Pub Date : 2018-03-14DOI: 10.1080/23288604.2018.1447242
A. Yazbeck, R. Fryatt, C. Connor, L. Hartel
Abstract Abstract—This special issue of Health Systems & Reform presents a series of commentaries and articles that reflect the work of the Health Finance and Governance (HFG) project, a global flagship health project of the United States Agency for International Development (USAID). Over its six-year life, the 200 million USD project has worked with more than 40 partner countries to increase their domestic resources for health, manage those resources more effectively, and reduce system bottlenecks in order to increase access to and use of priority health services and strengthen health systems overall.
{"title":"Learning from Doing: How USAID's Health Financing and Governance Project Supports Health System Reforms","authors":"A. Yazbeck, R. Fryatt, C. Connor, L. Hartel","doi":"10.1080/23288604.2018.1447242","DOIUrl":"https://doi.org/10.1080/23288604.2018.1447242","url":null,"abstract":"Abstract Abstract—This special issue of Health Systems & Reform presents a series of commentaries and articles that reflect the work of the Health Finance and Governance (HFG) project, a global flagship health project of the United States Agency for International Development (USAID). Over its six-year life, the 200 million USD project has worked with more than 40 partner countries to increase their domestic resources for health, manage those resources more effectively, and reduce system bottlenecks in order to increase access to and use of priority health services and strengthen health systems overall.","PeriodicalId":46168,"journal":{"name":"Health Systems & Reform","volume":"2 1","pages":"57 - 61"},"PeriodicalIF":4.1,"publicationDate":"2018-03-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"90201017","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2018-03-08DOI: 10.1080/23288604.2018.1446698
C. Hospedales, Lisa Tarantino
Recent multicountry infectious disease outbreaks of Ebola (2014) and Zika (2016–present) have raised global awareness of the importance of health security and the systems and capacities needed to prevent, detect, and respond to global health threats. Several mechanisms exist through which individual countries can plan and frame health security strengthening, such as the World Health Organization’s (WHO) International Health Regulations (IHR), the Joint External Evaluation tool, and the Global Health Security Agenda (GHSA). The IHR came into force in 2007, manifested in the form of bilateral agreements between individual countries and the WHO. They aim to reduce the spread of diseases internationally while minimizing disruption of travel and trade. Regional and multisectoral cooperation, however, has not yet been systematized or institutionalized in a manner befitting a security threat that crosses borders easily and indiscriminately. We know that an infected individual can travel from country to country and continent to continent in a matter of hours—and that health security is unachievable without a regional coordinated response. Nowhere is this more evident than in the countries and territories of the Caribbean. The Caribbean comprises some 30 small island and mainland countries and territories with 40 million Spanish, French, English, and Dutch speaking residents and over 50 million cruise and international tourist arrivals per year principally from North America and Europe. Diversity and vulnerability to external shocks, whether manmade or natural, characterize the region. With our small health systems and deeply intertwined and tourism-dependent economies, we recognize that uncontrolled disease outbreaks pose an existential threat. Our region is the first to take on the challenges and opportunities of multisectoral, regional planning, cooperation, coordination, and monitoring of global health security strengthening. Given the small sizes of our
