Economic crisis and counter-reform of universal health care systems: Spanish case

The economic crisis that has been affecting Europe in the 21st century has modified social protection systems in the countries that adopted, in the 20th century, universal health care system models, such as Spain. This communication presents some recent transformations, which were caused by changes in Spanish law. Those changes relate to the access to health care services, mainly in regards to the provision of care to foreigners, to financial contribution from users for health care services, and to pharmaceutical assistance. In crisis situations, reforms are observed to follow a trend which restricts rights and deepens social inequalities.

Surveillance of mother-to-child HIV transmission: socioeconomic and health care coverage indicators

OBJECTIVE: To identify clustering areas of infants exposed to HIV during pregnancy and their association with indicators of primary care coverage and socioeconomic condition. METHODS: Ecological study where the unit of analysis was primary care coverage areas in the city of Porto Alegre, Southern Brazil, in 2003. Geographical Information System and spatial analysis tools were used to describe indicators of primary care coverage areas and socioeconomic condition, and estimate the prevalence of liveborn infants exposed to HIV during pregnancy and delivery. Data was obtained from Brazilian national databases. The association between different indicators was assessed using Spearman's nonparametric test. RESULTS: There was found an association between HIV infection and high birth rates (r=0.22, p<0.01) and lack of prenatal care (r=0.15, p<0.05). The highest HIV infection rates were seen in areas with poor socioeconomic conditions and difficult access to health services (r=0.28, p<0.01). The association found between higher rate of prenatal care among HIV-infected women and adequate immunization coverage (r=0.35, p<0.01) indicates that early detection of HIV infection is effective in those areas with better primary care services. CONCLUSIONS: Urban poverty is a strong determinant of mother-to-child HIV transmission but this trend can be fought with health surveillance at the primary care level.

Probabilistic linkage in household survey on hospital care usage

OBJECTIVE: To evaluate the potential advantages and limitations of the use of the Brazilian hospital admission authorization forms database and the probabilistic record linkage methodology for the validation of reported utilization of hospital care services in household surveys. METHODS: A total of 2,288 households interviews were conducted in the county of Duque de Caxias, Brazil. Information on the occurrence of at least one hospital admission in the year preceding the interview was obtained from a total of 10,733 household members. The 130 records of household members who reported at least one hospital admission in a public hospital were linked to a hospital database with 801,587 records, using an automatic probabilistic approach combined with an extensive clerical review. RESULTS: Seventy-four (57%) of the 130 household members were identified in the hospital database. Yet only 60 subjects (46%) showed a record of hospitalization in the hospital database in the study period. Hospital admissions due to a surgery procedure were significantly more likely to have been identified in the hospital database. The low level of concordance seen in the study can be explained by the following factors: errors in the linkage process; a telescoping effect; and an incomplete record in the hospital database. CONCLUSIONS: The use of hospital administrative databases and probabilistic linkage methodology may represent a methodological alternative for the validation of reported utilization of health care services, but some strategies should be employed in order to minimize the problems related to the use of this methodology in non-ideal conditions. Ideally, a single identifier, such as a personal health insurance number, and the universal coverage of the database would be desirable.

Barriers for HIV testing during pregnancy in Southern Brazil

OBJECTIVE: To assess HIV testing rate and determine risk factors for not have been tested during pregnancy. METHODS: A cross-sectional study was carried out in Porto Alegre, Southern Brazil, from December 2000 to February 2001. Socioeconomic, maternal and healthcare variables were obtained by means of a standardized questionnaire. Crude and adjusted odds ratios and their 95% confidence intervals were obtained in logistic regression models. RESULTS: A total of 1,642 mothers were interviewed. Of them, 94.3% reported being offered HIV testing before or during pregnancy or during labor; 89 mothers (5.4%) were not tested or did not know if they were tested. Attending fewer than six prenatal visits, being single and younger than 18 years old were relevant barriers preventing HIV testing. There was found a relationship between maternal schooling and the category of prenatal care provider. Having low 22.20 (12.43-39.67) or high 3.38 (1.86-7.68). schooling and being cared in the private sector strongly reduced the likelihood of being HIV tested. CONCLUSIONS: The Brazilian Health Ministry's recommendation for universal counseling and HIV testing has been successfully implemented in the public sector. In order to improve HIV testing coverage, new strategies need to target women cared in the private sector especially those of low schooling.

