Health Policy and Planning Advance Access published May 6, 2015 Health Policy and Planning, 2015, 1–15 doi: 10.1093/heapol/czv013 Review

Review

Primary health care research in Bolivia: systematic review and analysis Francisco N. Alvarez,1* Mart Leys,2 Hugo E. Rivera Me´rida2 and Giovanni Escalante Guzma´n2 Downloaded from http://heapol.oxfordjournals.org/ at University of Florida on November 13, 2015

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College of Physicians and Surgeons, Columbia University, New York, NY, USA and 2 Health Systems and Services, Pan American Health Organization/World Health Organization, Calle 18 No. 8022, Edificio Parque 18 piso 2 y 3, Zona Calacoto, La Paz, Bolivia *Corresponding author. College of Physicians and Surgeons, Columbia University, 630W 168th St, New York, NY 10032, USA. E-mail: [email protected] Accepted on 10 February 2014

ABSTRACT Bolivia is currently undergoing a series of healthcare reforms centred around the Unified Family, Community and Intercultural Health System (SAFCI), established in 2008 and Law 475 for Provision of Comprehensive Health Services enacted in 2014 as a first step towards universal health coverage. The SAFCI model aims to establish an intercultural, intersectoral and integrated primary health care (PHC) system, but there has not been a comprehensive analysis of effective strategies towards such an end. In this systematic review, we analyse research into developing PHC in Bolivia utilizing MEDLINE, the Virtual Health Library and grey literature from Pan American Health Organization/World Health Organization’s internal database. We find that although progress has been made towards implementation of a healthcare system incorporating principles of PHC, further refining the system and targeting improvements effectively will require increased research and evaluation. Particularly in the 7 years since establishment of SAFCI, there has been a dearth of PHC research that makes evaluation of such key national policies impossible. The quantity and quality of PHC research must be improved, especially quasi-experimental studies with adequate control groups. The infrastructure for such studies must be strengthened through improved financing mechanisms, expanded institutional capacity and setting national research priorities. Important for future progress are improved tracking of health indicators, which in Bolivia are often out-of-date or incomplete, and prioritization of focused national research priorities on relevant policy issues. This study aims to serve as an aid towards PHC development efforts at the national level, as well as provide lessons for countries globally attempting to build effective health systems accommodating of a multi-national population in the midst of development. Key words: Bolivia, health policy research, health systems, primary health care, SAFCI

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Key Messages • •





Despite progress towards primary health care (PHC) development, there continues to be limited research into the current state of the Bolivian health system and the efficacy of new PHC policies and interventions. Consistent with previous international trends, there were no experimental or quasi-experimental studies, one-fifth of the studies were repeated cross-sections without adequate controls and almost two-thirds were qualitative or simple crosssection designs. Review of relevant health indicators and publications shows varied levels of progress in access and universal coverage, leadership and governance and health financing and resources. Particular deficits in the quantity and quality of recent research make it virtually impossible to draw definite conclusions. Improved tracking of health indicators and focused research on national health reform are imperative, particularly the Unified Family, Community and Intercultural Health System law as there is little direct data on the effect of this key piece of legislation.

The Declaration of Alma-Ata defined primary health care (PHC) as ‘essential health care based on political, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their developing in the spirit of self-reliance and self-determination’ (WHO 1978). In the past 35 years much progress has been made worldwide in implementing health systems based on the PHC model. Nevertheless, these reforms have been uneven across countries, with different rates of decline in under-five mortality and life expectancy between high- and lowincome countries and across regions (Rajaratnam et al. 2010; Wang et al. 2012). The World Health Report in 2008 focused on renewing the commitment to PHC with health system reforms focused on four areas: universal coverage, service delivery, public policy and leadership (WHO 2008). Bolivia is a landlocked state in South America with 37 recognized indigenous ethnic groups representing over 60% of the population, reflected in the recently adopted epithet of ‘plurinational’. Its Human Development Index was 0.675 in 2012, ranked 27 out of 33 in the region of Latin America and the Caribbean (LAC) (UNDP 2012). With regards to key health indicators, Bolivia’s under-five mortality and maternal mortality were 50 and 310, respectively; in the Americas only Haiti consistently ranks lower (PAHO 2012). Nevertheless, Bolivia has already met the targets for Millennium Development Goals (MDGs) 4 (reduce child mortality) and 6 (combat human immunodeficiency virus/ acquired immune deficiency syndrome, malaria and other diseases) (UN 2014). Bolivia is not projected to achieve MDG 5 (improve maternal health) by 2020 and is thus considered ‘moderately off target’ (World Bank 2014). The management of health services is decentralized to four levels: national, departmental, municipal and local (Ministerio de Salud y Deportes 2009) (Figure 1). At the national level, health policies are developed by the National Assembly of Health (Asamblea Nacional de Salud) and executed by the Ministry of Health and Sports [Ministerio de Salud y Deportes (MSD)]. Bolivia’s nine departments each contain a Departmental Assembly of Health (Asamblea Departamental de Salud) that design Departmental Health Plans (Plan Departamental de Salud) and administer the Health Networks (Redes de Salud). The 339 municipalities contain a Municipal Health Board (Mesa Municipal de Salud) that administers health establishments within the municipality.

