OBJETIVO: Analisar os fatores relacionados à determinação e às desigualdades no acesso e uso dos serviços de saúde por idosos. MÉTODOS: Estudo integrante do Projeto Saúde, Bem-estar e Envelhecimento (SABE), no qual foram entrevistados 2.143 indivíduos com 60 anos ou mais no município de São Paulo, SP, em 2000. A amostra foi obtida em dois estágios, utilizando-se setores censitários com reposição, probabilidade proporcional à população e complementação da amostra de pessoas de 75 anos. Foi mensurado o uso de serviços hospitalares e ambulatoriais nos quatro meses anteriores à entrevista, relacionando-os com fatores de capacidade, necessidade e predisposição (renda total, escolaridade, seguro saúde, morbidade referida, auto-percepção, sexo e idade). O método estatístico utilizado foi regressão logística multivariada. RESULTADOS: Dos entrevistados, 4,7% referiram ter utilizado a internação hospitalar e 64,4% o atendimento ambulatorial. Dos atendimentos ambulatoriais em serviço público, 24,7% ocorreram em hospital e 24,1% em serviço ambulatorial; dentre os que ocorreram em serviços privados, 14,5% foram em hospital e 33,7% em clínicas. Pela análise multivariada, observou-se associação entre a utilização de serviços e sexo...

Objetivos: Este estudo é parte do Projeto Saúde, Bem-estar e Envelhecimento (SABE), com o objetivo de identificar as desigualdades no acesso e uso de serviços de saúde entre idosos no município de São Paulo, Brasil. Métodos: Em 2000, foram entrevistados, 2143 indivíduos com 60 anos ou mais, utilizando-se o questionário padronizado do SABE. A amostra foi obtida em dois estágios, utilizando-se setores censitários com reposição, probabilidade proporcional à população e complementação da amostra de pessoas de 75 anos. Os dados finais foram ponderados, de forma a serem expandidos. Foi mensurado o uso de serviços hospitalares (internações) e ambulatoriais (consultas médicas) nos últimos quatro meses e o não uso de serviços de saúde (mesmo precisando), relacionando-os com fatores de capacidade, necessidade e predisposição (renda total, escolaridade, seguro saúde, morbidade referida, auto-percepção, sexo e idade). Resultados: A proporção dos entrevistados que referiu ter utilizado algum serviço de saúde, nos últimos quatro meses, foi de 4,7 por cento com relação à internação hospitalar e 64, 4 por cento com referência ao atendimento ambulatorial. Dos atendimentos ambulatoriais, 24,7 por cento ocorreu em hospital público e 24...

Dissertação de mestrado em Economia Social; O trabalho apresentado tem como objetivo o estudo das desigualdades no acesso aos cuidados de saúde, em particular aos cuidados de saúde primários. Estes representam o primeiro contacto dos utentes com os serviços de saúde. Apesar da evolução significativa da esperança de vida da população portuguesa e da diminuição da taxa de mortalidade ao longo dos últimos anos, as dificuldades em aceder a determinados cuidados de saúde em Portugalainda persistem. Neste sentido realizamos uma análise teórica sobre o conceito de cuidados primários e acesso aos serviços de saúde. Foram também alvo de análise as dimensões do acesso, mencionadas pelos diversos autores e diferentes estudos já publicados. Para a concretização do estudo empírico, foi utilizado um conjunto de variáveis quantitativas recolhidas pela Administração Central do Sistema de Saúde, sendo que o principal objetivo desta investigação consistiu em perceber se as variáveis em análise permitem, ou não, concluir sobre a existência de desigualdades no acesso aos cuidados primários. Para tal, socorremo-nos de um conjunto de “testes/procedimentos estatísticos”. A análise realizada pemite-nos concluir que existem desigualdades no acesso aos cuidados de saúde primários ao nível regional...