{"title":"Fighting Health Security Threats Requires a Cross-Border Approach","authors":"C. Hospedales, Lisa Tarantino","doi":"10.1080/23288604.2018.1446698","DOIUrl":"https://doi.org/10.1080/23288604.2018.1446698","url":null,"abstract":"Recent multicountry infectious disease outbreaks of Ebola (2014) and Zika (2016–present) have raised global awareness of the importance of health security and the systems and capacities needed to prevent, detect, and respond to global health threats. Several mechanisms exist through which individual countries can plan and frame health security strengthening, such as the World Health Organization’s (WHO) International Health Regulations (IHR), the Joint External Evaluation tool, and the Global Health Security Agenda (GHSA). The IHR came into force in 2007, manifested in the form of bilateral agreements between individual countries and the WHO. They aim to reduce the spread of diseases internationally while minimizing disruption of travel and trade. Regional and multisectoral cooperation, however, has not yet been systematized or institutionalized in a manner befitting a security threat that crosses borders easily and indiscriminately. We know that an infected individual can travel from country to country and continent to continent in a matter of hours—and that health security is unachievable without a regional coordinated response. Nowhere is this more evident than in the countries and territories of the Caribbean. The Caribbean comprises some 30 small island and mainland countries and territories with 40 million Spanish, French, English, and Dutch speaking residents and over 50 million cruise and international tourist arrivals per year principally from North America and Europe. Diversity and vulnerability to external shocks, whether manmade or natural, characterize the region. With our small health systems and deeply intertwined and tourism-dependent economies, we recognize that uncontrolled disease outbreaks pose an existential threat. Our region is the first to take on the challenges and opportunities of multisectoral, regional planning, cooperation, coordination, and monitoring of global health security strengthening. Given the small sizes of our","PeriodicalId":46168,"journal":{"name":"Health Systems & Reform","volume":"05 1","pages":"72 - 76"},"PeriodicalIF":4.1,"publicationDate":"2018-03-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"81867226","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2018-03-07DOI: 10.1080/23288604.2018.1445425
R. Bhat, J. Holtz, C. Ávila
Abstract Abstract—India has seen impressive investments in government-funded health insurance but still severely underfunds the health sector. The government of India has a critical role in ensuring effective health coverage to the “missing middle”: the urban poor. The urban poor have been excluded from benefits targeting eligible populations below the poverty line. Lack of access to public facilities and qualified primary health care providers in urban areas often results in treatment delays or patients relying predominantly on out-of-pocket payments to informal providers. The urban poor are also excluded from affordable health insurance markets. Illiteracy and poverty in the slums result in limited access to goods and services and unequal participation in social life, as well as in overall social exclusion. The government of India, in its 2018 union budget, announced a flagship National Health Protection Scheme (NHPS) that will provide health insurance benefits of up to INR 500,000 (7,692 USD) per family per annum. This article explores current and future opportunities to fill an important gap in access to health services, specifically targeting the urban poor by providing health insurance schemes that include primary health services for this population. Current public health insurance schemes providing exclusively hospitalization benefits are unsustainable; part of the solution is keeping people healthy and out of the hospital. Primary care integrated into health insurance improves population health management and is associated with higher patient satisfaction, fewer hospitalizations and emergency department visits, lower claim costs, and overall reductions in morbidity and mortality. There is no single solution to finance health services for the urban poor. This population mostly belongs to the informal sector, which encompasses workers whose jobs are not recognized formally and from whom no taxes are collected. However, the new NHPS could play a major role in expanding safety nets for the urban poor by providing financial risk protection and improving social inclusion. The government could use the introduction of the new scheme to shape approaches aimed at increasing opportunities for the urban poor through investing in public health facilities, subsidizing and fostering public–private affordable health insurance, and enhancing access to information, voice, and respect for rights.
