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We cover any subject you have. Set the deadline and keep calm. Receive your papers on time. Modernization, cultural change and democracy: the human hospital and primary care? Responsiveness, patient-centredness and prescribing development sequence. Cambridge, Cambridge University Press, Kickbush I. Innovation in health policy: responding to the health society.
Gaceta Health, , — Allen J et al. Ljubljana, Anand S. The concern for equity in health. Health, , — Road map for a health justice majority. Oakland, CA, American Environics, Gostin LO. Public health law in a new century. Welzel I. A human development view on value change trends — World Ottawa Charter for Health Promotion. First International Conference on World values surveys database.
Health Promotion, Ottawa, 17—21 November Geneva, Department of Human worldvaluessurvey. A global look at public perceptions of health problems, priorities and donors: the www. Kickbusch I. The contribution of the World Health Organization to a new public www. American Journal of Public Health, , Blumenthal D, Hsiao W.
Privatization and its discontents — the evolving Chinese Globalization and perceptions of social inequality. International Labour Blank RH. The price of life: the future of American health care. New York, Colombia Review, , Taylor, B, Thomson, K. Understanding change in social attitudes.
Aldershot, England, Weissert C, Weissert W. Governing health: the politics of health policy. Baltimore MD, Dartmouth Publishing, Johns Hopkins University Press, Gajdos T, Lhommeau B. Millenson ML. How the US news media made patient safety a priority. BMJ, Davies H. Falling public trust in health services: Implications for accountability.
Halman L et al. Changing values and beliefs in 85 countries. Leiden and Boston, Brill, European values studies Gilson L. Trust and the development of health care as a social institution. Science and Medicine, , — De Maeseneer J et al. Primary health care as a strategy for achieving equitable care: Nutley S, Smith PC.
League tables for performance improvement in health care. Health consumer groups and the national policy Increasing socio-economic inequalities process. Health Economics, , of health care, London, Routledge, Rao H. Marmot M. Achieving health equity: from root causes to fair outcomes. Lancet, organizations. American Journal of Sociology, , — Larkin M. Public health watchdog embraces the web. Lancet, , Health care: the stories we tell. Framing review.
Oakland CA, American Environics, — Lee K. Globalisation and the need for a strong public health response. The European Garland M, Oliver J. Oregon health values survey Decisions, McKee M, Figueras J. Set ting priorities: can Britain learn from Sweden? British Mullan F, Frehywot S. Non-physician clinicians in 47 sub-Saharan African countries. Medical Journal, , — Daniels N. Accountability for reasonableness. Establishing a fair process for priority Lancet, , setting is easier than agreeing on principles.
BMJ, , — Martin D. Fairness, accountability for reasonableness, and the views of priority Lehmann U, Sanders D. Community health workers: what do we know about them? The state of the evidence on programmes, activities, costs and impact on health outcomes of using community health workers. These root causes have to be tackled through intersectoral and cross-government action. The basis Chapter 2 The central place of for this is the set of reforms that health equity in PHC 24 aim at moving towards universal Moving towards universal coverage 25 coverage, i.
Deeply life in rural Canada prompted Matthew Anderson unequal opportunities for health combined with — to launch a tax-based health insur- endemic inequalities in health care provision ance scheme that eventually led to countrywide lead to pervasive inequities in health outcomes 3.
Unfortunately, equally shocking lose-lose is causing increasing intolerance of the whole situations abound today across the world. More spectrum of unnecessary, avoidable and unfair than 30 years after the clarion call of Alma-Ata differences in health4. They stem from inequitable method for fi nancing health-care ser- social stratification and political inequalities vices: out-of-pocket payments by the sick or their that lie outside the boundaries of the health sys- families at the point of service.
For 5. Income and social status matter, as do the people in low- and middle-income countries, over neighbourhoods where people live, their employ- half of all health-care expenditure is through out- ment conditions and factors, such as personal of-pocket payments. This deprives many families behaviour, race and stress 5. Health inequities of needed care because they cannot afford it.
Also, also fi nd their roots in the way health systems more than million people around the world exclude people, such as inequities in availability, are pushed into poverty each year because of access, quality and burden of payment, and even catastrophic health-care expenditures 2. There is in the way clinical practice is conducted6.
Left to a wealth of evidence demonstrating that fi nancial their own devices, health systems do not move protection is better, and catastrophic expenditure towards greater equity.
Most health services — less frequent, in those countries in which there hospitals in particular, but also fi rst-level care is more pre-payment for health care and less — are consistently inequitable providing more out-of-pocket payment.
Conversely, catastrophic and higher quality services to the well-off than expenditure is more frequent when health care to the poor, who are in greater need7,8,9, Dif- has to be paid for out-of-pocket at the point of ferences in vulnerability and exposure combine service Figure 2. These 5 interventions reach well beyond the traditional realm of health-service policies, relying on the mobilization of stakeholders and constituencies outside the health sector They include 0 Q reduction of social stratification, e.