Nicaragua has embarked on an ambitious health sector program, which has contributed to significant progress in the health sector over the past decade. Health indicators show gradual but steady improvements: access to basic services such as clean water and sanitation facilities has improved, as have other related performance indicators such as life expectancy, infant/child mortality, immunization rates, and child nutrition among others. Despite these achievements, there are still large inequities in access and quality of health services across socioeconomic groups and regions. Poor individuals living in rural areas (especially in the Central and Atlantic regions), the indigenous population, and individuals living in households engaged in agriculture have average access to health care services and preventive care. The lack of risk mitigation mechanisms such as insurance and social security is causing users in Nicaragua to spend, out-of-pocket, a significant share of their income on health care, especially to buy medications and other non-consultation items such as medical tests. Long distances...

This paper investigates the role of demand-side barriers in impeding access to the use of health services. Demand-side barriers are defined as determinants of use of health care that are not dependent on service delivery or price or direct price of those services. They include distance, education, opportunity cost, and cultural and social barriers. There is some evidence that these barriers are at least as important in determining access to services as the quality, volume, and price of services delivered by health care providers. The paper is divided into two sections. In the first section literature on demand barriers to accessing services is reviewed. Since the literature on these barriers is so substantial, the review is restricted to an illustrative survey of the main barriers in low-, middle-, and high-income countries. The second section surveys studies that report and evaluate methods for overcoming these barriers. The literature here is substantially less voluminous even when gray and unpublished sources are included in the survey. Many of the studies relate to access to obstetrical and family planning care. In most cases evaluation is not rigorous...

Community-based health insurance schemes are becoming increasingly recognized as an instrument to finance health care in developing countries. Taking the example of "les mutuelles de santes" (mutual health organization) in rural Senegal this paper analyzes whether or not members in a mutual health insurance scheme have better access to health care than nonmembers. A binary probit model is estimated for the determinants of participation in a mutual and a logit/log linear model is used to measure the impact on health care utilization and financial protection. The results show that, while the health insurance schemes reach otherwise excluded people, the very poorest in the communities are not covered. Regarding the impact on the access to health care, members have a higher probability of using hospitalization services than nonmembers and pay substantially less when they need care. Given the results of this study, community financing schemes have the potential to improve the risk-management capacity of rural households. To reduce identified limitations of the schemes...

Most community financing schemes have evolved in the context of severe economic constraints, political instability, and lack of good governance. Usually government taxation capacity is weak, formal mechanisms of social protection for vulnerable populations absent, and government oversight of the informal health sector lacking. In this context of extreme public sector failure, community involvement in the financing of health care provides a critical albeit insufficient first step in the long march towards improved access to health care by the poor and social protection against the cost of illness. Health Financing for Poor People stresses that community financing schemes are no panacea for the problems that low-income countries face in resource mobilization. They should be regarded as a complement to - not as a substitute for - strong government involvement in health care financing and risk management related to the cost of illness. Based on an extensive survey of the literature, the main strengths of community financing schemes are the extent of outreach penetration achieved through community participation...

The aim of the report is to review existing approaches and available policy options to improve access to health care services and financial protection against health shocks for informal-sector workers (ISWs). Along with their families, ISWs represent the majority of the population in many developing countries. The report reviews the definition and measurement of the informal sector and the literature on efforts toward its health insurance coverage. It also examines several country cases based on published and unpublished reports and on structured interviews of expert informants. Developing country efforts to expand health coverage are characterized by a common enrollment and financing pattern, starting with formal-sector workers and following with government-subsidized enrollment of the poor. Thus, ISWs are typically left behind and have been referred to as "the missing middle." They find themselves financially unprotected against health shocks and with limited access to quality and timely health care. ISWs are generally reluctant to enroll in insurance schemes...