Lastly, the Local Health Committees (Comite´s Locales de Salud) allow for community participation in the management of health services. The current era of PHC reforms in Bolivia began in 1994 with the Ley de Participacio´n Popular (Ley No. 1551) and, the following year, the Ley de Descentralizacio´n Administrativa (Ley No. 1654), which attempted to improve the equity, efficiency and quality of health services by decentralizing the management of health establishments to municipalities and human resources to departments. The Universal Maternal and Child Insurance [Seguro Universal Materno Infantil (SUMI)] was enacted in 2003 as an expansion of policies begun in 1996 and covers 762 health services with coverage for pregnant women from beginning of pregnancy to 6 months after childbirth, women in childbearing age for reproductive and sexual health services and children younger than 5 years (Pooley et al. 2008; Ministerio de Salud 2012). The Health Insurance for Older Adults [Seguro de Salud para el Adulto Mayor (SSPAM)] is a more limited policy enacted in 2006 to cover citizens older than 60 years (PAHO 2012). In 2008, the Decreto Supremo 29601 established the Unified Family, Community and Intercultural Health System [Modelo Sanitario: Salud Familiar Comunitaria Intercultural (SAFCI)] to serve as the cornerstone of healthcare nationwide based upon the principles of community participation, intersectorality, interculturality and integrality (Ministerio de Salud y Deportes 2009b). In 2009, Bolivia ratified a new national constitution that established health as a right as had the 1961 and 1967 constitutions before it (Bolivia 2009; Tejerina et al. 2014). Currently, the Bolivian government is taking steps towards ensuring universal coverage via a centralized national payer system, beginning with the unification of SUMI and SSPAM via Ley 475 on Provision of Comprehensive Health Services, which entered effect in March 2014 (Gaceta Oficial del Estado Plurinacional de Bolivia 2013). The SAFCI model was enacted over 5 years ago with the purpose of transforming the Bolivian health system by introducing primary care in an intercultural, intersectoral and integrated manner. This study attempts an overview and analysis of the published research regarding PHC in Bolivia. We conducted a systematic review of published journal articles utilizing MEDLINE and the Virtual Health Library along with grey literature from the Pan American Health Organization/ World Health Organization (PAHO/WHO) Bolivia’s internal database of studies. The analysis and resulting recommendations are complemented by perspective from our own observations and experiences, as well as those gathered from various levels of Bolivia’s health system, including health workers from the departmental health services

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Introduction

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(Servicio Departamental de Salud [SEDES]) and physicians and auxiliary health personnel from primary hospitals and local health centres. The strengthening of PHC is essential not only for the progress of Bolivia’s health system but also to aid in the establishment of an equitable and socially just road to development. It is hoped this study will be of aid in such efforts at the national level, provide context and information for other countries in the Americas as they work together to provide a healthy future for all people in the region and provide lessons for countries globally that are attempting to build effective health systems accommodating of a multi-national population in the midst of development.

Methods Definition and evaluation of PHC The analysis presented on this article relies upon the thirteen elements of PHC as established by a PAHO position paper and elucidated further in a subsequent technical publication (PAHO 2007, 2008). To facilitate analysis and comparison of the sample of published studies, the 13 PHC elements were joined into five combined elements. Appropriate care, emphasis on promotion and prevention and comprehensive, integrated and continuing care were combined into ‘Prevention and Appropriate Care’. Sound policy, legal and institutional framework, pro-equity policies and programmes and intersectoral actions were combined into ‘Political and Legal Framework, Equity, and Intersectoral Collaborations’. Optimal organization and management, appropriate human resources and adequate sustainable resources were combined into ‘Organization, Management, and Resources’. Universal coverage and access and first contact were joined into ‘Access and Universal Coverage’. Family and community-based and active participation mechanisms

were combined into ‘Community and Family Orientation and Social Participation’.

