This paper briefly outlines how the political scenario and the mobilization of different actors have contributed to the construction of a public health policy in response to the AIDS epidemics in Brazil. Three factors are presented and discussed: the political context of the 1980s, characterized by redemocratization, growth of social movements, and consolidation of the Brazilian health care reform; the socio-cultural context of the 1970s and 1980s, characterized by achievement of individual freedom, which was key to the organization of the AIDS movement; and finally the actions carried out in the international scenario to support the sustainability of the Brazilian domestic policy and the reinforcement of a global response to face the epidemics in lower-middle income economies.

The American Public Health Association (APHA) has long advocated the development of a system of universal health care for all US residents. APHA has adopted several policies on this topic that stress the financing of the system of universal health care under a single-payer mechanism. However, this approach has never been adopted by US policymakers.

Members of the Rekindling Reform Steering Committee collaborated over a period of several months in early 2002 to develop a set of principles and goals to help guide and define the group’s efforts for comprehensive health care reform in the United States.

Because of the importance of grassroots social movements, or “change from below,” in the history of US reform, the relationship between social movements and demands for universal health care is a critical one.

Amidst mounting federal debt, slowing the growth of health care spending is one of the nation’s top domestic priorities. This dissertation evaluates three current policy ideas: (1) global payment within an accountable care contracting model, (2) physician fee cuts, and (3) expanding the role of competitive bidding in Medicare. Chapter one studies the effect of global payment and pay-for-performance on health care spending and quality in accountable care organizations. I evaluate the Blue Cross Blue Shield of Massachusetts Alternative Quality Contract (AQC), which was implemented in 2009 with seven provider organizations comprising 380,000 enrollees. Using claims and quality data in a quasi-experimental difference-in-differences design, I find that the AQC was associated with a 1.9 percent reduction in medical spending and modest improvements in quality of chronic care management and pediatric care in year one. Chapter two studies Medicare’s elimination of payments for consultations in the 2010 Medicare Physician Fee Schedule. This targeted fee cut (largely to specialists) was accompanied by a fee increase for office visits (billed more often by primary care physicians). Using claims data for 2.2 million Medicare beneficiaries, I test for discontinuities in spending...

Health care reform in Latin America has been a continuous process over recent decades, and several countries have implemented programs of universal care. This dissertation looks at the implementation of universal care programs in Brazil and Mexico, and highlights the politics of implementing these reforms. In the first paper, I evaluate the implementation of infrastructural reforms as part of Seguro Popular in Mexico. I conclude that the reforms were partially successful, but that success varied considerably by region. In the second paper, I show that spending on health care in Brazil is strongly related to political partisanship, and that the reform process has not significantly changed this relationship. In the third paper, I suggest that individual characteristics, and not political variables, best explain variations in the quality of care patients receive in Brazil. As a whole, these papers serve to highlight the understudied role of politics in the implementation of health care reform.; Government

The main purpose of this report is to assess the degree to which progress has been made by the Government of Uzbekistan in increasing the transparency, accountability, and efficiency of its primary health services, and to identify what further steps could be taken to improve the effectiveness of delivery, some of which may be applicable to other sectors as well. The report examines public spending, public financial management, and human resource management and remuneration in the primary health care sector at the local level. It draws lessons from the experience of Ferghana and Samarkand, two oblasts that have implemented reforms in primary health care, and incorporates the findings drawn from other sources, such as public expenditure data, the laws and regulations governing these systems, and the Service Quality Delivery Survey (SQDS) conducted in 2007. This report discusses the key governance issues related to improving service delivery in the primary health care area, and concludes with recommendations tailored to decision makers at the central and local government levels and those in local facilities.

To describe local sociopolitical and organizational factors that influence health system development in Karachi, Pakistan, we conducted participant observation while working with health providers and communities in one urban district to reorient services towards a primary health care district health system. We found that the community characteristics, particularly the diverse socialpolitical and cultural make-up and organizational complexity that involved multiple levels of government, influenced efforts towards collaboration and shaped the development of the health system. We conclude that for effective implementation of health sector reform there is a need to comprehend fully the community context and complexity of existing health service provision.; M.A. Mahmood, J. Moss and R. Karmaliani; © World Health Organisation. Regional Office for the Eastern Mediterranean

The current crisis in the distribution of health care resources in the U.S. derives largely from insufficient access to health care, on the one hand, and inadequate control of rising costs, on the other hand. The response to the problem of insufficient access should not be the recognition of a moral right to health care but rather the establishment of a legal right to health care for all. In turn, the contours of this legal right can be the means to create the needed cost controls. To this end, they should include a laundry list of covered condition-treatment pairs, which would be informed by the measuring stick of quality-adjusted-lifeyears, and which would be the product of input from the public, the medical profession, and the Congress. The resultant structure of universal coverage, under a system of explicit rationing, would include a morally mandated second tier. Universal coverage, explicit rationing, and a second tier are the indispensable building blocks of meaningful health care reform in the U.S.