{"title":"Reaching the Missing Middle: Ensuring Health Coverage for India's Urban Poor","authors":"R. Bhat, J. Holtz, C. Ávila","doi":"10.1080/23288604.2018.1445425","DOIUrl":"https://doi.org/10.1080/23288604.2018.1445425","url":null,"abstract":"Abstract Abstract—India has seen impressive investments in government-funded health insurance but still severely underfunds the health sector. The government of India has a critical role in ensuring effective health coverage to the “missing middle”: the urban poor. The urban poor have been excluded from benefits targeting eligible populations below the poverty line. Lack of access to public facilities and qualified primary health care providers in urban areas often results in treatment delays or patients relying predominantly on out-of-pocket payments to informal providers. The urban poor are also excluded from affordable health insurance markets. Illiteracy and poverty in the slums result in limited access to goods and services and unequal participation in social life, as well as in overall social exclusion. The government of India, in its 2018 union budget, announced a flagship National Health Protection Scheme (NHPS) that will provide health insurance benefits of up to INR 500,000 (7,692 USD) per family per annum. This article explores current and future opportunities to fill an important gap in access to health services, specifically targeting the urban poor by providing health insurance schemes that include primary health services for this population. Current public health insurance schemes providing exclusively hospitalization benefits are unsustainable; part of the solution is keeping people healthy and out of the hospital. Primary care integrated into health insurance improves population health management and is associated with higher patient satisfaction, fewer hospitalizations and emergency department visits, lower claim costs, and overall reductions in morbidity and mortality. There is no single solution to finance health services for the urban poor. This population mostly belongs to the informal sector, which encompasses workers whose jobs are not recognized formally and from whom no taxes are collected. However, the new NHPS could play a major role in expanding safety nets for the urban poor by providing financial risk protection and improving social inclusion. The government could use the introduction of the new scheme to shape approaches aimed at increasing opportunities for the urban poor through investing in public health facilities, subsidizing and fostering public–private affordable health insurance, and enhancing access to information, voice, and respect for rights.","PeriodicalId":46168,"journal":{"name":"Health Systems & Reform","volume":"63 1 1","pages":"125 - 135"},"PeriodicalIF":4.1,"publicationDate":"2018-03-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"90141010","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2018-02-21DOI: 10.1080/23288604.2018.1440348
S. Dominis, A. Yazbeck, L. Hartel
Abstract—Due to their shared history under the Soviet Union and similar health systems, countries in the Central Asia Region offer an important opportunity for the analysis of health system reforms. Building on extensive documentation of health reforms in the region, this article draws on information from a key informant virtual focus group and uses a systematic health systems framework to compare the national health reforms that Kazakhstan, the Kyrgyz Republic, Tajikistan, Turkmenistan, and Uzbekistan implemented. This comparison across the five countries captures variations in their approaches to health system reform. In alignment with health needs shared by the five nations, most country reforms and external investments focused on strengthening primary care, benefit packages, and institutional capacity. The comparison shows that of the five countries, the Kyrgyz Republic underwent the broadest, most sustained, and most successful health sector reform in the region. Though the Kyrgyz Republic enacted many reforms that were similar to those in the other countries, it was unique in implementing a comprehensive set of health financing reforms. This article also provides lessons based on external investment made by the donor community in this region's health reforms. Three implementation factors are identified as critical to making the external investment in the Central Asia region effective: sustained and coordinated external support; early and frequent investment in national ownership; and utilization of a sequenced, pragmatic approach. Based on analysis of the shared experiences of these countries and their supporters, the article offers lessons for other countries undertaking health reform.
{"title":"Keys to Health System Strengthening Success: Lessons from 25 Years of Health System Reforms and External Technical Support in Central Asia","authors":"S. Dominis, A. Yazbeck, L. Hartel","doi":"10.1080/23288604.2018.1440348","DOIUrl":"https://doi.org/10.1080/23288604.2018.1440348","url":null,"abstract":"Abstract—Due to their shared history under the Soviet Union and similar health systems, countries in the Central Asia Region offer an important opportunity for the analysis of health system reforms. Building on extensive documentation of health reforms in the region, this article draws on information from a key informant virtual focus group and uses a systematic health systems framework to compare the national health reforms that Kazakhstan, the Kyrgyz Republic, Tajikistan, Turkmenistan, and Uzbekistan implemented. This comparison across the five countries