Systematic review: data sources The literature review was conducted searching for relevant articles in PubMed and Virtual Health Library operated by BIREME to cover articles published in international journals and Latin American journals, respectively. In addition, PAHO/WHO Bolivia’s internal archive of studies was reviewed to identify relevant articles in the grey literature. Grey literature from the internal archive and indexed in the Virtual Health Library but not published in journals was reviewed and is referenced in our analysis but is not included in the systematic review analysis. This allows for direct comparison of research output with other countries whose grey literature is not included in the PAHO/WHO Bolivia archive; additionally, a primary objective of this study is to quantify the research output concerning Bolivian PHC in internationally available journals. The search used the Boolean operator ‘and’ to combine ‘Bolivia’ with the term ‘primary health care’, its Spanish translation ‘atencio´n primaria de salud’, and various truncations of the terms, all linked with ‘or’. All terms were searched using both the Medical Subject Headings (MeSH) indexing and a general search for the terms in ‘all fields’. All terms were searched in ‘exploded’ versions to include terms categorized below in the vocabulary hierarchies. No language or publication year restrictions were used. Search algorithms are included in the Appendix 1. The only inclusion criteria were that the study results should be applicable to at least one PHC element, described above, and relate specifically to Bolivia. Results from the search algorithms underwent abstract review to exclude entries that were not published in indexed journals, consisted of abstracts only or were news briefs, clinical

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Figure 1. Organizational chart of Bolivian governmental health care system

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Table 1. PHC elements researched by published articles PHC element

n

Percent of total

Appropriate care Universal coverage and access Emphasis on promotion and prevention Optimal organization and management Family and community based Sound policy, legal and institutional framework Active participation mechanisms Appropriate human resources Adequate and sustainable resources Comprehensive, integrated and continuing care Intersectoral actions Pro-equity policies and programmes First contact

9 8 8 7 5 5 3 3 3 2 2 0 0

35 31 31 27 19 19 12 12 12 8 8 0 0

PHC element

Topics studied

n

Political and Legal Framework, Equity and Intersectoral Collaborations Prevention and Appropriate Care

(see Table 4)

11

Breastfeeding, diarrhoea, tuberculosis, mental health, sexual and reproductive health, oral health Healthcare provider training (2), auditing, community health workers, family physicians Distance to health establishment (2)

6

2

Women’s organizations

2

Organization, Management and Resources Access and Universal Coverage Community and Family Orientation and Social Participation

5

manuals or editorials. Duplicates between the databases were also reconciled. The remaining entries underwent full-text analysis to exclude those that did not have an outcome relating to a PHC element, were not related to Bolivia or which had grouped multinational results from which Bolivia-specific information could not be extracted. The remaining articles were included in the systematic review and underwent full-text analysis to extract study design, population, outcome measures and results. Table 5 includes a compilation of the extracted characteristics of the studies included in the systematic review. The articles under final review were classified by the 13 PHC elements as described by PAHO according to their outcomes (PAHO 2008). The total number of articles in the analysis sum to more than the total number of articles in the review since an article may have multiple results that each fall under a different PHC element (Table 1). To gain a granular appreciation for the topics covered, the articles were also classified by what was judged to be the single best fit of the five combined PHC elements described above (Table 2).

Systematic review: PHC investigations in comparison An impetus for conducting the systematic review was to evaluate the quantity of investigations about PHC in Bolivia. To generate a

