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The reform approved in Peru in 2009 during a right-wing government deviates from similar attempts in the region to expand access to healthcare. Left-wing parties in Peru were extremely weak during the policy-making process and the political parties were non-programmatic. Based on original field research, this article demonstrates how parties that lacked core values uniting their leaders and had no commitment to the health reform did not care for the definition of specifications regarding funding and implementation. Instead, technocrats dominated the process of policy formation, which, accompanied by the lack of commitment from key political actors, led to poorly specified policy and deficient implementation. [ABSTRACT FROM AUTHOR]

Background: In a time of growing health expenditures and inefficiencies, ageing populations, rise of chronic diseases, co-morbity and technical evolutions, there is a worldwide quest for performant, innovative and sustainable health systems that are, a.o. effective and cost-efficient, patient-centric and co-creative and able to deal with the growing society dynamics. Problem statement: Effectively implementing strategic initiatives that tackle these challenges appears a frightening task since the majority of implementations fail. Current approaches and frameworks addressing organizational changes are fragmented, heterogeneous and mostly descriptive. We aimed to design and develop a more prescriptive, holistic and integrated approach. Literature review: Methodologies, governance techniques, approaches and other "best practices" from a.o. the manufacturing and generic services sector are being applied to health and health care services. We observed the existing organizational science literature and found that most existing approaches are not, or inadequately concerned with design and many share the same underlying mechanistic characteristics: strongly management and planning oriented, focus on internal control that apparently should secure success of future health system organizations. Theory: We summarize the needed concepts and theoretical background of the Enterprise Engineering discipline, including Enterprise Ontology (the implementation-independent essence of organizations) and the DEMO methodology, Enterprise Governance and the Normalized Systems theory. Method: We used the Design Science Research Methodology (DSRM) and demonstration is based on real health reform proposals and (fictitious) anecdotal scenarios. Discussion: Formal publication of architectural principles and requirements according to the Enterprise Architecture discipline aids in: correlating enterprise design principles to areas of concern, and further to strategic choices, norms and values, and policies; providing coherent and consistent attention to the various implications of architecture; defining a coherent and consistent set of follow-up activities defined as key actions (studies, pilots, projects) to enable the architecture to be effective; As main characteristics of using Enterprise Ontology, we demonstrated: it ensures completeness in unambiguously discerning all activities required to deliver health services; it aids considering and comparing different implementations of these activities and their executing actor roles in health organizations, people and automation; the models can be used in "just in time, just enough detail"-mode; creating the models is possible with an attractive return-on-modeling-effort (ROME); Different strategic choices, areas of concern, as well as functional and constructional requirements are not met at the implementation-independent level. In order to perform optimally and to implement changes successfully, these organizations must operate as a unified and integrated whole, which can only be achieved through deliberate Enterprise Development and Enterprise Governance. Furthermore, we show it is possible to integrate compatible and relevant analysis techniques and improvement/quantification methods to prepare a better, more objective and more "calculated" change reform proposal, or to assess the impact of an existing one. Conclusion: Lack of enterprise integration and coherence has been identified as one of the core reasons for not successfully operationalizing strategic initiatives. In view of the several enterprise aspects, a design approach must be able to address all aspects. Realization must be intentionally designed, as virtually all causes for poor enterprise performance are systemic. Also, a fundamentally different perspective on governance is essential for: (1) addressing enterprise dynamics, complexity and associated uncertainty; (2) iteratively, evolutionary, and emergent development of strategic initiatives and their operationalization and (3) realizing a unified and integrated enterprise organization and operation. The Enterprise Engineering paradigm and integrated with compatible analysis techniques, improvement and quantification methods; provide a solid foundational theory and methodology, different and unified approach for integrating several enterprise aspects that would otherwise be treated incoherently and inconsistently, causing failures in strategic initiative implementations. In relation to the theories underlying our proposal, we experienced: (1) an initial steep learning curve and emergence of the EE Discipline; (2) that not all activities in organizations are transaction based as they experience emergent properties, and can therefore not be expressed in the current EO theory, e.g. strategy development, decision making processes, knowledge workers or enterprise design itself; (3) that the understandability of the produced EO models by the stakeholders must not be taken for granted; (4) a strong desire for an (unattainable) fully codified method. During our research, we also experienced a strong pull towards the financing and expenditure context, both in literature interviews, reform proposals, demonstrative cases and interviews. Another phenomena, was the lack of public availability and scarcity of up-to-date, reliable and comparable data and measures to work with. We have high confidence in the application of our proposal to address problems of inefficiency and unsustainability in health system organization using a deliberate enterprise development and governance approach. [ABSTRACT FROM AUTHOR]

