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Making heathcare affordable to poorest communities through acupuncture: India

Author(s) Walter Fischer1
Affiliation(s) 1Barefoot Acupuncturists, Barefoot Acupuncturists, Mumbai, India.
Country - ies of focus India
Relevant to the conference tracks Health Systems
Summary Barefoot Acupuncturists is a non-profit organisation registered in Belgium and founded by acupuncturist Walter Fischer in 2009. We run acupuncture clinics in slums of Mumbai and villages in Tamil Nadu (south of India), and also train local acupuncturists in order to encourage autonomy.Our services have been developed to give the poorest communities access to affordable and efficient healthcare, limited mainly to pathologies for which acupuncture has been recognised and proven (among others by the WHO) to be an effective treatment.
Our range of action covers chronic or acute pain, paralysis and stroke recovery, digestive disorders, fatigue, gynaecological issues and hypertension.
What challenges does your project address and why is it of importance? In India the healthcare sector, which is highly privatised, urged around 39 million people to fall into poverty in 2004-2005 because of out-of-pocket expenditures for their treatments.
India is the country with the largest number of poor people in the world and also has one of the most privatized healthcare systems.
It was estimated in 2010 that in India there was a shortfall of 100.000 doctors and 1000.000 nurses.High absenteeism and corruption amongst health workers discourage the poor to access public facilities. Surveys have pointed out that even when the poor try to seek medical assistance in the public sector, richer people have a greater share of public services.The challenge we are trying to address with Barefoot Acupuncturists is the great disparity between rich and poor, between public and private health systems, in which the poorest:
- choose to be treated in private sector at a high cost that puts them at even higher risk in terms of financial insecurity and social instability.
- often choose low quality publics services with the risk of not being taken care of properly and with the threat of developing more chronic diseases, which in the long term might negatively impact their future.

In both cases, the poor become poorer.

How have you addressed these challenges? Do you see a solution? We have been trying to address that great disparity between rich and poor in healthcare by providing efficient and affordable health services to the poorest through low-cost acupuncture clinics and offering acupuncture training to local communities.
Acupuncture is a unique tool not only for social health practitioners as it is cheap, effective and easy to teach. It treats pain and illness without harmful side effects. A healthcare system provided by local «barefoot doctors» who offer first-line services is a simple solution to ensure much-needed healthcare in slums or rural areas where there is little or sometimes no access to medical facilities.Why is acupuncture a unique tool against poverty:
Acupuncture from an economic perspective:
• Allows treatment at a low cost (acupuncture equipment is cheap).
• Is highly adaptable to different environments due to its simplicity and portability.
• Provides an alternative to expensive and sophisticated treatments.
Acupuncture from a healthcare perspective:
• Offers a proven and effective solution to health related issues.
• Can offer help in cases that have not been successful with conventional medicine.
• Can reduce the excessive use of chemical drugs and their potential side effects.85% of our patients consult for pain related to musculoskeletal disorders.
Coolies, farmers, workers, housewives, drivers, and maids are the majority of people at the lowest economic level who earn their living through physical works. Those are our patients.
Because their body is overused, often misused, and because of poor living conditions, this group will suffer more than others from physical pain. At the same time, they cannot afford to remain inactive without wages. Acupuncture (well known for and particularly effective against pain) allows them to recover faster and better.
The well-known efficiency of acupuncture against pain has not only been an observation through our practice in India, but globally in our acupuncture clinics around the world. In 2002 The World Health Organisation (WHO) issued a detailed report about acupuncture and a list of diseases for which through controlled clinical trails acupuncture has been proven to be an effective treatment.

- In 5 years, we have treated more than 3.500 patients, both in slums and villages.
- Today we offer 10.000 treatments every year.
- We are employing a team of 20 local people, including 7 acupuncturists.
- We are preparing to organise acupuncture trainings at a larger scale.

How do you know whether you have made a difference? We are presently making a difference at a very local level, in the slums and the villages where our clinics operate. Our clinics are busy due to our reputation spreading in the community by patients who have been encouraged to consult us by relatives or neighbours who were treated by our barefoot acupuncturists and found relief and solutions to their health problems.
A medical survey and various testimonies have shown and explained the impact and the level of satisfaction among slums dwellers and villagers.
Although our impact is clear upon surrounding poor communities, it is true that we lack scientific data to support our field experience and to quantify that impact.
We plan to hire specialised external skills to enable us to build our practises and communication.In order to expend our impact to other areas, others states in India and later in different countries, Barefoot Acupuncturists is developing an acupuncture training program. This program is aimed at the staff of local NGO’s that will fully manage their own acupuncture clinics, based on their own network and financial resources. This will allow an exponential growth of low-cost clinics, independently of Barefoot Acupuncturists’ human and financial resources. By bringing all the knowledge and tools into the hands of local communities, we hope to create more sustainable growth and functioning.
Have you or the project mobilized others and if so, who, why and how? - Founders: private founders in Europe and India have supported us financially and made it possible for our project to develop during these 6 years.
- Around 30 experienced acupuncturists and medical doctors from all over the world have joined us to work and teach in our Indian clinics.
- In 2012 we signed a collaboration with the "World Federation of Chinese Medicine Societies", an important group of Chinese doctors and professors in Beijing (China) to work on the elaboration of an acupuncture training manual.
- The Foundation Frédéric et Jean Maurice in Switzerland has offered us financial and technical support.
- The association "Humanitarian Acupuncture Project" was created in 2012 in the United-States by American acupuncturists to support our work in India with funding and volunteer acupuncturists.
- Two Indian organisations, UnLtd India and Toolbox, have been advising and coaching us for the year to help us strategise our goals and grow more efficiently.
- Professionals from various fields share their skills continuously with us: graphic designers, photographers, web designers, professional development coaches, accountants, lawyers, film makers…
When your donor funding runs out how will your idea continue to live? Today Barefoot Acupuncturists fully manages and finances all its activities. If funds run out, clinics close and all our patients lose the benefit of our services. This is the main reason (added to the need of a better cost-efficiency ratio) why in the following two years we are preparing to become an organisation offering acupuncture training to local NGO’s and communities, making possible not only an exponential growth but also sustainable structures that will function independently from Barefoot Acupuncturists resources.

Sexual Health of Prison Inmates: a neglected component of Integrated Reproductive Health Services in Nigeria.

