RESUMO
BACKGROUND: Improving access and quality in health care is a pressing issue worldwide and pay for performance (P4P) strategies have emerged as an alternative to enhance structure, process and outcomes in health. In 2011, Brazil adopted its first P4P scheme at national level, the National Programme for Improving Primary Care Access and Quality (PMAQ). The contribution of PMAQ in achieving the Sustainable Development Goals related to maternal and childcare remains under investigated in Brazil. OBJECTIVE: To estimate the association of PMAQ with the provision of maternal and childcare in Brazil, controlling for socioeconomic, geographic and family health team characteristics. METHOD: We used cross-sectional quantile regression (QR) models for two periods, corresponding to 33,368 Family Health Teams (FHTs) in the first cycle and 39,211 FHTs in the second cycle of PMAQ. FHTs were analysed using data from the Brazilian Ministry of Health (SIAB and CNES) and the Brazilian Institute for Geography and Statistics (IBGE). RESULTS: The average number of antenatal consultations per month were positively associated with PMAQ participating teams, with larger effect in the lower tail (10th and 25th quantiles) of the conditional distribution of the response variable. There was a positive association between PMAQ and the average number of consultations under 2 years old per month in the 10th and 25th quantiles, but a negative association in the upper tail (75th and 90th quantiles). For the average number of physician consultations for children under 1 year old per month, PMAQ participating teams were positively associated with the response variable in the lower tail, but different from the previous models, there is no clear evidence that the second cycle gives larger coefficients compared with first cycle. CONCLUSION: PMAQ has contributed to increase the provision of care to pregnant women and children under 2 years at primary healthcare level. Teams with lower average number of antenatal or child consultations benefited the most by participating in PMAQ, which suggests that PMAQ might motivate worse performing health providers to catch up.
Assuntos
Cuidado do Lactente/organização & administração , Programas Nacionais de Saúde/organização & administração , Cuidado Pré-Natal/organização & administração , Atenção Primária à Saúde/organização & administração , Reembolso de Incentivo , Brasil , Estudos Transversais , Feminino , Acessibilidade aos Serviços de Saúde/economia , Acessibilidade aos Serviços de Saúde/organização & administração , Humanos , Lactente , Cuidado do Lactente/economia , Recém-Nascido , Programas Nacionais de Saúde/economia , Gravidez , Cuidado Pré-Natal/economia , Atenção Primária à Saúde/economia , Avaliação de Programas e Projetos de Saúde , Qualidade da Assistência à SaúdeRESUMO
BACKGROUND: Evidence on immunization costs is a critical input for cost-effectiveness analysis and budgeting, and can describe variation in site-level efficiency. The Expanded Program on Immunization Costing and Financing (EPIC) Project represents the largest investigation of immunization delivery costs, collecting empirical data on routine infant immunization in Benin, Ghana, Honduras, Moldova, Uganda, and Zambia. METHODS: We developed a pooled dataset from individual EPIC country studies (316 sites). We regressed log total costs against explanatory variables describing service volume, quality, access, other site characteristics, and income level. We used Bayesian hierarchical regression models to combine data from different countries and account for the multi-stage sample design. We calculated output elasticity as the percentage increase in outputs (service volume) for a 1% increase in inputs (total costs), averaged across the sample in each country, and reported first differences to describe the impact of other predictors. We estimated average and total cost curves for each country as a function of service volume. RESULTS: Across countries, average costs per dose ranged from $2.75 to $13.63. Average costs per child receiving diphtheria, tetanus, and pertussis ranged from $27 to $139. Within countries costs per dose varied widely-on average, sites in the highest quintile were 440% more expensive than those in the lowest quintile. In each country, higher service volume was strongly associated with lower average costs. A doubling of service volume was associated with a 19% (95% interval, 4.0-32) reduction in costs per dose delivered, (range 13% to 32% across countries), and the largest 20% of sites in each country realized costs per dose that were on average 61% lower than those for the smallest 20% of sites, controlling for other factors. Other factors associated with higher costs included hospital status, provision of outreach services, share of effort to management, level of staff training/seniority, distance to vaccine collection, additional days open per week, greater vaccination schedule completion, and per capita gross domestic product. CONCLUSIONS: We identified multiple features of sites and their operating environment that were associated with differences in average unit costs, with service volume being the most influential. These findings can inform efforts to improve the efficiency of service delivery and better understand resource needs.
