Decentralization and privatization in Portuguese health reforms

ABSTRACT - The Portuguese National Health Service (SNS), a universal, centralized and public owned health care system, exhibits an extraordinary record of equalization in the access to health care and health gains in the late thirty years. However, the most recent history of the Portuguese health reform is pervaded by the influence of decentralization and privatization. Decentralization has been present in the system design since the 1976 Constitution, at least in theory. Private ownership of health care suppliers and out-ofpocket expenditures, on the financing side, both have a long tradition of relevance in the NHS mix of services. The initial aim of this study was to demonstrate expected parallelism between health reforms and public administration reforms, where a common pattern of joint decentralization and privatization was observed in many countries. Observers would be tempted to consider these two movements as common signs of new public management (NPM) developments. They have common objectives, are established around the core concepts of gains in effectiveness, efficiency, equity and quality of public services, through improved accountability. However, in practice, in Portugal, each movement was developed in a totally separated way. Besides those rooted in the NPM theory, there are few visible signs of association between decentralization and privatization. Decentralization, in the Portuguese SNS, was never intended to be followed by a privatization movement; it was seen merely as a public administration tool. Private management of health services, as stated in the most recent SNS legislation, was never intended to have decentralization as a condition or as a consequence. Paradoxically, in the Portuguese context, it has led invariably to centralized control. While presented as separate instruments for a common purpose, the association between decentralization and privatization still lacks a convincing demonstration. Many common health care management stereotypes remain to be checked out if we want to look for eventual associations between these two organizational tools.

Economic grand rounds: financial burden of medical care and risk of forgoing care among Europeans with depressive symptoms

Little is known about the financial burden of individuals with depressive symptoms. This study explored that burden, using data from the Survey of Health, Ageing, and Retirement in Europe. To assess the association between depressive symptoms and the individuals' financial burden for medical care and whether they forwent medical care because of costs, logistic regressions were performed that adjusted for age, gender, marital status, education, and chronic diseases. A total of 16,696 noninstitutionalized individuals aged 50-79 years were included in the study. Individuals with depressive symptoms and those without such symptoms bore a similar financial burden. However, individuals with depressive symptoms were at increased risk of forgoing care because of costs, which may worsen their health and financial situation

Improving the oral health status of functionally independent and dependent seniors residing in long-term care facilities through dental hygiene education /

The purpose of this study was to evaluate the oral health status of residents residing in 2 long-term care facilities and determine if dental hygiene education was required in order to improve their current oral health. The oral health status of 6 independent and 4 dependent individuals residing in 2 long-term care facilities was evaluated. In addition, the current oral health and disease prevention practices employed by 4 caregivers who were responsible for providing oral care to dependent residents in the long-term care facilities were evaluated. Furthermore, an evaluation of the oral care practices of independent residents who were responsible for providing their own care was conducted. Finally, the challenges that caregivers and independent residents faced when performing oral care were determined, and methodological changes were proposed. Using a generic qualitative research methodology, data collection was comprised of semi structured interviews, field observations, and documentation. The oral health status of the residents was reevaluated 3 months later. The findings of this study demonstrated an increase in plaque accumulation, gingival inflammation, and unhealthy gingival tissue colour changes among the residents over the 3-month period. The study revealed that poor oral health among the residents was a result of inadequate oral hygiene care techniques, difficulties accessing oral health care, financial limitations, insufficient care staff, insufficient time for personal care duties, lack of professional development, minimal interprofessional collaboration of health disciplines, and lack of perseverance on the part of the caregivers and residents. Overall, oral health is essential, and maintaining optimal oral health requires increased collaboration and communication between health care providers.

Rashtriya Swasthya Bhima Yojana-Comprehensive Health Insurance Scheme (Rsby-Chis) In Kerala: A Study On The Effectiveness And Utilization Of The Scheme With Special Reference To Ernakulam And Wayanad Districts

Health insurance has become a necessity for the common man, next to food, clothing and shelter. The financing of health expense is either catastrophic or sometimes even frequently contracted illnesses, is a major cause of mental agony for the common man. The cost of care may sometimes result in the complete erosion of the family savings or may even lead to indebtedness as many studies on causes of rural indebtedness bear testimony (Jayalakshmi, 2006). A suitable cover by way of health insurance is all that is required to cope with such situations. Health care insurance rightly provides the mechanism for both individuals and families to mitigate the financial burden of medical expenses in the present context. Hence a well designed affordable health insurance policy is the need of the hour.Therefore, it is very significant to study the extent to which the beneficiaries in Kerala make use of the benefits provided by a social health insurance scheme like RSBY-CHIS. Based on the above pertinent points, this study assumes national relevance even though the geographical area of the study is limited to two districts of Kerala. The findings of the study will bring forth valuable inputs on the services availed by the beneficiaries of RSBYCHIS and take appropriate measures to improve the effectiveness of the scheme whereby maximum quality benefit could be availed by the poorest of the poor and develop the scheme as a real dawn of the new era of health for them