Author(s) Muhammad Lawan Umar1, Sanusi Abubakar2, Isa Sadeeq Abubakar3, Nafisa Wali Yusuf 4
Affiliation(s) 1Community Medicine, Bayero University and Aminu Kano Teaching Hopital, Kano, Nigeria, 2Community Medicine, Bayero University and Aminu Kano Teaching Hospital, Kano, Nigeria, 3Community Medicine, Bayero University and Aminu Kano Teaching Hospital, Kano, Nigeria, 4Physiology, Bayero University, Kano, Nigeria.
Country - ies of focus Nigeria
Relevant to the conference tracks Health Systems
Summary The ancillary policy for integrating Reproductive Health (RH) into the Primary Health Care (PHC) system in Nigeria aims to achieve a complete state of physical, social and mental well-being of all Nigerians in matters relating to RH. However, the sexual and reproductive health needs of the vulnerable prisons inmates has not been addressed yet. This work highlights the needs of this population in order to address the gaps needed for full integration of RH into the PHC system in Nigeria.
Background Sexual deprivation in prisons is considered a punitive measure for prison inmates in Nigeria thereby subjecting them to circumstantial deviant sexual acts and psychological ill health.
Objectives This study was to investigate the guidelines and provisions for sexual and reproductive health of prison inmates in Kano Central prison, Nigeria, and the various forms of expressing sexual desire and coping strategies among inmates.
Methodology A mixed method study comprising of 20 in-dept interviews with different cadres of the prison officials and quantitative interviews with 160 inmates. Data were analysed using SPSS version 16.0, and the grounded theory approach was used for the qualitative component.
Results There is currently no guideline on sexual and reproductive health of prison inmates in Nigeria. Cases of sexual harrassment/abuse are being reported but there are no registers or reported documentations of sexual harrasment/abuse, nor provision for conjugal visits or furlough for inmates. There is no stipulated punishment for sexual abuse/harrassment in the prison. About three-quarters (74.4%) and 55.6% inmates reported that sexual harassment and mastubartion respectively were the most common forms of expressing sexual desire in the prison. Sexual desire is more among male inmates (χ2 = 4.31, p 0.05) and married inmates (χ2 = 0.27, p > 0.05). Coping strategies for sexual desire reported were anal sex (59.4%), masturbation (57.5%), fondling with each other’s genitals (26.3%), digital stimulation of each other’s anus (16.9%), or vagina (2.5%) and oral sex (1.3%). Nineteen respondents (11.9%) reported being sexually abused either by anal sex, 3 (15.8%), inserting finger/object in the anus, 4 (21.0%), rape, 3 (15.8%) or forceful fondling with genitalia, 9 (47.4%).
Conclusion Sexual and reproductive health of prison inmates suffers from serious neglect in Nigeria. There is a need for the RH unit of the FMOH to work closely with Nigerian prisons to develop guidelines on the reproductive health and rights of inmates in Nigeria in order to promote full integration of RH into the PHC system, and to preserve the fundamental human rights of Nigerian inmates.

The Impact of the Family Health Team (FHT) model on UNRWA PHC clinics: a success story in a resource-limited refugee setting.

Author(s) Ali khader1, Majed Hababeh2, Irshad Shaikh3, Yousef Shahin 4, Wafaa Zeidan 5, Akihiro Seita6.
Affiliation(s) 1Health Department- UNRWA, UNRWA, Amman, Jordan, 2health, UNRWA, Amman, Jordan, 3Health, UNRWA, Amman, Jordan, 4Health, UNRWA, Amman, Jordan, 5Health, UNRWA, Amman, Jordan, 6Health, UNRWA, Amman, Jordan.
Country - ies of focus Palestine
Relevant to the conference tracks Health Systems
Summary The Family Health Team (FHT) approach brought substantive changes to the PHC services provided by UNRWA to Palestine refugees. It improved staff satisfaction and positive working environments for staff as well as a fair distribution of workload. The relationship with the community and clients become stronger. The quality of care and the utilization of resources also improved.
Background UNRWA provides comprehensive primary health care to 5 million Palestine refugees through 137 clinics in Gaza, Jordan, Lebanon, Syria and the West Bank. UNRWA has, for over six decades, used a vertical, program-oriented model to achieve substantial gains in maternal and child health in particular.
In response to the changing health care needs of Palestine refugees, particularly in the context of an aging population facing a growing burden of non-communicable diseases, increasing client loads, rising costs and stagnating resources, UNRWA is reforming its primary health care services.
The framework for this new service delivery model is the Family Health Team (FHT) approach. This is a patient-centered model that provides comprehensive PHC services to the entire family through a multi-disciplinary team of service providers at every stage of life. Families are registered with a team consisting of a doctor and one or more nurses and the team is responsible for all the primary care needs of all the family members.
Currently the FHT model is implemented in 51 health centres serving 1.5 million. Plans are ongoing to expand this model to all health centres by the end of 2015.
Objectives To assess quality and efficiency gains brought by the Family Health Team model on UNRWA primary health care services.
Methodology Methodology.
We have used different instruments to assess the impact of the FHT approach after 6 months of implementation in Rashidieh health centre providing PHC services for Palestine refugees in Rashidieh camp in Lebanon including:
Client Flow Analysis (CFA): Conducted on 23rd June 2012 . CFA tracks a client’s movements from point of arrival to the clinic, measuring time spent between service delivery points and with each service provider.
Rational drug use survey: The methodology is based on a method described in the WHO manual “How to investigate drug use in health facilities” (WHO, 1993). The survey was conducted during two consecutive days, 23rd and 24th June 2012.
Client satisfaction Survey & staff satisfaction surveys: the Survey was conducted during June 2013 and the questionnaire was developed and tested in-house.
Work-load Assessment: The assessment was conducted during two consecutive days on 23rd and 24th June 2012 to measure the workload between teams and for each staff within the team. It was developed and tested in-house.
Results The CFA indicated that the implementation of the FHT Model appears to have resulted in significantly shorter waiting times to see the physician, which was reduced from 16.0 to 8.2 minutes, (P< 5%). The mean contact time with the physician increased by 1.51 minutes (from 3.19 minutes to 4.7 minutes). The team structure had resulted in a balanced distribution of workload between staff. For example, the number of consultations with physicians were similar for both teams: (team I: 52% vs team II: 48%). The number of medical consultations decreased by 33%, a more integrated and comprehensive care (NCD, General, MCH) is provided by both teams, a more equitable workload distribution among teams with relatively equal age and gender distribution of clients. The antibiotic prescription rate decreased from 26.2% to 20.8%.
83% of staff considered the FHT either very helpful or helpful, 76% of clients are more satisfied, 66% of clients perceived higher quality and longer consultation time after the FHT implementation.
Conclusion Conclusion.
The FHT model implemented by UNRWA is an innovative approach in a refugee context with limited resources. It improves the quality of care provided at primary health care facilities with more efficient use of limited resources in term of staff, time and premises by decreasing waiting time and increasing contact time with the physician and improving client’s inflow-outflow.