Results Systematic review The initial search produced 72 articles on PubMed and 154 articles through Virtual Health Library/BIREME. After excluding 164 entries after abstract review and 36 entries after full-text review, 26 articles are included in this systematic review (Figure 2). The earliest articles were published in 1990 and 5 were published before 1998, 12 between 1998 and 2002, 4 between 2003 (passage of SUMI) and 2007 and 5 since 2008 (passage of SAFCI). To assess study design, a classification system used in previous systematic reviews of PHC interventions was employed (Macinko et al. 2009). Of the 26 publications in review, 10 were qualitative studies, 7 were simple cross-sections, 5 were repeated (pre–post) cross-sectional designs without controls and 4 were repeated (pre– post) cross-sectional designs with controls. To date, there are no experimental or quasi-experimental studies, prospective studies with control groups, case-control studies or systematic literature reviews. To evaluate the quantity of investigations about Bolivian PHC, we did a cross-country comparison of the Americas using a standardized search algorithm (Table 3). Bolivia out-performs the trend of Latin American countries for its population and GDP, ranking 10/ 17 in total search results, 8/17 in results per capita (compared with 10/17 in population), 3/17 in results per GDP (compared with 13/17 in GDP), 5/17 in results per GDP per capita (compared with 15/17 in GDP per capita) and 4/17 in results as a factor of MEDLINE publications in 2010. Nevertheless, the United States and Canada outpace the Latin American countries, even when adjusting for GDP and population (top ranked in total results, results per capita, results per GDP per capita, and within top four of results per GDP). Therefore, as a whole, research productivity on PHC in Latin American countries is not keeping pace with that in the United States and Canada. Jamaica was included to control for overrepresentation of English-speaking countries in English-language journals. Although Jamaica’s results per capita is higher than the rest of Latin America, the fact that it is not an outlier in any other calculation suggests that result is due to Jamaica’s small population. To evaluate the subject of investigation of the Bolivian studies, the results of the studies were classified according to PAHO’s 13 PHC elements (Table 1). Approximately one-third of studies had results relating to appropriate care, universal coverage and access and emphasis on promotion and prevention. The least-studied elements were comprehensive, integrated and continuing care, intersectoral actions, pro-equity policies and programmes and first contact. In addition, the studies were categorized by their single best fit of the combined PHC elements (Table 2). Studies that focused on Political and Legal Framework, Equity and Intersectoral Collaborations accounted for 42% of the total studies, followed by 23% focusing on Prevention and Appropriate Care. Organization, Management and Resources accounted for 19% of the studies, whereas Access and Universal Coverage and Community and Family Orientation and Social Participation accounted for 8% each.

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Table 2. Published articles by combined PHC element primary focus and topics researched

standardized, raw index of research output, we prepared a crosscountry comparison of the Americas using the same PubMed search algorithm as above and substituting the given country’s name for the ‘Bolivia’ search term to produce a standardized measure of PHC publications in international journals by country. We then normalized the search results by population, gross domestic product (GDP), GDP per capita and publications indexed in MEDLINE in 2010 (Table 3).

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Table 3. Research productivity in PHC by country Country

Results/100 000 population

Results/GDP ($billions)

Results/GDP per capita ($hundreds)

Results/MEDLINE publications in 2010

44 181 7243 904 310 209 183 168 148 117 102 101 73 72 72 57 43 34 31 29 21

14.07 20.75 0.75 1.77 0.51 1.62 0.35 5.48 0.39 1.70 0.67 1.52 0.69 0.46 0.19 0.54 0.89 0.91 0.46 0.31

2.82 3.98 0.77 1.16 0.44 3.00 0.45 0.99 0.59 9.27 1.98 1.62 2.67 0.85 0.15 2.39 0.94 0.63 1.20 0.81

88.36 13.88 9.32 2.01 1.80 3.39 2.15 2.69 1.78 5.67 2.97 0.78 2.77 1.31 0.45 1.87 0.36 0.22 0.76 0.55

0.30 0.27 0.08 0.75 0.24 1.18 0.35 5.37 3.61 0.80 3.43 1.18 0.19 4.30 0.92 0.15 2.42 1.40

Source: Author’s calculations using 2012 data from the World Bank (‘Population, total’, ‘GDP (current $)’, ‘GDP per capita (current $)’) and the latest available data from the Red de Indicadores de Ciencia y Tecnologı´a—Iberoamericana e Interamericana (RICYT) (‘Papers in MEDLINE’). a Last available GDP data for Cuba is from 2008.

Access and universal coverage

Figure 2. Systematic review process diagram

The studies focusing on Political and Legal Framework, Equity and Intersectoral Collaborations are further dissected in Table 4. It is notable that of the 11 studies published in indexed journals focusing on evaluating the framework and organization of the primary health system, only one has been published in the past decade.

Access and coverage in PHC is often considered by availability, accessibility, affordability and acceptability (Jacobs et al. 2012). These are primary concerns for PHC development in Bolivia due to its difficult geography, multi-national population and high poverty levels. Improved social participation and outreach have been key factors in interventions to improve access to care. The census-based, impact-oriented (CBIO) approach developed by Consejo de Salud Rural Andino/Asosiacio´n de Programas de Salud del Area Rural (CSRA/APSAR) increased coverage in terms of prenatal care and immunizations through a health system centred around social participation in determining health priorities and outreach through home visitations (Moshman 2011; Perry et al. 1998, 1999, 2003). Similarly, Kwast (1996) found that women’s organizations were influential for increasing prenatal care and institutional births, and Kinman (1999) reported that time spent living in a community was predictive of health services use, suggesting acceptability of health services increases with community engagement. Distance to a health establishment was also found to be predictive of usage of health services (Kinman 1999). Perry and Gesler (2000) reported in a study of three representative communities in Bolivia that between 12% and 70% of the population lived at greater than 1-h distance from the closest primary care clinic depending on the community. This highlights the need for effective and resource-conscious strategies for providing access to health services given Bolivia’s geography and dispersed population. Decentralization of health services through the development of the sistema local de salud (SILOS) programme had marginal improvements in health access and coverage (Lavadenz Mantilla and Roca de Sangueza 1990). Furthermore, intercultural initiatives, a major emphasis of the SAFCI reform, may result in improved access as Kinman (1999) reported that languages spoken were predictive of health services use. Notably, education level