Oral health in the family health strategy: a change of practices or semantics diversionism

OBJECTIVE:To evaluate public health dentistry practices of two different family health models. METHODS: Qualitative study conducted with data obtained from focus groups consisting of 58 dentists working in the Family Health Strategy for at least three years between August-October, 2006. The Paideia Family Health Approach was used in the city of Campinas and the Oral Health Initiative as part of the Family Health Strategy was implemented in the city of Curitiba, Southeastern and Southern Brazil, respectively. Data was analyzed using the hermeneutic-dialectic method. Analysis indicators were employed to indicate backwardness, stagnation or progress in oral health practices effective from the implementation of the strategies referred. The indicators used were: work process; interdisciplinary approach; territorialization; capacity building of human resources; health promotion practices; and responsiveness to users' demands. RESULTS: There was progress in user access to services, humanization of health care, patient welcoming and patient-provider relationship. The results related to health promotion practices, territorialization, interdisciplinary approach and resource capacity building indicated a need for technical and operational enhancements in both cities. CONCLUSIONS: Both models have brought about important advances in terms of increased access to services and humanization of health care. Universal access to oral health at all levels of complexity was not achieved in both cities studied. Local health managers and oral health program coordinators must bring more weight to bear in the arena that defines public policy priorities.

Socioeconomic inequities in the health and nutrition of children in low/middle income countries

OBJECTIVE: To describe the effects of social inequities on the health and nutrition of children in low and middle income countries. METHODS: We reviewed existing data on socioeconomic disparities within-countries relative to the use of services, nutritional status, morbidity, and mortality. A conceptual framework including five major hierarchical categories affecting inequities was adopted: socioeconomic context and position, differential exposure, differential vulnerability, differential health outcomes, and differential consequences. The search of the PubMed database since 1990 identified 244 articles related to the theme. Results were also analyzed from almost 100 recent national surveys, including Demographic Health Surveys and the UNICEF Multiple Indicator Cluster Surveys. RESULTS: Children from poor families are more likely, relative to those from better-off families, to be exposed to pathogenic agents; once they are exposed, they are more likely to become ill because of their lower resistance and lower coverage with preventive interventions. Once they become ill, they are less likely to have access to health services and the quality of these services is likely to be lower, with less access to life-saving treatments. As a consequence, children from poor family have higher mortality rates and are more likely to be undernourished. CONCLUSIONS: Except for child obesity and inadequate breastfeeding practices, all the other adverse conditions analyzed were more prevalent in children from less well-off families. Careful documentation of the multiple levels of determination of socioeconomic inequities in child health is essential for understanding the nature of this problem and for establishing interventions that can reduce these differences.

Patterns of deliveries in a Brazilian birth cohort: almost universal cesarean sections for the better-off

OBJECTIVE: To describe the patterns of deliveries in a birth cohort and to compare vaginal and cesarean section deliveries. METHODS: All children born to mothers from the urban area of Pelotas, Brazil, in 2004, were recruited for a birth cohort study. Mothers were contacted and interviewed during their hospital stay when extensive information on the gestation, the birth and the newborn, along with maternal health history and family characteristics was collected. Maternal characteristics and childbirth care financing - either private or public healthcare (SUS) patients - were the main factors investigated along with a description of C-sections distribution according to day of the week and delivery time. Standard descriptive techniques, Χ² tests for comparing proportions and Poisson regression to explore the independent effect of C-section predictors were the methods used. RESULTS: The overall C-section rate was 45%, 36% among SUS and 81% among private patients, where 35% of C-sections were reported elective. C-sections were more frequent on Tuesdays and Wednesdays, reducing by about a third on Sundays, while normal deliveries had a uniform distribution along the week. Delivery time for C-sections was markedly different among public and private patients. Maternal schooling was positively associated with C-section among SUS patients, but not among private patients. CONCLUSIONS: C-sections were almost universal among the wealthier mothers, and strongly related to maternal education among SUS patients. The patterns we describe are compatible with the idea that C-sections are largely done to suit the doctor's schedule. Drastic action is called for to change the current situation.