Lessons from the Commercial Sector: How Integration Can Transform Public Health Supply Chains

Author(s) Carmit Keddem1, Nadia Olson2, Carolyn Hart3, Joseph McCord4.
Affiliation(s) 1Center for Health Logistics, John Snow, Inc., Boston, United States, 2USAID | DELIVER PROJECT, John Snow, Inc., Washington, DC, United States, 3Center for Health Logistics, John Snow, Inc., Washington, DC, United States, 4USAID | DELIVER PROJECT, John Snow, Inc., Washington, DC,United States.
Country - ies of focus Global
Relevant to the conference tracks Health Systems
Summary Successful health programs require an uninterrupted supply of health products provided by a well-designed, well-operated and well maintained supply chain. By applying a new approach to end-to-end integration, adapted from the commercial sector, health managers can ensure that public health supply chains deliver an adequate supply of essential health commodities to the clients who need them.
What challenges does your project address and why is it of importance? Health programs can succeed only if people have access to the essential health products they need. Although many countries have strengthened their public health supply chains and, thus, improved product availability in recent years, they continuously face new challenges. Countries are under increasing pressure to deliver a rising volume of products to support expanding health programs and respond to greater demand from donors for accountability and sustainability. New technology and commercial sector approaches can help countries build dynamic supply chains that respond to these changes and yield health and development benefits.
How have you addressed these challenges? Do you see a solution? JSI has researched and applied commercial sector approaches to public health supply chains, including supply chain integration, and has seen significant results. While public health systems in resource-limited settings are very different than private companies, public health supply chain managers face many of the same challenges as commercial supply chain managers did many years ago. Over the past few decades, commercial sector supply chains of major corporations, including Apple, Proctor & Gamble, Wal-Mart, and Dell, have undergone a major transformation to become cost-effective, agile, and responsive to consumer needs. This occurred in an environment where consumers were expecting wider choice and better service from retailers, and increasing globalization encouraged companies to build international, outsourced supply chains with increased management complexity. With the right approach, integration can be as transformative for public health as it has been in the commercial sector – leading to more cost-effective and reliable supply chains that effectively deliver health products to clients and contribute to better health outcomes.When adapted for public health, supply chain integration involves linking the actors managing health products from the top to the bottom of the supply chain, or from end-to-end, into one cohesive organization, which oversees all supply chain functions, levels, and partners, ensuring an adequate supply of products to clients. Lessons from the commercial sector teach us that integration is more than merging health program supply chains - for example putting malaria and HIV and AIDS products on the same truck. JSI has worked to design and strengthen various public health supply chains according to the principles of supply chain integration by better linking people, information, and activities from where products are made to the people who need them.
How do you know whether you have made a difference? In Zimbabwe, after applying supply chain integration principles to integrate key products into a well-functioning family planning supply chain, stockout rates for nevirapine tablets decreased from 33 percent to 2 percent and supply chain costs were reduced. This, ultimately, resulted in 35 percent more mothers treated to prevent mother-to-child transmission of HIV.
Have you or the project mobilized others and if so, who, why and how? JSI, through various supply chain projects, works with government, civil society, academic and funder organizations to strengthen public health supply chains worldwide. We have incorporated supply chain integration concepts into our system strengthening approaches in various countries – from a supply chain orientation of animal health specialists in Indonesia, to pre-service training in Tanzania, to guiding the supply chain system design process for essential medicines in Nigeria.
When your donor funding runs out how will your idea continue to live? Strengthening supply chain systems requires significant investment and resources, but can reap significant long-term benefits for health programs and the broader health system. While supply chains required sustained investment, designing public health supply chains according to the principles of supply chain integration will improve their efficiency and effectiveness in the long-term, protecting the investment in commodities and the supply chain system and leading to more sustainable health solutions.

Integrating HIV Commodity Supply Chains to Prevent Mother to Child Transmission Scale Up in Nigeria.

Author(s) Chioma Nwuba1, Sunday Aguora2, Ogubuike Inmpey3, Elvis Okafor4, Okechukwu Agbo5, Vincent Ihaza6.
Affiliation(s) 1HIV/AIDS, Supply Chain Management Systems, John Snow Inc., Enugu, Nigeria, 2HIV/AIDS, Supply Chain Management Systems, John Snow Inc., Abuja, Nigeria, 3HIV/AIDS, Supply Chain Management Systems, John Snow Inc., Enugu, Nigeria, 4HIV/AIDS, Supply Chain Management Systems, John Snow Inc., Abuja,Nigeria, 5HIV/AIDS, Supply Chain Management Systems, John Snow Inc., Enugu, Nigeria, 6HIV/AIDS, Supply Chain Management Systems, John Snow Inc., Enugu, Nigeria.
Country - ies of focus Nigeria
Relevant to the conference tracks Health Systems
Summary Reduction in the rate of mother to child transmission of HIV in Nigeria depends on the availability of antiretroviral (ARV) drugs and HIV test kits in sufficient quantities at service delivery points.
The challenge of multiple storage and distribution channels for HIV commodities, late submission of reports, coupled with low commodity delivery coverage of rural clinics has led to pregnant women travelling long distances to access ARV treatment at urban hospitals.
Integrating existing supply chain management systems to prevent stockouts of essential commodities is crucial for preventing new HIV infections among children and for improving the lives of HIV positive pregnant women in Nigeria.
What challenges does your project address and why is it of importance? Globally, the gap for pregnant women receiving antiretroviral (ARV) medicines for the prevention of mother to child transmission (PMTCT) of HIV is 80% and Nigeria alone accounts for 32% of this gap. In addition, Nigeria has the largest number of children acquiring HIV infection with nearly 60,000 children infected with HIV in 2012 alone.
Thus, ensuring that all pregnant women receive access to HIV testing services and anti-retroviral treatment if tested positive is a priority for achieving PMTCT targets in Nigeria. The current system for collection and transmission of logistics management information system (LMIS) reports, from service delivery points at rural clinics to the central medical store, are complex and labor intensive. As a result, report submission is often delayed, leading to stockouts of critical HIV/AIDS commodities and a reduction in the number of pregnant women who have access to the much needed life-saving antiretroviral treatment.
In addition, multiple storage and distribution channels are often uncoordinated, and this has resulted in stockouts of commodities at some health facilities when there are excess stocks at other facilities.
How have you addressed these challenges? Do you see a solution? In order to improve access to HIV testing services and antiretroviral drugs for HIV positive pregnant women, at 471 rural clinics in five focus states, the USAID funded SCMS project of John Snow Inc. in Nigeria implemented the following data driven interventions: Integrated existing parallel HIV/AIDS commodity management system in the region to form a unified system for procurement, storage and distribution of commodities.
 Integrated collection and analysis of LMIS reports with already existing data collection systems thus facilitating timely report submission which informs resupply decisions to health facilities offering PMTCT services.
 Established an axial storage location within the region for storage & distribution of HIV/AIDS commodities to health facilities.
 Strengthened capacity and skills of community health workers on logistics management of HIV/AIDS commodities through on-site training and mentoring on the use of logistics management information system (LMIS) tools, standard operating procedures, good storage practices and quality improvement processes for efficient delivery of PMTCT services
 Introduced simplified reporting forms to aid community health workers in the collection and timely submission of accurate consumption and requisition reports.
 Initiated bi-monthly cluster review meetings which provides a forum for community health workers to have access to continuing education on the management of HIV commodities, review logistics management information reports, share best practices and address challenges.
 Increased collaboration with government agencies and implementing partners to support LMIS report collation and to address stock imbalances through timely inter facility transfer and redistribution of commodities to avert stockouts and reduce wastages due to expiration.
 Commenced monitoring and supportive visits to monitor quality of services delivered and strengthen the performance of health workers at service delivery points.
 Challenges and issues identified at service delivery points are shared with health facility management teams and the regional technical working group who proffer and implement solutions to address these challenges.
How do you know whether you have made a difference? At the end of six months, the reporting rate for ARV drugs increased from 28.7% to 60% while that of HIV test kits increased from 30.4% to 63.7%.
Due to improved availability of rapid test kits, the number tested for HIV increased from 39,044 before intervention to 79, 384 after intervention. Subsequently, the quantity of test kits ordered increased by 98.5% post intervention.
Integration of all existing HIV/AIDS commodity management systems in the region has resulted in improved commodity security of HIV test kits and ARV drugs thus ensuring continuous availability of these commodities for HIV positive pregnant women and children. Furthermore, the introduction of a simplified HIV commodity reporting form which harmonizes collection of data on ARV drugs and HIV test kits has made it easier for community health workers in rural clinics offering PMTCT services to report consumption of commodities and to make requisitions for re-supply.
The cluster review meetings have improved quality of logistics data as well as the collection and timely transmission of such data required for resupply decision making, resulting in increased availability of HIV-related commodities and improved quality of care.
Have you or the project mobilized others and if so, who, why and how? The outcome of our interventions and lessons learned were adopted during the implementation of the third phase of the HIV/AIDS Supply Chain Unification Project , which covered seven states in the South Western region of Nigeria. It integrated all existing HIV/AIDS commodity management systems in the region aimed at improving commodity security in the supply of HIV rapid test kits and ARV drugs. We commenced by convening a stakeholders meeting with the state ministry of health, implementing partners and other relevant agencies on the need to harmonize the warehousing and distribution of HIV commodities to all service delivery points. The importance of HIV testing services especially for pregnant women and the outcome of treatment interruptions due to stock-out of essential ARV drugs was discussed.
Health workers at service delivery points were trained on the logistics management of HIV/AIDS commodities, use of standard operating procedures, logistics management information system (LMIS) tools and good storage practices.Bi-monthly reports on consumption and requisition of commodities are reviewed during cluster review meetings thus ensuring that commodity requests sent to the central level more accurately reflect health facility needs and, consequently, decrease the occurrence of stock imbalances (under/over stocking) which could result in stockouts or wastage due to expiration and damage.
When your donor funding runs out how will your idea continue to live? This program was executed in collaboration with the Federal/State Ministry of Health (HIV/AIDS Division), National Agency for the Control of AIDS and relevant stakeholders of each participating state. Government ownership and leadership of the program is facilitated through the Procurement and Supply Management Technical Working Group (PSM TWG) which is government driven and has representatives of each participating state as members.
This group conducts regular on site monitoring and supportive visits to health facilities in the region where they review performance of the supply chain system at various facilities, assess program implementation, identify and addresses challenges relating to the management of health commodities and quality improvement of supply chain processes in the region.
The government driven PSM TWG also advocates for funding support from respective state governments while seeking ways to improve overall program efficiency.Furthermore, to facilitate ownership and sustainability, each state is actively involved in the collection, transmission of LMIS reports and inter facility redistribution of commodities to health facilities within their states through the state logistics management team.
Working closely with relevant key stakeholders, we hope to achieve government’s leadership and ownership of the project in three to five years from now.