Assuntos
Custos de Cuidados de Saúde , Programas de Imunização/economia , Cuidado do Lactente/economia , Teorema de Bayes , Benin , Análise Custo-Benefício , Gana , Instalações de Saúde/economia , Honduras , Humanos , Lactente , Moldávia , Análise de Regressão , Uganda , ZâmbiaRESUMO
Little information exists on the cost structure of routine infant immunization services in low- and middle-income settings. Using a unique dataset of routine infant immunization costs from six countries, we estimated how costs were distributed across budget categories and programmatic activities, and investigated how the cost structure of immunization sites varied by country and site characteristics. The EPIC study collected data on routine infant immunization costs from 319 sites in Benin, Ghana, Honduras, Moldova, Uganda, Zambia, using a standardized approach. For each country, we estimated the economic costs of infant immunization by administrative level, budget category, and programmatic activity from a programme perspective. We used regression models to describe how costs within each category were related to site operating characteristics and efficiency level. Site-level costs (incl. vaccines) represented 77-93% of national routine infant immunization costs. Labour and vaccine costs comprised 14-69% and 13-69% of site-level cost, respectively. The majority of site-level resources were devoted to service provision (facility-based or outreach), comprising 48-78% of site-level costs across the six countries. Based on the regression analyses, sites with the highest service volume had a greater proportion of costs devoted to vaccines, with vaccine costs per dose relatively unaffected by service volume but non-vaccine costs substantially lower with higher service volume. Across all countries, more efficient sites (compared with sites with similar characteristics) had a lower cost share devoted to labour. The cost structure of immunization services varied substantially between countries and across sites within each country, and was related to site characteristics. The substantial variation observed in this sample suggests differences in operating model for otherwise similar sites, and further understanding of these differences could reveal approaches to improve efficiency and performance of immunization sites.
Assuntos
Programas de Imunização/economia , Cuidado do Lactente/economia , Vacinação/economia , África Subsaariana , Países em Desenvolvimento , Instalações de Saúde/economia , Pessoal de Saúde/economia , Honduras , Humanos , Programas de Imunização/organização & administração , Lactente , Moldávia , Vacinas/economiaRESUMO
The purpose of this study was to identify the demands of home care of children born exposed to HIV in the perspective of the environmental theory. It consists of an exploratory descriptive qualitative study, developed between January and April of 2011. Study participants were ten HIV-infected mothers with infants exposed to the virus, living in Fortaleza, Ceará. The data collection instruments included a disposable digital camera and forms to obtain information on health associated with the home environment. Results were contextualized according to the theory and organized into the following categories: vulnerabilities associated with the physical structure of the house; contaminated intra and peridomestic air; unclean water used for drinking; sanitation and sewerage system; lighting and ventilation of the house. In conclusion, the home environment offers unfavorable environmental conditions for the child. Targeted interventions in the home environment are necessary so as to promote the health of children born exposed to HIV.