captures variations in their approaches to health system reform. In alignment with health needs shared by the five nations, most country reforms and external investments focused on strengthening primary care, benefit packages, and institutional capacity. The comparison shows that of the five countries, the Kyrgyz Republic underwent the broadest, most sustained, and most successful health sector reform in the region. Though the Kyrgyz Republic enacted many reforms that were similar to those in the other countries, it was unique in implementing a comprehensive set of health financing reforms. This article also provides lessons based on external investment made by the donor community in this region's health reforms. Three implementation factors are identified as critical to making the external investment in the Central Asia region effective: sustained and coordinated external support; early and frequent investment in national ownership; and utilization of a sequenced, pragmatic approach. Based on analysis of the shared experiences of these countries and their supporters, the article offers lessons for other countries undertaking health reform.","PeriodicalId":46168,"journal":{"name":"Health Systems & Reform","volume":"17 1","pages":"160 - 169"},"PeriodicalIF":4.1,"publicationDate":"2018-02-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85255935","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2018-02-10DOI: 10.1080/23288604.2018.1441621
L. Hartel, A. Yazbeck, P. Osewe
Abstract Abstract—The characteristics of tuberculosis (TB)—such as links to poverty, importance of patient actions, and prevalence of multisectoral drivers—require more from health systems than traditional medically oriented interventions. To combat TB successfully, health systems must also address social risk factors and behavior change in a multisector response. In this, many health systems are failing. To explore why, and how they can do better, we apply the Flagship Framework and its five “control knobs” (financing, payment, organization, regulation, and behavior) to the literature on TB control programs, focusing on the mining population of Southern Africa, among whom the incidence of TB is highest in the world. We conclude by recommending a patient-centered approach that broadens a system's engagement to a whole-of–health sector, whole-of-government response.
{"title":"Responding to Health System Failure on Tuberculosis in Southern Africa","authors":"L. Hartel, A. Yazbeck, P. Osewe","doi":"10.1080/23288604.2018.1441621","DOIUrl":"https://doi.org/10.1080/23288604.2018.1441621","url":null,"abstract":"Abstract Abstract—The characteristics of tuberculosis (TB)—such as links to poverty, importance of patient actions, and prevalence of multisectoral drivers—require more from health systems than traditional medically oriented interventions. To combat TB successfully, health systems must also address social risk factors and behavior change in a multisector response. In this, many health systems are failing. To explore why, and how they can do better, we apply the Flagship Framework and its five “control knobs” (financing, payment, organization, regulation, and behavior) to the literature on TB control programs, focusing on the mining population of Southern Africa, among whom the incidence of TB is highest in the world. We conclude by recommending a patient-centered approach that broadens a system's engagement to a whole-of–health sector, whole-of-government response.","PeriodicalId":46168,"journal":{"name":"Health Systems & Reform","volume":"34 1","pages":"100 - 93"},"PeriodicalIF":4.1,"publicationDate":"2018-02-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85266575","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2018-01-02DOI: 10.1080/23288604.2017.1368432
John Q Wong, Jhanna Uy, N. J. Haw, J. Valdes, D. B. Bayani, Charl Panganiban Bautista, M. Haasis, R. Bermejo, W. Zeck
Abstract Abstract—Achievement of universal health coverage requires better allocative efficiency in health systems. Countries like the Philippines, however, do not have quality local data for these decisions. We present a method that applies existing global data, e.g., Global Burden of Disease and Disease Control Priorities project, into creating a local priority list of diseases and interventions that may be useful in providing a rational plan for expanding coverage of health services paid by public financing. In the context of the Philippines, this refers to the Department of Health for vertical programs like immunization and disease control, and the Philippine Health Insurance Corporation for inpatient and outpatient health services. We found that the top 48 (or 22%) of diseases account for 80% of total disability-adjusted life years (DALYs), reflecting a well-known concept in management, the Pareto principle. Due to its simplicity and widespread applicability, the Pareto principle facilitated interest in rational priority setting among high-level officials in the Philippine health sector. Priority setting must not be limited to disease burden and cost-effectiveness criteria. Our lists can be used after further deliberation and stakeholder consultation. Priority setting is a complex, value-laden process, and a purely utilitarian approach to prioritization may lead to further deterioration in the health status of vulnerable populations. We recommend that DOH and PHIC set up a joint, independent agency primarily responsible for implementing a sustainable, transparent, and participatory priority-setting process that will advise them on future service coverage expansions.