Barriers for Care and Medicines in Diabetes and Hypertension: A pilot study in Lima-Peru.

Author(s) MARIA KATHIA CARDENAS1, Dulce Morán2, Jaime Miranda3, David Beran4
Affiliation(s) 1CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru, 2CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru, 3CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru, 4Division of International and Humanitarian Medicine at the Faculty of Medicine, University of Geneva, Geneva, Switzerland.
Country - ies of focus Peru
Relevant to the conference tracks Health Systems
Summary The aim of this study is to pilot test the implementation, for the first time in Peru, of World Health Organization manual to identify barriers to access to medicines and care in patients with non-communicable diseases (NCD). As part of an active stakeholder engagement in the process, this study aims to promote a policy response. Tools were prepared to collect quantitative and qualitative data. In total, 141 interviews and meetings were conducted in four levels . This study identifies existing bottlenecks in the access to care and management of patients with diabetes and hypertension. This system-level analysis elicits current challenges and opportunities to improve care for NCDs in Peru.
What challenges does your project address and why is it of importance? Non-communicable diseases (NCDs) have been recognized by the global community as a major public health challenge. World Health Organization's (WHO) response includes the development of a Global Action Plan for the Prevention and Control of NCDs for years 2013-2020 and a Research Agenda with focus on the prevention and control of NCDs in low- and middle-income countries (LMICs) such as Peru. The importance of the challenge posed by NCDs in the context of Peruvian health system was also highlighted by the Peruvian Ambassador during the 43rd Session of the Commission on Population and Development. For Peru, WHO estimates a NCD burden that represents 60% of mortality in Peru, which highlights the relevance of chronic diseases for our health system. According to Nolte and McKee the management of chronic NCDs is one of the largest challenges that health systems throughout the world currently face and each system needs to find locally-adapted solutions. These solutions require a clear understanding of the barriers within the health system to access to NCDs care and medicines, from higher policy-level to the individual patient-care experience. Our projects precisely address this challenge.
How have you addressed these challenges? Do you see a solution? We have addressed this challenge by contributing to the limited available body of evidence concerning NCDs and health systems in Peru. Specifically, our study determined barriers for the access to medicines and health care for diabetes and hypertension using a novel tool for health system assessment that was adapted for the Peruvian health sector context. The tool applied was based on the Rapid Assessment Protocol for Insulin Access (RAPIA), a tool that has previously been implemented in six countries (representing four WHO Regions) with the support of the International Insulin Federation: Kyrgyzstan, Mali, Mozambique, Zambia, Nicaragua and Vietnam. Previous implementations of the RAPIA have resulted in improvements in access to medicines like insulin (Mali, Mozambique and Zambia), development of NCD policies (Mozambique and Zambia), inclusion of recommendations in government policies and programmes (Kyrgyzstan, Mali, Mozambique, Nicaragua and Viet Nam), improvement and increase in the visibility of Diabetes Associations (Mali, Mozambique, Nicaragua and Zambia), inclusion of recommendations in projects and programmes of national NGOs (Mali and Nicaragua), external funding and support for diabetes programmes (Mozambique, Zambia and Vietnam) and the use of RAPIA for monitoring and evaluation (Mozambique).At the health system level, the introduction of this tool for the assessment of NCDs will also be helpful for developing future research agendas in the field. This tool can also serve as a field guide to assist researchers in collection, analysis and presentation of data to evaluate and inform the development of health-care services and policies for specific NCDs or groups of diseases.Policy makers can also benefit from these assessments as it can inform them about ongoing challenges or bottlenecks in NCDs-related health care provision. It is expected that the engagement in the planning phases of the study will provide windows of opportunity and knowledge translation that will likely directly translate in policy changes aimed to improve NCD care.
How do you know whether you have made a difference? The results from this study will contribute to a better understanding of the current situation of the management of diabetes and hypertension in the context of the Peruvian health system, in order to formulate appropriate recommendations for the policy decision makers. However, we know that it is premature to attribute any change to this study. In the context of almost non-existing systematic assessments of health systems in the Peruvian health sector, in particular around NCDs, we expect this research to set the grounds for future policy recommendations. Our results show that NCDs are not yet a priority for policy-makers in Peru, at least not in the practice. There are some initiatives that have not yet reached the expected results such as the basic regulation to protect patients with diabetes and a policy to promote reduction of anti-diabetic drug prices. Presently there is only a national guideline for hypertension attention at the primary health level but no guideline approved for diabetes as well as a National Strategy for NCDs without a current Strategic Plan. The universal health coverage in Peru includes a list of essential treatments for each disease covered by any insurance, but it is partially implemented due to the lack of clinical guidelines and the lack of awareness on this topic by the health professionals. At an intermediate and local level we found problems facilitating the demand for medication and laboratory consumables.General practitioners in the lower-level of management provide care mostly to those patients with no complications. Patients with complicated disease are referred to Hospitals, where patients must wait long periods to obtain an appointment. Even those patients with public health insurance often buy their medication at private pharmacies, due to the lack of stock in pharmacy facilities of public sectors. The high price of medicine in private pharmacies is one of the main reasons for treatment cessation by the patient.In order to strive towards achieving a difference we will perform a follow-up on the following activities. As part of the implementation study, a list of recommendations will be shared with the stakeholders before the end of year 2013 and a follow-up of activities will be performed starting the year 2014. During year 2014, every 4-6 months, a member of the research team will contact the stakeholders by e-mail, telephone or by person in order to monitor the implementation of the recommendations.
Have you or the project mobilized others and if so, who, why and how? Since the beginning of the project we participated in different meeting with stakeholders from different sectors in order to establish initial contacts. The purpose of the meetings was to provide information about the project, to listen to different perspectives, and finally, a last activity will be developed before the end of the year to jointly discuss potential recommendations and to define an action plan towards policy changes that are pragmatic and feasible in the current local context. We have developed a presentation of the study to stakeholders, in which we invited them to a workshop session in order to receive feedback of the study. At this workshop we explained the past experience with RAPIA as well as the background and methodology of the present study. The stakeholders gave suggestions and confirmed their support and interest. Among the participants was a high officer of Ministry of Health (MoH), as well as members of different areas of Peruvian MoH, social Security, public health insurance, health organizations, acadaemia, among others.Members of our CRONICAS research team also participated in meetings with the Experts Committee in NCDs, a coordination unit of the MoH. We participated in one of the activities of this Committee which was the discussion of the National Strategic Plan for Prevention and Control of NCD 2014-2021, as well as the meeting for discussing the National Guidelines for Diabetes Management, which has not yet been approved. Additionally, regarding to the Social Security, we also contributed to the Health Services Portfolio, which is a technical guideline for the effective interventions for specific chronic diseases during the patient's lifespan. CRONICAS contribution was cited in the technical document.
When your donor funding runs out how will your idea continue to live? CRONICAS Center of Excellence in Chronic Diseases has as part of its goals "to contribute to research development on NCD in Peru (Goal 1)" and "to participate actively with public health policy-makers and study population (Goal 2)". Therefore, when funding runs out we will still remain in communication with stakeholders. Most of policy makers and stakeholders find our evidence-generation group an ally for policy-related interactions and a source of technical expertise in the generation of future health policies. Whilst being a research-based institution, our group strives towards contributing to the transition from research to action for the improvement of health care in patients with diabetes and hypertension. We also plan to obtain funding in order to develop the study in other regions in Peru which are less-urban and poorer, and have different epidemiological profiles and, obviously, different health-system needs.