Care arrangements for people with dementia in developing countries

Background: Rapid demographic ageing will soon lead to large increases in the numbers of persons with dementia in developing countries. This study is the first comprehensive assessment of care arrangements for people with dementia in those regions. Methods: A descriptive and comparative study of dementia care; caregiver characteristics, the nature of care provided, and the practical, psychological (Zarit Burden Interview, General Health Questionnaire) and economic impact upon the caregiver in 24 centres in India, China and South East Asia, Latin America and the Caribbean and Africa. Results: We interviewed 706 persons with dementia, and their caregivers. Most caregivers were women, living with the person with dementia in extended family households. One-quarter to one-half of households included a child. Larger households were associated with lower caregiver strain, where the caregiver was co-resident. However, despite the traditional apparatus of family care, levels of caregiver strain were at least as high as in the developed world. Many had cutback on work to care and faced the additional expense of paid carers and health services. Families from the poorest countries were particularly likely to have used expensive private medical services, and to be spending more than 10% of the per capita GNP on health care. Conclusions: Older people in developing countries are indivisible from their younger family members. The high levels of family strain identified in this study feed into the cycle of disadvantage and should thus be a concern for policymakers in the developing world. Copyright © 2004 John Wiley & Sons, Ltd.

Shaping the future of social protection: access, financing and solidarity: summary

Includes bibliography

Millennium development goals: progress towards the right to health in Latin america and the Caribbean

Includes bibliography

Public policy for pensions, health and sickness insurance

Includes bibliography

HEALTH EDUCATION IN THE CARE TO CLIENTS OF THE BLOOD GLUCOSE SELF-MONITORING PROGRAM

This article reports, in a systemized and analytical way, the experience of an Outreach Program in the period between 2010 and 2011. The study focused on health education interventions as strategies to improve the adherence of individuals with insulin- dependent diabetes mellitus (IDDM), clients of a blood glucose self-Monitoring program. In addition, we intended to contribute to the reorganization of the program's working processes in the unit. Health education strategies were used in both educational groups and home visits, thus permitting the provision of care that was more individualized. Data regarding the clients were organized on a spreadsheet and in files for the Family Health teams, which made it easier to identify the patients, including those who were absent, helping to decentralize the care. By using health education strategies, we intended to contribute to a more comprehensive and emancipatory care of the clients, aimed at a continuous reflection of the workers regarding their practices.

Family Health Support Centers: challenges and opportunities from the perspective of primary care professionals in the city of Sao Paulo, Brazil

Family Health Support Centers (NASF) were created in Brazil to increase the case-resolution capacity of primary healthcare. Prior to their implementation in the West Side of the city of Sao Paulo, Brazil, a series of workshops were held for primary healthcare professionals to prepare a proposal for such centers. Hermeneutic analysis was used to study the transcribed material. The thematic categories were: role, constitution, and functioning of the NASF, relationship with family health teams, and interdisciplinarity. The participants' expected the NASF to be an empowering device for comprehensiveness of care, intervening in an existing culture of unnecessary referrals while fostering linkage with other levels of care. The participants also expected the NASF to contribute to the discussion on health professionals' training and stimulating reflection with policy-makers on health indicators based exclusively on the number of consultations. These indicators fail to reflect the impact on the services' activities and the quality of care offered to the population in the coverage area.

GeoHealth: A Georeferenced System for Health Data Analysis in Primary Care

The Primary Care Information System (SIAB) concentrates basic healthcare information from all different regions of Brazil. The information is collected by primary care teams on a paper-based procedure that degrades the quality of information provided to the healthcare authorities and slows down the process of decision making. To overcome these problems we propose a new data gathering application that uses a mobile device connected to a 3G network and a GPS to be used by the primary care teams for collecting the families' data. A prototype was developed in which a digital version of one SIAB form is made available at the mobile device. The prototype was tested in a basic healthcare unit located in a suburb of Sao Paulo. The results obtained so far have shown that the proposed process is a better alternative for data collecting at primary care, both in terms of data quality and lower deployment time to health care authorities.