Social protection systems in vulnerable families: their importance for the public health

OBJECTIVE To analyze the effectiveness of the Chilean System of Childhood Welfare in transferring benefits to socially vulnerable families. METHODS A cross-sectional study with a sample of 132 families from the Metropolitan Region, Chile, stratified according to degree of social vulnerability, between September 2011 and January 2012. Semi-structured interviews were conducted with mothers of the studied families in public health facilities or their households. The variables studied were family structure, psychosocial risk in the family context and integrated benefits from the welfare system in families that fulfill the necessary requirements for transfer of benefits. Descriptive statistics to measure location and dispersion were calculated. A binary logistic regression, which accounts for the sample size of the study, was carried out. RESULTS The groups were homogenous regarding family size, the presence of biological father in the household, the number of relatives living in the same dwelling, income generation capacity and the rate of dependency and psychosocial risk (p ≥ 0.05). The transfer of benefits was low in all three groups of the sample (≤ 23.0%). The benefit with the best coverage in the system was the Single Family Subsidy, whose transfer was associated with the size of the family, the presence of relatives in the dwelling, the absence of the father in the household, a high rate of dependency and a high income generation capacity (p ≤ 0.10). CONCLUSIONS The effectiveness of benefit transfer was poor, especially in families that were extremely socially vulnerable. Further explanatory studies of benefit transfers to the vulnerable population, of differing intensity and duration, are required in order to reduce health disparities and inequalities.

Regional governance: strategies and disputes in health region management

OBJECTIVE To analyze the regional governance of the health systemin relation to management strategies and disputes.METHODOLOGICAL PROCEDURES A qualitative study with health managers from 19 municipalities in the health region of Bahia, Northeastern Brazil. Data were drawn from 17 semi-structured interviews of state, regional, and municipal health policymakers and managers; a focus group; observations of the regional interagency committee; and documents in 2012. The political-institutional and the organizational components were analyzed in the light of dialectical hermeneutics.RESULTS The regional interagency committee is the chief regional governance strategy/component and functions as a strategic tool for strengthening governance. It brings together a diversity of members responsible for decision making in the healthcare territories, who need to negotiate the allocation of funding and the distribution of facilities for common use in the region. The high turnover of health secretaries, their lack of autonomy from the local executive decisions, inadequate technical training to exercise their function, and the influence of party politics on decision making stand as obstacles to the regional interagency committee’s permeability to social demands. Funding is insufficient to enable the fulfillment of the officially integrated agreed-upon program or to boost public supply by the system, requiring that public managers procure services from the private market at values higher than the national health service price schedule (Brazilian Unified Health System Table). The study determined that “facilitators” under contract to health departments accelerated access to specialized (diagnostic, therapeutic and/or surgical) services in other municipalities by direct payment to physicians for procedure costs already covered by the Brazilian Unified Health System.CONCLUSIONS The characteristics identified a regionalized system with a conflictive pattern of governance and intermediate institutionalism. The regional interagency committee’s managerial routine needs to incorporate more democratic devices for connecting with educational institutions, devices that are more permeable to social demands relating to regional policy making.