{"title":"Priority Setting for Health Service Coverage Decisions Supported by Public Spending: Experience from the Philippines","authors":"John Q Wong, Jhanna Uy, N. J. Haw, J. Valdes, D. B. Bayani, Charl Panganiban Bautista, M. Haasis, R. Bermejo, W. Zeck","doi":"10.1080/23288604.2017.1368432","DOIUrl":"https://doi.org/10.1080/23288604.2017.1368432","url":null,"abstract":"Abstract Abstract—Achievement of universal health coverage requires better allocative efficiency in health systems. Countries like the Philippines, however, do not have quality local data for these decisions. We present a method that applies existing global data, e.g., Global Burden of Disease and Disease Control Priorities project, into creating a local priority list of diseases and interventions that may be useful in providing a rational plan for expanding coverage of health services paid by public financing. In the context of the Philippines, this refers to the Department of Health for vertical programs like immunization and disease control, and the Philippine Health Insurance Corporation for inpatient and outpatient health services. We found that the top 48 (or 22%) of diseases account for 80% of total disability-adjusted life years (DALYs), reflecting a well-known concept in management, the Pareto principle. Due to its simplicity and widespread applicability, the Pareto principle facilitated interest in rational priority setting among high-level officials in the Philippine health sector. Priority setting must not be limited to disease burden and cost-effectiveness criteria. Our lists can be used after further deliberation and stakeholder consultation. Priority setting is a complex, value-laden process, and a purely utilitarian approach to prioritization may lead to further deterioration in the health status of vulnerable populations. We recommend that DOH and PHIC set up a joint, independent agency primarily responsible for implementing a sustainable, transparent, and participatory priority-setting process that will advise them on future service coverage expansions.","PeriodicalId":46168,"journal":{"name":"Health Systems & Reform","volume":"104 1","pages":"19 - 29"},"PeriodicalIF":4.1,"publicationDate":"2018-01-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"75931334","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2018-01-02DOI: 10.1080/23288604.2017.1413494
I. Postolovska, R. Lavado, G. Tarr, S. Verguet
Abstract Abstract—The majority of Armenian adult males smoke, yet tobacco taxes in Armenia are among the lowest in Europe and Central Asia. Increasing taxes on tobacco is one of the most cost-effective public health interventions, but many opponents often cite regressivity as an argument against tobacco taxation. We use a mixed-methods approach to study the potential regressivity of tobacco taxation and the extent to which the regressivity argument hindered increases in tobacco taxation in Armenia. First, we pursued an extended cost-effectiveness analysis (ECEA) to assess the health, financial, and distributional consequences (by consumption quintile) of increases in the excise tax on cigarettes in Armenia. We simulated a hypothetical price hike leading to a tax rate of about 75% of the retail price of cigarettes, which would be fully passed on to consumers. Second, we conducted a series of stakeholder interviews to examine the importance of the regressivity argument and identify the factors that allowed tobacco tax increases to be adopted as public policy in Armenia. We show that increased excise taxes would bring large health and financial benefits to Armenian households. Half of tobacco-related premature deaths and 27% of associated poverty cases averted would be concentrated among the bottom 40% of the population. Though regressivity was raised as a concern at the initial stages of the policy adoption process, our qualitative stakeholder analysis indicates that the recent accession to the Eurasian Economic Union and the fiscal constraints faced by the government created a window of opportunity for tobacco taxation to be placed on the policy agenda and adopted as government policy, and the ECEA findings were an important input into the process.