This paper examines the impact of access to health facilities and personnel on infant and child mortality in Indonesia. Demographic and Health Survey data are combined with village-level censuses of infrastructure collected by the Central Bureau of Statistics. Because the village-level data are available from two points in time, it is possible to analyse the effects on mortality risks within the village of changes in access to health care. Factors about villages that might affect both access to health care and mortality risks are held constant. Adding a maternity clinic to a village decreases the odds of infant mortality by almost 15 per cent, in comparison to the risk before the clinic was added. An additional doctor reduces the odds by about 1.7 per cent.; yes

Immigrants often lose their health advantage as they start adapting to the ways of the new society. Having access to care when it is needed is one way that individuals can maintain their health. We assessed the healthcare access in Canadian immigrants and the socioeconomic factors associated with access over a 12-year period. We compared two measures of healthcare access (having a regular doctor and reporting an unmet healthcare need in the past 12 months) among immigrants and Canadian-born men and women, aged more than 18 years. We applied a logistic random effects model to evaluate these outcomes separately, in 3081 males and 4187 females from the National Population Health Survey (1994-2006). Adjusting for all covariates, immigrant men and women (white and non-white) had similar odds of having a regular doctor than the Canadian-born individuals (white immigrants: males OR: 1.32, 95% C.I.: 0.89-1.94, females OR: 1.14, 95% C.I.: 0.78-1.66; non-white immigrants: males OR: 1.28, 95% C.I.: 0.73-2.23, females OR: 1.23, 95% C.I.: 0.64-2.36). Interestingly, non-white immigrant women had significantly fewer unmet health needs (OR: 0.32, 95% C.I.: 0.17-0.59). Among immigrants, time since immigration was associated with having access to a regular doctor (OR per year: 1.02...

Health care expenditures can be financed through a mix of public resources and private spending. Private spending is a much larger share of total health spending in low- and middle-income countries than in higher income countries. Moreover, a significant percentage of private spending in those countries is out-of-pocket direct payments for health care services by individuals. Out of pocket expenditures account for more than 60 percent of the total health care spending in low-income countries and 40 percent of total health care spending in middle-income countries. A growing number of low- and middle-income governments are considering private health insurance as a way of both reducing the risk that individuals will have a catastrophic financial burden and achieving other public health care goals. Among these goals are reducing the financial burden on overstretched public health financing, achieving more equitable access to health care, and improving quality and efficiency in the delivery of health care services. An important component of a successful private health insurance market, however, is its legal framework. As discussed in detail later in this book, countries regulate insurance companies to counter systemic market failures that lead to an inefficient and inequitable market. In particular...

This paper focuses on recent and significant health reform implemented in 2005, known as Universal Access with explicit guarantees (Acceso Universal con Garantias Explicitas - AUGE or GES), which mandated SHI insurers to adopt a broad benefits package defined via explicit legal guarantees for all beneficiaries. This innovative reform is a policy reaction to that which previously existed in Chile and which is widespread in many developing countries, whereby the health rights of citizens remain largely undefined or implicit. Limited public resources imply in those countries that access to health care is rationed through queues, patient deflection, legal or under-the-table user fees, and low-quality care. This paper describes the AUGE reform, its implementation, and the functioning of AUGE for the poor and for non-poor citizens. This paper is organized as: section two provides a brief historic overview of health coverage in Chile's SHI system. Section three describes the SHI system in existence today. Section four describes the services offered and mechanisms in place to cover the poor under SHI, while section five spells out the benefits of SHI. Section six introduces the AUGE health reform of 2005, which sought to broaden and make explicit the rights of all SHI beneficiaries. Section seven offers information about the flows and magnitudes of health financing in SHI. Section eight focuses on the system used by Fonasa to target the poor. Section nine explains how Fonasa manages AUGE. Section ten comments on the information environment of AUGE. Section eleven addresses the equity and fiscal implications of expanding the AUGE benefits. Finally...

