Has Latin America achieved universal health coverage yet? Lessons from four countries.

BACKGROUND: Seven years after the commitment to United Nations' call for Universal Health Coverage, healthcare services in Argentina, Brazil, Colombia, Mexico are generally accessible and affordable; but they still struggle to meet population health demands and address the rising health care costs. We aim to describe measures taken by these four countries to commit by Universal Health Coverage, addressing their barriers and challenges. METHODS: Scoping literature review, supplemented with targeted stakeholders survey. RESULTS: The four countries analysed achieved an overall index of essential coverage of 76-77%, and households out of pocket health expenditures fall below 25%. Services coverage was improved by expanding access to primary healthcare systems and coverage for non-communicable diseases, while provided community outreach by the increase in the number of skilled healthcare workers. New pharmaceutical support programs provided access to treatments for chronic conditions at zero cost, while high-costs drugs and cancer treatments were partially guaranteed. However, the countries lack with effective financial protection mechanisms, that continue to increase out of pocket expenditure as noted by lowest financial protection scores, and lack of effective financial mechanisms besides cash transfers. CONCLUSIONS: Argentina, Brazil, Colombia, and Mexico have made progress towards UHC. Although, better financial protection is urgently required.

Alma Ata after 40 years: Primary Health Care and Health for All-from consensus to complexity.

Forty years ago, the 134 national government members of the WHO signed the Alma Ata Declaration. The Declaration made Primary Health Care (PHC) the official health policy of all members countries. Emerging from the conference was the consensus that health was a human right based on the principles of equity and community participation. Alma Ata broadened the perception of health beyond doctors and hospitals to social determinants and social justice. In the following years implementing this policy confronted many challenges. These included: (1) whether PHC should focus on vertical disease programmes where interventions had the most possibility of success or on comprehensive programmes that addressed social, economic and political factors that influenced health improvements; (2) whether primary care and PHC are interchangeable approaches to health improvements; (3) how equity and community participation for health improvements would be institutionalised; and (4) how financing for PHC would be possible. Experiences in implementation over the last 40 years provide evidence of how these challenges have been met and what succeeded and what had failed. Lessons from these experiences include the need to understand PHC as a process rather than a blueprint, to understand the process must consider context, culture, politics, economics and social concerns, and therefore, to recognise the process is complex. PHC needs to be examined within evaluation frameworks that address complexity. Recent developments in monitoring and evaluation have begun to respond to this need. They include realist evaluation and implementation research.

Examining the links between community participation and health outcomes: a review of the literature.

As a key principle of Primary Health Care (PHC) and Health Systems Reform, community participation has a prominent place in the current global dialogue. Participation is not only promoted in the context of provision and utilization of health services. Advocates also highlight participation as a key factor in the wider context of the importance of social determinants of health and health as a human right. However, the evidence that directly links community participation to improved health status is not strong. Its absence continues to be a barrier for governments, funding agencies and health professionals to promote community participation. The purpose of this article is to review research seeking to link community participation with improved health status outcomes programmes. It updates a review undertaken by the author in 2009. The search includes published articles in the English language and examines the evidence of in the context of health care delivery including services and promotion where health professionals have defined the community's role. The results show that in most studies community participation is defined as the intervention seeking to identify a direct causal link between participation and improved health status modeled on Randomized Control studies (RCT). The majority of studies show it is not possible to examine the link because there is no standard definition of 'community' and 'participation'. Where links are found, they are situation-specific and are unpredictable and not generalizable. In the discussion, an alternative research framework is proposed arguing that community participation is better understood as a process. Once concrete interventions are identified (i.e. improved birth outcomes) then the processes producing improved health status outcomes can be examined. These processes may include and can lead to community uptake, ownership and sustainability for health improvements. However, more research is needed to ensure their validity.

Primary health care, now and forever? A case study of a paradigm change.

The year 2008 marked the 30th anniversary of the Alma Ata Declaration that made Primary Health Care (PHC) the global health policy of member states of the World Health Organization (WHO). Why has PHC remained relevant? In part, this is because of growing evidence that health is a result of social, political, and economic environments, not merely of control of diseases and infirmities through interventions based on biomedical science. Using the conceptual framework developed by Thomas Kuhn, this article traces the emergence of PHC as a new paradigm based on social determinants to address poor health among populations (not individuals), especially those that are low-income. It traces the history of PHC over the last 30 years, focusing on policy developments within WHO. It selects three issues: definitions of PHC; financing and delivery of health services, including lay people's involvement in health care, as examples of the new paradigm; and opposition by those whose concept of health is based on the control of disease and infirmities paradigm. The article concludes by asking whether PHC will continue to be relevant and whether the question mark in the title of this article will be removed in the future.

