Research capacity for institutional collaboration in implementation research on diseases of poverty.

OBJECTIVE: To assess the capacity for research collaboration and implementation research in strengthening networks and institutions in developing countries. METHODS: Bibliometric analysis of implementation research on diseases of poverty in developing countries from 2005 to 2010 through systematically searching bibliographic databases. Methods identified publication trends, participating institutions and countries and the cohesion and centrality of networks across diverse thematic clusters. RESULTS: Implementation research in this field showed a steadily growing trend of networking, although networks are loose and a few institutions show a high degree of centrality. The thematic clusters with greatest cohesion were for tuberculosis and malaria. CONCLUSIONS: The capacity to produce implementation research on diseases of poverty is still low, with the prominence of institutions from developed countries. Wide ranges of collaboration and capacity strengthening strategies have been identified which should be put into effect through increased investments.

Beyond health gain: the range of health system benefits expressed by social groups in Mexico and Central America.

Current health reform proposals in most developing countries stress health gain as the chief evaluation criterion. Essential service packages are formulated using cost-effectiveness methods for the selection of interventions without sufficient regard for other factors that are significant for successful implementation and acceptance by the needy. This paper presents the results of research undertaken in Mexico and Central America to test the hypothesis that population groups view health gain as only one among several benefits derived from health systems. The goal at this stage was two-fold: (a) to identify through qualitative methods the range of benefits that are significant for a wide cross-section of social groups and (b) to classify such benefits in types amenable to be used in the development of instruments to measure the benefits intended and actually produced by health systems. Fourteen focus groups were undertaken in Costa Rica, El Salvador, Guatemala, Mexico and Nicaragua representing diverse age, gender, occupation and social conditions. Six major types of health system benefits were identified besides health gain: reassurance/uncertainty reduction, economic security, confidence in health system quality, financial benefits derived from the system, health care process utility and health system fairness. Benefits most often mentioned can be classed under health care process utility and confidence in system quality. They also have the most consensus across social groups. Other benefits mentioned have an affinity with social conditions. Human resource-derived utility stands out by its frequency in the range of benefits mentioned. Health systems and health sector reform proposals must emphasise those aspects of quality related to human resources to be in accord with population expectations.

Comparative research and analysis methods for shared learning from health system reforms.

The pace and breadth of health reforms point to the need for a comparative methodology to support shared learning from country experiences. A common understanding of health reforms is a first prerequisite for comparative research. Dimensions characterising content, sequence, process, purpose and scope of policy change are identified on the basis of a literature review. Reforms can have a gradual build up, starting with piecemeal policy changes that can be eventually integrated to enhance their benefits. Comprehensive reforms can be defined as policy formulation and implementation that comprises the systemic, programmatic, organisational and instrumental policy levels through explicit strategies sustained in well-documented experiences and theories and implemented with the support of a specialised agency with consensus-building capacity. A minimum-data set is proposed on the basis of an extensive literature review to support the comparability of health reform case studies and descriptions. Its components are: the current health system, its background and context, the reform rationale, the specific proposals, political actors and processes, achievements and limitations, and lastly the reform's wider impact. Case studies can be compared historically, through particularistic comparisons, using ideal types and by means of exemplars. The advantages and limitation of each method are analysed as well as how they can be combined to frame the research questions and minimise resources. Finally, the International Clearinghouse for Health System Reform Initiatives is described as an instrument to disseminate comparative research and analysis in support of shared learning.

[The decentralization of the Secretaría de Salud de México. The case of local health systems 1989-1994]. / La descentralización de la Secretaría de Salud de México. El caso de los sistemas locales de salud 1989-1994.

This article constitutes an analysis of the decentralization of the Ministry of Health of Mexico though the project to develop its jurisdictions to strengthen Local Health System (SILOS) implemented between 1989 and 1994. The relationship between decentralization and jurisdictional socioeconomic, demographic and resource availability differences was studied using qualitative and quantitative methods. The impact of jurisdictional strengthening on deconcentration and their combined effect on primary health care (PHC) and coverage were measured. The strengthening of technical capacity within the jurisdictions increased moderately but did not show a significant association with primary health care efficiency. However, when jurisdictions attain more autonomy, a significant association between strengthening and PHC efficiency appears. Deconcentration is a key factor to guarantee the strengthening of technical capacity and to assure that greater efficiency impacts on poverty reduction: however, deconcentration was limited due to the fact that the general strategies of the project were not differentiated according to the inequality across jurisdictions. To decentralize the Ministry of Health effectively, the federation must formulate objectives and strategies according to jurisdictional socioeconomic conditions and service need and capacity. Jurisdictions must be restructured and rescaled to improve their interaction with municipal governments, the health sector and the community.

[Burden of disease in the aged, Mexico, 1994]. / El peso de la enfermedad en adultos mayores, México 1994.