Este artículo analiza los procedimientos y los procesos de contratación de trabajadores de salud en el Programa de Salud de la Familia en el Brasil, discutiendo los méritos, problemas y resultados relativos de cada uno de los mecanismos utilizados para la contratación de médicos, enfermeras y agentes de salud comunitarios. Antes de iniciar propiamente el análisis de los mecanismos de contratación, el autor hace una breve descripción de la importancia y del papel del Programa de Salud de la Familia para el sistema de salud brasileño. Ahí, el artículo procura demostrar las características y el impacto sobre el desarrollo de los recursos humanos de este programa clave, que es considerado como la «reforma de la reforma» o la «contrarreforma» del sistema único de salud. Finalmente, después de presentar y analizar los datos disponibles sobre las formas de contratación y los sueldos para médicos y enfermeras en algunos estados y municipios del Brasil, el autor llama la atención sobre el nuevo contexto social, donde son los propios gobiernos, en los distintos niveles, quienes estimulan el incumplimiento de reglas y leyes laborales que es su responsabilidad mantener. Esto sólo refuerza la hipótesis de que una nueva etapa de reformas ya se ha puesto en marcha.This article analyzes the procedures involved in the hiring of health personnel in the Family Program in Brazil. We examine the values, problems and relative outcomes of each of the processes used in hiring doctors, nurses and health community workers. Before analyzing hiring procedures, the author briefly describes the importance and role of the Family Health Program of the Brazilian health care system. Based on these factors, this article aims to demonstrate the characteristics and effects of this key program, considered a pivotal reform in the Brazilian health system, on the development of human resources. Finally, after presenting and analyzing the data available on the hiring models and the various salaries of physicians and nurses in several Brazilian states and municipalities, the author highlights the new social context in which the government, at different levels, flouts the labor regulations, which are their responsibility to enforce. This fact alone reinforces the hypothesis that a new phase of reforms has already begun.

Actualmente, muchos países en todo el mundo están llevando a cabo reformas de sus sistemas de salud. Estas reformas, si bien difieren de acuerdo con las características del país, comparten muchas de sus políticas, y una de éstas es la promoción de la participación social en salud. Con todo, esta política no es una iniciativa nueva en lo que a organización de los servicios de salud se refiere. A lo largo del último siglo la colaboración individual o colectiva de la población con los servicios de salud ha sido fomentada a partir de diversas filosofías y conceptos, y persigue objetivos diversos: desde la búsqueda de la colaboración de la población para la extensión de la cobertura de los servicios de salud al fomento de la creación de mecanismos que permitan a la sociedad ejercer un control sobre la actuación de los servicios. No obstante, para que exista algún tipo de implicación de la población con los servicios, deben confluir diversos factores, tanto relativos a los servicios como a la población. A pesar de que los marcos teóricos que han sustentado la participación social a lo largo del desarrollo de los sistemas de salud difieren considerablemente, su puesta en práctica ha compartido muchos elementos comunes en todas las épocas, desde la participación como medio para obtener unos objetivos, a ser un fin en sí misma, como proceso democrático. Esto es también aplicable a la promoción actual de las políticas de participación social en el contexto de las reformas, que se analizan fundamentalmente a partir de los ejemplos de Colombia y Brasil.Currently, many countries throughout the world are reforming their health services. Even though these reforms differ according to the country's characteristics, they share many policies, one of which is the promotion of social participation in health-related matters. This policy, however, is not new in the field of health service organization. Throughout the last century, individual or collective collaboration between the population and health services has been promoted by several philosophies and concepts with different aims: from the search for collaboration with the general public to broaden public health system coverage to the promotion of the creation of mechanisms that would allow society to exercise control over these services' performance. Nevertheless, for the public to be involved with these services, several factors concerning both the services themselves and the population, need to converge. Although the theoretical frameworks that have encouraged social participation throughout the history of the development of health systems differ considerably, their practical implementation shares many common elements in all periods, from participation as a means of obtaining certain objectives to being an end in itself, as a democratic process. This can also be applied to the current promotion of social participation policies in the context of health care reforms, which are analyzed using Colombia and Brazil as examples.