Approved for public release; distribution is unlimited; Health care reform in the 103rd and 104th Congresses has run the gambit from extremely ambitious to less than ambitious undertakings. Proposals have engendered partisan debates, because of the scope and complexity of the issues involved and their implications for the federal deficit. Estimating the budget consequences of health care reform has become critical because of the strong link between health care programs and the growth in the deficit. This thesis examines the major health care reform proposals considered by Congress during the period 1993-1996. These included the comprehensive bills considered in response to President Clinton's proposed overhaul in 1993-94, the cuts included in the Republican-led balanced budget plan in 1995 and the Kassebaum- Kennedy Bill, which became law in 1996. In each case, the thesis examined the deficit situation facing Congress at the time health care reform was engaged, plans to address the deficit, and the impact of each health care reform on the federal deficit. Data was obtained from congressional reports and periodicals, journals and Congressional Budget Office documentation. The major finding was that health care legislation which portends minimal impact on beneficiaries...

Approved for public release; distribution is unlimited; Physicians are the most difficult health care professional group to retain on active duty beyond their first obligated tour. A major problem is the disparity between military and civilian physician income. In fiscal year 1997, the Department of the Navy spent approximately $135 million in specialty pay on the Navy's 4,000 active duty physicians. Health care reform has altered the demand for specialty and primary care physicians, accelerating the movement toward managed care. In this thesis, the authors quantify the role of the pay differential using a multivariate logistic model and conclude that the civilian- military pay differential has a significant influence on the probability that a physician remains in the Navy. Physician personnel and earnings data were gathered from the Defense Manpower Data Center, the American Association of Medical Colleges, and the Hay Group. Results indicate that recent shifts in demand have resulted in a greater sensitivity of retention to pay for primary care physicians. Specialty specific elasticities can be applied to analyze the expected impact of pay on retention of representative pay plans. Increases in pay to the civilian median level would substantially increase retention...

This paper investigates comparative public attitudes as a mechanism to explain American welfare state “exceptionalism” in health care. The countries of Germany, Great Britain, and the United States were chosen as three distinct cases that exemplify different health care models. Using data collected from the 2006 International Social Survey Program (ISSP), this study 1) analyzed the influence of individual-level indicators on public attitudes toward government’s role in health care in the three countries and 2) looked at how these relationships differed cross nationally. Based upon past research regarding path-dependency research and demographics, 11 individual-level indicators were chosen. Findings revealed that although significant differences exist across the nations, majority of participants from Germany, Great Britain, and the United States felt that their governments have a responsibility to provide health care and that the government should be spending more on health care. This goes against conventional wisdom regarding public opinion and health care reform. Overall, Americans wanted to see more government responsibility and spending in health care, but did not feel that the government was successful in delivering health care. Political affiliation in the United States was the only individual-level indicator to predict greater odds of attitudes in government spending...

O artigo revisa os êxitos e fracassos da reforma do setor de saúde sueco, assim como as lições que deixou em sua proposta de alcançar melhores resultados financeiros e padrões de qualidade.; El artículo revisa los éxitos y fracasos de la reforma sueca de salud, así como las lecciones que dejó en su afán de alcanzar mejores resultados financieros y estándares de calidad.; The paper reviews the outcomes and failures of the Swedish health care reform, as well as the lessons learned for accomplishing better financial results and quality standards.

Field sites for demographic and health surveillance have made well-recognized contributions to the evaluation of new or untested interventions, largely through efficacy trials involving new technologies or the delivery of selected services, e.g. vaccines, oral rehydration therapy and alternative contraceptive methods. Their role in health system reform, whether national or international, has, however, proved considerably more limited. The present article explores the characteristics and defining features of such field sites in low-income and middle-income countries and argues that many currently active sites have a largely untapped potential for contributing substantially to national and subnational health development. Since the populations covered by these sites often correspond with the boundaries of districts or subdistricts, the strategic use of information generated by demographic surveillance can inform the decentralization efforts of national and provincial health authorities. Among the areas of particular importance are the following: making population-based information available and providing an information resource; evaluating programmes and interventions; and developing applications to policy and practice. The question is posed as to whether their potential contribution to health system reform justifies arguing for adaptations to these field sites and expanded investment in them.

The authors argue that "health for all" is not achievable in most countries without health sector reform that incorporates a process of coordinated health and human resources development. They examine the situation in countries in the Eastern Mediterranean Region of the World Health Organization. Though advances have been made, further progress is inhibited by the limited adaptation of traditional health service structures and processes in many of these countries. National reform strategies are needed. These require the active participation of health professional associations and academic training institutions as well as health service managers. The paper indicates some of the initiatives required and suggests that the starting point for many countries should be a rigorous appraisal of the current state of human resources development in health.