Pediatric Cancer: Integrating referral systems

Author(s) Ramesh Menon1, R.K Marwaha2, Shashidhara Jayappa3.
Affiliation(s) 1Dept of Paediatrics, Institute of Maternal and Child Health, Govt Medical College, Calicut, Kerala, India, 2Dept of Paediatric Haematology and oncology, PGIMER, Chandigarh, India, 3Dept of Paediatrics, Institute of Maternal and Child Health, Govt Medical College, Calicut, Kerala, India.
Country - ies of focus India
Relevant to the conference tracks Health Systems
Summary There is no systematized referral path for centralized care for children with cancer in India which adversely affects outcome. We undertook a questionaire based survey of patients/ health care seekers in this group (children < 18 years of age) who used a tertiary care centre unit in North India ( PGIMER, Chandigarh). This study attempted to tease out the section of maximum delay in the existent variety of paths taken by health seekers among cancer patients, patient delay (symptom- contact) and system delay (contact- diagnosis) were analysed separately. Over a period of one year data was collected the saliant findings were the symptom- contact delay was 2 to 3 days and the contact- diagnosis delay was 27 to 40 days.
Background Estimated number of new cancers diagnosed in India every year is 700,000 to 900,000. The geographic, socioeconomic, educational and health system inequalities in cancer treatment, in children, have only now begun to be addressed. This study was designed to assess referral patterns of children with haematological malignancies (HM) in Northern India.
Objectives To identify the modifiable factors causing delay in the early referral of children with Haematological malignancies and to quantify the relative significance of the factors analysed.
Methodology In the period between the months of October 2001 and November 2002, based on a predesigned performa, parents/guardians
of children with haematological malignacy were interviewed at presentation to a tertiary cancer care facility for children in North India. Details from previous prescriptions and referrals, if available, and details of diagnosis (staging and categorization) were recorded. Haematological malignancies included acute leukemia (lymphocytic (ALL), myeloid (AML), undifferentiated (AUL) and non-Hodgkin's lymphoma (NHL)). Risk stratification of disease categories at presentation, from high risk disease and standard risk disease, was completed. Patient delay (symptom - contact interval), health systems delay (contact-diagnosis interval), total delay (symptom- diagnosis interval) and number of contacts were recorded and compared between high risk and standard risk disease groups using descriptive analysis.
Results Of the 79 children (55 boys; 69.6%) with HM, the total number in the high- risk category was 40 (50.6%), and the rest were of the  standard-risk group. The mean age was 5.9 ±3.2 years. The median patient delay of care seeking for children with high - risk HM was 2 (95 % CI; 1.27, 3) days and for children with standartd risk HM was 3 (95% CI;1, 4.22) days (P=0.42). The median system delay of care provided for children with high- risk HM was 27 days and for children with standard risk HM was 40 days (P=0.19). The median symptom to diagnosis interval for children with high risk HM was 29 days and for children with standard risk HM was 45 days (P=0.09). In the standard risk group, 19 (48.7%) had more than 3 contacts whilst in the high-risk category, only 11 (27.7%) had more than 3 contacts (P=0.043). The private sector was similarly approached in both risk groups for medical care. In the study group, the risk category had a significant association with the total delay (spearman correlation coefficient= -0.262, P= 0.02)
Conclusion Sensitizing the private sector practioners and primary care physicians to the possibility of haematological malignancy in children with obvious signs may be the most effective step in a resource poor setting for an early referral.

Relations and Communication of the Centres for Mental Health with Other Relevant Stakeholders in Bosnia and Herzegovina.