Lessons from community participation in health programmes: a review of the post Alma-Ata experience.

The year 2008 marked the 30 year anniversary of Primary Health Care, the health policy of all member nations of the WHO. Community participation was one of the key principles of this policy. This article reviews the experiences of and lessons learned by policy makers, planners and programme managers in attempting to integrate community participation into their health programmes. The lessons, identified in an earlier article by the author, are still relevant today. They help to identify three reasons why integrating community participation into health programmes is so difficult. These reasons are: (1) the dominance of the bio-medical paradigm as the main planning tool for programmes, leading to the view of community participation as an intervention; (2) the lack of in-depth analysis of the perceptions of community members regarding the use of community health workers; and (3) the propensity to use a framework that limits investigation into what works, why and how in community participation in health programmes. Despite these challenges, evidence suggests that community participation has contributed to health improvements at the local level, particularly in poor communities, and will continue to be relevant to programme professionals.

Health sector reforms in Kenya: an examination of district level planning.

The paper examines health sector reforms in Kenya at the district level based on the Government of Kenya's Health Policy Framework of 1994. The authors present the context of and historical perspective to health sector reforms in Kenya and discuss the major reform policies including decentralization to the district level. The authors then review intended policy outcomes, investigating assumptions on which the implementation and effectiveness of the reform agenda at the local level are based. The authors argue that emphasis on outcomes rather than process has not supported sustainable reforms or achieved the government's goal of improving health and ensuring equity for the citizens of the country.

A framework linking community empowerment and health equity: it is a matter of CHOICE.

This paper presents a framework to explore the relationship between health equity and community empowerment. It traces the progression of the concept of participation to the present term of empowerment and the links among empowerment, equity, and health outcomes. It argues that the relationship can best be described by using the acronym CHOICE (Capacity-building, Human rights, Organizational sustainability, Institutional accountability, Contribution, and Enabling environment). Based on the concept of development as freedom put forward by Nobel Laureate Amartya Sen, the paper describes how each factor illustrates the relationship between equity and empowerment in positive health outcomes, giving appropriate examples. In conclusion, it is suggested that these factors might form the basis of a tool to assess the relationship between equity and empowerment and its impact on health outcomes.

Participación de la comunidad en los programas de salud de la madre y el niño y de planificación familiar / Participación de la comunidad en los programas de salud de la madre y el niño y de planificación familiar

Desde la Declaración de Alta-Ata sobre atención primaria de salud de 1978, se viene reconociendo, de manera cada vez más unánime, la importancia de la participación de la comunidad como elemento de la prestación de atención de salud. Con el fin de determinar si es posible aislar los factores y condiciones que determinan la eficacia de la participación comunitaria, la autora de este libro examina un gran número de diversos programas de salud y otros afines de desarrollo, sobre todo en el sector de la salud de la madre y el niño y de la planificación de la familia

Se debate el concepto de participación de la comunidad tanto desde el punto de vista de sus orígenes históricos como de sus diferentes definiciones e interpretaciones. Se presentan dos conjuntos de factores que determinan el progreso de los programas de salud con participación comunitaria, ilustrándolos mediante el análisis de los objetivos de los programas y del éxito en su aplicación. Se evalúa igualmente las limitacines y posibilidades de este planteamiento analítico

El libro tiene por objeto servir de ayuda a los planificadores sanitarios, permitiéndoles plantearse determinados problemas en materia de gestión, así como factores de comportamiento que influirán sobre la naturaleza y evolución de los programas de salud que se apoyen en la participación de la comunidad

Participación de la comunidad en los programas de salud de la madre y el niño y de planificación familiar : análisis basados en estudios de casos / Susan B. Rifkin / Community participation in maternal and child health/family planning programmes : an analysis based on case study materials

