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Researchers and Policymakers Form Alliances to Research Social Protection in Health in Latin America and the Caribbean The Pan American Health Organization (PAHO), the International Development Research Centre (IDRC) and AcademyHealth joined forces to launch a research program in Latin America and the Caribbean to inform and evaluate social protection in health.1 Representatives from three sub-regional research networks were key partners in this initiative: the Network for Health Systems and Services Research in the Southern Cone of Latin America (REDES), NEVALAT in the Andean and Central American region, and the Caribbean Network of Health System Research and Policy. In a review of research on health sector reforms in the Region during the 1990s, numerous authors found that there was a dearth of evaluation research to support these policies.2 Perhaps as a result, they have largely faltered. Today, many of these same countries have turned their attention to the expansion of social protection in health. The three organizations sponsoring this initiative are intent on ensuring that this time research plays a role in informing and evaluating the new policies. The research funded under these grants focuses on government policies to expand social protection in health, defined as financial, geographic and cultural access to high quality health care and public health services. They also explore how governance styles -- defined as the patterns of interactions among formal and informal groups that lead to conventions and rules in the health system -- affect equity in health care and health outcomes. But the challenge is not merely to fund relevant and rigorous research on this topic. In order for the research to be used, the sponsoring agencies agreed that there was a need to alter some of the structures and processes of traditional funding, in order to increase the chances that decision-makers actually consider research in their policy deliberations. Research has shown that dissemination of research results is not enough. The demand side also needs to be strengthened by building capacity, interest and incentives to seek out research. These are sometimes referred to as push and pull strategies. Yet the single most powerful predictor of health policy research use is the level of interaction between the researchers and policymakers throughout the research cycle.3 The Design This project utilized all three strategies, push, pull and interaction, in a new funding design called Allied Research. Key elements of this approach included:
Preliminary Results Early results of this first round of funding indicate that Phase I was critical to consolidating the alliances and to improving the research relevance and rigor. Notably, in every case the initial research question posed by the researchers changed over the course of the three months of interaction with policymakers. Moreover, all of the projects evolved from descriptive studies to include evaluative components, and in some cases, simulation research to explore future policy alternatives. Researchers also concluded that their studies had become more relevant, rigorous and feasible as a result of the interaction. They reported that policymakers had brought substantive knowledge to the project regarding both the political environment and the technical conditions in which health care is delivered. They saw this "on the ground perspective" as an essential contribution to the process. Another indication that Phase I altered the evolution of the research was that the teams reported that relationships between the two groups had changed. Tensions regarding respective roles, including the distribution and use of power, were explicitly addressed in several cases. Indeed, even those that most empathized with their policymaker partners felt the need to avoid being subsumed by the policymakers' logic. All agreed that this differentiation of roles was key to establishing a relationship of trust and mutual respect. It was also interesting to note that the four teams that were not selected for Phase II eventually received funding from the local policymakers with whom they had formed alliances. As this round
of research projects are implemented, PAHO, IDRC and AcademyHealth will
continue to monitor the process and evaluate whether and to what degree
the research is ultimately used. Lessons derived from this first round
will be used to inform the design of future research funding. The Design and Implementation of a Public Maternal and Child Insurance System in the Province of Buenos Aires Alliance:
Contacts:
Project Description: Maternal and child health of the poor in the Province of Buenos Aires remains a critical problem, with infant and maternal death rates of 22% per 100, and 3.8% per 1000 respectively. National and provincial health authorities have agreed that reforms should promote a health system based on the development of public sector provincial Maternal and Infant Insurance programs. The province of Buenos Aires is the first jurisdiction to implement this program. The objective of the research project is to evaluate the results of the Buenos Aires Maternal and Child Health Insurance Program in primary care services, with special emphasis on certain tracer health conditions. It will examine different dynamics of governance at the municipal and provincial levels, and explore whether they are associated with different levels of program impact. The evaluation seeks to inform the design and management of the Buenos Aires program, It will also produce useful lessons for other provinces considering implementing this type of social insurance program. Lastly, the discussion of findings may be relevant to a larger debate in Latin American on the successes and failures of maternal and child health insurance programs. BRAZIL Challenges of Social Protection in Health in the Context of Inequities in the Brazilian Amazon Alliance:
Contacts:
Project Description: Two policy priorities of the new Lula Government defined the topic of this project. On the one hand, the Legal Amazon Region was prioritized as the most important area of inter-sectorial collaboration for development. On the other hand, there was very early exploration of a policy option to partially recentralize the current descentralized management of health resources at the regional level. Ministry of Health officials were concerned that the descentralization of the 1990s may have gone too far, and the resulting local power silos had made the equitable allocation of resources more difficult. The hypothesis that emerged from discussions among the policymakers and researchers was that inequities in the allocation of resources may be exacerbated by poor relations among different governmental decision-making levels and the lack of inter-sectorial coordination. The team therefore focused on a new policy in the Amazon region to regionalize health policy. Anticipating political resistance to the policy, the team proposed to study the political relationships that evolved during this period among multiple government and non-governmental bodies. They also proposed to evaluate the impact of the regionalization policy by examining its effects on the equitable distribution of resources and health, and to the extent possible, health outcomes, both within the region, and in comparison to other regions of Brazil. The project team expects to use their findings on the political process and on the equity impact of the new policies to inform the national health policy making process. JAMAICA Evaluation of the Impact of User Fees for Preventive Care Services on Health Seeking Behavior and Coping Strategies of Patients in Jamaica Alliance:
Contacts:
Project Description: The Ministry of Health implemented user fees in an attempt to build financial sustainability of the system, yet providers in Jamaica are complaining that the poorest sectors of the population have stopped seeking care as a result. While they acknowledge considerable international research on the impact of user fees, the Ministry officials want to see the results of local research before considering altering the policy. Furthermore, they say they need alternative funding sources if they are planning to halt user fees for preventive services. In response to this situation, the research team has designed a two-part project. First, it tracks utilization of four services-antenatal care, immunization, family planning and management of diabetes and hypertension. It uses both quantitative and qualitative methods to determine who uses them, who does not and why. Second, recognizing the Ministry's need for additional financial resources to supplement declining budgetary flows from tax sources, the study also applies modeling strategies to examine alternative revenue measures that would not create barriers of access to services. The research seeks to provide local empirical data to the policymakers that will enable them to replace a current policy with an alternative. The experience will also be of relevance to other Caribbean nations that have implemented similar user fee policies. BOGOTA, COLOMBIA Improving the Effectiveness of Social Protection in Health for Populations Displaced by Violence in Bogota. Alliance:
Contacts:
Project Description: More than three million people have been displaced by violence in Colombia in the last eight years. Bogotá, where approximately 450,000 refugees have recently arrived, is the single largest settlement. These individuals have been victims of systematic human rights violations, and have been exposed to more health-risk factors than other poor and marginal populations in the country. Nevertheless, they continue to receive inadequate health and social care from the State. The study explores the barriers to healthcare services faced by refugees, and proposes specific interventions that the city government can implement to improve access to quality care. The methodology is participatory with multiple groups of displaced persons engaged in the process, as well as NGOs, international agencies, the Church and governmental bodies. The research objective is to identify ways to reduce out-of-pocket health care expenditures and to improve the dignity of care for these groups, to pilot them and to evaluate them. It will explore options relating to the stewardship role of the health department, insurance mechanisms and health care delivery systems. On a larger scale, the study will contribute to a debate in the Region concerning the benefits of differential policies for groups with special needs, in this case displaced populations. This is of interest not only to other jurisdictions within Colombia, but to other countries around the world. MEDELLIN, COLOMBIA Protecting Unemployed Workers in Colombia: Strategies to Create a Reimbursable Credit Fund for Health Insurance Alliance:
Contacts:
Project Description: One of the reasons that Law 100 of 1993 (which created the General Social Security System in Colombia) has not achieved higher coverage rates is the continued high level of unemployment. During the planning phase for the research, university researchers brought the problem of the uninsured unemployed workers to the attention of policymakers in the city of Medellin and Department of Antioquia. They convinced the government to allocate resources to subsidize the startup of a special health insurance fund. This agreement was reached. The research will examine the socio-economic characteristics of unemployed workers in the Metropolitan Area of Medellin, and will describe employment-unemployment cycle of recent years. It will then explore alternatives designs for an insurance program for unemployed workers and their families. It will be based on the creation of a Reimbursable Credit Fund with an initial investment by local State representations and premiums that will eventually be reimbursed by beneficiaries when they return to work. Given the similar unemployment rates in other parts of the country, the project aims to elevate the visibility of the problem and some of the potential solutions that could be applied either nationally, or on a city by city basis. Similarly, the issue is relevant to other Latin-American countries, and may provide lessons relevant to their policy debates on healthcare for the unemployed. _______________________________ 1 Social protection in health is defined by PAHO as "society's guarantee, through public authorities, that individuals or groups of individuals can meet their health needs and demands through adequate access to health services of the system or any of the existing sub systems in the country, regardless of their ability to pay." IDRC has also prioritized the issue through its Program Initiative on Governance, Equity and Health (GEH). GEH supports applied research that will both strengthen and monitor the capacity of governments to ensure equitable financing and delivery of priority public health and health care services, especially to marginalized and underserved populations. 2 Almeida A, Bazzani R & Pittman P (ed). Investigacion Sobre Reformas del Sector Salud en America Latina y el Caribe: Reflexiones sobre sus Contribuciones al Desarrollo de Politicas. Washington: Organizacion Panamericana de la Salud. 2001. 3 Landry R, Lamari M, & Amara N. Extent And Determinants Of Utilization Of University Research In Government Agencie, Public Administration Review, March/April, vol 63, no 2, pp 192-205. 2000. 4 Lavis J. et al. "Measuring the Impact of Health Research," Journal of Health Services Research & Policy, Vol. 8, No. 3: 165-70, July 2003. 5 Lomas J. "Improving Research Dissemination and Uptake in the Health Sector: Beyond the Sound of One Hand Clapping," McMaster University Centre for Health Economics and Policy Analysis Policy Commentary C97-1, November 1997. |
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