Author(s) Ahmed Novo1, Sinisa Stevic2, Srdjan Dusanic3, Darko Paranos 4, Vera Kerleta-Tuzovic 5, Nadja Bascausevic6
Affiliation(s) 1Agency for Quality Improvment and Accreditation in Healthcare of Federation of BiH, AKAZ, Sarajevo, Bosnia and Herzegovina, 2ASKVA , ASKVA RS, Banja Luka, Bosnia and Herzegovina, 3Faculty of Philosophy, University of Banja Luka, Banja Luka, Bosnia and Herzegovina, 4Mental Health Project in BiH, MHP BiH, Sarajevo, Bosnia and Herzegovina, 5Agency for Quality Improvment and Accreditation in Healthcare of Federation of BiH, AKAZ, Sarajevo, Bosnia and Herzegovina, 6Agency for Quality Improvment and Accreditation in Healthcare of Federation of BiH, AKAZ, Sarajevo, Bosnia and Herzegovina.
Country - ies of focus Bosnia and Herzegovina
Relevant to the conference tracks Health Systems
Summary Within scope of the Mental Health Project in Bosnia and Herzegovina (BIH) two BIH agencies for safety and quality improvement and accreditation in health care, AKAZ and ASKVA conducted series of training seminars in order to improve the importance, role and visibility of the Centres for Mental Health (CMH) in the health systems, as well as their relations with other relevant stakeholders in health and social systems of Bosnia and Herzegovina. Two surveys at the beginning and the end of the project activities have been performed in order to measure the successes of the training seminars. Final survey results have showed that CMH have improved their importance as well as communication.
Background Activities were conducted within the scope of the Mental Health Project (MHP) in Bosnia and Herzegovina (BIH). The Mental Health Project in BIH is a result of continuous commitment of the health ministries to continue the mental health reform in BIH. The mental health reform was launched in 1996 and focused on community-based care as a contrast to the traditional model which was mainly oriented towards hospital treatment of persons with mental disorders.The overall goal of the Mental Health Project in BIH, in the period June 2010 - December 2013, was to improve general mental health of the population and enhance the capacities of policy makers and competent institutions in complying with European standards in mental health care in BIH.Since 2008, two Agencies for quality improvement AKAZ and ASKVA were involved in training and accreditation of health centres in field of mental health with the aim to improve the quality of provided care. Therefore they were selected to perform training for representatives of relevant stakeholders in order to improve importance, role and visibility of the Centres for Mental Health, as well as their relations with other relevant stakeholders in the health systems of Bosnia and Herzegovina.
Objectives The objectives of the Mental Health in BiH Project from the period June 2010 to December 2013 were as follows:1.Improved administrative and legislative framework to enable efficient operations and processes in mental health care in both BiH entities, Federation of Bosnia and Herzegovina and Republika Srpska.
2.Persons with mental problems have access to improved and better quality services of mental health care at the community level.
3.Provision of high-quality mental health services at the community level supported as a priority of the reform process by the management structures in Community Health Centres.
4.To strengthen the capacities to fight against stigmatisation and discrimination related to mental disorders.Within the objective 3, the specific objectives include: a) Improved understanding of managers of DZs and centres for social welfare on the importance and role of mental health centres within DZ organizational structure and b) Establishment of improved cooperation between centres for mental health and other services within primary health care centres, other relevant sectors and local community.
More precisely, AKAZ and ASKVA needed to conduct a series of training seminars in order to improve the importance, role and visibility of the Centres for Mental Health in the health systems, as well as their relations with other relevant stakeholders in health and social systems of Bosnia and Herzegovina. It was also planned to perform two surveys at the beginning and the end of the project activities in order to measure the successes of the training seminars and to examine whether the training made a difference in the initial and final report, emphasising the following questions and tasks:
•Assessment of the current human resources and technical capacities of centres for mental health;
•Assessment of the cooperation established among centres for mental health and other relevant stakeholders in the sector (family medicine teams - FMT and primary healthcare centres - PHC as a whole, psychiatric clinics/wards, centres for social welfare - CSW, local community);
•Definition of the major challenges in inter-sectoral and intra-sectoral cooperation among the aforesaid stakeholders;
•Identifying the respondents’ attitudes toward mental health (centres for mental health, working professionals, individuals with mental disorders);
•Assessment of the respondents’ acquaintance with basic terms and data in the field of mental health.
Methodology Within the MHP in BiH, Agencies for healthcare quality, AKAZ and ASKVA, conducted a series of surveys on “Relations and Communication of the Centres for Mental Health with Other Relevant Stakeholders in Bosnia and Herzegovina. Both Agencies have compared results of the baseline and final survey on respondents’ view and evaluation of the capacity, role and importance of the Centres for Mental Health and their relations with other relevant stakeholders. AKAZ and ASKVA applied different research methodologies. AKAZ developed five questionnaires for the survey: for mental health centres staff, for social work centre staff, for DZ management, for members of the family medicine teams and for staff from psychiatry departments/clinics. All participants completed questionnaires anonymously and questionnaires did not contain questions about the identity of respondents. Questionnaires had seven parts: data on respondent, cooperation between CMH and management of DZ, cooperation between CMH and family medicine teams in DZ, cooperation between centre for mental health and and psychiatry department/clinics, cooperation between CMH and centred for social work, cooperation between centre for mental health and other services and part seven was for comment, suggestions and questions in an open end format. The first survey was conducted in January-March 2012 and the second was conducted in February 2013. Questionnaires were sent by e-mail to the survey participants who filled it in and sent it back in electronic format or as hard copy. ASKVA conducted interviews in two different phases, at the beginning of the first round of seminars and at the end of project implementation, during the third round of seminars. There were four rounds of trainings and seminars in whole, organised regionally (Banjaluka region, Herzegovina region and Teslic region). The baseline survey was conducted in December 2010 and the final survey was conducted in November 2011. The same respondents participating in the survey, fulfilled questionnaire both at the beginning and at the end of the survey and their responses were compared. The interviews were conducted by the RS Agency’s staff. The survey was quantitative, since it was questionnaire based. Respondents needed approximately 30-45 minutes to fill in the survey questionnaire. Data processing was completed in SPSS statistical software. Responses to the survey questions were presented in form of frequencies, percentages and arithmetic averages.
Results In Federation of BIH AKAZ conducted two surveys in the period from January 2012 till March 2013. 40 organisations participated in the first survey from primary health care level (12 DZ, 14 CMH and 14 FMT), 16 CSW and 6 hospitals. 60 organizations from primary health care level (19 DZ, 24 CMH and 17 FMT), 9 CSW and 5 hospitals participated in the second survey.
Analysis of the results of cooperation between CMH, FMT and management of DZ shows obvious progress in cooperation. Significant contribution provided CMH with improved service through the use of accreditation standards and development of cooperation protocols, working procedures and better communication with management of DZs and FMTs. Furthermore, cooperation between CMH and CSW was also improved. Analysis of the results shows the progression of attitudes of both institutions. Improvement is especially noticeable in the area of general cooperation and frequency and quality of communication. Cooperation between
CMH and psychiatry departments/clinics are also ameliorated (efficiency of the referral system, role and importance of CMH and psychiatry departments, etc.). None of the results from all stakeholders and participants in the survey show that disagreement in general cooperation, frequency in communication and definition of mutual relationships are still present.
In RS, ASKVA conducted the first survey in December 2010, using the sample of 77 respondents and the second was conducted in November 2011 with the sample of 61 respondents. Results show that the capacities of the Centres for mental health (CMH) are improved when compared to the initial survey and respondents are more pleased with cooperation they have between CMH and other institutions. The biggest impacts are related to regular communication and signed protocols of cooperation. The following challenges are recognized in inter-sector cooperation: development of better communication, organization of meetings within healthcare centres, better positioning of CMH within health centre, development of procedures and work standards, more intensive work and better cooperation in smaller communities.
Challenges in the intra-sectoral communication are as follows: better communication and information, defining and realization of protocol on cooperation, provision of more education/training for all employees. Participants have positive relations towards mental health and there are no open signs of stigmatization.
Conclusion Summarized conclusions in regards to the survey on “Relations and Communication of the Centres for Mental Health with Other Relevant Stakeholders in Bosnia and Herzegovina” are as follows:
• CMH capacities are improved when compared to the initial survey. Respondents are satisfied with premises, furniture and technical equipment as well as professional instruments and additional education.
• Respondents are mainly satisfied with cooperation of CMH and other institutions in the final survey. They are the most pleased with the cooperation with organizational units within healthcare centres and the least happy with cooperation with associations of beneficiaries.
• The biggest leap forward was made in the final survey with regard to more regular communication and signed protocols of cooperation between CMH and CSW. Besides, there is a progress in regular communication between CMH and family medicine teams.
• There is a positive attitude of participants towards the mental health, CSW and psychiatric clinics.
• At the end of project, the number of those who think they knew the Strategy of Mental Health Development increased. Besides, participants evaluated that the Strategy was better implemented in practice.
• Challenges in intra-sector cooperation are: development of better communication and organization of more meetings within healthcare centres, better positioning of CMH within healthcare centres, development of work procedures and standards, intensified work and cooperation in smaller communities.
• Challenges in inter-sector cooperation are as follows: development of better communication and information, defining and realization of protocols on cooperation, provision of better education for employees.A complex organisational health care structure and the complex political structure in BIH may jeopardise the project implementation in the planned timeframes. Different understanding of roles and functions by mental health authorities at different levels could be also be one of the risks. Through the intra- and inter-sectoral cooperation, the Project should develop clear allocation of responsibilities between the institutions and stakeholders involved. Clear commitment of the BIH health care authorities to the sector reform and kind support and joint efforts of Donors (SDC and the Swiss Cantons) and the ensured domestic ownership of the project should guarantee the sustainability of the reform process.