Since the signing of the 1996 Peace Accords, Guatemala has made efforts to establish economic and political stability, and to improve its social indicators. The country's Constitution states that access to health care is a basic right of all Guatemalans. In practice, however, it has been challenging for the Government of Guatemala to guarantee this right using public facilities. As a result, it has been trying to improve access to health services using both Ministry of Public Health and Social Assistance (MOH) facilities and staff, and alternative health service providers, particularly nongovernmental organizations (NGOs). This case study reviews the experience implementing the Expansion of Coverage Program (Programa de Extension de Cobertura, PEC) that was established by the Government of Guatemala in 1997 to improve coverage of health and nutrition services to poor, rural, and largely indigenous areas by contracting NGOs. It describes its origins; its package of services; contracting, financing, monitoring, and supervision mechanisms; and its contributions to improving access and strengthening primary health care services in Guatemala. It also discusses opportunities and challenges that need to be addressed to continue to improve health services coverage in the country.

Jamaica's primary health care system was a model for the Caribbean region in the 1990s. Because of it, Jamaicans enjoy relatively better health status than people in other countries of similar income level in the Caribbean region. However, Jamaica's health system is being severely challenged by persistent and reemerging infectious diseases and by the rapid increase in noncommunicable diseases (NCDs) and injuries. At the same time, the country has suffered from low economic growth and carries a high debt burden, which leaves limited fiscal space for improving health care. The Government of Jamaica has been trying to sustain the gain in health outcomes and improve access to health care for its population in an environment of constrained resources during the last decade. With the establishment of the Jamaica National Health Fund (NHF) in 2003 and the abolition of user fees at public facilities in 2008, the Government of Jamaica has taken steps toward achieving universal coverage. This study reviews the achievements and challenges in expanding universal access in Jamaica and assesses the impact of the NHF's drug-subsidy programs and the abolition of user fees on universal access, and discusses policy options for achieving universal coverage.

This case study describes and assesses Jamkesmas, Indonesia's government-financed health coverage program for the poor and near-poor. It provides a detailed description of the scope, depth, and breadth of coverage provided under Jamkesmas, and highlights ways in which the program interacts with the rest of Indonesia's health system. It also summarizes and discusses evidence on whether Jamkesmas is attaining its stated objectives of removing financial barriers and improving access to health care by the poor and near-poor, what could be improved, and what lessons can be learned from the experience of Jamkesmas that could help inform Indonesia's quest for universal coverage. The primary theme underlying the study is that supply-side constraints and supply-side subsidies have not been leveraged to increase the effectiveness of the Jamkesmas program. There are significant geographic deficiencies in the availability and quality of the basic benefits package, especially for those living in relatively remote and rural locations of the country, and this limits the effective availability of benefits for many Jamkesmas beneficiaries. The remainder of the case study is organized as follows. Section two provides general background and information on health system outcomes in Indonesia. Section three is an overview of health care financing and delivery. Section four describes the institutional architecture of Jamkesmas. Section five highlights the process of targeting...

Universal coverage with the health care insurance function may be defined as physical and financial access to necessary health care of good quality for all persons in a society. It implies protection against the risk that if expensive (relative to an individual's or family's means) health care services are needed, services of adequate quality will be physically accessible, and the costs of these services will not prevent persons from using them or impoverish their families. Defined in this way, the extent of protection is an important determinant of performance vis-a-vis broad health and social welfare policy objectives, because it entails quality of care (a means for improving the health status of the population), equity in access to effective care (a means to reduce inequality in health status), and protection against the risk of impoverishment as a consequence of health care costs. This paper was motivated by the perception that, with respect to health care financing, there is frequently confusion between policy tools and policy objectives. The paper emphasizes the importance of distinguishing between the ends and means of health policy in general...

The relationship between disability and poverty has been described in different contexts. Nevertheless, the basic characteristics of this relationship have not yet been fully established. The social exclusion and discrimination against people with disabilities increase the risk of poverty and reduce the access to basic opportunities such as health and education. This study examines the impact of a health limitation and poverty in the access to health care services in Colombia. Data from the Colombian National Health Survey (2007) was used in the analysis. Variables related with health condition and socio economic characteristics were first generated. Then interactions between health limitations and the lower levels of the asset index were created. This variable gave information related to the relationship between disability and poverty. A probabilistic model was estimated to examine the impact of a health condition and the relation between poverty and disability on the access to health care. The results suggest that living with a physical limitation increases by 10% the probability of access to health care services in Colombia. However, people with a disability and in the lowest quartile of the asset index have a 5% less probability of access to health care services. We conclude that people who live with a physical...