OBJECTIVE: To estimate the disability adjusted life years lost (DALYs) in population over 60 years of age in Mexico during 1994. MATERIAL AND METHODS: Years of life lost due to premature mortality (YLL) and years lived with disability (YLD) were estimated for 108 diseases, both sexes, and 32 states of the Mexican Republic divided in rural and urban areas in the population over 60 years of age, using the methodology originally proposed by Murray and López adapted to specific local characteristics. The inputs used were: mortality statistics for 1994 (after corrections of under-registration and misclassification), statistics on incidence and prevalence from local epidemiological studies, national health surveys and estimates by the authors. RESULTS: During 1994 the Mexican population over 60 years of age lost 1.8 million DALYs, 59% of which were YLL while 41% were YLD. Most of the burden of disease is due to noncommunicable diseases. The principal health needs of the elderly in Mexico can be divided in two groups: a) those that traditionally are frequent in this age group, such as ischaemic heart disease, diabetes, stroke and b) disabling diseases such as dementia, falls and arthritis as the most important. CONCLUSIONS: The use of composite indicators such as DALYs to assess health needs in older adult can help decision-makers and planners to incorporate disabling and lethal diseases within the list of priority needs, thereby achieving greater equity in the assignment of resources to different health care, prevention and rehabilitation programs.

[A community referral system for the permanent program of universal vaccination]. / Sistema comunitario de referencia para el programa continuo de vacunación universal.

This article describes a community referral system for the permanent immunization program, tested in Tijuana, Baja California, Mexico, by the Regional Nucleus for Health Systems Development (NUREDESS-Norte). The model was designed to facilitate the participation of the intermediate organizations that make up the community in urban settings. Through appropriate technology, health counselors identify with precision, ease and rapidity the specific immunization needs of pre-school age children. The counselors also help diminish the barriers in the way to service access, and follow-up the children at highest risk.

[Essential research in health systems]. / La investigación esencial en sistemas de salud.

Public health research and education in Mexico require further decentralization to improve its availability, quality and relevance for the development of local health systems. This article presents the experience of the Northern Regional Center for Health Systems Development (Nuredess-Norte), a consortium for the decentralization and regionalization of public health research and education of El Colegio de la Frontera Norte and the National Institute of Public Health. Nuredess-Norte initiated its activities in 1990 establishing a binational network of health systems consultants along the border, following a common methodology to improve health system quality through research. Later a Health Systems Development Teaching Program was established at the level of specialization with a high degree of decentralization and linkage with local health systems. Nuredess-Norte undertakes research, design and evaluation of innovations along the US-Mexico border. Emphasis is given to community participation and the development of primary health care.

Access policies and utilization patterns in prenatal and child delivery care in Mexico.

In Mexico, people utilize public, private and traditional health providers interchangeably and in contrast to official access policies. Access policies for prenatal and child delivery services are evaluated using data from the National Health Survey of 1988. The study documents significant coverage gaps on the part of public providers with respect to their potential coverage, and especially, large cross-utilization of social security, Ministry of Health and private providers by beneficiaries. Child deliveries in Mexico are attended by a physician in only 66% of cases. The percentages are 85% for social security affiliates, 53% for women within reach of IMSS-Solidarity services (a relief programme for the rural poor) and only 31% for women with official access to private or Ministry of Health care, or beyond the reach of services. Seventy-eight per cent of medical deliveries by women affiliated to social security occur at their pre-paid facilities, while 14% deliver at extra cost with private physicians, contributing to 32% of deliveries so offered. Even though only 7% of insured women deliver at Ministry of Health facilities, this amounts to 20% of the Ministry's relief offer. In all, only 66% of affiliates use social security delivery services. On the other hand, 36% of deliveries by non-insured women are cared for by Ministry of Health providers, and 39% by the private sector; 22% of such deliveries occur in social security institutions, amounting to 18% of these institutions' care offer. These results indicate a wide departure between policy and fact, and the working of distributive and redistributive forces that impinge on the quality and efficiency of health care. Open access to the reproductive health services of all public institutions, with coordination among them and private providers, is suggested as a possible solution.

Primary care and reform of health systems: a framework for the analysis of Latin American experiences.

The article first proposes a framework within which to assess the potential of health sector reforms in Latin America for primary health care (PHC). Two dimensions are recognized: the scope of the reforms, content, and the means of participation that are put into play. This framework is then complemented through a critique of the often-sought but little-analyzed PHC reform strategies of decentralization and health sector integration. The analytical framework is next directed to the financing of health services, a chief aspect of any reform aiming toward PHC. Two facets of health service finance are first distinguished: its formal aspect as a means for economic subsistence and growth, and its substantive aspect as a means to promote the rational use of services and thus improvement of health. Once finance is understood in this microeconomic perspective, the focus shifts to the analysis of health care reforms at the macro, health policy level. The article concludes by positing that PHC is in essence a new health care paradigm, oriented by the values of universality, redistribution, integration, plurality, quality, and efficiency.

[Decentralization of the health sector in Mexico. Scope and limitations of local health systems]. / La descentralización del sector salud en México. Alcances y limitaciones de los sistemas locales de salud.