Objective. To identify changes in nursing practice and the nursing-practice environment that have occurred with implementation of health sector reform in five countries in the Americas. Methods. An exploratory study of selected settings in Argentina, Brazil, Colombia, Mexico, and the United States of America was conducted between 1997 and 1999 to collect narrative data from 125 professional nurses about their perceptions of nursing practice and changes in work environments. Descriptions of characteristics and trends in nursing practice in the study sites were also obtained. Results. Reorganization of health services has occurred in all five of the countries, responding to health sector reform initiatives and affecting nursing practice in each country. Respondents from all five countries mentioned an emphasis on private enterprise, changes in payment systems for patients and providers, redistributions in the nursing workforce, changes in the personnel mix and nursing-practice functions, work shifting from the hospital to the community, and greater emphasis on cost control and prevention in practice settings. Conclusions. The study provides initial information about current nursing issues that have arisen as a result of health care reform initiatives. Regardless of differences in service models or phases of health sector reform implementation...

The Lao People's Democratic Republic (Lao PDR) is classified by the World Bank as a low-income country under stress. Development partners have sought to utilize effective aid instruments to help countries classified in this way achieve the Millennium Development Goals; these aid instruments include sector-wide approaches (SWAps) that support decentralized district health systems and seek to avoid fragmentation and duplication. In Asia and the Pacific, only Bangladesh, Papua New Guinea and the Solomon Islands have adopted SWAps. Since 1991, a comprehensive primary health care programme in the remote Sayaboury Province of Lao PDR has focused on strengthening district health management, improving access to health facilities and responding to the most common causes of mortality and morbidity among women and children. Between 1996 and 2003, health-facility utilization tripled, and the proportion of households that have access to a facility increased to 92% compared with only 61% nationally. By 2003, infant and child mortality rates were less than one-third of the national rates. The maternal mortality ratio decreased by 50% despite comprehensive emergency obstetric care not being available in most district hospitals. These trends were achieved with an investment of approximately US$ 4 million over 12 years (equivalent to US$ 1.00 per person per year). However...

Teams of collaborators from Colombia, Mexico, Pakistan, and Thailand have adapted a policy tool originally developed for evaluating health insurance reforms in the United States into "benchmarks of fairness" for assessing health system reform in developing countries. We describe briefly the history of the benchmark approach, the tool itself, and the uses to which it may be put. Fairness is a wide term that includes exposure to risk factors, access to all forms of care, and to financing. It also includes efficiency of management and resource allocation, accountability, and patient and provider autonomy. The benchmarks standardize the criteria for fairness. Reforms are then evaluated by scoring according to the degree to which they improve the situation, i.e. on a scale of -5 to 5, with zero representing the status quo. The object is to promote discussion about fairness across the disciplinary divisions that keep policy analysts and the public from understanding how trade-offs between different effects of reforms can affect the overall fairness of the reform. The benchmarks can be used at both national and provincial or district levels, and we describe plans for such uses in the collaborating sites. A striking feature of the adaptation process is that there was wide agreement on this ethical framework among the collaborating sites despite their large historical...

Most commonly, lessons derived from comparisons of international health sector reform can only be generalized in a limited way to similar countries. However, there is little guidance as to what constitutes "similarity" in this respect. We propose that a framework for assessing similarity could be derived from the performance of individual policies in different contexts, and from the cause and effect processes related to the policies. We demonstrate this process by considering research evidence in the "public-private mix", and propose variables for an initial framework that we believe determine private involvement in the public health sector. The most influential model of public leadership places the private role in a contracting framework. Research in countries that have adopted this model suggests an additional list of variables to add to the framework. The variables can be grouped under the headings "demand factors", "supply factors", and "strength of the public sector". These illustrate the nature of a framework that could emerge, and which would help countries aiming to learn from international experience.

This paper examines the current health care reform issues in Canada. The provincial health insurance plans of the 1960s and 1970s had the untoward effects of limiting the federal government’s clout for cost control and of promoting a system centered on inpatient and medical care. Recently, several provincial commissions reported that the current governance structures and management processes are outmoded in light of new knowledge, new fiscal realities and the evolution of power among stake-holders. They recommend decentralized governance and restructuring for better management and more citizen participation. Although Canada’s health care system remains committed to safeguarding its guiding principles, the balance of power may be shifting from providers to citizens and "technocrats". Also, all provinces are likely to increase their pressure on physicians by means of salary caps, by exploring payment methods such as capitation, limiting access to costly technology, and by demanding practice changes based on evidence of cost-effectiveness.