{"title":"The Health Gains, Financial Risk Protection Benefits, and Distributional Impact of Increased Tobacco Taxes in Armenia","authors":"I. Postolovska, R. Lavado, G. Tarr, S. Verguet","doi":"10.1080/23288604.2017.1413494","DOIUrl":"https://doi.org/10.1080/23288604.2017.1413494","url":null,"abstract":"Abstract Abstract—The majority of Armenian adult males smoke, yet tobacco taxes in Armenia are among the lowest in Europe and Central Asia. Increasing taxes on tobacco is one of the most cost-effective public health interventions, but many opponents often cite regressivity as an argument against tobacco taxation. We use a mixed-methods approach to study the potential regressivity of tobacco taxation and the extent to which the regressivity argument hindered increases in tobacco taxation in Armenia. First, we pursued an extended cost-effectiveness analysis (ECEA) to assess the health, financial, and distributional consequences (by consumption quintile) of increases in the excise tax on cigarettes in Armenia. We simulated a hypothetical price hike leading to a tax rate of about 75% of the retail price of cigarettes, which would be fully passed on to consumers. Second, we conducted a series of stakeholder interviews to examine the importance of the regressivity argument and identify the factors that allowed tobacco tax increases to be adopted as public policy in Armenia. We show that increased excise taxes would bring large health and financial benefits to Armenian households. Half of tobacco-related premature deaths and 27% of associated poverty cases averted would be concentrated among the bottom 40% of the population. Though regressivity was raised as a concern at the initial stages of the policy adoption process, our qualitative stakeholder analysis indicates that the recent accession to the Eurasian Economic Union and the fiscal constraints faced by the government created a window of opportunity for tobacco taxation to be placed on the policy agenda and adopted as government policy, and the ECEA findings were an important input into the process.","PeriodicalId":46168,"journal":{"name":"Health Systems & Reform","volume":"495 1","pages":"30 - 41"},"PeriodicalIF":4.1,"publicationDate":"2018-01-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89698084","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2018-01-02DOI: 10.1080/23288604.2017.1405770
Mara Rejane Barroso Barcelos, B. P. Nunes, S. M. Duro, E. Tomasi, R. C. D. Lima, Malgorzata Chalupowski, T. Rebbeck, L. Facchini
Abstract Breast cancer is the most frequent type of cancer in women and the second leading cause of cancer death after lung cancer in more developed countries and the leading cause of death in developing countries. The aim of this study was to analyze the association between three sets of variables and the utilization of breast cancer screening among women attending primary health care centers participating in the Primary Care Access and Quality Improvement Program in Brazil. A survey of 65,391 women was conducted across Brazil in 2012. The primary outcomes were percentage of women who never had a clinical breast examination and percentage of women who never had a mammography. Crude and adjusted analyses performed using Poisson regression assessed the association of these outcomes with service organization variables, as well as with socioeconomic and demographic variables. Results showed that 37.7% of women never had a clinical breast examination and 30.3% never had a mammography. Never having had both screening procedures decreased as the Human Development Index increased. Never having had a clinical breast examination increased with increasing population size and increasing municipal family health strategy coverage. The proportion of women never having had a clinical breast examination was highest in the northern region. White women and those who had a partner had greater utilization of screening. Women who had paid work and lived in families with higher per capita income had greater utilization of clinical breast examination. The proportion of women who never had a mammography was highest for women living in households with six or more people and receiving the Bolsa Família benefit. Women with lower per capita family income had higher utilization of mammography. Appropriate structures and work processes were associated with greater utilization of mammography. Investments in primary health care structure and teamworking processes are essential to improve the utilization of screening, prevention, and early diagnosis of breast cancer in Brazil.