Advancing and sustaining universal coverage adequate pay, using labour intensive growth the same: pooling pre-paid contributions col- strategies, promoting equal opportunities for lected on the basis of ability to pay, and using women and making free education available, these funds to ensure that services are available, etc.
Universal cover- developing social networks at community level, age is not, by itself, sufficient to ensure health introducing social inclusion policies and poli- for all and health equity — inequalities persist in cies that protect mothers while working or countries with universal or near-universal cover- studying, offering cash benefits or transfers, age — but it provides the necessary foundation 9.
Indeed, in countries against exposure to health hazards, e. As with from unfair dismissal from their jobs. There is now wide- which they have little influence. Yet, they do spread consensus that providing such coverage is have a responsibility to address health inequal- simply part of the package of core obligations that ity. In itself, this is a political achievement exacerbate or mitigate health inequalities and that shapes the modernization of society.
The question, therefore, is not the 20th century. The opportunity now exists for if, but how health leaders can more effectively low- and middle-income countries to implement pursue strategies that will build greater equity comparable approaches. Costa Rica, Mexico, in the provision of health services.
Other countries are weighing sim- coverage: universal access to the full range of ilar options The technical challenge of moving personal and non-personal health services they towards universal coverage is to expand coverage need, with social health protection. Whether the in three ways Figure 2. Public expenditure The third dimension, the height of coverage, Extend to uninsured on health i. Expanding the breadth of coverage context of disengagement of the state and dwin- is a complex process of progressive expansion dling public resources for health.
Most undertook and merging of coverage models Box 2. Dur- these measures without anticipating the extent ing this process, care must be taken to ensure of the damage they would do. In many settings, safety nets for the poorest and most vulnerable dramatic declines in service use ensued, par- until they also are covered.
It may take years to ticularly among vulnerable groups 20, while the cover the entire population but, as recent experi- frequency of catastrophic expenditure increased.
Particularly in these countries, however, it is crucial to move towards pre-payment systems from a very early stage and to resist the temptation to rely on user fees. Coordinate funding sources. In order to organize universal coverage, it is necessary to consider all sources of funding in a country: public, private, external and domestic. In low-income countries, it is particularly important that international funding be channelled through nascent pre-payment and pooling schemes and institutions rather than through project or programme funding.
Routing funds in this way has two purposes. Combine schemes to build towards full coverage. Many countries with limited resources and administrative capacity have experi- mented with a multitude of voluntary insurance schemes: community, cooperative, employer-based and other private schemes, as a way to foster pre-payment and pooling in preparation for the move towards more comprehensive national systems Such schemes are no substitute for universal coverage although they can become building blocks of the universal system Realizing universal coverage means coordinating or combining these schemes progressively into a coherent whole that ensures coverage to all population groups15 and builds bridges with broader social protection programmes Advancing and sustaining universal coverage Box 2.
This has been one of the key strategies in improving the effectiveness of health systems and the equitable distribution of resources. It is supposed to make priority setting, rationing of care, and trade-offs between breadth and depth of coverage explicit.
In most cases, their scope has been limited to maternal and child health care, and to health problems considered as global health priorities. Q It should specify what should be provided at primary and secondary levels. Q The implementation of the package should be costed so that political decision-makers are aware of what will not be included if health care remains under-funded. This has resulted risk that people will incur catastrophic expenses in substantial increases in the use of services, when they are sick.
Finally, it provides the means especially by the poor In Uganda, for example, to re-invest in the availability, range and quality service use increased suddenly and dramatically of services. Challenges in moving Pre-payment and pooling institutionalizes solidarity between the rich and the less well-off, towards universal coverage All universal coverage reforms have to fi nd com- and between the healthy and the sick. It lifts bar- promises between the speed with which they riers to the uptake of services and reduces the increase coverage and the breadth, depth and height of coverage.
However, the way countries devise their strategies and focus their reforms Figure 2. In some countries, a very large part of the pop- 30 ulation lives in extremely deprived areas, with an absent or dysfunctional health-care infra- 20 structure. Ensuring access to quality care in these vices are grossly inadequate or fragmented, the settings entails grappling with the diseconomies basic health-care infrastructure needs to be built of scale connected with small, scattered popula- or rebuilt, often from the ground up.
These areas tions; logistical constraints on referral; difficulties are always severely resource-constrained and linked to limited infrastructure and communica- frequently affected by confl icts or complex emer- tions capacities; and, in some cases, more specific gencies, while the scale of under-servicing, also technical complications, such as maintaining in other sectors, engenders logistical difficulties patient records for nomadic groups. A different challenge is extending coverage in Health planners in these settings face a funda- settings where inequalities do not result from the mental strategic dilemma: whether to prioritize a lack of available health infrastructure, but from massive scale-up of a limited set of interventions the way health care is organized, regulated and, to the entire population or a progressive roll-out above all, paid for by official or under-the-counter of more comprehensive primary-care systems on user charges.
These are situations where under- a district-by-district basis. Such pat- number of priority programmes is rolled out terns of exclusion occur in countries such as simultaneously to all the inhabitants in the Colombia, Nicaragua and Turkey Figure 2.