The Chilean health care system has been intensively reformed in the past 20 years. Reforms under the Pinochet government (1973-1990) aimed mainly at the decentralization of the system and the development of a private sector. Decentralization involved both a deconcentration process and the devolution of primary health care to municipalities. The democratic governments after 1990 chose to preserve the core organization but introduced reforms intended to correct the system's failures and to increase both efficiency and equity. The present article briefly explains the current organization of the Chilean health care system. It also reviews the different reforms introduced in the past 20 years, from the Pinochet regime to the democratic governments. Finally, a brief discussion describes the strengths and weaknesses of the system, as well as the challenges it currently faces.El sistema de salud chileno ha sido intensamente reformado en los últimos 20 años. Las reformas bajo el gobierno de Pinochet (1973-1990) apuntaron principalmente a la descentralización del sistema y al desarrollo del sector privado. La descentralización involucró un proceso de desconcentración y la devolución de las unidades de atención primaria a las municipalidades. Los gobiernos democráticos posteriores a 1990 escogieron preservar el núcleo organizacional, pero las reformas introducidas buscaron corregir las fallas del sistema y aumentar la eficacia y la equidad. El presente artículo explica brevemente la organización actual del sistema de salud chileno y revisa las diferentes reformas introducidas en los últimos 20 años desde el régimen de Pinochet hasta los gobiernos democráticos. Finalmente, presenta una discusión breve para describir las fortalezas y debilidades del sistema, así como los desafíos que enfrenta actualmente.

Actualmente, muchos países en todo el mundo están llevando a cabo reformas de sus sistemas de salud. Estas reformas, si bien difieren de acuerdo con las características del país, comparten muchas de sus políticas, y una de éstas es la promoción de la participación social en salud. Con todo, esta política no es una iniciativa nueva en lo que a organización de los servicios de salud se refiere. A lo largo del último siglo la colaboración individual o colectiva de la población con los servicios de salud ha sido fomentada a partir de diversas filosofías y conceptos, y persigue objetivos diversos: desde la búsqueda de la colaboración de la población para la extensión de la cobertura de los servicios de salud al fomento de la creación de mecanismos que permitan a la sociedad ejercer un control sobre la actuación de los servicios. No obstante, para que exista algún tipo de implicación de la población con los servicios, deben confluir diversos factores, tanto relativos a los servicios como a la población. A pesar de que los marcos teóricos que han sustentado la participación social a lo largo del desarrollo de los sistemas de salud difieren considerablemente, su puesta en práctica ha compartido muchos elementos comunes en todas las épocas, desde la participación como medio para obtener unos objetivos, a ser un fin en sí misma, como proceso democrático. Esto es también aplicable a la promoción actual de las políticas de participación social en el contexto de las reformas, que se analizan fundamentalmente a partir de los ejemplos de Colombia y Brasil.

Este artículo analiza los procedimientos y los procesos de contratación de trabajadores de salud en el Programa de Salud de la Familia en el Brasil, discutiendo los méritos, problemas y resultados relativos de cada uno de los mecanismos utilizados para la contratación de médicos, enfermeras y agentes de salud comunitarios. Antes de iniciar propiamente el análisis de los mecanismos de contratación, el autor hace una breve descripción de la importancia y del papel del Programa de Salud de la Familia para el sistema de salud brasileño. Ahí, el artículo procura demostrar las características y el impacto sobre el desarrollo de los recursos humanos de este programa clave, que es considerado como la «reforma de la reforma» o la «contrarreforma» del sistema único de salud. Finalmente, después de presentar y analizar los datos disponibles sobre las formas de contratación y los sueldos para médicos y enfermeras en algunos estados y municipios del Brasil, el autor llama la atención sobre el nuevo contexto social, donde son los propios gobiernos, en los distintos niveles, quienes estimulan el incumplimiento de reglas y leyes laborales que es su responsabilidad mantener. Esto sólo refuerza la hipótesis de que una nueva etapa de reformas ya se ha puesto en marcha.

Durante los últimos seis años, México ha llevado a cabo una profunda transformación de su sistema de salud. Este artículo presenta una visión general de las principales características de la experiencia de reforma mexicana. Como resultado del alto grado de desigualdad social, México es un microcosmos de la diversidad de problemas que afectan a los países de todos los niveles de desarrollo. Su sistema de salud no estaba a la altura de las presiones impuestas por la doble carga de enfermedad, en donde la desnutrición, las infecciones comunes y los problemas de salud reproductiva coexisten con las enfermedades no transmisibles y las lesiones. Con la mitad de su población sin acceso al aseguramiento en salud, México enfrentaba una paradoja inaceptable: si bien la salud es un factor clave en la lucha contra la pobreza, un gran número de familias se empobrecía como consecuencia de los gastos para la atención de su salud, incluyendo los medicamentos. La reforma se diseñó para corregir esta paradoja mediante la introducción de un innovador esquema denominado Seguro Popular, a través del cual se protege de manera gradual a 50 millones de mexicanos, la mayoría de ellos pobres, que hasta ahora habían sido excluidos de la seguridad social formal. Este artículo presenta una serie de resultados alentadores para lograr el fin último de la reforma: el acceso universal a servicios de salud de alta calidad con protección social para todos.During the past six years, Mexico has undergone a large-scale transformation of its health system. This paper provides an overview of the main features of the Mexican reform experience. Because of its high degree of social inequality, Mexico is a microcosm of the range of problems that affect countries at all levels of development. Its health system had not kept up with the pressures of the double burden of disease, whereby malnutrition, common infections, and reproductive health problems coexist with non-communicable disease and injury. With half of its population uninsured, Mexico was facing an unacceptable paradox: whereas health is a key factor in the fight against poverty, a large number of families became impoverished by expenditures in health care and drugs. The reform was designed to correct this paradox by introducing a new scheme called Popular Health Insurance (Seguro Popular). This innovative initiative is gradually protecting the 50 million Mexicans, most of them poor, who had until now been excluded from formal social insurance. This paper reports encouraging results in the achievement of the ultimate objective of the reform: universal access to high-quality services with social protection for all.