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The United States Canada Mexico Chile Argentina Cubaa Colombia Jamaica Peru Nicaragua Guatemala Costa Rica Bolivia Ecuador Venezuela Honduras Panama Uruguay El Salvador Paraguay

MEDLINE results

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Table 4. Published articles focusing on Bolivian health system models n

Pro

Con

References

Bolivian government health system reforms Consejo de Salud Rural Andino/ Asociacio´n de Programas de Salud del Area Rural (CSRA/APSAR) Asociacio´n Proteccio´n a la Salud (PROSALUD) (United States Agency for International Development [USAID]) Integrated Primary Health Care Project (PROISS) (World Bank)

3

No sufficient recent data

No sufficient recent data

3

Social participation, increased coverage

Long implementation time (10–15 years)

Pereira et al. (2012), Bermu´dez et al. (2001), Mendiza´bal Lozano (1998) Perry et al. (1998, 1999, 2003)

2

Self-financing, increased coverage

Less social focus, privatization

Wayland and Crowder (2002) and Fiedler (1990)

1

Increased coverage

Homedes (2001)

Health Network transfer to NGO

1

SILOS

1

Increased use of services, improved management Emphasis on prevention, increased coverage

Dependent on foreign financing, little structural reform, heavily personnel dependent Not scalable Little increase in use of services

Lavadenz Mantilla and Roca de Sangueza (1990)

was not significant in use of services or health outcomes (Kinman 1999; Caruso et al. 2010). It should be noted that the SILOS study and that published by Kinman (1999) were conducted before the recent changes in Bolivia’s sociopolitical climate and may not be representative of attitudes towards health services among the general population today. Caruso et al. (2010) found that neither access to care nor maternal experience and behaviour altered reported prevalence of diarrhoea in children, suggesting that improved access is necessary but not sufficient for improving health indicators. Factors that did alter reported prevalence were economic status and maternal agency, reinforcing a role for social participation and intersectoral approaches. Kinman (1999) further found that economic concerns were the most reported reason for not utilizing health services.

Prevention and appropriate care A cornerstone of PHC implementation in low- and middle-income countries is a focus on prevention and an increase in appropriate care. Various studies have shown the need for improving appropriate care in the Bolivian healthcare system. Tuberculosis and other respiratory infections have been the most studied, with Lanza et al. (2000) finding that in primary care centres 69 different treatment protocols for tuberculosis were utilized on 423 patients and only 14.49% of the protocols were officially approved. Camacho et al. (2007) found that after a 1-week training session for general practitioners, sputum microscopy ordered for patients with cough of more than 15 days increased from 42.5 to 55.1% and for patients with cough of less than 15 days decreased from 4.7 to 1.3%. Similarly, Siddiqi et al (2007) implemented audits of primary health clinics over a 2-year period and found that patients indicated for sputum microscopy who had at least two samples examined increased from 30 to 53%. The need for improved mental health care has also been documented, with only 0.05% of studied PHC consults including any mental health evaluation (Camacho-Arce et al. 2009). Furthermore, only 10 out of the 15 centres visited in El Alto had available psychotropic drugs and 20% of physicians cited the lack of appropriate medications as a barrier to mental health treatment (Camacho-Arce et al. 2009).

Lavadenz et al. (2001)