Assuntos
Exposição Ambiental , Saúde da Família , Infecções por HIV/prevenção & controle , Necessidades e Demandas de Serviços de Saúde , Habitação , Cuidado do Lactente , Determinantes Sociais da Saúde , Adolescente , Adulto , Poluição do Ar em Ambientes Fechados/economia , Poluição do Ar em Ambientes Fechados/estatística & dados numéricos , Brasil , Exposição Ambiental/economia , Exposição Ambiental/estatística & dados numéricos , Saúde da Família/economia , Saúde da Família/estatística & dados numéricos , Feminino , Infecções por HIV/congênito , Infecções por HIV/transmissão , Necessidades e Demandas de Serviços de Saúde/economia , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Visita Domiciliar , Habitação/economia , Habitação/estatística & dados numéricos , Humanos , Higiene/economia , Higiene/normas , Lactente , Cuidado do Lactente/economia , Cuidado do Lactente/normas , Cuidado do Lactente/estatística & dados numéricos , Controle de Infecções , Transmissão Vertical de Doenças Infecciosas , Masculino , Modelos Teóricos , Fotografação , Pobreza , Gravidez , Complicações Infecciosas na Gravidez , Medição de Risco , Saneamento/economia , Saneamento/estatística & dados numéricos , Determinantes Sociais da Saúde/economia , Determinantes Sociais da Saúde/estatística & dados numéricos , Fatores Socioeconômicos , Poluição da Água/economia , Poluição da Água/estatística & dados numéricos , Abastecimento de Água/economia , Abastecimento de Água/estatística & dados numéricos , Adulto JovemRESUMO
Objetivou-se identificar as demandas de cuidado domiciliar da criança nascida exposta ao HIV, sob a perspectiva da teoria ambientalista. Trata-se de estudo qualitativo exploratório-descritivo realizado de janeiro a abril de 2011. Participaram dez mães infectadas pelo HIV, com crianças nascidas expostas ao vírus, em Fortaleza, Ceará. Constituíram-se como instrumentos de coleta de dados: câmera fotográfica descartável e digital e formulários para captação de informações em saúde associadas ao ambiente domiciliar. Os resultados foram contextualizados de acordo com a teoria e organizados em categorias: "vulnerabilidades associadas à estrutura física da moradia"; "ar intradomiciliar e peridomiciliar impuro"; "água utilizada para consumo"; "rede de esgoto e saneamento"; "iluminação e ventilação da residência". Conclui-se que o ambiente domiciliar oferece condições ambientais desfavoráveis para a criança. Urge a realização de intervenções focalizadas no ambiente domiciliar, para promover a saúde da criança nascida exposta ao HIV.
Se objetivó identificar las demandas de atención en el hogar de los niños nacidos expuestos al VIH en la perspectiva de la teoría ambientalista. Estudio cualitativo exploratorio-descriptivo realizado entre enero y abril de 2011. Participaron diez madres VIH-positivas con bebés expuestos al virus, en Fortaleza, Ceará. Fueron instrumentos de recolección de datos: cámara desechable y digital y formularios para capturar información sobre la salud asociada con el ambiente del hogar. Los resultados fueron contextualizados de acuerdo a la teoría y organizado en categorías: vulnerabilidades asociadas con la estructura física de la casa; aire intra y peridoméstico impuro; agua utilizada para el consumo; saneamiento y alcantarillado; iluminación y ventilación de la residencia. Se concluye que el hogar ofrece condiciones ambientales desfavorables para el niño. Hay necesidad de intervenciones específicas en el entorno del hogar para promover la salud de los niños nacidos expuestos al VIH.
The purpose of this study was to identify the demands of home care of children born exposed to HIV in the perspective of the environmental theory. It consists of an exploratory descriptive qualitative study, developed between January and April of 2011. Study participants were ten HIV-infected mothers with infants exposed to the virus, living in Fortaleza, Ceará. The data collection instruments included: a disposable digital camera and forms to obtain information on health associated with the home environment. Results were contextualized according to the theory and organized into the following categories: vulnerabilities associated with the physical structure of the house; contaminated intra and peridomestic air; unclean water used for drinking; sanitation and sewerage system; lighting and ventilation of the house. In conclusion, the home environment offers unfavorable environmental conditions for the child. Targeted interventions in the home environment are necessary so as to promote the health of children born exposed to HIV.