Equity and Local Government: Sao Paulo, Brazil

Author(s) Vera Coelho1
Affiliation(s) Citizenship, Health and Development Group , Brazilian Centre of Analysis and Planning , Sao Paulo, Brazil.
Country - ies of focus Brazil
Relevant to the conference tracks Health Systems
Summary Brazil has established a nationwide health system (SUS) aimed at ensuring universal access and has made enormous progress towards this goal over the past two decades. However, a number of studies have shown that certain vulnerable groups often do not have effective access to the services they need. The study analyzes the evolution of the supply and consumption of public healthcare services within the municipality of São Paulo between 2000 and 2011. The results show that there has been equity gains that favored groups living in areas that present the worst socio-economic indices. The paper discusses how municipal health policies and politics helped to guarantee these achievements.
Background During the 1990’s a new governance structure was forged and contracts were initiated between the federal, state and municipal governments, which defined responsibilities and transparent financing rules for the implementation of the national health policy. At that time the effective institutionalization of the health conferences, a national health council, and the health councils in all twenty-six states and in nearly all of the 5,561 municipalities also took place. Today the national government has an important role in regulating and financing health services, while state and municipal governments are responsible for delivering services and allocating supplementary funding. One major challenge facing the SUS is how to increase the system’s equity as the provision of services is still skewed in favor of wealthier regions and citizens. In particular, the study focus on the difficulties posed in tackling internal equity gaps in mega cities as, despite the fact that these are highly unequal areas, the national policy only focuses on inequalities between regions, states and municipalities. The study explores how municipal politics favored the adoption of policies that helped in guaranteeing a more equitable distribution of public health services in the mega city of Sao Paulo.
Objectives The study evaluates the redistributive efficiency of the Sao Paulo municipal policies’ adopted between 2001 and 2011. The period covers three municipal terms. The study: 1) follows the distribution of public health services – equipment and service supply - in all the 31 sub-municipalities between 2001 and 2011; 2) describes the health policies implemented by each of the three administrations and explores the rationale for its adoption; 3) tests the plausibility of the assumption that relates, on one hand, the coupled presence of competitive election for local office and citizen participation and, on the other hand, the adoption of innovations that favored greater equity. The main questions we planned to answer were: Did the gap across areas with the highest and lowest Intra-Municipal Development Index narrow during the period? Can we identify how the different strategies adopted by the municipal government in each term worked to reduce or widen this gap? What was the role played by local politics in favoring the adoption of these strategies?
Methodology The analyses gauge the effect of municipal health policies on indicators of access to public health services. The study was organized in three steps. First, a geographic Information System (GIS) was organized. It contains data from the years 2000 to 2011 on per capita primary appointments of a given submunicipality, the rate of hospital admission per 10.000 residents of a given submunicipality; age, income, and educational level of the submunicipalites’ resident population and the proportion of SUS users and out-of-pocket or private insurance users. The SUS-user is a citizen without a private health insurance, who uses the public health system, which in São Paulo’s case representes 48% of the total population. For primary consultations there is no information to allow for identification of the beneficiary for a given appointment and we assumed a plausible premise that this kind of service tends to be produced in a decentralized fashion and consumed locally. For hospital admissons we worked with the Hospital Admission Authorization (AIH), the means through which healthcare service providers in Brazil are reimbursed. AIH records indicate the zip code of those who used the SUS service which allows for mapping of the consumption of hospitalizations in the sub-municipalities areas. Equity gains have been estimated as the difference between each outcome in the sub-municipalities areas, which are in the highest socioeconomic quartile compared to the lowest quartile. The sources are CENSUS (IBGE) and Data SUS (Ministry of Health).In the second step a structured questionnaire with closed and semi-open questions was applied to health councilors, service providers and municipal public officials. Moreover, we collected data provided to official media for public announcements and mass media. The analysis of these materials helped in understanding the political context and the decisions made by each of the three administrations.In the third step we analyzed the distribution of health units and basic appointments as well as hospital admissions and sought to locate turning points that favored the equity gains identified in the first step. Once we identified these turning points we investigated the relationship between them and the policy decisions made by each of the three administrations, which were identified in the second step.
Results Despite the fact that the SUS population was concentrated in the outskirts, in 2001 in the city of Sao Paulo equipment and services were concentrated in the central and oldest areas of the city of Sao Paulo. This meant that the populations who lived in areas with better socioeconomic indicators were privileged compared to populations living in the outskirts of the city. In this sense, it is important to note that the differences in distribution measured in the present work are between the poor that live in different areas of the city, rather than between poor and non-poor as such. The bias in favor of central areas was partially reversed in more recent years and this was made possible through heavy investment in infrastructure. The average number of basic health units per 20,000 SUS users increased from 0.79 to 1.42, and there was considerable progress in the distribution of these equipments to areas in the outskirts of the city. The implementation of new hospitals has privileged poorer areas, as can be noted by the fact that four out of five new hospitals built in this period were in areas among the 10 sub-municipalities with the lowest Human Development Index (MHDI) in the city. Along with this expansion there was a shift in the distribution of hospital beds: in 2001 the 9 sub-municipalities with the smallest MHDI supplied 5.75% of the public hospital beds in the municipality, while 10 years later this percentage had increased to 13.48%. It should also be noted that, in 2010, hospitalizations were 61.9% higher among SUS users residing in the first quartile (the poorest) and were only 13.8% higher among fourth quartile residents (the richest).The rate of primary appointments increased by 154.7% between 2001 and 2010, with the average rate of basic appointments per SUS user per year going from 1.28 to 3.26. From 2002 to 2006 the standard deviation in the distribution of these appointment between submunicipalities decreased from 0.93 to 0.66.The data collected and analyzed by the study clearly shows that there was significant expansion in the supply as well in the consumption of services in the regions that presented the worst socio-economic and health indicators. An analysis of the distribution of these resources also showed that we now have a more equitable distribution pattern of public health services between locations with a reduction in the geographic inequalities hindering access to the public health system.
Conclusion The results described in the preceding section may seem expected, after all, the distribution of public health services was and still is biased towards wealthier areas and the correction of this situation is the most logical step. However, this is a striking result given how difficult it is to reverse this tendency as attested by the findings of a number of studies in different parts of the world, which indicate that the richest tend to persistently benefit more than the poorest from public spending on health (World Bank 2003; Liu, Hotchkiss and Bose 2007). The guidelines and programs established by the Brazilian Ministry of Health starting in the 1990s guaranteed that new resources reached the municipality. The simple use of these resources, replicating the distributive profile of the pre-existing equipment could, however, have easily led to a deepening of existing inequalities. As seen in the previous section, this was not what happened. From 2001, municipal managers began to take on a major role in proactively coordinating municipal policy and prioritizing those areas with higher populations of SUS users, which are the poorest areas and those with worse health indicators. The analysis suggests that the equity gains reported in the study happened trough cycles of micro and macro politics that reinforced each other. The micro cycles were lead by active local health councils which used political mobilization and contacts to pressure the municipal health secretariat for more resources. The macro cycles involved political projects and efforts by both the Workers' Party (PT), that held municipal office from 2001 until 2004, and the Brazilian Social Democracy Party (PSDB), which entered office in 2005. The equity gains made possible by the macro cycles were assured by the use of technical criteria to make sure that the new resources made available for basic health were distributed in a manner that would serve the population living in the municipality in a more equitable way. As it is described in detail in the study, these two dynamics, fed by political competition between PT and PSDB, allows for an explanation of the adoption of many of the policies that forged the distributive results described in the previous section.