To address the need for improved care, training of providers has proved to be effective. The results of a 1-week training session in respiratory infections have been discussed above (Camacho et al. 2007). Likewise, a 1-day course on tuberculosis for community health workers increased scores on a proficiency exam, including identifying a respiratory infection (60% to 83%) and treating respiratory infections (34% to 76%) (Zeitz et al. 1994). Improving the training of physicians may lead to better mental health care since in one study none of the physicians observed in practice pursued mental health issues in-depth and 30% of physicians cited the lack of trained specialists as a barrier to mental health care (CamachoArce et al. 2009). The need for improved provider training in the needs of adolescents and treatments in sexual and reproductive health was also emphasized among healthcare providers (Jaruseviciene et al. 2013). Another strategy for improving care is improved auditing, whose results are described above (Siddiqi et al. 2007). Lastly, there is a need for improved implementation of standardized protocols, as documented in the treatment of tuberculosis discussed above (Lanza et al. 2000) and in a study of primary health clinics in El Alto, which found that none had mental health protocols (Camacho-Arce et al. 2009). Appropriate care is most effective when combined with prevention, and numerous studies have shown room for improvement in preventive care in Bolivia. In the CSRA/APSAR system, 78% of children aged 1–2 years received all recommended vaccinations compared with 8% of children in the control area, and infant mortality was 52.1% lower in the intervention area (Perry et al. 2003). The early evaluation of the SILOS programme found geographical coverage of vaccinations increased to 100%, and total vaccinations for children younger than 5 years was 98% (Lavadenz Mantilla and Roca de Sangueza 1990). Furthermore, transferring a health network to non-governmental organization (NGO) administration increased institutional births by 41% (Lavadenz et al. 2001). Finally, the development of a PHC programme for preventative oral health was the primary recommendation in a study of dental cavities and fluorosis (Soza-Gonza´les et al. 2012). Health promotion is a socially active method for concentrating the gains made in improved care and prevention. Mobilizing

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Political and legal framework, equity and intersectoral collaborations

Simple cross-section

Qualitative study

Caruso, Stephenson and Leon 2010

Ceitlin (2006)

Prevalence of mental health visits, reported barriers to mental health care

Logistic regression model of determinants of diarrhoea in children across three indices: maternal behaviour and experience, access to care, maternal agency Population per family physician, history of family medicine in Latin America

Appropriate care in mental health

Prevention of diarrhoea in children

Human resources in family medicine

Number of consults, tuberculosis detection rate, number of medications per capita, cost of medications per capita

Concordance of Bolivian PHC reforms with international standards and PHC elements

Qualitative assessment of community health workers efficacy and barriers to care

Main outcome

Appropriate care in pulmonary diseases

PHC policy, legal and institutional framework

Appropriate human resources in community health workers

PHC measures

(continued)

The author concludes that community health workers can aid in integration of Western and traditional medicine. Efficacy was maximized by active community involvement, adopting community beliefs and customs and adapting to existing leadership systems. Barriers arose when workers used their position to promote their own religious beliefs or abused their technical knowledge to gain social status. The authors find that the governmental PHC reforms from 1993 to 1999 are in agreement with international recommendations. They assert it is too early to measure reform impact but report a qualitative improvement in geographic access to services, basic insurance implementation and community orientation. After a 1-week course in pulmonary disease management, consults were reduced by 34.6%, medications per capita were reduced by 16.2% and the average medication cost per capita was reduced by 32.3%. The authors found 0.05% of visits were mental health oriented. Barriers to care per providers included lack of a specialized mental health referral centre (60% of providers), insufficient time (40%), lack of specialized personnel (33.3%), shortage of psychiatric medications (20%) and insufficient training (16.6%). Observations included lack of human resources, lack of protocols for mental health care and lack of integration of mental health problems with medical records system. Statistically significant (P < 0.05) predictors of decreased prevalence of diarrhoea in children were increased maternal agency and economic status. Maternal primary education (but not secondary education or higher) was significantly correlated with increased prevalence of diarrhoea compared with no maternal education. Bolivia has 21 000 population per family physician (sixth in Latin America), but the actual number of family physicians (400) falls short of the ideal (4200). The author finds that throughout Latin America, there is a shortage of family physicians that hinders PHC progress.

Impact/result

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Cross-country comparison of family medicine in Latin America

Women with children under 5 years in Bolivia Demographic Health Survey 2003 (n ¼ 4383)

Interviews and focus groups of PHC providers and patients, chart review and observation in 15 public PHC centres in Red Corea, El Alto

Qualitative study

Bolivian government PHC reforms 1993–1999

Camacho-Arce et al. (2009)

Qualitative study

Bermu´dez et al. (2001)

Observation of 70 community health workers in Oruro 1982–1988

78 general practitioners from 65 public PHC centres in El Alto, La Paz, Oruro and Potosı´

Qualitative study

Bastien (1990)

Population

Camacho et al. (2007) Repeated (pre-post) cross-sectional design without control

Design

Reference

Table 5. Summary of PHC research in Bolivia

PRIMARY CARE RESEARCH IN BOLIVIA 7

Design

Simple cross-section

Simple cross-section

Qualitative study

Qualitative study

Simple cross-section

Repeated (pre-post) cross-sectional design without control

Reference

Fiedler (1990)

Forste (1998)

Homedes (2001)

Jaruseviciene et al. (2013)

Kinman (1999)

Kwast (1996)