Factors associated with vaccination coverage in children < 5 years in Angola

OBJECTIVE To analyze vaccination coverage and factors associated with a complete immunization scheme in children < 5 years old. METHODS This cross-sectional household census survey evaluated 1,209 children < 5 years old living in Bom Jesus, Angola, in 2010. Data were obtained from interviews, questionnaires, child immunization histories, and maternal health histories. The statistical analysis used generalized linear models, in which the dependent variable followed a binary distribution (vaccinated, unvaccinated) and the association function was logarithmic and had the children’s individual, familial, and socioeconomic factors as independent variables. RESULTS Vaccination coverage was 37.0%, higher in children < 1 year (55.0%) and heterogeneous across neighborhoods; 52.0% of children of both sexes had no immunization records. The prevalence rate of vaccination significantly varied according to child age, mother’s level of education, family size, ownership of household appliances, and destination of domestic waste. CONCLUSIONS Vulnerable groups with vaccination coverage below recommended levels continue to be present. Some factors indicate inequalities that represent barriers to full immunization, indicating the need to implement more equitable policies. The knowledge of these factors contributes to planning immunization promotion measures that focus on the most vulnerable groups.

Cervical cancer screening coverage in a high-incidence region

OBJECTIVE To analyze the coverage of a cervical cancer screening program in a city with a high incidence of the disease in addition to the factors associated with non-adherence to the current preventive program.METHODS A cross-sectional study based on household surveys was conducted. The sample was composed of women between 25 and 59 years of age of the city of Boa Vista, RR, Northern Brazil who were covered by the cervical cancer screening program. The cluster sampling method was used. The dependent variable was participation in a women’s health program, defined as undergoing at least one Pap smear in the 36 months prior to the interview; the explanatory variables were extracted from individual data. A generalized linear model was used.RESULTS 603 women were analyzed, with an mean age of 38.2 years (SD = 10.2). Five hundred and seventeen women underwent the screening test, and the prevalence of adherence in the last three years was up to 85.7% (95%CI 82.5;88.5). A high per capita household income and recent medical consultation were associated with the lower rate of not being tested in multivariate analysis. Disease ignorance, causes, and prevention methods were correlated with chances of non-adherence to the screening system; 20.0% of the women were reported to have undergone opportunistic and non-routine screening.CONCLUSIONS The informed level of coverage is high, exceeding the level recommended for the control of cervical cancer. The preventive program appears to be opportunistic in nature, particularly for the most vulnerable women (with low income and little information on the disease). Studies on the diagnostic quality of cervicovaginal cytology and therapeutic schedules for positive cases are necessary for understanding the barriers to the control of cervical cancer.

Lack of access and continuity of adult health care: a national population-based survey

OBJECTIVE To describe the lack of access and continuity of health care in adults.METHODS A cross-sectional population-based study was performed on a sample of 12,402 adults aged 20 to 59 years in urban areas of 100 municipalities of 23 states in the five Brazilian geopolitical regions. Barriers to the access and continuity of health care and were investigated based on receiving, needing and seeking health care (hospitalization and accident/emergency care in the last 12 months; care provided by a doctor, by other health professional or home care in the last three months). Based on the results obtained by the description of the sample, a projection is provided for adults living in Brazilian urban areas.RESULTS The highest prevalence of lack of access to health services and to provision of care by health professionals was for hospitalization (3.0%), whilst the lowest prevalence was for care provided by a doctor (1.1%). The lack of access to care provided by other health professionals was 2.0%; to accident and emergency services, 2.1%; and to home care, 2.9%. As for prevalences, the greatest absolute lack of access occurred in emergency care (more than 360,000 adults). The main reasons were structural and organizational problems, such as unavailability of hospital beds, of health professionals, of appointments for the type of care needed and charges made for care.CONCLUSIONS The universal right to health care in Brazil has not yet been achieved. These projections can help health care management in scaling the efforts needed to overcome this problem, such as expanding the infrastructure of health services and the workforce.