It deprived areas. This allows for task shifting to is particularly striking in the many urban areas low-skilled personnel, lay workers and volunteers of low- and middle-income countries where a and, consequently, rapid extension of coverage. It is still central to what the global community Figure 2. Births attended by medically est countries 28, and quite a number of countries trained personnel percentage , by income group27 have chosen this option over the last 30 years. Nevertheless, skill limitations reinforce 20 the focus on a limited number of effective but simple interventions.
Scaling up a limited number of interventions 0 Quintille 1 Quintille 2 Quintille 3 Quintille 4 Quintille 5 has the advantage of rapidly covering the entire lowest highest population and focusing resources on what is known to be cost effective. Advancing and sustaining universal coverage when people experience health problems, they want them to be dealt with, whether or not they Box 2.
They offer tion as a long-term investment, allocation of resources to rural and patients an appealing alternative, but one that is under-privileged areas, and prioritizing ambulatory care over hospitaliza- tion.
A network of district teams to manage and oversee almost often exploitative and harmful. Compared with village-based rural health centres was established. These centres are a situation of utter lack of health action, there staffed by a team that includes a general practitioner, midwife, nurse and is an indisputable benefit in scaling up even a several health technicians. In remote rural areas, these health houses are staffed by Behvarz it an attractive option. However, upgrading often multi-purpose health workers who are selected by the community, proves more difficult than initially envisaged 30 receive between 12 and 18 months training and are then recruited by and, in the meantime, valuable time, resources the Government.
The district teams provide training based on problem- and credibility are lost which might have allowed solving, as well as ongoing supervision and support. Over the years, the PHC network has grown infrastructure. Rural health service support. Such a response obviously includes the utilization rates are now the same as in urban areas. The progressive priority interventions, but integrated in a com- roll-out of this system has helped to reduce the urban-rural gap in child mortality Figure 2.
The extension platform is the primary-care centre: a profession- Figure 2. The limiting factors for a progressive roll-out 0 of primary-care networks are the lack of a sta- ble cadre of mid-level staff with the leadership qualities to organize health districts and with the ability to maintain, over the years, the constant adequately, a blend of response to need and effort required to build sustainable results for the demand, and participation of the population and entire population.
Where the roll-out has been key actors has made it possible to build robust conducted as an administrative exercise, it has primary-care networks, even in very difficult and led to disappointment: many health districts exist resource-constrained settings of confl ict, and in name only. But where impatience and pres- post-confl ict environments Box 2.
However, of external health funding, in addition to popula- for all the convergence, trying to balance speed tion size. Supplements are paid to districts with and sustainability is a real political dilemma In Chile, budgets are allocated on a choice, people willingly opt for progressive roll- capitation basis but, as part of the PHC reforms, out, making community health centres — whose these were adjusted using municipal human infrastructure is owned and personnel employed development indices and a factor to reflect the by the local community — the basis of functional isolation of underserved areas.
Quality and sustainabil- persed populations is often a daunting logisti- ity are important, particularly since nowadays cal challenge, some countries have dealt with the multitude of varied and dynamic governmen- it by developing creative approaches.
Devising tal, not-for-profit and for-profit private providers mechanisms to share innovative experiences and of various kinds are in dire need of alignment. Nevertheless, there is curative health-care services, but also reinforcing no getting away from the need for massive and promotive strategies and cross-sectoral action on sustained investment to expand and maintain the determinants of health and health equity.
The fi rst concerns Extending health-care networks to under- collaboration in organizing infrastructure that served areas depends on public initiative and maximizes scales of efficiency.
An isolated com- incentives. One way to accelerate the extension munity may be unable to afford key inputs to of coverage is to adjust budget allocation for- expand coverage, which includes infrastructure, mulae or contract specifications to reflect the technologies and human resources particularly extra efforts required to contact hard-to-reach the training of personnel. However, when com- populations. Several countries have taken steps in munities join forces, they can secure such inputs this direction.
In January , for example, the at manageable costs Depending on the setting, this five mortality as a proxy for disease burden and strategic focus may include transportation, radio poverty level, while adjusting for the differential communications, and other information and com- costs of providing health services in rural and munications technologies.
It has a health centres and the district hospital took care of more than network of health centres, a referral hospital and a district man- 1 disease episodes in 20 years, immunized more than agement team where community participation has been fostered infants, provided midwifery care to 70 women and for years through local committees. Rutshuru has experienced carried out 8 surgical procedures.
This shows that, even in severe stress over the years, testing the robustness of the district disastrous circumstances, a robust district health system can health system. Over the last 30 years, the economy of the country has gone These results were achieved with modest means.
Out-of-pocket into a sharp decline. This was compounded by an interruption of over- ally nil during most of these 20 years. The continuity of the work seas development aid in the early s. This complex of disasters severely affected the and maintain a critical mass of dedicated human resources, and working conditions of health professionals and access to health limited but constant nongovernmental support, which provided a services for the people living in the district.
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