Burden of care and its impact on health-related quality of life of caregivers of individuals with spinal cord injury

Objective: to analyze the impact and burden of care on the Health-Related Quality of Life (HRQOL) of caregivers of individuals with a spinal cord injury (SCI). Method: cross-sectional observational study carried out by reviewing medical records and applying questionnaires. The scale Short Form 36 (SF-36) was used to assess HRQOL and the Caregiver Burden Scale (CBScale) for care burden. Results were analyzed quantitatively. Most patients with SCIs were male, aged 35.4 years old on average, with a predominance of thoracic injuries followed by cervical injuries. Most caregivers were female aged 44.8 years old on average. Results: tetraplegia and secondary complications stand out among the clinical characteristics that contributed to greater care burden and worse HRQOL. Association between care burden with HRQOL revealed that the greater the burden the worse the HRQOL. Conclusion: Preventing care burden through strategies that prepare patients for hospital discharge, integrating the support network, and enabling access to health care services are interventions that could minimize the effects arising from care burden and contribute to improving HRQOL.

Examining the Role of Vocational Rehabilitation on Access to Care and Public Health Outcomes for People Living with HIV/AIDS

The purpose of this study is to examine the role of vocational rehabilitation services in contributing to the goals of the National HIV/AIDS strategy. Three key research questions are addressed: (a) What is the relationship among factors associated with the use of vocational rehabilitation services for people living with HIV/AIDS? (b) Are the factors associated with use of vocational rehabilitation also associated with access to health care, supplemental employment services and reduced risk of HIV transmission? And (c) What unique role does use of vocational rehabilitation services play in access to health care and HIV prevention? Survey research methods were used to collect data from a broad sample of volunteer respondents who represented diverse racial (37% Black, 37% White, 18% Latino, 7% other), gender (65% male, 34% female, 1% transgender) and sexual orientation (48% heterosexual, 44% gay, 8% bisexual) backgrounds. The fit of the final structural equation model was good (root mean square error of approximation = .055, Comparative Fit Index=.953, Tucker Lewis Index=.945). Standardized effects with bootstrap confidence intervals are reported. Overall, the findings support the hypothesis that vocational rehabilitation services can play an important role in health and prevention strategies outlined in the National HIV/AIDS strategy.

Towards a new model of care: integrating mental health, substance use, and somatic care

Although research and clinical interventions for patients with dual disorders have been described since as early as the 1980s, the day-to-day treatment of these patients remains problematic and challenging in many countries. Throughout this book, many approaches and possible pathways have been outlined. Based upon these experiences, some key points can be extracted in order to guide to future developments. (1) New diagnostic approaches are warranted when dealing with patients who have multiple problems, given the limitations of the current categorical systems. (2) Greater emphasis should be placed on secondary prevention and early intervention for children and adolescents at an increased risk of later-life dual disorders. (3) Mental, addiction, and somatic care systems can be integrated, adopting a patient-focused approach to care delivery. (4) Recovery should be taken into consideration when defining treatment intervention and outcome goals. (5) It is important to reduce societal risk factors, such as poverty and early childhood adversity. (6) More resources are needed to provide adequate mental health care in the various countries. The development of European guidance initiatives would provide benefits in many of these areas, making it possible to ensure a more harmonized standard of care for patients with dual disorders.

Consumer satisfaction with primary care provider choice and associated trust

Trust is important in medical relationships and for the achievement of better health outcomes. Developments in managed care in the recent years are believed to affect the quality of healthcare services delivery and to undermine trust in the healthcare provider. Physician choice has been identified as a strong predictor of provider trust but has not been studied in detail. Consumer satisfaction with primary care provider (PCP) choice includes having or not having physician choice. This dissertation developed a conceptual framework that guided the study of consumer satisfaction with PCP choice as a predictor of provider trust, and conducted secondary data analyses examining the association between PCP choice and trust, by identifying factors related to PCP choice satisfaction, and their relative importance in predicting provider trust. The study specific aims were: (1) to determine variables related to the factors: consumer characteristics and health status, information and consumer decision-making, consumer trust in providers in general and trust in the insurer, health plan financing and plan characteristics, and provider characteristics that may relate to PCP choice satisfaction; (2) to determine if the factors in aim one are related to PCP choice satisfaction; and (3) to analyze the association between PCP choice satisfaction and provider trust, controlling for potential confounders. Analyses were based on secondary data from a random national telephone survey in 1999, of residential households in the United States which included respondents aged over 20 and who had at least two visits with a health professional in the past two years. Among 1,117 eligible households interviewed (response rate 51.4%), 564 randomly selected to respond to insurer related questions made up the study sample. Analyses using descriptive statistics, and linear and logistic regressions found continual effective care and interaction with the PCP beyond the medical setting most predictive of PCP choice satisfaction. Four PCP choice satisfaction factors were also predictive of provider trust. Findings highlighted the importance of the PCP's professional and interpersonal competencies for the development of sustainable provider trust. Future research on the access, utilization, cognition, and helpfulness of provider specific information will further our understanding of consumer choice and trust. ^