Seguir o no seguir las recomendaciones farmacológicas de los prescriptores: «this is the question» / To follow or not to follow the advice of health professionals, this is the question

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Descentralización del sector salud en America Latina / Descentralization in health sector in Latin America

Este trabajo analiza la experiencia latinoamericana con la descentralización de servicios de salud. Los autores examinan el significado de la descentralización: geográfica, institucional y de funciones. Se ídentifícan los objetivos que según los promotores de la descentralización la justifican y se documenta que, en general, no se han conseguido. Una revisión de la bibliografía y los estudios llevados a cabo por los autores sugieren que con frecuencia la descentralización ha producido resultados opuestos a los buscados, es decir, ha incrementado la inequidad, ha disminuido la encienda y calidad de los servicios, y ha aumentado los costes. Se señala que la información existente no permite determinar con seguridad si el fracaso de la descentralización se debe a la selección de políticas inadecuadas o a fallos en el proceso de implementación. Se reconoce que la descentralización es un proceso político complejo que no se puede diseñar ni imponer desde fuera y que antes de tomar la decisión de descentralizar es necesario identifícar cuál de las muchas modalidades de descentralización se quiere implementar, estimar los costes, anticipar los problemas que se pueden presentar en su proceso de implementación y buscar soluciones a los mismos. Los autores concluyen sugiriendo que los bancos multilaterales han errado al forzar a los países a descentralizar de una manera improvisada sin tener en cuenta los diferentes contextos históricos, políticos y socioeconómicos(AU)

Privatización de los servicios de Salud: las experiencias de Chile y Costa Rica / Health cervises privatization: Chile and Costa Rica experience

El trabajo cuestiona los argumentos que justifican la privatización neoliberal de la financiación, gestión y prestación de servicios de salud, y analiza el significado y estrategias de privatización.Comparamos la privatización en Costa Rica y Chile, y en la discusión se sugiere que el modelo costarricense de privatización selectiva, limitada y concebida autóctonamente de Costa Rica lleva a un sistema de salud más solidario, equitativo, enciente y satisfactorio para los usuarios que el modelo importado de privatización chileno(AU)

Descentralización del sector salud en America Latina / Descentralization in health sector in Latin America

Este trabajo analiza la experiencia latinoamericana con la descentralización de servicios de salud. Los autores examinan el significado de la descentralización: geográfica, institucional y de funciones. Se ­dentifícan los objetivos que según los promotores de la descentralización la justifican y se documenta que, en general, no se han conseguido. Una revisión de la bibliografía y los estudios llevados a cabo por los autores sugieren que con frecuencia la descentralización ha producido resultados opuestos a los buscados, es decir, ha incrementado la inequidad, ha disminuido la encienda y calidad de los servicios, y ha aumentado los costes. Se señala que la información existente no permite determinar con seguridad si el fracaso de la descentralización se debe a la selección de políticas inadecuadas o a fallos en el proceso de implementación. Se reconoce que la descentralización es un proceso político complejo que no se puede diseñar ni imponer desde fuera y que antes de tomar la decisión de descentralizar es necesario identifícar cuál de las muchas modalidades de descentralización se quiere implementar, estimar los costes, anticipar los problemas que se pueden presentar en su proceso de implementación y buscar soluciones a los mismos. Los autores concluyen sugiriendo que los bancos multilaterales han errado al forzar a los países a descentralizar de una manera improvisada sin tener en cuenta los diferentes contextos históricos, políticos y socioeconómicos

Privatización de los servicios de Salud: las experiencias de Chile y Costa Rica / Health cervises privatization: Chile and Costa Rica experience

El trabajo cuestiona los argumentos que justifican la privatización neoliberal de la financiación, gestión y prestación de servicios de salud, y analiza el significado y estrategias de privatización.Comparamos la privatización en Costa Rica y Chile, y en la discusión se sugiere que el modelo costarricense de privatización selectiva, limitada y concebida autóctonamente de Costa Rica lleva a un sistema de salud más solidario, equitativo, enciente y satisfactorio para los usuarios que el modelo importado de privatización chileno

[Decentralization of the health sector in Latin America]. / Descentralización del sector salud en América Latina.

