World Health Report 2000: a step towards evidence-based health policy.
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Child↗
Biomedical subjects
J Frenk
Publications and source records attributed to J Frenk.
Science or marketing at WHO? A response to Williams.
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Delivery of Health Care↗
Measuring quality: from the system to the provider.
The literature on quality has often focused on process indicators. In this paper we outline a framework for describing and measuring the quality of health systems in terms of a set of desirable outcomes. We illustrate how it can be measured using data collected from a recent evaluation of health system performance conducted by the World Health Organization (WHO). We then explore the extent to which this framework can be used to measure quality for all components of the system; for example, regions, districts, hospitals, and providers. There are advantages and disadvantages to defining quality in terms of outcomes rather than process indicators. The advantage is that it focuses the attention of policy makers on whether systems are achieving the desired goals. In fact, without the ability to measure outcomes it is not possible to be sure that process changes actually improve attainment of socially desired goals. The disadvantage is that measuring outcomes at all levels of the system poses some problems particularly related to the sample sizes necessary to measure outcomes. WHO is exploring this, initially in relation to hospitals. The paper discusses two major challenges. The first is the question of attribution, deciding what part of the outcome is due to the component of the system under discussion. The second is the question of timing, including all the effects of current health actions now and in the future.
Delivery of Health Care↗
The gender composition of the medical profession in Mexico: implications for employment patterns and physician labor supply.
The gender composition of the medical profession is changing rapidly in many parts of the world, including Mexico. We analyze cross-sectional and longitudinal data on sex differences in physician employment from household employment surveys. The results suggest that Mexico is a particularly interesting example of the feminization of physician employment. Female enrollment in medical school increased from 11% in 1970 to about 50% in 1998. The increased participation of women in medicine seems to be accompanied by differences in employment patterns that could generate significant reductions in the total supply of physician hours of service. Women physicians are unemployed at a much higher rate than men and hence account for half of underused physician human capital. The results suggest that improved educational opportunities do not translate automatically into equal employment opportunities.
Adult↗
Defining and measuring health inequality: an approach based on the distribution of health expectancy.
This paper proposes an approach to conceptualizing and operationalizing the measurement of health inequality, defined as differences in health across individuals in the population. We propose that health is an intrinsic component of well-being and thus we should be concerned with inequality in health, whether or not it is correlated with inequality in other dimensions of well-being. In the measurement of health inequality, the complete range of fatal and non-fatal health outcomes should be incorporated. This notion is operationalized through the concept of healthy lifespan. Individual health expectancy is preferable, as a measurement, to individual healthy lifespan, since health expectancy excludes those differences in healthy lifespan that are simply due to chance. In other words, the quantity of interest for studying health inequality is the distribution of health expectancy across individuals in the population. The inequality of the distribution of health expectancy can be summarized by measures of individual/mean differences (differences between the individual and the mean of the population) or inter-individual differences. The exact form of the measure to summarize inequality depends on three normative choices. A firmer understanding of people's views on these normative choices will provide a basis for deliberating on a standard WHO measure of health inequality.
Analysis of Variance↗
A framework for assessing the performance of health systems.
Health systems vary widely in performance, and countries with similar levels of income, education and health expenditure differ in their ability to attain key health goals. This paper proposes a framework to advance the understanding of health system performance. A first step is to define the boundaries of the health system, based on the concept of health action. Health action is defined as any set of activities whose primary intent is to improve or maintain health. Within these boundaries, the concept of performance is centred around three fundamental goals: improving health, enhancing responsiveness to the expectations of the population, and assuring fairness of financial contribution. Improving health means both increasing the average health status and reducing health inequalities. Responsiveness includes two major components: (a) respect for persons (including dignity, confidentiality and autonomy of individuals and families to decide about their own health); and (b) client orientation (including prompt attention, access to social support networks during care, quality of basic amenities and choice of provider). Fairness of financial contribution means that every household pays a fair share of the total health bill for a country (which may mean that very poor households pay nothing at all). This implies that everyone is protected from financial risks due to health care. The measurement of performance relates goal attainment to the resources available. Variation in performance is a function of the way in which the health system organizes four key functions: stewardship (a broader concept than regulation); financing (including revenue collection, fund pooling and purchasing); service provision (for personal and non-personal health services); and resource generation (including personnel, facilities and knowledge). By investigating these four functions and how they combine, it is possible not only to understand the proximate determinants of health system performance, but also to contemplate major policy challenges.
