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The European Commission periodically classifies viruses on their occupational hazards to define the level of protection that workers are entitled to claim. Viruses belonging to Groups 3 and 4 can cause severe human disease and hazard to workers, as well as a spreading risk to the community. However, there is no effective prophylaxis or treatment available for Group 4 viruses. European trade unions and the Commission are negotiating the classification of the COVID-19 virus along these 2 categories. This article weighs the reasons to classify it in Group 3 or 4 while comparing its risks to those of the most significant viruses classified in these 2 categories. COVID-19 characteristics justify its classification in Group 4. Contaminated workers in contact with the public play an important role in disseminating the virus. In hospitals and nursing homes, they increase the overall case fatality rate. By strongly protecting these workers and professionals, the European Union would not only improve health in work environments, but also activate a mechanism key to reducing the COVID-19 burden in the general population. Admittedly, the availability of a new vaccine or treatment would change this conclusion, which was reached in the middle of the first pandemic.

The 2010 World Health Assembly (WHA) tabled, but did not manage to discuss, a resolution on regulating the private health care sector. 1 With hindsight, it seems fitting to thoroughly review an earlier 2008 Rockefeller Foundation (RF) report on the same issue: "Public Stewardship of Private Providers in Mixed Health Systems." The key weakness of the RF document – and also of the above WHA draft resolution – is that both fail to provide the necessary empirical evidence to show that better 'stewarding' regulation in low and middle income countries (LMICs) has worked to provide quality, accessible, and affordable health care for all in mixed public-private health systems. In this article, we voice our skepticism about whether public stewardship can work in mixed systems in LMICs. Moreover, the RF report does not address the access to quality health care from a human rights perspective. The right to quality health care is simply overlooked. The report prescribes "new solutions" to well known regulatory problems and fails to offer any evidence of their benefit. It argues that regulation of mixed public-private health systems can be successful without providing any evidence even at local level. This lack of evidence is striking since we have a good 20 years of experience with such regulation. We conclude that a) private providers will never be effectively controlled in LMICs with regulation alone, and b) that the report reflects RF's ideological bias against single payer, universal coverage public health care systems. We argue that the "regulation alternative" is simply not a substitute for strengthening the public sector. Many of the measures proposed by the Rockefeller Foundation report are not necessarily wrong, but they are applied to a private sector enjoying an established position that has given them access to deliver health care as a privilege and not as a right. Indeed, we remain convinced that if some of the proposed measures were applied to the public health sector with adequate long-term government and donor financing, they would go a longer way to achieve Health Care For All. The past experiences of Costa Rica and Sri Lanka suggest that LMICs private health markets have only effectively been controlled in countries where the public sector was effective in competing with the private sector. A well organized and funded public health system, delivering comprehensive health care (not restricted to vertical disease control programs and not treating health as a commodity) is the only alternative to reign-in the excesses of LMIC private providers in mixed health systems.

BACKGROUND: Since the 1980s, markets have turned increasingly to intangible goods – healthcare, education, the arts, and justice. Over 40 years, the authors investigated healthcare commoditisation to produce policy knowledge relevant to patients, physicians, health professionals, and taxpayers. This paper revisits their objectives, methods, and results to enlighten healthcare policy design and research. MAIN TEXT: This paper meta-analyses the authors' research that evaluated the markets impact on healthcare and professional culture and investigated how they influenced patients' timely access to quality care and physicians' working conditions. Based on these findings, they explored the political economic of healthcare. In low-income countries the analysed research showed that, through loans and cooperation, multilateral agencies restricted the function of public services to disease control, with subsequent catastrophic reductions in access to care, health de-medicalisation, increased avoidable mortality, and failure to attain the narrow MDGs in Africa. The pro-market reforms enacted in middle-income countries entailed the purchaser-provider split, privatisation of healthcare pre-financing, and government contracting of health finance management to private insurance companies. To establish the materiality of a cause-and-effect relationship, the authors compared the efficiency of Latin American national health systems according to whether or not they were pro-market and complied with international policy standards. While pro-market health economists acknowledge that no market can offer equitable access to healthcare without effective regulation and control, the authors showed that both regulation and control were severely constrained in Asia by governance and medical secrecy issues. In high-income countries they questioned the interest for population health of healthcare insurance companies, whilst comparing access to care and health expenditures in the European Union vs. the U.S., the Netherlands, and Switzerland. ...