Assuntos
Adolescente , Adulto , Feminino , Humanos , Lactente , Masculino , Gravidez , Adulto Jovem , Exposição Ambiental , Saúde da Família , Infecções por HIV/prevenção & controle , Necessidades e Demandas de Serviços de Saúde , Habitação , Cuidado do Lactente , Determinantes Sociais da Saúde , Poluição do Ar em Ambientes Fechados/economia , Poluição do Ar em Ambientes Fechados/estatística & dados numéricos , Brasil , Exposição Ambiental/economia , Exposição Ambiental/estatística & dados numéricos , Saúde da Família/economia , Saúde da Família/estatística & dados numéricos , Infecções por HIV/congênito , Infecções por HIV/transmissão , Necessidades e Demandas de Serviços de Saúde/economia , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Visita Domiciliar , Habitação/economia , Habitação/estatística & dados numéricos , Higiene/economia , Higiene/normas , Cuidado do Lactente/economia , Cuidado do Lactente/normas , Cuidado do Lactente/estatística & dados numéricos , Controle de Infecções , Transmissão Vertical de Doenças Infecciosas , Modelos Teóricos , Fotografação , Pobreza , Complicações Infecciosas na Gravidez , Medição de Risco , Saneamento/economia , Saneamento/estatística & dados numéricos , Determinantes Sociais da Saúde/economia , Determinantes Sociais da Saúde/estatística & dados numéricos , Fatores Socioeconômicos , Poluição da Água/economia , Poluição da Água/estatística & dados numéricos , Abastecimento de Água/economia , Abastecimento de Água/estatística & dados numéricosRESUMO
BACKGROUND: The increase in expenses of the health care system caused by sick leaves, especially those granted to mothers with children of less than one year of age with severe diseases, is a topic of concern. AIM: To describe the rates of sick leaves granted to mothers with children of less than one year of age with severe diseases from 2004 to 2008. MATERIAL AND METHODS: Analysis of databases containing information about sick leaves coming from Chilean public and private health care subsystems. Leaves granted to mothers with sick children of less than one year were specifically analyzed in terms of days off work and the amount of monetary benefits. RESULTS: A sustained increase, ranging from 20 to 120% in the number of sick leaves motivated by diseases of children of less than one year, was observed. Thirty four percent of maternity leaves concentrate immediately after finishing the legal period (24 weeks after birth) and almost 60% of them occured within the first 6 months after birth. The most frequent diagnoses that motivated the higher number of leaves were gas-troesophageal reflux and bronchitis. CONCLUSIONS: There is probably a bad use of the benefit in a percentage of leaves. The benefit is also regressive since it favors mostly mothers of a better socioeconomic condition. The law that will extend the postnatal maternity leave will solve in part these problems.
Assuntos
Cuidado do Lactente/tendências , Licença Parental/tendências , Adolescente , Adulto , Chile , Feminino , Humanos , Lactente , Cuidado do Lactente/economia , Cuidado do Lactente/estatística & dados numéricos , Recém-Nascido , Pessoa de Meia-Idade , Licença Parental/economia , Licença Parental/estatística & dados numéricos , Índice de Gravidade de Doença , Fatores Socioeconômicos , Fatores de Tempo , Adulto JovemRESUMO
Background: The increase in expenses of the health care system caused by sick leaves, especially those granted to mothers with children of less than one year of age with severe diseases, is a topic of concern. Aim: To describe the rates of sick leaves granted to mothers with children of less than one year of age with severe diseases from 2004 to 2008. Material and Methods: Analysis of databases containing information about sick leaves coming from Chilean public and private health care subsystems. Leaves granted to mothers with sick children of less than one year were specifically analyzed in terms of days off work and the amount of monetary benefits. Results: A sustained increase, ranging from 20 to 120% in the number of sick leaves motivated by diseases of children of less than one year, was observed. Thirty four percent of maternity leaves concentrate immediately after finishing the legal period (24 weeks after birth) and almost 60% of them occured within the first 6 months after birth. The most frequent diagnoses that motivated the higher number of leaves were gas-troesophageal reflux and bronchitis. Conclusions: There is probably a bad use of the benefit in a percentage of leaves. The benefit is also regressive since it favors mostly mothers of a better socioeconomic condition. The law that will extend the postnatal maternity leave will solve in part these problems.