Delivery of Health Care↗
Trends in medical employment: persistent imbalances in urban Mexico.
OBJECTIVES: This study examined the extreme medical unemployment and underemployment in the urban areas of Mexico. The conceptual and methodological approach may be relevant to many countries that have experienced substantial increases in the supply of physicians during the last decades. METHODS: On the basis of 2 surveys carried out in 1986 and 1993, the study analyzed the performance of physicians in the labor market as a function of ascription variables (social origin and gender), achievement variables (quality of medical education and specialty studies), and contextual variables (educational generation). RESULTS: The study reveals, despite some improvement, persistently high levels of open unemployment, qualitative underemployment (i.e., work in activities completely outside of medicine), and quantitative underemployment (i.e., work in medical activities but with very low levels of productivity and remuneration). The growing proportion of female doctors presents new challenges, because they are more likely than men to be unemployed and underemployed. CONCLUSIONS: While corrective policies can have a positive impact, it is clear that decisions regarding physician supply must be carefully considered, because they have long-lasting effects. An area deserving special attention is the improvement of professional opportunities for female doctors.
Employment↗
Health inequalities and social group differences: what should we measure?
Both health inequalities and social group health differences are important aspects of measuring population health. Despite widespread recognition of their magnitude in many high- and low-income countries, there is considerable debate about the meaning and measurement of health inequalities, social group health differences and inequities. The lack of standard definitions, measurement strategies and indicators has and will continue to limit comparisons--between and within countries, and over time--of health inequalities, and perhaps more importantly comparative analyses of their determinants. Such comparative work, however, will be essential to find effective policies for governments to reduce health inequalities. This article addresses the question of whether we should be measuring health inequalities or social group health differences. To help clarify the strengths and weaknesses of these two approaches, we review some of the major arguments for and against each of them.
Causality↗
Medical care and health improvement: the critical link.
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Health Services Accessibility↗
International collective action in health: objectives, functions, and rationale.
To improve the performance of international health organisations, their essential functions must be agreed. This paper develops a framework to discuss these essential functions. Two groups are identified: core functions and supportive functions. Core functions transcend the sovereignty of any one nation state, and include promotion of international public goods (eg, research and development), and surveillance and control of international externalities (eg, environmental risks and spread of pathogens). Supportive functions deal with problems that take place within individual countries, but which may justify collective action at international level owing to shortcomings in national health systems-such as helping the dispossessed (eg, victims of human rights violations) and technical cooperation and development financing. Core functions serve all countries, whereas supportive functions assist countries with greater needs. Focus on essential functions appropriate to their mandate will better prepare international health organisations to define their roles, eg for WHO to focus on core functions and for the World Bank to focus on supportive ones.
Global Health↗
The New World order and international health.
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Delivery of Health Care↗
Structured pluralism: towards an innovative model for health system reform in Latin America.
Health systems throughout the world are searching for better ways of responding to present and future challenges. Latin America is no exception in this innovative process. Health systems in this region have to face a dual challenge: on the one hand, they must deal with a backlog of accumulated problems characteristic of underdeveloped societies; on the other hand, they are already facing a set of emerging problems characteristic of industrialized countries. This paper aims at analyzing the performance of current health systems in Latin America, while proposing an innovative model to promote equity, quality, and efficiency. We first develop a conceptualization of health systems in terms of the relationships between populations and institutions. In order to meet population needs, health systems must perform four basic functions. Two of these-financing and delivery-are conventional functions performed by every health system. The other two have often been carried out only in an implicit way or not at all. These neglected functions are 'modulation' (a broader concept than regulation, which involves setting transparent and fair rules of the game) and 'articulation' (which makes it possible to organize and manage a series of transactions among members of the population, financing agencies, and providers so that resources can flow into the production and consumption of services). Based on this conceptual framework, the paper offers a classification of current health system models in Latin America. The most frequent one, the segmented model, is criticized because it segregates the different social groups into three segments: the ministry of health, the social security institute(s), and the private sector. Each of these is vertically integrated, so that it performs all functions but only for a particular group. As an alternative, we propose a model of 'structured pluralism', which would turn the current system around by organizing it according to functions rather than social groups. In this model, modulation would become the central mission of the ministry of health, which would move out of the direct provision of personal health services. Financing would be the main function of social security institutes, which would be gradually extended to protect the entire population. The articulation function would be made explicit by fostering the establishment of 'organizations for health services articulation', which would perform a series of crucial activities, including the competitive enrollment of populations into health plans in exchange for a risk-adjusted capitation, the specification of explicit packages of benefits or interventions, the organization of networks of providers so as to structure consumer choices, the design and implementation of incentives to providers through payment mechanisms, and the management of quality of care. Finally, the delivery function would be open to pluralism that would be adapted to differential needs of urban and rural populations. After examining the convergence of various reform initiatives towards elements of the structured pluralism model, the paper reviews both the technical instruments and the political strategies for implementing changes. The worldwide health reform movement needs to sustain a systematic sharing of the unique learning opportunity that each reform experience represents.