A partir de 2001 se inicia en México un proceso de diseño, legislación e implementación de la Reforma Mexicana de Salud. Un componente clave de ésta fue la creación del Seguro Popular, que pretende extender la cobertura de aseguramiento médico por siete años a la población que no cuenta con seguridad social, la cual constituía en ese momento casi la mitad de la población total. La reforma incluyó cinco acciones: modificar la ley para garantizar el derecho a la protección a la salud para las familias afiliadas, lo cual al ser implantado completamente incrementará el gasto público en salud entre 0.8 y 1.0% del PIB; la creación de un paquete de servicios de salud explícito; la asignación de recursos a secretarías estatales de salud descentralizadas, proporcional al número de familias incorporadas; la división de los recursos federales destinados a los estados en fondos independientes para servicios de salud personales y no personales; así como la creación de un fondo para garantizar recursos cuando se presentan eventos catastróficos en salud. Mediante el uso del marco conceptual de los sistemas de salud de la OMS, se han examinado diversos conjuntos de datos para evaluar el impacto de esta reforma en distintas dimensiones del sistema de salud. Entre los principales hallazgos clave se encuentran que: la afiliación alcanza de manera preferente a las comunidades pobres y marginadas; el gasto federal no correspondiente a la seguridad social aumentó 38% de 2000 a 2005 en términos reales; ha mejorado la equidad del gasto público entre los estados; los afiliados al Seguro Popular presentan una mayor utilización de servicios, tanto a nivel ambulatorio como para pacientes externos y pacientes hospitalarios en comparación con los no asegurados; la cobertura efectiva de 11 intervenciones en salud ha mejorado entre 2000 y 2005; han disminuido las desigualdades en cobertura efectiva durante este periodo en todos los estados y deciles de ingresos; los gastos catastróficos para los afiliados al Seguro Popular son más bajos que los de los no asegurados, a pesar de que se haya incrementado su utilización en México. Este trabajo presenta algunas lecciones para México con base en esta evaluación provisional, así como algunas implicaciones potenciales para otros países que consideran desarrollar reformas en materia de salud.Since 2001, Mexico has been designing, legislating, and implementing a major health-system reform. A key component was the creation of Seguro Popular, which is intended to expand insurance coverage over seven years to uninsured people, nearly half the total population at the start of 2001. The reform included five actions: legislation of entitlement per family affiliated which, with full implementation, will increase public spending on health by 0.8-1.0% of gross domestic product; creation of explicit benefits packages; allocation of monies to decentralised state ministries of health in proportion to number of families affiliated; division of federal resources flowing to states into separate funds for personal and non-personal health services; and creation of a fund to protect families against catastrophic health expenditures. Using the WHO health-systems framework, a wide range of datasets to assess the effect of this reform on different dimensions of the health system was used. Key findings include: affiliation is preferentially reaching the poor and the marginalised communities; federal non-social security expenditure in real per-head terms increased by 38% from 2000 to 2005; equity of public-health expenditure across states improved; Seguro Popular affiliates used more inpatient and outpatient services than uninsured people; effective coverage of 11 interventions has improved between 2000 and 2005-06; inequalities in effective coverage across states and wealth deciles has decreased over this period; catastrophic expenditures for Seguro Popular affiliates are lower than for uninsured people even though use of services has increased. We present some lessons for Mexico based on this interim evaluation and explore implications for other countries considering health reforms.