OBJETIVO: Analisar os fatores relacionados à determinação e às desigualdades no acesso e uso dos serviços de saúde por idosos. MÉTODOS: Estudo integrante do Projeto Saúde, Bem-estar e Envelhecimento (SABE), no qual foram entrevistados 2.143 indivíduos com 60 anos ou mais no município de São Paulo, SP, em 2000. A amostra foi obtida em dois estágios, utilizando-se setores censitários com reposição, probabilidade proporcional à população e complementação da amostra de pessoas de 75 anos. Foi mensurado o uso de serviços hospitalares e ambulatoriais nos quatro meses anteriores à entrevista, relacionando-os com fatores de capacidade, necessidade e predisposição (renda total, escolaridade, seguro saúde, morbidade referida, auto-percepção, sexo e idade). O método estatístico utilizado foi regressão logística multivariada. RESULTADOS: Dos entrevistados, 4,7% referiram ter utilizado a internação hospitalar e 64,4% o atendimento ambulatorial. Dos atendimentos ambulatoriais em serviço público, 24,7% ocorreram em hospital e 24,1% em serviço ambulatorial; dentre os que ocorreram em serviços privados, 14,5% foram em hospital e 33,7% em clínicas. Pela análise multivariada, observou-se associação entre a utilização de serviços e sexo...

Background. In Colombia, maternal near miss morbidity is monitored in the health surveillance system. The National Health Institute included a special report on cases that met three or more World Health Organization criteria according to the World Health Organization criteria. Objective. To estimate the relationship between variables related to opportune access to health care services in Colombia during 2013 depending on inclusion criteria -three or more- for maternal near miss morbidity. Materials and methods. A cross-sectional analysis of the national registry of obligatory notification on maternal near miss morbidity was performed. Cases with three or more criteria were compared with those with one or two according to some variables related to the timely access of health care services. Results. A total of 8 434 maternal near miss morbidity cases were reported, women were aged between 12 and 51 years old (M=26.4, SD=7.5). 961 (11.4%) lived in remote rural areas; 4 537 (53.8%) were uninsured under the health system, or they were affiliated to either the subsidized or special health care regime; 845 (10.0%) belonged to an ethnic minority; 3 696 (44.4%) were referred to a more complex service; 4 097 (49.2%) were admitted to the intensive care unit; and 3 975 (47.1%) met three or more of the inclusion criteria for maternal near miss morbidity. They were combined to meet three or more of the case inclusion criteria: intensive care unit admission (OR=5.58; IC95% 5.06-6.15); being uninsured or affiliated to the subsidized or special regime (OR=1.57; IC95% 1.42-1.74); and referral to a more complex service (OR=1.18; IC95% 1.07-1.31). Conclusions. In Colombia...

The prevention and treatment of infectious diseases remain among the greatest challenges faced by today's developing countries. The World Health Organisation estimates that about one-third of the world's population lacks access to essential medicine, a fact which, according to the United Nations, directly contradicts the fundamental principle of health as a human right. According to the World Summit for Social Development, poor health and illness are factors that contribute to poverty, while the adverse effects of illness ensure that the poor become poorer. A lack of access to health care, amongst other rights, (including access to medicines as an element thereof) aggravates poverty. The most important provision in international law relating to the right to health is article 12 of the United Nations International Covenant on Economic, Social and Cultural Rights. Article 12(1) of this Covenant provides a broad formulation of the right to health in international law, while article 12(2) prescribes a non-exhaustive list of steps to be taken in pursuit of the highest attainable standard of health. Article 12(2), in particular, illustrates the role that adequate access to medication plays in the right of access to health care. The United Nations Committee on Economic...