Assuntos
Adolescente , Adulto , Feminino , Humanos , Lactente , Recém-Nascido , Pessoa de Meia-Idade , Adulto Jovem , Cuidado do Lactente/tendências , Licença Parental/tendências , Chile , Cuidado do Lactente/economia , Cuidado do Lactente/estatística & dados numéricos , Licença Parental/economia , Licença Parental/estatística & dados numéricos , Índice de Gravidade de Doença , Fatores Socioeconômicos , Fatores de TempoRESUMO
Process evaluation was used to examine the implementation of a randomized, controlled trial of an education intervention that improved infant growth in Trujillo, Peru. Health personnel delivered the multi-component intervention as part of usual care in the government health centers. Quantitative and qualitative methods were used to examine process indicators, which included the extent of delivery (dose), fidelity to intervention protocol, barriers to implementation and context. Results demonstrated that most intervention components were delivered at a level of 50-90% of expectations. Fidelity to intervention protocol, where measured, was lower (28-70% of expectations). However, when compared with existing nutrition education, as represented by the control centers, significant improvements were demonstrated. This included both improved delivery of existing educational activities as well as delivery of new intervention components to strengthen overall nutrition education. Barriers to, and facilitators of, implementation were explored with health personnel and helped to explain results. This study demonstrates the importance of examining actual versus planned implementation in order to improve our understanding of how interventions succeed. The information gained from this study will inform future evaluation designs, and lead to the development and implementation of more effective intervention programs for child health.
Assuntos
Cuidadores/educação , Desenvolvimento Infantil/fisiologia , Serviços de Saúde da Criança/normas , Educação em Saúde/normas , Transtornos da Nutrição do Lactente/prevenção & controle , Avaliação de Processos e Resultados em Cuidados de Saúde , Pais/educação , Serviços Urbanos de Saúde/normas , Serviços de Saúde da Criança/organização & administração , Centros Comunitários de Saúde/normas , Educação em Saúde/métodos , Humanos , Lactente , Cuidado do Lactente/economia , Cuidado do Lactente/métodos , Transtornos da Nutrição do Lactente/epidemiologia , Fenômenos Fisiológicos da Nutrição do Lactente , Entrevistas como Assunto , Peru/epidemiologia , Áreas de Pobreza , Avaliação de Programas e Projetos de Saúde , Serviços Urbanos de Saúde/organização & administraçãoRESUMO
This study analyzed the implementation of the Kangaroo Mother method in 28 different São Paulo State public hospitals. Teaching hospitals, Baby-Friendly Hospitals, hospitals with human milk banks, and those with more than 12 trained health professionals showed higher implementation scores. Because of staff resistance to family participation in neonatal care, the Kangaroo Mother method is basically applied in-hospital. Changes in the initial training, including manager awareness-raising and proper financial resource allocation, are necessary for implementation, follow-up, assessment, and feedback.
Assuntos
Implementação de Plano de Saúde , Hospitais Públicos/organização & administração , Cuidado do Lactente/organização & administração , Brasil , Estudos Transversais , Feminino , Humanos , Lactente , Cuidado do Lactente/economia , Recém-NascidoRESUMO
This study uses a natural experiment approach to evaluate the effect of health insurance on infant and child mortality. In the 1970s Costa Rica adopted national health insurance, which expanded children's insurance coverage from 42 percent in 1973 to 73 percent by 1984. Aggregate infant and child mortality rates dropped rapidly during this period, but this trend had begun prior to the insurance expansion, and may be related to other changes during this period. We use county-level vital statistics and census data to isolate the causal insurance effect on mortality using county fixed effects models. We find that insurance increases are strongly related to mortality decreases at the county level before controlling for other time-varying factors. However, after controlling for changes in other correlated maternal, household, and community characteristics, fixed effects models indicate that the insurance expansion could have explained only a small portion of the mortality change. These results question the proposition that health insurance can lead to large improvements in infant and child mortality, and that expanding insurance to the poor can substantially narrow socioeconomic differentials in mortality.