This paper analyzes the Latin American experience of decentralizing health services within the context of health reform. We examine the meaning of the term decentralization and discuss the various modalities of this concept: geographical, institutional and functional. The objectives that, in general, these objectives have not been achieved. After reviewing the literature and drawing on our own fieldwork, we conclude that in many instances the Latin American decentralization programs have produced results opposite to those intended, i.e., these programs have increased inequality and the cost of services and have reduced efficiency and quality of care. We point out that existing information is insufficient to determine with exactitude whether the failure of decentralization is due to the selection of inappropriate policies or to failures in the implementation process. Decentralization is a complex political process, policy makers should decide on the modality of decentralization they wish to implement, estimate the costs, identify the potential obstacles that could surface during the implementation phase and provide solutions. We conclude by suggesting that the multilateral banks have erred by pressing governments to improvise the implementation of decentralization programs without taking into account the different historical, political and socioeconomic contexts.

[Health services privatization: the experiences of Chile and Costa Rica]. / Privatización de los servicios de salud: las experiencias de Chile y Costa Rica.

This study questions the premises that justify the neoliberal privatization of financing, managing and delivering health services. It also analyses the meaning of privatization and its strategies. We compare privatization in Chile and Costa Rica and suggest that the more limited, selective and locally designed privatization process in Costa Rica has resulted in a more equitable, and efficient health system than the imported privatization model introduced in Chile. The Costa Rican system also produces greater patient satisfaction and at the same time preserves the solidarity principle.

Descentralización del sector salud en América Latina / Descentralization of the health sector in Latin America

Este trabajo analiza la experiencia latinoamericana con la descentralización de servicios de salud. Los autores examinan el significado de la descentralización: geográfica, institucional y de funciones. Se identifican los objetivos que según los promotores de la descentralización la justifican y se documenta que, en general, no se han conseguido. Una revisión de la bibliografía y los estudios llevados a cabo por los autores sugieren que con frecuencia la descentralización ha producido resultados opuestos a los buscados, es decir, ha incrementado la inequidad, ha disminuido la eficiencia y calidad de los servicios, y ha aumentado los costes.Se señala que la información existente no permite determinar con seguridad si el fracaso de la descentralización se debe a la selección de políticas inadecuadas o a fallos en el proceso de implementación. Se reconoce que la descentralización es un proceso político complejo que no se puede diseñar ni imponer desde fuera y que antes de tomar la decisión de descentralizar es necesario identificar cuál de las muchas modalidades de descentralización se quiere implementar, estimar los costes, anticipar los problemas que se pueden presentar en su proceso de implementación y buscar soluciones a los mismos. Los autores concluyen sugiriendo que los bancos multilaterales han errado al forzar a los países a descentralizar de una manera improvisada sin tener en cuenta los diferentes contextos históricos, políticos y socioeconómicos (AU)

Privatización de los servicios de salud: las experiencias de Chile y Costa Rica / Health services privatization: the experiences of Chile and Costa Rica

El trabajo cuestiona los argumentos que justifican la privatización neoliberal de la financiación, gestión y prestación de servicios de salud, y analiza el significado y estrategias de privatización. Comparamos la privatización en Costa Rica y Chile, y en la discusión se sugiere que el modelo costarricense de privatización selectiva, limitada y concebida autóctonamente de Costa Rica lleva a un sistema de salud más solidario, equitativo, eficiente y satisfactorio para los usuarios que el modelo importado de privatización chileno (AU)

Managing externally financed projects: the Integrated Primary Health Care Project in Bolivia.