{"title":"Utilization of Breast Cancer Screening in Brazil: An External Assessment of Primary Health Care Access and Quality Improvement Program","authors":"Mara Rejane Barroso Barcelos, B. P. Nunes, S. M. Duro, E. Tomasi, R. C. D. Lima, Malgorzata Chalupowski, T. Rebbeck, L. Facchini","doi":"10.1080/23288604.2017.1405770","DOIUrl":"https://doi.org/10.1080/23288604.2017.1405770","url":null,"abstract":"Abstract Breast cancer is the most frequent type of cancer in women and the second leading cause of cancer death after lung cancer in more developed countries and the leading cause of death in developing countries. The aim of this study was to analyze the association between three sets of variables and the utilization of breast cancer screening among women attending primary health care centers participating in the Primary Care Access and Quality Improvement Program in Brazil. A survey of 65,391 women was conducted across Brazil in 2012. The primary outcomes were percentage of women who never had a clinical breast examination and percentage of women who never had a mammography. Crude and adjusted analyses performed using Poisson regression assessed the association of these outcomes with service organization variables, as well as with socioeconomic and demographic variables. Results showed that 37.7% of women never had a clinical breast examination and 30.3% never had a mammography. Never having had both screening procedures decreased as the Human Development Index increased. Never having had a clinical breast examination increased with increasing population size and increasing municipal family health strategy coverage. The proportion of women never having had a clinical breast examination was highest in the northern region. White women and those who had a partner had greater utilization of screening. Women who had paid work and lived in families with higher per capita income had greater utilization of clinical breast examination. The proportion of women who never had a mammography was highest for women living in households with six or more people and receiving the Bolsa Família benefit. Women with lower per capita family income had higher utilization of mammography. Appropriate structures and work processes were associated with greater utilization of mammography. Investments in primary health care structure and teamworking processes are essential to improve the utilization of screening, prevention, and early diagnosis of breast cancer in Brazil.","PeriodicalId":46168,"journal":{"name":"Health Systems & Reform","volume":"194 1","pages":"42 - 55"},"PeriodicalIF":4.1,"publicationDate":"2018-01-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79759900","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2018-01-02DOI: 10.1080/23288604.2017.1395503
Hélène Barroy, Joseph Kutzin, A. Tandon, C. Kurowski, G. Lie, M. Borowitz, Susan P Sparkes, E. Dale
Abstract—Initially defined for overall public purposes, the concept of fiscal space was subsequently developed and adapted for the health sector. In this context, it has been applied in research and policy in over 50 low- and middle-income countries over the past ten years. Building on this vast experience and against the backdrop of shifts in the global health financing landscape in the Sustainable Development Goals (SDG) era, the commentary highlights key lessons and challenges in the approach to assessing potential fiscal space for health. In looking forward, the authors recommend that future fiscal space for health analyses primarily focus on domestic sources, with specific attention to potential expansion from the improved use and performance of public resources. Embedding assessments in national health planning and budgeting processes, with due consideration of the political economy dynamics, will provide a way to inform and impact allocative decisions more effectively.