Serological findings during a measles outbreak occurring in a population with vaccine coverage

From March 1991 to April 1992, serum samples for IgM detection were collected from 112 clinical measles cases reported to the Health Department of Niterói, State of Rio de Janeiro. The positivity exceeded 90% for specimens collected from the 5th to the 29th day after the onset of the disease. After day 30 a decline in IgM detection was observed, although positivity has been detected up to 90 days after the onset of the symptoms. Forty-four patients (48.9%) with an IgM response had a history of prior measles vaccination. In 5 of the 22 measles-IgM negative cases the infection was due to other agents (rubella: 4 cases, dengue: 1 case). These results show that sensitivity of the test employed for confirming suspected measles cases is high, even in vaccinated patients.

Health problems awareness during travel among faculty members of a large university in Latin America: preliminary report

Health safety during trips is based on previous counseling, vaccination and prevention of infections, previous diseases or specific problems related to the destination. Our aim was to assess two aspects, incidence of health problems related to travel and the traveler's awareness of health safety. To this end we phone-interviewed faculty members of a large public University, randomly selected from humanities, engineering and health schools. Out of 520 attempts, we were able to contact 67 (12.9%) and 46 (68.6%) agreed to participate in the study. There was a large male proportion (37/44, 84.1%), mature adults mostly in their forties and fifties (32/44, 72.7%), all of them with higher education, as you would expect of faculty members. Most described themselves as being sedentary or as taking occasional exercise, with only 15.9% (7/44) taking regular exercise. Preexisting diseases were reported by 15 travelers. Most trips lasted usually one week or less. Duration of the travel was related to the destination, with (12h) or longer trips being taken by 68.2% (30/44) of travelers, and the others taking shorter (3h) domestic trips. Most travelling was made by air (41/44) and only 31.8% (14/44) of the trips were motivated by leisure. Field research trips were not reported. Specific health counseling previous to travel was reported only by two (4.5%). Twenty seven of them (61.4%) reported updated immunization, but 11/30 reported unchecked immunizations. 30% (9/30) reported travel without any health insurance coverage. As a whole group, 6 (13.6%) travelers reported at least one health problem attributed to the trip. All of them were males travelling abroad. Five presented respiratory infections, such as influenza and common cold, one neurological, one orthopedic, one social and one hypertension. There were no gender differences regarding age groups, destination, type of transport, previous health counseling, leisure travel motivation or pre-existing diseases. Interestingly, the two cases of previous health counseling were made by domestic travelers. Our data clearly shows that despite a significant number of travel related health problems, these highly educated faculty members, had a low awareness of those risks, and a significant number of travels are made without prior counseling or health insurance. A counseling program conducted by a tourism and health professional must be implemented for faculty members in order to increase the awareness of travel related health problems.

Perceptions of the usefulness of external support to immunization coverage in Guinea-Bissau: a Delphi analysis of the GAVI-Alliance cash-based support

INTRODUCTION: Although many countries have improved vaccination coverage in recent years, some, including Guinea-Bissau, failed to meet expected targets. This paper tries to understand the main barriers to better vaccination coverage in the context of the GAVI-Alliance (The Global Alliance for Vaccines and Immunisation) cash-based support provided to Guinea-Bissau. METHODS: The analysis is based on a document analysis and a three round Delphi study with a final consensus meeting. RESULTS: Consensus attributed about 25% of the failure to perform better to implementation problems; and about 10% to governance and also 10% to scarce resources. The qualitative analysis validates the importance of implementation issues and upgraded the relevance of the human resources crisis as an important drawback. The recommendations were balanced in their upstream-downstream focus but were blind to health information issues and logistical difficulties. CONCLUSIONS: It is commendable that such a fragile state, with all sorts of barriers, manages to sustain a slow steady growth of its vaccination coverage. Not reaching the targets set reflects the inappropriateness of those targets rather than a lack of commitment of the health workforce. In the unstable context of countries such as Guinea-Bissau, the predictability of the funds from global health initiatives like the GAVI-Alliance seem to make all the difference in achieving small consistent health gains even in the presence of other major bottlenecks.