The reform of the Colombian health sector in 1993 was founded on the internationally advocated paradigm of privatization of health care delivery. Taking into account the lack of empirical evidence for the applicability of this concept to developing countries and the documented experience of failures in other countries, Colombia tried to overcome these problems by a theoretically sound, although complicated, model. Some ten years after the implementation of "Law 100," a review of the literature shows that the proposed goals of universal coverage and equitable access to high-quality care have not been reached. Despite an explosion in costs and a considerable increase in public and private health expenditure, more than 40 percent of the population is still not covered by health insurance, and access to health care proves uncreasingly difficult. Furthermore, key health indicators and disease control programs have deteriorated. These findings confirm the results in other middle- and low-income countries. The authors suggest the explanation lies in the inefficiency of contractingout, the weak economic, technical, and political capacity of the Colombian government for regulation and control, and the absence of real participation of the poor in decision-making on (health) policies. ; La reforma del sector salud en Colombia en 1993 se fundamentó en el paradigma defendido internacionalmente de la privatización de los servicios de atención médica. Teniendo en cuenta la falta de evidencia empírica en la aplicación de este concepto en los países en desarrollo y la experiencia documentada de fracasos en otros países, Colombia trató de superar estos problemas a través de un modelo teóricamente sólido pero, a la vez, complicado. Después de 10 años de la implementación de la Ley 100, una revisión de la literatura muestra que los objetivos propuestos de cobertura universal y acceso equitativo a atención de alta calidad no se han logrado. A pesar de un gran aumento en los costos y un incremento considerable en los gastos públicos y privados en salud más del 40% de la población aún no está cubierto por la seguridad en salud y el acceso a la atención médica es cada vez más difícil. Además, indicadores claves de salud y programas de control de enfermedades han desmejorado. Estas conclusiones confirman los resultados en otros países de ingresos medios y bajos. Los autores sugieren que la explicación radica en la ineficiencia de la subcontratación con terceros, la débil capacidad económica, técnica y política del gobierno colombiano para regular y controlar y la ausencia de participación real de los pobres en la toma de decisiones sobre políticas de salud.

In 1987, district health care policies were officially adopted by a majority of developing countries. Many operational problems constraining implementation of such policies have subsequently been identified, most of which are attributable to well-known characteristics of less developed countries. However, the policy of operational and administrative decentralization has often been critically obstructed by inappropriate organizational structures in ministries of health. By applying Mintzberg's analytical framework to several ministries of health, we identify structural deficiencies that make systems unfit to match their policy environment and yield the expected outcomes of functional and decentralized services. We propose a typology likely to elicit strategies for decentralizing health care administration. Our analysis is based on the following steps: a description of Mintzberg's concepts of organizational structure, generic components (strategic apex, technostructure, supporting structure, middle line, operational core) and functions (horizontal and vertical integration, liaison devices, vertical and horizontal decentralization) applied to health systems; a discussion of divisionalized adhocracy as a suitable configuration for health organizations with a need for a high degree of regional autonomy, community participation, medical staff initiative, action research and operational research, and continuous evaluation; a discussion of the organizational features of a number of health ministry systems and a consideration of strategies for transforming configurations towards divisionalized adhocracy.

In 1987, district health care policies were officially adopted by a majority of developing countries. Many operational problems constraining implementation of such policies have subsequently been identified, most of which are attributable to well-known characteristics of less developed countries. However, the policy of operational and administrative decentralization has often been critically obstructed by inappropriate organizational structures in ministries of health. By applying Mintzberg's analytical framework to several ministries of health, we identify structural deficiencies that make systems unfit to match their policy environment and yield the expected outcomes of functional and decentralized services. We propose a typology likely to elicit strategies for decentralizing health care administration. Our analysis is based on the following steps: a description of Mintzberg's concepts of organizational structure, generic components (strategic apex, technostructure, supporting structure, middle line, operational core) and functions (horizontal and vertical integration, liaison devices, vertical and horizontal decentralization) applied to health systems; a discussion of divisionalized adhocracy as a suitable configuration for health organizations with a need for a high degree of regional autonomy, community participation, medical staff initiative, action research and operational research, and continuous evaluation; a discussion of the organizational features of a number of health ministry systems and a consideration of strategies for transforming configurations towards divisionalized adhocracy.