La falta de protección financiera en salud es una enfermedad recientemente diagnosticada de los sistemas de salud. El síntoma más obvio es que las familias enfrentan la ruina económica y el empobrecimiento por financiar su atención médica. México fue uno de los primeros países en diagnosticar el problema, atribuirlo a la falta de protección financiera y proponer una terapia sistémica a través de la reforma del sistema de salud. Este trabajo analiza la manera en que México convirtió las evidencias sobre los gastos catastróficos y empobrecedores en salud en un catalizador de la renovación institucional a través de la reforma que creó el Seguro Popular de Salud (SPS). Presentamos tanto las tendencias de los últimos 15 años sobre la evolución de los gastos catastróficos y emprobrecedores en salud, como las evidencias recientes sobre el mejoramiento en estos indicadores con la expansión del SP. Los resultados de la experiencia mexicana sugieren que la organización y el financiamiento del sistema de salud han jugado un papel muy importante en la reducción del empobrecimiento y en la protección de los hogares durante los periodos de crisis financiera individual y colectiva.Absence of financial protection in health is a recently diagnosed "disease" of health systems. The most obvious symptom is that families face economic ruin and poverty as a consequence of financing their health care. Mexico was one of the first countries to diagnose the problem, attribute it to lack of financial protection, and propose systemic therapy through health reform. In this article we assess how Mexico turned evidence on catastrophic and impoverishing health spending into a catalyst for institutional renovation through the reform that created Seguro Popular de Salud (Popular Health Insurance). We present 15-year trends on the evolution of catastrophic and impoverishing health spending, including evidence on how the situation is improving. The results of the Mexican experience suggest an important role for the organisation and financing of the health system in reducing impoverishment and protecting households during periods of individual and collective financial crisis.

Since 2001, Mexico has been designing, legislating, and implementing a major health-system reform. A key component was the creation of Seguro Popular, which is intended to expand insurance coverage over seven years to uninsured people, nearly half the total population at the start of 2001. The reform included five actions: legislation of entitlement per family affiliated which, with full implementation, will increase public spending on health by 0.8-1.0% of gross domestic product; creation of explicit benefits packages; allocation of monies to decentralised state ministries of health in proportion to number of families affiliated; division of federal resources flowing to states into separate funds for personal and non-personal health services; and creation of a fund to protect families against catastrophic health expenditures. Using the WHO health-systems framework, a wide range of datasets to assess the effect of this reform on different dimensions of the health system was used. Key findings include: affiliation is preferentially reaching the poor and the marginalised communities; federal non-social security expenditure in real per-head terms increased by 38% from 2000 to 2005; equity of public-health expenditure across states improved; Seguro Popular affiliates used more inpatient and outpatient services than uninsured people; effective coverage of 11 interventions has improved between 2000 and 2005-06; inequalities in effective coverage across states and wealth deciles has decreased over this period; catastrophic expenditures for Seguro Popular affiliates are lower than for uninsured people even though use of services has increased. We present some lessons for Mexico based on this interim evaluation and explore implications for other countries considering health reforms. [ABSTRACT FROM AUTHOR]

Absence of financial protection in health is a recently diagnosed "disease" of health systems. The most obvious symptom is that families face economic ruin and poverty as a consequence of financing their health care. Mexico was one of the first countries to diagnose the problem, attribute it to lack of financial protection, and propose systemic therapy through health reform. In this article we assess how Mexico turned evidence on catastrophic and impoverishing health spending into a catalyst for institutional renovation through the reform that created Seguro Popular de Salud (Popular Health Insurance). We present 15-year trends on the evolution of catastrophic and impoverishing health spending, including evidence on how the situation is improving. The results of the Mexican experience suggest an important role for the organisation and financing of the health system in reducing impoverishment and protecting households during periods of individual and collective financial crisis. [ABSTRACT FROM AUTHOR]

During the past six years, Mexico has undergone a large-scale transformation of its health system. This paper provides an overview of the main features of the Mexican reform experience. Because of its high degree of social inequality, Mexico is a microcosm of the range of problems that affect countries at all levels of development. Its health system had not kept up with the pressures of the double burden of disease, whereby malnutrition, common infections, and reproductive health problems coexist with non-communicable disease and injury. With half of its population uninsured, Mexico was facing an unacceptable paradox: whereas health is a key factor in the fight against poverty, a large number of families became impoverished by expenditures in health care and drugs. The reform was designed to correct this paradox by introducing a new scheme called Popular Health Insurance (Seguro Popular). This innovative initiative is gradually protecting the 50 million Mexicans, most of them poor, who had until now been excluded from formal social insurance. This paper reports encouraging results in the achievement of the ultimate objective of the reform: universal access to high-quality services with social protection for all. [ABSTRACT FROM AUTHOR]