Gap between Individual Perception and Expectations and Services Quality in Health Centres of Tehran, Iran.

Author(s) Davoud Shojaeizadeh1, Sima Esmaeili Shahmirzadi2, Monavvar Moradian3, Esmaeil Shojaeizadeh 4.
Affiliation(s) Health Education and Promotion Department, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran, Tehran University of Medical Sciences, Tehran, Iran, tehran, Iran, Health Education and Promotion Department, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran, Tehran University of Medical Sciences, Tehran, Iran, tehran, Iran, Health Education and Promotion Department, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran, Tehran University of Medical Sciences, Tehran, Iran, tehran, Iran, 4 Health Education and Promotion Department, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran, Tehran University of Medical Sciences, Tehran, Iran, tehran, Iran.
Country - ies of focus Iran
Relevant to the conference tracks Health Systems
Summary Services quality is the determining factor of an organisations success in a competitive environment. Evaluation of services is an essential step in the improvement of health programs. The aim of this study was to survey the gap between individual perception and expectations concerning the service quality in the health Centers of Tehran, Iran by usage of SERVQUAL.
This research was a descriptive and analytical. The cross-sectional study was performed between 2012-2013 in the health centers under the coverage of Medical and health network of Tehran city. Data gathering was conducted with two questionnaires. The first questionnaire contained four questions on demographic characteristics (gender, age, educational status and marital status).
Background Service quality is the determining factor of an organisations success in a competitive environment. Evaluation of services is an essential step in health program improvement. The aim of this study was to survey the gap between individual perception and expectations concerning service quality in the health Centers of Tehran, Iran by usage of SERVQUAL.
Objectives The aim of this study was to survey the gap between individual perception and expectations concerning service quality in the health Centers of Tehran, Iran by usage of SERVQUAL.
Methodology This research was a descriptive and analytical. The cross-sectional study was performed between 2013 in the health centers under the coverage of Medical and Health network of Tehran city. Data gathering was conducted with two questionnaires. The first questionnaire contained four questions on demographic characteristics (gender, age, educational status and marital status). The second one consisted of the SERVQUAL questionnaire. The SERVQUAL tool consists of the expectations and perceptions sections. In each section there were 22 statements on five domains: tangibility (4 items), reliability (4 items), responsiveness (4 items), assurance (5 items) and empathy (5 items). The Persian version of SERVQUAL questionnaire has gained necessary validity and Cronbach's alpha was calculated at 0.9. Results were considered significant at conventional p0.05 level. The sample size was 200 people and participants randomly selected from individuals that were referred to health centers affiliated to the Tehran University of medical science in 2012-2013. For data analysis SPSS 18 and Independent T- Test, ANOVA test and Pearson correlation were used.
Results The age average of the subjects was 28.79±7. 41. Among them, 99.5% were female and only 0.5% were male. Also 99.5 percent of the participants (199 persons) were married, and 0.5% (1 person) was single. Gap Average of Individual’s perceptions and expectations were calculated respectively in the domains of tangibility (0.95±0.88), reliability (0.48±0.86), responsiveness (0.53±0.85), assurance (0.49±0.77) and empathy (0.67±0.93) respectively. The total gap between perceptions and expectations of service quality was 0.63±0.73. The gap maximum between perceptions and expectations was in the tangibility domain (0.95±0.88) and the gap minimum was in the reliability (0.48±0.86).
200 participants were in the study. 11% were illiterate, 54.5 percent of the respondents had an elementary educational level, 32% were high school and 2.5 percent had a College education.
Conclusion The large gap between perceptions and expectations of the participants in the tangible indicator suggests that the physical environment and facilities need to be improved in the health centers. Cooperation from the private sector investment in public centers may be effective in reducing the present problems.