Background Regional-based Integrated Healthcare Networks (IHNs) have been promoted in Brazil to overcome the fragmentation due to the health system decentralization to the municipal level; however, evaluations are scarce. The aim of this article is to analyse the content of IHN policies in force in Brazil, and the factors that influence policy implementation from the policymakers' perspective. Methods A two-fold, exploratory and descriptive qualitative study was carried out based on (1) content analysis of policy documents selected to meet the following criteria: legislative documents dealing with regional-based IHNs; enacted by federal government; and in force, (2) semi-structured individual interviews were conducted to a theoretical sample of policymakers at federal (eight), state (five) and municipal levels (four). Final sample size was reached by saturation of information. An inductive thematic analysis was conducted. Results The results show difficulties in the implementation of IHN policies due to weaknesses that arise from the policy design and the performance of the three levels of government. There is a lack of specificity as to the criteria and tools for configuring and financing IHNs that need to be agreed upon between involved governments. For their part, policymakers emphasize the difficulty of establishing agreements in a health system with disincentives for collaboration between municipalities. The allocation of responsibilities that are too complex for the capacity and size of the municipalities, the abandonment of essential functions such as network planning by states and the strategic role by the Ministry, the 'invasion' of competences among levels of government and high political turnover are also highlighted. Conclusions The implementation of regional-based IHN policy in Brazil is hampered by the decentralized organization of the health system to the municipal level, suggesting the need to centralize certain functions to regional structures or states and to define better the role of the ...

BACKGROUND: Ethical medical practice requires managing health services to promote professionalism and secure accessibility to care. Commercially financed and industrially managed services strain the physicians' clinical autonomy and ethics because the industry's profitability depends on commercial, clinical standardisation. Private insurance companies also reduce access to care whilst fragmenting and segmenting health systems. Against this background, given the powerful, symbolic significance of their common voice, physicians' and patients' organisations could effectively leverage together political parties and employers' organisations to promote policies favouring access to professional care. MAIN TEXT: To provide a foundation for negotiations between physicians' and patients' organisations, we propose policy principles derived from an analysis of rights-holders and duty-bearers' stakes, i.e., patients, physicians and health professionals, and taxpayers. Their concerns are scrutinised from the standpoints of public health and right to health. Illustrated with post-WWII European policies, these principles are formulated as inputs for tentative action-research. The paper also identifies potential stumbling blocks for collective doctor/patient negotiations based on the authors' personal experience. The patients' concerns are care accessibility, quality, and price. Those of physicians and other professionals are problem-solving capacity, autonomy, intellectual progress, ethics, work environment, and revenue. The majority of taxpayers have an interest in taxes being progressive and public spending on health regressive. Mutual aid associations tend to under-estimate the physician's role in delivering care. Physicians' organisations often disregard the mission of financing care and its impact on healthcare quality. CONCLUSION: The proposed physicians-patients' alliance could promote policies in tune with professional ethics, prevent European policies' putting industrial concerns above suffering and death, bar care ...

Background: Ethical medical practice requires managing health services to promote professionalism and secure accessibility to care. Commercially financed and industrially managed services strain the physicians' clinical autonomy and ethics because the industry's profitability depends on commercial, clinical standardisation. Private insurance companies also reduce access to care whilst fragmenting and segmenting health systems. Against this background, given the powerful, symbolic significance of their common voice, physicians' and patients' organisations could effectively leverage together political parties and employers' organisations to promote policies favouring access to professional care. Main text: To provide a foundation for negotiations between physicians' and patients' organisations, we propose policy principles derived from an analysis of rights-holders and duty-bearers' stakes, i.e. patients, physicians and health professionals, and taxpayers. Their concerns are scrutinised from the standpoints of public health and right to health. Illustrated with post-WWII European policies, these principles are formulated as inputs for tentative action-research. The paper also identifies potential stumbling blocks for collective doctor/patient negotiations based on the authors' personal experience. The patients' concerns are care accessibility, quality, and price. Those of physicians and other professionals are problem-solving capacity, autonomy, intellectual progress, ethics, work environment, and revenue. The majority of taxpayers have an interest in taxes being progressive and public spending on health regressive. Mutual aid associations tend to under-estimate the physician's role in delivering care. Physicians' organisations often disregard the mission of financing care and its impact on healthcare quality. Conclusion: The proposed physicians-patients' alliance could promote policies in tune with professional ethics, prevent European policies' putting industrial concerns above suffering and death, bar care ...

Costa Rica is a middle-income country with a strong governmental emphasis on human development. For more than half a century, its health policies have applied the principles of equity and solidarity to strengthen access to care through public services and universal social health insurance.