Bolivia is one of the poorest countries in Latin America. Health indicators are very poor, communicable diseases are prevalent and, coupled with malnutrition, remain the major killers of children under 5 years old. The Integrated Primary Health Care Project (PROISS) was a US$39 million project executed by the Ministry of Health (MOH), 50% financed by the World Bank and aimed at improving primary health care in the four largest Bolivian municipalities. The implementation of the project started in 1990 and ended in 1997. During implementation it went through three distinct phases: Phase 1 (1990-94) was a period characterized by conflict and confusion; Phase 2 (1995-mid-1996) documented major improvements in coverage and service quality; and Phase 3 (mid-1996-97) witnessed the decline of the project. This paper explores the factors that contributed to the success and the decline of the project, draws lessons for project managers and international agencies involved in the definition and implementation of social sector projects, and discusses the unlikelihood that externally financed projects can have a sustainable impact on the development of the health sector of recipient countries.

The impact of the maquiladoras on health and health policy along the U.S.-Mexico border.

Over the last three and one-half decades, the development of twin industrial plants, maquilas, along the U.S.-Mexico border has resulted in industrialization of the northern tier of Mexican states and rapid population growth on both sides of the border. Maquilas have been responsible for some environmental contamination and may contribute to changes in family cohesiveness. At the same time they have not supported the needed expansion of public infrastructure. These are major public health consequences that must be considered by both countries. Solutions will require better cooperative efforts than have occurred in the past.

Improving the use of pharmaceuticals through patient and community level interventions.

Pharmaceuticals represent an increasing share of private and public health care expenditures. However, while most governments are interested in ensuring availability and access to drugs, the issue of adequate use of drugs remains a low priority in most third world countries. This paper summarizes the results of interventions conducted in developing countries aimed at improving patients' compliance with the advice of health professionals and/or to decrease the unnecessary use of drugs by the general population. Forty-five studies were identified through literature searches and networking; and only about a third of them fulfilled the eligibility criteria for inclusion in the review. Given the paucity of information available and the importance of the topic the authors report on all 45 studies identified. Although much remains to be explored there are several interventions that deserve to be highlighted. The authors argue that improving the use of pharmaceuticals through interventions directed only to consumers may have a small impact and suggest that in order to obtain meaningful changes it might be necessary to design interventions to modify the behavior of all the actors in the medication cycle (manufacturers, health professionals, retailers, consumers and governments). They suggest that the extraordinary therapeutic effects of antibiotics, coupled with the problems that may arise when they are inappropriately used and with the extraordinary amount of resources spent on antibiotics worldwide justify a global effort to reduce their inappropriate use and promote their adequate administration. The complexity of this type of intervention would require the support of the pharmaceutical industry, governments, private foundations, and international organizations.

Scientific evaluations of interventions to improve the adequate use of pharmaceuticals in Third World countries.

The inadequate use of pharmaceuticals continues to be a severe problem in most parts of the world. Developing nations waste very large amounts of scarce health resources on medicines of doubtful therapeutic value, and many persons do not comply with physicians advice or engage in risky self-medication practices contributing to additional misuse of resources and iatrogenia. This paper examines the few scientifically designed interventions at the community and patient s levels to improve the appropriate use of pharmaceuticals in developing nations. The authors analyze the contribution made by these studies and identify several limitations including the absence of independent evaluations of outcomes, lack of sufficient information to judge the quality and adequacy of the instruments used, problems relating to replicability of interventions at regional or country level, or outside the cultural context within which they took place, lack of information on costs of interventions, a crucial variable in poor countries, and the absence of standardized outcome measures that makes comparative analysis very difficult.

Utilization of health services along the Arizona-Sonora border: the providers' perspective.

Under the proposed North American Free Trade Agreement between Mexico, Canada, and the United States, issues of health policy and health care delivery will have to be addressed. People at the U.S.-Mexico border have been using health care providers on either side of the border for many years. Studying how the movement of patients has been taking place, and how it has affected health care providers' practices, is the first step towards the understanding and organization of health care services for the border region. This paper reports on the results of a health care provider survey conducted between 1987 and 1989 in Arizona and Sonora border towns. The paper includes information on the characteristics of border health care providers (98 residing on the U.S. side of the border and 249 on the Mexican side) and the demographics and diagnosis of patients who engage in border crossing behavior. The opinions of health care providers about why patients from the neighboring country come to their offices; the existing communication system between providers in both nations; and some of the problems that result from attending patients residing in the neighboring nation are also reported. Results from the survey demonstrate that although the border constitutes a region in itself, health services at the border are not structured to recognize this regional orientation. Improved communication between health care providers on both sides of the border, the establishment of health care protocols with quality assurance programs, and suitable health care financing mechanisms are some of the issues that require immediate attention if the health care delivery system at the border is to function more efficiently and to the satisfaction of health care providers and consumers.