Women’s groups in 50 communities in Inquisivi

5400 visits at an NGO clinic in Chilimarca and 369 households

Discussions with 46 PHC providers in Cochabamba

Observation of PROISS intervention, World Bank documents, interviews with functionaries and PHC providers

Children 3-36mo in Bolivia Demographic and Health Survey 1989 (n ¼ 2575)

17 self-financed NGO (PROSALUD) PHC centres 1987–1989

Population

Social participation in maternal health

Service utilization at an NGO PHC clinic

Access and use of sexual and reproductive health services by adolescents; provision of reproductive health services

Organization and management of externally funded PHC interventions

Prevention of diarrhoea in children

Organization and management of PHC clinics

PHC measures

Impact/result

(continued)

Cost of NGO service as percentage NGO clinics offered services at a fraction of the of recommended cost; preventive recommended minimal price (36.7% of recommended services as percentage of total price for general/family practitioner visit, 34.4% of health services recommended price for specialist visit, 18.3% of recommended price for birth/delivery, 17.8% of recommended price for sutures). Between 1987 and 1989 preventive services accounted for 39.3–48.1% of total services. Logistic regression models of Stopping breastfeeding before 6 months was significantly breastfeeding in relation to correlated with increased prevalence of diarrhoea diarrhoea and stunting in (P < 0.001). Supplementing with solids (but not liquids) children was also significantly correlated with increased prevalence of diarrhoea (P < 0.001). Success factors and barriers in The author finds there were multiple barriers to PROISS PROISS implementation, implementation, but ultimately the World Bank and 1990–1997 MSD were focused on maintaining the grant at the expense of health services improvement, there was a lack of accountability and short-term gains were preferred to long-term structural reform. The author further reports administrative instability, dysfunctional public administration and dysfunctional legal and institutional framework. Major recommendations included management and Management optimization, appropriate human resources, human resource optimization (prioritize adolescents, policy and institutional educate providers on treating adolescents), increased social participation (integrate with schools, families and framework community) and improvement in policy and institutional framework (standardized clinical protocols, intersectoral action) Service utilization by household A Lorenz curve showed 50% of clinic visits were by 20% of patients and 50% of patients made 15% of clinic and logistic regression of factors visits. Statistically significant factors predictive of service predictive of utilization (length of residence, distance from utilization included length of residence (P ¼ 0.0002), distance from clinic (P ¼ 0.0018) and language spoken clinic, language spoken at home, at home (0.007). Place of origin and education level place of origin, education level) were not significant factors. Strengthening of women’s organizations between 1990 Prenatal care rates, births assisted by traditional birth attendants, and 1993 led to an increase in prenatal care from 45 to breastfeeding within 1hr 77%, births assisted by traditional birth attendants postpartum, family planning increased from 13 to 57%, breastfeeding within 1hr use, perinatal mortality postpartum increased from 25 to 57%, family planning use increased from 0 to 27%, perinatal mortality decreased from 11 to 7 (105/1000 population to 38/1000 population).

Main outcome

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Table 5. Continued

8 Health Policy and Planning, 2015, Vol. 0, No. 0

Design

Simple cross-section

Repeated (pre-post) cross-sectional design with control

Repeated (pre-post) cross-sectional design without control

Qualitative study

Repeated (pre-post) cross-sectional design with control

Qualitative study

Repeated (pre-post) cross-sectional design with control

Reference

Lanza, Campos and Urquieta (2000)

Lavadenz, Schwab and Straatman (2001)

Lavadenz Mantilla and Roca de Sangueza (1990)

Mendiza´bal Lozano (1998)

O’Rourke, HowardGrabman and Seoane (1998)

Pereira et al. (2012)

Perry et al. (1998)

PHC measures

PHC policy, legal and institutional framework

Optimal organization and management of health system

Optimal organization and management of health centre resources

3 intervention sites and 2 comparison sites in La Paz, Cochabamba and Santa Cruz departments

Cross-country comparison of Bolivia, Brazil, Venezuela and Uruguay legal framework

Integrated PHC service delivery of basic health services by an NGO

PHC legal and institutional framework

409 women in 50 communities in Social participation in Inquivisi province maternal health

History of PHC in Bolivia, 1978–1998

1 health district in Santa Cruz (population ¼ 74 000)

1 secondary-level health centre and 8 primary-level health centres in El Alto

423 tuberculosis patients in 11 Appropriate care in health centres (5 primary-level, tuberculosis 6 secondary-level)

Population

Under-five mortality, vaccination coverage, percentage of children with three growth assessments, programme cost