Delivery of Health Care↗
Commerce in health services in North America within the context of the North American Free Trade Agreement.
This article discusses the future of commercial trade in personal health services in North America within the context of the North American Free Trade Agreement (NAFTA) and the latter's potential influence on health care for the Mexican people. It begins by defining concepts related to international trade of services, particularly health services, and then proceeds to analyze elements of NAFTA that affect the delivery, regulation, and financing of such services, as well as their future trade within the NAFTA area. It concludes with some recommendations directed at helping Mexico's national health care system confront the risks posed while taking advantage of the opportunities offered by the Mexican economy's entry into a broader market.
Commerce↗
[Hospital certification].
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Certification↗
Monitoring and Protecting Health and Human Rights in Mexico.
This paper describes a unique system through which health care-related human rights are now being monitored and protected in Mexico. Based on the ombudsman concept, the system focuses on identifying and responding to violations of human rights and dignity which may occur in the context of health care delivery. Experience thus far has been encouraging; the Mexican population has identified and used the National Commission of Human Rights as a forum for a variety of health-related complaints. The Mexican system, while requiring strengthening and expansion, is an effort to integrate the monitoring and protection of health-related human rights into the broader field of human rights work in Mexico.
Journal Article↗
Dimensions of health system reform.
During recent years there has been a growth of worldwide interest in health system reform. Countries at all levels of economic development are engaged in a creative search for better ways of organizing and financing health care, while promoting the goals of equity, effectiveness, and efficiency. Together with economic, political, and ideological reasons, this search has been fueled by the need to find answers to the complexities posed by the epidemiologic transition, whereby many nations are facing the simultaneous burdens of old, unresolved problems and new, emerging challenges. In order to better understand reform attempts, it is necessary to develop a clear conception of the object of reform: the health system. This paper presents the health system as a set of relationships among five major groups of actors: the health care providers, the population, the state as a collective mediator, the organizations that generate resources, and the other sectors that produce services with health effects. The relationships among providers, population, and the state form the basis for a typology of health care modalities. The type and number of modalities present in a country make it possible to characterize its health system. In the last part, the paper proposes that health system reform operates at four policy levels: systemic, which deals with the institutional arrangements for regulation, financing, and delivery of services; programmatic, which specifies the priorities of the system, by defining a universal package of health care interventions; organizational, which is concerned with the actual production of services by focusing on issues of quality assurance and technical efficiency; and instrumental, which generates the institutional intelligence for improving system performance through information, research, technological innovation, and human resource development. The dimensions of reform offer a repertoire of policy options, which need to be enriched by cross-national comparison of experiences and rigorous social experimentation. Maybe then reform will be a more systematic effort, and nations will be better able to learn from each other.
Delivery of Health Care↗
Consequences of the North American Free Trade Agreement for health services: a perspective from Mexico.
OBJECTIVES: The purposes of the study were to assess the potential impact of the North American Free Trade Agreement (NAFTA) on medical care in Mexico and to identify internal measures Mexico could take to increase the benefits and minimize the risks of free trade. METHODS: The dual nature of the health sector is examined; the Mexican, Canadian, and US health care systems are compared; and modes and consequences of international exchange of health services are analyzed. RESULTS: Four issues require immediate attention: accreditation of health care facilities, licensing and certification of professionals, technology assessment, and financial equity. CONCLUSIONS: NAFTA offers opportunities for positive developments in Mexico, provided risks can be anticipated and preventive measures can be taken to avoid negative impacts on the health system. Medical services, like other elements of the Mexican economy, must be modernized to respond to the demands of global competition. The Mexican National Academy of Medicine has recommended to the Mexican government (1) internal strengthening of the Mexican health care system to improve its ability to respond to the new conditions created by NAFTA and (2) a gradual process to facilitate equitable and mutually beneficial interactions among the three countries.
Canada↗