to achieve them. While Brazil attempted to reestablish a greater level of State control through a public national health system, Colombia embraced market competition under an employer-based social insurance scheme. This work thus aims to shed some light onto why they pursued divergent strategies and what that has meant in terms of health outcomes. Methods: A critical review of the literature concerning equity frameworks, as well as the health care reforms in Brazil and Colombia was conducted. Then, the shortfall inequality values of crude mortality rate, infant mortality rate, under-five mortality rate, and life expectancy for the period 1960-2005 were calculated for both countries. Subsequently, bivariate and multivariate linear regression analyses were performed and controlled for possibly confounding factors. Results: When controlling for the underlying historical time trend, both countries appear to have experienced a deceleration of the pace of improvements in the years following the reforms, for all the variables analyzed. In the case of Colombia, some of the previous gains in under-five mortality rate and crude mortality rate were, in fact, reversed. Conclusions: Neither reform seems to have had a decisive positive impact on the health outcomes analyzed for the defined time period of this research. This, in turn, may be a consequence of both internal characteristics of the respective reforms and external factors beyond the direct control of health reformers. Among the internal characteristics: underfunding, unbridled decentralization and ...

A institucionalização de um aparelho formador: o caso da Secretaria de Saúde do Estado da Bahia, 1971-2006 / The institutionalization of an educational apparatus: the case of the Health Department of the State of Bahia, 1971-2006

O presente estudo procura analisar o processo de institucionalização dos espaços para formação e desenvolvimento de Recursos Humanos em Saúde ­ RHS na Secretaria de Saúde do Estado da Bahia - SESAB, entre 1971 e 2006. Observando as modificações no campo da saúde e a evolução histórica e política brasileira e baiana, a pesquisa buscou compreender a criação, desenvolvimento e (re)estruturação do Aparelho para Formação e Desenvolvimento de RHS (AFD-RHS) na SESAB, em três períodos históricos (1971 - 1986, 1987 - 1990 e 1991 - 2006). No primeiro período, sob a face do governo militar, se organizam movimentos para o surgimento de um espaço de formação dentro dessa instituição. No segundo período observa-se certa ruptura com a linha política e ideológica que dominava a Bahia, com repercussões para o setor saúde e para o AFD-RHS. No terceiro período, houve o retorno e continuidade de aliados que se revezavam no poder no chamado Carlismo. O desenho desse estudo de caso histórico privilegiou a investigação qualitativa de caráter exploratório, com pesquisa documental e entrevistas, voltadas para ex-dirigentes dos órgãos de RHS da SESAB. Na fundamentação teórica utilizou-se o referencial elaborado por Mario Testa para análise de instituições, considerando os diferentes tipos de poder setorial (técnico, administrativo, político) e as estratégias de hegemonia. Os resultados apresentados indicam a trajetória de expansão do AFD-RHS, destacando a ação dos sujeitos na conformação dessa estrutura. Condiz com algumas reflexões no sentido de interpretar as razões quanto a criação, surgimento ou (re)estruturação (motivo-porque) desse aparelho e quanto à necessidade ou demanda social (motivo-para) que tem buscado atender.