This book presents some of the results from the international research project "Impact on equity of access and efficiency of Integrated Health care Networks in Colombia and Brazil (Equity-LA)". Equity-LA was funded by the European Union and had the participation of six institutions from Spain, Belgium, Colombia and Brazil. The project's main objective was to understand the impact of implementing integrated health care networks on access, coordination, efficiency, and equity of access in different Latin American contexts. This study provided results, but also generated new questions that led to Equity LA II project (www.equity-la.eu). Currently undergoing and funded by the European Union, Equity LA II will include data from four additional countries in Latin America (Argentina, Chile, Mexico, and Uruguay) with the objective of broadening this understanding. The analyses described in this work refer exclusively to questions of access, coordination, continuity, and quality of care in health service networks, which are analyzed through a cases study, based on qualitative and quantitative data collected between 2009 and 2012. En este libro se presenta una parte de los resultados del proyecto internacional de investigación "Impacto en la equidad de acceso y la eficiencia de las redes integradas de servicios de salud en Colombia y Brasil (Equity-LA)", financiado por la Unión Europea y en el que participaron seis instituciones de cuatro países, dos europeos (España y Bélgica) y dos latinoamericanos (Colombia y Brasil). La investigación se diseñó con el propósito de mejorar la comprensión sobre el impacto de la implementación de las redes integradas de servicios de salud en el acceso, la coordinación, la eficiencia y la equidad de acceso, en diferentes contextos de Latinoamérica. El estudio además de evidencia, generó nuevas preguntas, que dieron lugar al proyecto Equity LA II (www.equity-la.eu), actualmente en desarrollo, también financiado por la Unión Europea, que profundiza en sus resultados y amplía el análisis a ...

This paper aims at offering alternative methodological perspectives in health systems research, to produce critical, theoretical knowledge in domains such as health policy and management of health care, organization of disease control, political economy of health and medical practice.We first examined the reasons to believe that worldwide economic agents have driven publicly funded schools of public health to adopt their preferred policies and to orient their priority research topics. We then studied whether this hidden leadership has also contributed to shape research methodologies, which we contrasted with the epistemological consequences of a quest for intellectual independence, that is, the researcher's quest to critically understand the state of health systems and generalize results of related action-research. To do so, we applied concepts of what could be named the 'French School of Critical Sociology' to qualitative research methodologies in descriptive health systems research. To do so, we applied concepts of what could be named the 'French School of Critical Sociology' to qualitative research methodologies in descriptive health systems research.

This paper aims at offering alternative methodological perspectives in health systems research, to produce critical, theoretical knowledge in domains such as health policy and management of health care, organization of disease control, political economy of health and medical practice.We first examined the reasons to believe that worldwide economic agents have driven publicly funded schools of public health to adopt their preferred policies and to orient their priority research topics. We then studied whether this hidden leadership has also contributed to shape research methodologies, which we contrasted with the epistemological consequences of a quest for intellectual independence, that is, the researcher's quest to critically understand the state of health systems and generalize results of related action-research. To do so, we applied concepts of what could be named the 'French School of Critical Sociology' to qualitative research methodologies in descriptive health systems research. To do so, we applied concepts of what could be named the 'French School of Critical Sociology' to qualitative research methodologies in descriptive health systems research.

Background Selective vertical programs prevailed over comprehensive primary health care in Latin America. In Bolivia and Ecuador, socialist governments intend to redirect health policy. We outline both countries' health system's features after reform, explore their efforts to rebuild primary health care, identify and explain policy gaps, and offer considerations for improvement. Methods Qualitative document analysis. Findings Earlier reform left Bolivia's and Ecuador's population in bad health, with limited access to a fragmented health system. Today, both countries focus their policy on household and community-based promotion and prevention. The negative effects on access to care of decentralization, dual employment, vertical programming and targeting are largely left unattended. Neglecting care is understandable in the light of particular interpretations of social medicine and social determinants, international policy pressures, reliance on external funding and institutional inertia. Current policy choices preserve key elements of selective care and consolidate commodification. It might not improve health and worsen poverty. Interpretation Care can be considered as a social determinant on its own. Key to the accomplishment of primary care is an integrated application of family medicine, taking advantage of individual care as one of the ways to act on social determinants. It deserves a central place on the policy-makers' priority list, in Bolivia and Ecuador as elsewhere.