{"title":"Assessing Fiscal Space for Health in the SDG Era: A Different Story","authors":"Hélène Barroy, Joseph Kutzin, A. Tandon, C. Kurowski, G. Lie, M. Borowitz, Susan P Sparkes, E. Dale","doi":"10.1080/23288604.2017.1395503","DOIUrl":"https://doi.org/10.1080/23288604.2017.1395503","url":null,"abstract":"Abstract—Initially defined for overall public purposes, the concept of fiscal space was subsequently developed and adapted for the health sector. In this context, it has been applied in research and policy in over 50 low- and middle-income countries over the past ten years. Building on this vast experience and against the backdrop of shifts in the global health financing landscape in the Sustainable Development Goals (SDG) era, the commentary highlights key lessons and challenges in the approach to assessing potential fiscal space for health. In looking forward, the authors recommend that future fiscal space for health analyses primarily focus on domestic sources, with specific attention to potential expansion from the improved use and performance of public resources. Embedding assessments in national health planning and budgeting processes, with due consideration of the political economy dynamics, will provide a way to inform and impact allocative decisions more effectively.","PeriodicalId":46168,"journal":{"name":"Health Systems & Reform","volume":"33 1","pages":"4 - 7"},"PeriodicalIF":4.1,"publicationDate":"2018-01-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"84983869","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2018-01-02DOI: 10.1080/23288604.2017.1409858
M. Reich
Reference Welcome to the first issue in 2018 of Health Systems & Reform, marking the start of our fourth year of publication. The topic of how to improve the performance of health systems in countries around the world remains high on the global policy agenda. The global meeting of the UHC Forum 2017 in Tokyo, in mid-December last year, illustrates the continuing high priority given to health systems issues. The articles published in this issue continue our efforts to identify critical topics for health systems and reform. First, the commentary on “fiscal space analysis” represents a hot topic in global health policy—the article was cited by Japan’s Minister of Finance Taro Aso in his Lancet article published just before the UHC Forum. The four research articles in this issue explore themes of deliberative democracy and prioritysetting at the community level in rural Arkansas, using burden of disease analysis and cost-effectiveness to decide on national health priorities in the Philippines, assessing the distributional cost-effectiveness and political feasibility of a tobacco tax in Armenia, and the implementation of breast cancer screening in Brazil’s primary health care centers. These articles reflect Health Systems & Reform’s commitment to research that examines the interaction of technical, ethical, and political analyses in health reform processes around the world. Following are my reflections on the articles. The commentary by H el ene Barroy and colleagues on “Assessing Fiscal Space for Health in the SDG Era: A Different Story” is notable for several reasons. First, the authors come from three key agencies in global health financing— the World Health Organization, the World Bank, and the Global Fund to Fight AIDS, Tuberculosis and Malaria—and the article received approval from all three institutions; no mean feat. Second, the article uses the World Bank’s framework on the five sources of fiscal space for health (“conducive macroeconomic conditions; reprioritization of health within the government budget; earmarked income and consumption taxes directed toward the health sector; better efficiency of existing health expenditure; and external aid”) to reflect on the lessons of doing such assessments in over 50 lowand middle-income countries. Perhaps not surprising, the authors found “high variability” in how the assessments Received 22 November 2017; accepted 22 November 2017. *Correspondence to: Michael R. Reich; Email: michael_reich@harvard.edu
欢迎阅读《卫生系统与改革》2018年第一期，这标志着我们出版的第四个年头的开始。如何改善世界各国卫生系统绩效的主题仍然是全球政策议程上的重要议题。去年12月中旬在东京举行的2017年全民健康覆盖论坛全球会议表明，卫生系统问题继续受到高度重视。本期发表的文章继续我们确定卫生系统和改革的关键主题的努力。首先，关于“财政空间分析”的评论是全球卫生政策中的一个热门话题——就在全民健康覆盖论坛召开之前，日本财务大臣麻生太郎在《柳叶刀》杂志上发表的一篇文章引用了这篇文章。本期的四篇研究文章探讨了以下主题:阿肯色州农村社区层面的协商民主和优先事项设定;菲律宾利用疾病负担分析和成本效益来决定国家卫生优先事项;亚美尼亚评估烟草税的分配成本效益和政治可行性;巴西初级卫生保健中心实施乳腺癌筛查。这些文章反映了《卫生系统与改革》致力于研究世界各地卫生改革进程中技术、伦理和政治分析的相互作用。以下是我对这些文章的感想。el ene Barroy及其同事关于“评估可持续发展目标时代的卫生财政空间:一个不同的故事”的评论值得注意，原因如下。首先，作者来自全球卫生融资的三个关键机构——世界卫生组织、世界银行和全球抗击艾滋病、结核病和疟疾基金——这篇文章得到了这三个机构的批准;绝非易事。其次，文章使用了世界银行关于卫生财政空间的五个来源的框架(“有利的宏观经济条件;在政府预算中重新确定卫生的优先次序;指定用于卫生部门的所得税和消费税;提高现有卫生支出的效率;以及外部援助”)，以反思在50多个低收入和中等收入国家进行此类评估的经验教训。也许不足为奇的是，作者发现评估结果的“高度可变性”。于2017年11月22日接受。通信:Michael R. Reich;电子邮件:michael_reich@harvard.edu
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