En este libro se reseña una amplia serie de experiencias de programas de salud de la madre y el niño y planificación familiar, con ánimo de identificar los factores y condiciones que favorecen la participación eficaz de la comunidad. Dirigida a los planificadores sanitarios, esta obra se concentra en las cuestiones de gestión y de comportamiento humano que han de tenerse en cuenta al planear programas sanitarios basados en el concepto o los métodos de la participación de la comunidad. En todo el libro se usan numerosos estudios de casos para disponer de una base analítica que permita comprender por qué esos programas dejan tan a menudo de alcanzar sus objetivos. La obra consta de cuatro capítulos. En el pri-mero se hace una breve reseña histórica de la participación de la comunidad en la atención de salud, insistiéndose en los cambios de actitud que han llevado a interesarse por las posibilidades que ofrece la participación de la comunidad para extender la cobertura sanitaria a los sectores insuficientemente atendidos y contribuir al desarrollo socioeconómico gene-ral. En el segundo capítulo se exponen diversas interpretaciones de la participación de la comunidad, subrayando las que están más relacionadas con la prestación de servicios de salud de la madre y el niño y de planificación familiar. El enfoque analítico del estudio se desarrolla en el tercer capítulo -- el más extenso -, que describe los programas por sus objetivos y por la forma en que estos objetivos se persiguen. La autora sugiere que los progresos y éxitos de un programa vienen regidos por dos series de factores: los factores descriptivos, que son principalmente de naturaleza ambiental, y los factores de acción, que se refieren a la organización, la gestión y la movilización de recursos. El capítulo final encierra cierto número de conclusiones relativas a las cuestiones que habrán de abordar y de resolver los planificadores y los organismos

Participation communautaire aux programmes de santé maternelle et infantile/planification familiale : analyse sur la base d' études de cas / Susan B. Rifkin / Community participation in maternal and child health/family planning programmes : an analysis based on case study materials

Cet ouvrage passe en revue toute une série de programmes de santé maternelle et infantile et de planification familiale pour tenter de discerner, sur la base d'expériences concrètes, les facteurs et conditions favorables à une participation communautaire efficace. Destiné aux planificateurs de la santé, il traite de problèmes de gestion et de facteurs comportementaux dont il faut tenir compte pour planifier les programmes de santé fondés sur la notion ou les méthodes de participation communautaire. Tout au long de l'ouvrage, l'auteur se réfère à de nombreuses études de cas pour mettre au point un cadre analytique qui permette de comprendre pourquoi ces programmes ont si souvent des difficultés à atteindre leurs objectifs

Community participation in maternal and child health/family planning programmes : an analysis based on case study materials / Susan B. Rifkin / Participation communautaire aux programmes de santé maternelle et infantile/planification familiale : analyse sur la base d' études de cas / Participación de la comunidad en los programas de salud de la madre y el niño y de planificación familiar : análisis basados en estudios de casos

Reviews a wide range of experiences in maternal, child health, and family planning programmes in an effort to identify factors and conditions that encourage effective community participation. Addressed to health planners, the book concentrates on issues of management and behaviour that can influence the nature and course of health programmes that rely on community participation. Throughout, numerous case studies and anecdotes are used to illustrate the strengths and weaknesses of various programmes. The book has four main chapters. The first provides a brief history of community participation in health care, concentrating on the changes in attitudes since the Second World War and the influence of new ideas on community participation in health care. The second chapter discusses the various interpretations of community participation, emphasizing those most relevant to the delivery of maternal, child, and family planning services. The analytical framework for the study is developed in the third chapter, which describes programmes on the basis of their objectives and the ways in which those objectives are pursued. The author suggests that the progress and success of a programme are governed by two sets of factors: descriptive factors, which are mainly of an environmental nature, and action factors, which refer to organization, management, and resource mobilization. The final chapter draws a number of conclusions concerning the questions that will need to be addressed and answered by planners and agencies

Cómo medir la participación de la comunidad / Towards the measurement of community participation

En el presente artículo se describen las etapas iniciales de la elaboración de una metodología aplicable para evaluar la participación de la comunidad en los sistemas de salud. Un estudio realizado en Nepal indica que el procedimiento adoptado será útil para los planificadores que deseen evaluar la intervención en los programas de atención primaria

Towards the measurement of community participation

A description is given on the initial stages in the development of a methodology for assessing community participation in health schemes. A study in Nepal indicates that the approach adopted will be useful to planners who wish to evaluate involvement in primary care programmes