[The utilization of Arizona medical services by residents of Mexico]. / Utilización de servicios médicos de Arizona por residentes de México.

Arizona physicians practicing in the four counties bordering Mexico were surveyed regarding the use of their services by residents of Mexico. One hundred eighty-eight (79%) of the 239 respondents to the mail survey reported seeing at least one Mexican resident per week during 1988. Ninety-nine of these physicians (53%) practiced in Tucson; 89 (47%) practiced elsewhere in the four border counties. The mean number of Mexican resident patients seen per week was nine (9% of total) for border physicians and 5 (6% of total) for Tucson physicians. The most frequent responses from border physicians asked to list the most common health conditions of their Mexican resident patients were injury and poisoning (21%) and circulatory diseases (11%), while the most frequent responses of Tucson physicians were circulatory diseases (10%) and digestive diseases (9%). Problems and solutions in the border care health system are mainly related to quality of care and health care financing.

Research on patient compliance in developing countries.

Patient compliance with health care provider advice is a subject of particular importance in developing countries, one that has not been sufficiently studied. This article begins by explaining why this type of research is important and describing the various methodologies used to examine patient compliance in developed nations--notably self-reporting by the patient, collateral reporting by friends or relatives, pill or bottle counting, review of the patient's clinic attendance, review of clinical outcomes, and use of biochemical tracers. The applicability of each of these methods to scenarios commonly found in developing countries is then considered, and the results of the limited compliance research performed in developing countries are described. In general, it is suggested that self-reporting, collateral reporting, and pill or bottle counting can be employed effectively in many Third World situations. The article also notes the importance of standardizing research procedures, provides logistic advice about applying various compliance research methods in Third World conditions, and points up the need to validate the accuracy of the methods used.

PIP: Research is needed on patient compliance with health care provider advice in developing countries because 1) the consumption of pharmaceuticals is on the rise in developing countries due to the expansion of health care services and successful marketing of drugs by multinational pharmaceutical companies, 2) pharmaceuticals consume a large share of developing countries' limited health care budgets, 3) patient compliance plays an important role in improving patient health and enabling health care systems to be effective, 4) poor medical outcomes resulting from noncompliance may prompt dissatisfaction with the health care delivery system and cause deterioration of the patient-physician relationship, and 5) lack of compliance with pharmaceutical regimens leads to the storage of leftover medicine in homes, thus increasing the risk of accidental poisoning and misuse of pharmaceuticals. The authors explain how self-reporting by the patient, collateral reporting by friends or relatives, pill or bottle counting, review of the patient's clinic attendance, review of clinical outcomes, and use of biochemical tracers are used in developed countries to assess patient compliance. The applicability of each of these methods to scenarios commonly found in developing countries is then considered and the results of the limited compliance research performed in developing countries described. It is generally suggested that self-reporting, collateral reporting, and pill or bottle counting can be used effectively in many Third World situations. The authors stress the importance of standardizing research procedures, provide logistic advice about applying various compliance research methods in the Third World, and note the need to validate the accuracy of the methods used.

Do we know how to influence patients' behaviour? Tips to improve patients' adherence.

This paper discusses the importance of achieving patients' compliance with a health care provider's recommendations. It includes a summary of the different approaches and meanings given by different researchers to the term compliance. Different methods of measuring compliance are described. The aim of the paper is to provide health care professionals, especially physicians, with the necessary background information to interpret compliance studies and, more importantly, to present different strategies that have been proved to be effective at improving patients' compliance (adherence) with medical recommendations.