This paper is a product of the reflection on the decentralization and sectorization experiences in Mexico since 1917 with particular emphasis on the 1980s. The historical analysis included the creation of an analytical model designed to identify the relationship between the distinct sanitary policies implemented in Mexico and the tendencies towards decentralization and integration. This analysis is combined with a critical review of the recent decentralization experiences undertaken in the states of Guerrero, Oaxaca and Nuevo León. While comparing Guerrero and Oaxaca, restitution and deconcentration under similar socio-economic conditions were discussed. The comparison between Guerrero and Nuevo Leon allowed the discussion of the benefits and limits of restitution under different socio-economic conditions. In addition, with this model the author discusses a few generalizations regarding the possible future of decentralization.

Corporatism and health care: a comparison of Sweden and Mexico.

Up to now, the Swedish health care system has been used as a model for comparisons with other developed nations, chiefly in Northern Europe and the United States. This article departs from the mainstream and poses that similarities along the political factor of corporatism warrant a comparative analysis between the Swedish and Mexican cases. The most widely accepted definitions and typologies of corporatism are reviewed. The arena of manpower policy is used to illustrate the effects of alternative modes of interest representation on health care organization. The final aim of this comparative exercise is to enrich the empirical basis required to build a theory about the complex determinants of health care systems. State corporatism has acted in Mexico largely unchecked by geographical interest representation, in contrast with Sweden where centralist and decentralist forces are more balanced. This finding helps to understand why Sweden and Mexico mark extreme points along the health equity continuum. The comparison underscores the need for Sweden to avoid the risk of weakening the equity basis of its health care system as it moves along its current reform. The importance of these transformations go beyond Sweden, since they will undoubtedly offer new models of thinking and acting for the rest of the world.

[AIDS: the silent threat to the bi-national security]. / SIDA: la callada amenaza a la seguridad binacional.

This paper discusses the relationship between migration and health using as a case study the problem of Acquired Immunodeficiency Syndrome (AIDS) in the Mexican-American border. The authors state that the permanent nature of migration between Mexico and the United States points to the need of binational health programs offering health education and promotion, and a greater interaction between the Mexican and the American health care systems.

First contact, simplified technology, or risk anticipation? Defining primary health care.

PIP: Elements important to defining primary health care (PHC) are discussed, with examples from Latin American countries. Topics are identified as follows: the origins and dilemmas of PHC, conflicting PHC values and practices, organizational changes and PHC, health care reforms and examples from Latin America, and the implications for medical education. The new paradigm for medical education and practice is in the classic Kuhn tradition. A paradigm for health care is an ideological model about the form, content, and organization of health care. There are rules that prescribe in a normative way how resources should be combined to produce health services. The current dominant paradigm is that of curative medicine, and the PHC paradigm assumes that a diversified health care team uses modern technology and resources to actively anticipate health damage and promote well being. The key word is anticipatory. As a consequence secondary care also needs to be redefined as actually treating the illness or damage itself. Organizations must be changed to establish this model. Contrasting primary, anticipatory health care with technical, curative medicine has been discussed over at least the past 150 years. An important development was the new model for developing countries which was a result of a Makerere, Kenya symposium on the Medicine of Poverty. The Western model of physicians acting independently and in a highly specialized fashion to address each patient's complaints was considered inappropriate. The concern must be for training and supervising auxiliaries, designing cost-effective systems, and a practice mode limited to what can actually be provided to the population. How to adapt this to existing medical systems was left undetermined. In 1978 with the WHO drive for health for all, there emerged different conceptions and models of PHC. Conceptually, PHC is realized when services are directed to identifying and modifying risk factors at the collective level, where the health team anticipates and prevents problems through active programming and community participation, and in secondary care, the doctors wait for the ill patient. Level of care and type of contact are subordinate to PHC. 1st contact and 1st level facilities are responsible for PHC, although secondary interventions (prenatal care) are handled. The best technology should be evaluated in terms of the capacity to anticipate severe, irreversible, or fatal damage. Simplified technology is not primitive technology.^ieng

[Genesis and articulation of public health guidelines in Mexico]. / Génesis y articulación de los principios rectores de la salud pública de México.

Mexican postrevolutionary health policy has been oriented by changing views on the process of development and of the role that State should play towards the health of specific groups. The article reconstructs how deep-seated health policy values were originated and legitimated. The gestation process is followed through the contest between specific groups and interest in key conjunctures of mexican history. The article proposes that for 1940 three linkage principles between policy makers and beneficiaries had been fully legitimated: the technical, the geopolitical and the corporativist.

[AIDS and social strata in Mexico: the importance of bisexuality]. / SIDA y estratos sociales en México: la importancia del bisexualismo.

The prevalence of AIDS in Mexico and the frequency of sexually transmitted risks was analyzed in relation to the socioeconomic strata of the patients. The study was based on the obligatory notifications of AIDS received by the Ministry of Health between 1982 and september of 1988. The findings show that AIDS is accumulating more rapidly among the low socioeconomic strata, where the bisexual and heterosexual risk factors are also more frequent. These findings are explained in the context of the sexual mores and living conditions of the low social strata of the country. The study leads to the recommendation of diversified preventive activities that meet the peculiarities of the various social strata in Mexico.