Health system type, organization, financing, regulation; concept of PHC and resource distribution, models of service delivery, integration, intersectorality, social participation, human resources, interculturality

Perinatal mortality rate, participation rate in women’s organizations, prenatal care rates, 1d-postpartum breastfeeding rates

Geographic area of immunization coverage, immunization coverage children under 5 years, hospital-based births, health services coverage of children under 5 years Concepts of health and their relation to socioeconomic development

Percentage of hospital beds occupied, average hospital stay, number of external consults, hospital-based births

Number of different clinical protocols for tuberculosis management

Main outcome

(continued)

The authors find that across the 423 patients, 69 different clinical protocols for tuberculosis management were employed; 14.49% of the 69 clinical protocols were officially approved and only 40.43% of patients received care by officially approved protocols. After transferring a health network to management by an NGO, percentage of hospital beds occupied increased from 74% to 83% (despite an increase in total number of beds from 33 to 110), external consults increased 55% (83% in the hospital and 18% in PHC centres) and hospital-based births increased 41%. After a government pHC intervention lasting 10 months, immunization coverage reached 100% of geographic areas, 98% of children under 5 years received immunizations, hospital-based births increased from 14% to 16%, health services coverage for children under 5 years increased from 18 to 27%. The author concludes that in 20 years since Alma-Ata and with 3 WHO/PAHO initiatives, health has been accepted as a central tenant of development and a key product of PHC initiatives. After strengthening of 50 women’s organizations throughout 2 years, perinatal mortality rate decreased from 117/1000 population to 43.8/1000 population (P < 0.001); participation in women’s organizations increased from 7.6 to 54.4% (P < 0.001); perinatal care rates increased from 49 to 64.2% (P ¼ 0.009); breastfeeding 1 day postpartum increased from 25.3 to 50.3% (P < 0.001). Found common trend towards universal coverage and comprehensive PHC. In Bolivia, PHC services are first contact and integrate health promotion, prevention, appropriate care and rehabilitation. Social participation is established in SAFCI law. Financing is decentralized to municipalities. Group-specific insurance persist and co-pays are not covered by public insurance. SAFCI is focused on social medicine but not social determinants of health. Under-five mortality was 32–64% lower in intervention areas vs comparison areas; 78% of children 12–23 mo had all vaccinations compared with 8% in comparison area; 80% of children 12–23 mo had three growth assessments compared with 8% in comparison area; estimated program cost was USD $8.57 per capita.

Impact/result

Downloaded from http://heapol.oxfordjournals.org/ at University of Florida on November 13, 2015

Table 5. Continued

PRIMARY CARE RESEARCH IN BOLIVIA 9

Qualitative study

Simple cross-section

Repeated (pre-post) cross-sectional design with control

Repeated (pre-post) cross-sectional design without control Simple cross-section

Perry et al. (1999)

Perry and Gesler (2000)

Perry, et al. (2003)

Siddiqi et al. (2007)

Qualitative study

Repeated (pre-post) cross-sectional design without control

Wayland and Crowder (2002)

Zeitz et al. (1994)

Soza-Gonza´les et al. (2012)

Design

Reference

80 community health workers in Tambillo (La Paz), Mizque (Cochabamba) and Anzaldo (Cochabamba)

Interviews with 93 households and 402 patients in a PROSALUD PHC clinic in El Alto

School-aged children (4-15years) in 4 municipalities of Potosı´ department (n ¼ 213)

8 PHC centres in Cochabamba

Children under 5 years in intervention (n ¼ 2103) and nonintervention (n ¼ 596) areas

3 areas in El Alto department (Carabuco, Ambana´, Charazani)

7 intervention sites in Northern Altiplano, Cochabamba and Santa Cruz

Population

Appropriate care in respiratory infections

Family and community orientation of PHC services

Prevention in dental care

Comprehensive PHC services (prenatal care, immunizations, growth monitoring, nutrition rehabilitation, acute care treatment) Appropriate care in tuberculosis diagnosis

Geographical access to PHC services

Integrated PHC service delivery of basic health services by an NGO

PHC measures

Exam scores in clinical management of respiratory infections

Definitions of ‘community’ and their relation to barriers in PHC services

Percentage of patients with suspected tuberculosis in which sputum microscopy was utilized (sputum examinations x2) Prevalence of dental caries (decayed-missing-filled teeth (DMFT) index) and fluorosis (Dean index)

Under-five mortality

Number of communities and percentage of population

Primary health care research in Bolivia: systematic review and analysis.

Bolivia is currently undergoing a series of healthcare reforms centred around the Unified Family, Community and Intercultural Health System (SAFCI), e...
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