Health is a universal human right, which should be safeguarded by government responsibility and included in all social policies. Only as such it is possible to ensure effective responses to the health needs of an entire population. The Cuban Constitution recognizes the right to health, and the country’s single, free, universal public health system and high-level political commitment promote intersectorality as a strategy to address health problems. Intersectorality is reflected in national regulations that encourage participation by all social sectors in health promotion/disease prevention/treatment/rehabilitation policies and programs. The strategy has increased the response capacity of Cuba’s health system to face challenges in the national and international socioeconomic context and has helped improve the country’s main health indicators. New challenges (sociocultural, economic and environmental), due to their effects on the population’s health, well-being and quality of life, now require improved intersectoral coordination in the primary health care framework to sustain achievements made thus far.

KEYWORDS Universal coverage, public health, health policy, social planning, intersectoral collaboration, Cuba

INTRODUCTION Health systems are one determinant of health; their role is to facilitate timely and equitable access to quality services. The way in which a health system is organized can profoundly affect achievement of its objectives. The main feature of the Chilean health system is the coexistence of a public health insurance program (based on a social insurance model) with several market-based private health insurance companies. This hybrid structure provides an interesting framework for analyzing and evaluating the system’s effects on health inequalities.

OBJECTIVE Assess Chilean public and private health insurance schemes’ performance and its effects on health inequalities.

METHODS Public health insurance was compared with private insurance using indicators from 2013 (or the closest year) in the following domains: inputs, outputs (provider visits, discharges), outcomes (coverage) and impact (on health, quality of life, finances and patient satisfaction) as well as demographic and social determinant indicators. A conceptual framework for measuring health system performance was used. Data were obtained from administrative records and population-based surveys.

RESULTS The publicly insured population had greater health care needs, was older (aging index 83.4 vs. 36.5) and poorer (17.2% vs. 1.5% below the poverty line) than the population covered by private insurers. The public insurer received average monthly funding of US$50.94 per beneficiary and spent US$51.43, while private insurers on average collected US$94.79 monthly per beneficiary, and spent US$69.63 on health services (excluding medical leave benefits). Private health insurance beneficiaries were more likely than their publicly insured counterparts to access specialized medical services (18.3% vs. 9.3%) and dentists (11.2% vs. 5.9%), have laboratory tests (18.1% vs. 4.8%), and undergo surgery (7.8% vs. 5.9%). Risk factor and disease prevalence was lower among private insurance beneficiaries for 16 of 18 tracer conditions, although age-adjusted differences were not significant. Finally, incidence of catastrophic spending was slightly lower among private insurance beneficiaries (3.7% vs. 4.2%), and a greater proportion of them were satisfied or very satisfied with the health system (37% vs. 17%).

CONCLUSIONS The relative youth and better financial status of beneficiaries of private insurers is compatible with selection for lower risk. While private plans offer greater financial protection and receive higher user satisfaction ratings than the public plan, differences in financing between the two types of insurance affect availability and utilization of services. This constitutes a structural problem for the Chilean health system. There is an urgent need to move toward an integrated health system, in which incentives are aligned with social insurance objectives.

KEYWORDS Health policy, health insurance, health care economics and organizations, Chile

INTRODUCTION Over the last decade, total cardiovascular risk assessment and management has been recommended by cardiovascular prevention guidelines in most high-income countries and by WHO. Cardiovascular risk prediction charts have been developed based on multivariate equations of values of some well-known risk factors such as age, sex, smoking, systolic blood pressure and diabetes, including or omitting total blood cholesterol.

OBJECTIVE The objectives of this study were: to determine the distribution of cardiovascular risk in a Cuban population using the WHO/International Society of Hypertension risk prediction charts with and without cholesterol; and to assess applicability of the risk prediction tool without cholesterol in a middle-income country, by evaluating concordance between the two approaches and comparing projected drug requirements resulting from each (at risk thresholds of ≥20% and ≥30%) and for the single-risk-factor approach.

METHODS From April through December 2008, a cross-sectional study was conducted in 1287 persons (85.8% of the sample selected), aged 40–80 years living in a polyclinic catchment area of Havana, Cuba, based on the protocol and data from a WHO multinational study. The study used the two sets of the WHO and the International Society of Hypertension (WHO/ISH) risk prediction charts, with and without cholesterol. Percentages and means were calculated, as well as prevalence (%) of risk factors. The chi-square test was used to compare means (p ≤0.05). Concordance between the two prediction charts was calculated for different risk levels, using the chart with cholesterol as a reference.

RESULTS Using the risk assessment tools with and without cholesterol, 97.1% and 95.4% respectively of the study population were in the ten-year cardiovascular risk category of <20%, while 2.9% and 4.6% respectively were in the category of ≥20%. Risk categories were concordant in 88.1% of the population; overestimation was higher among the nonconcordant (136/153). When risk assessment did not include cholesterol, there was 2.6% (34/1287) overestimation of drug requirements and 0.5% (6/1287) underestimation, compared to estimates including cholesterol.

CONCLUSION Total cardiovascular risk assessment using the WHO/ISH charts without cholesterol could be a useful approach to predict cardiovascular risk in settings where cholesterol cannot be measured. This does not introduce overconsumption of drugs, but does enable better targeting of resources to those who are more likely to develop cardiovascular disease.

KEYWORDS Cardiology, risk assessment, health risk appraisal, hypertension, health policy, cost savings, atherosclerosis, Cuba

This article provides an overview of governance arrangements and changes in the Brazilian public health system since 1988, when the “Citizen’s Constitution” declared health to be a universal right. Since then, population coverage has grown substantially and health indicators have improved. Despite these achievements, inequities in access remain an important barrier to universal coverage, in particular for marginalized groups such as indigenous peoples. This article discusses the innovation cycle that produced the gains and recent efforts to guarantee more equitable access to health services for the indigenous population in a continent-sized country historically plagued by great inequalities.

KEYWORDS Health care systems, indigenous health services, access to health care, health policy, healthcare disparities, inequalities, indigenous population, Brazil

The Health Extension Program is one of the most innovative community-based health programs in Ethiopia. It is based on the assumption that access to and quality of primary health care in rural communities can be improved through transfer of health knowledge and skills to households. Since it became operational in 2004–2005, the Program has had a tangible effect on the thinking and practices of rural people regarding disease prevention, family health, hygiene and environmental sanitation. It has enabled Ethiopia to increase primary health care coverage from 76.9% in 2005 to 90% in 2010.

KEYWORDS Family health, health education, health program, disease prevention, health policy, health priorities, environmental hygiene, sanitation, Millennium Development Goals, Ethiopia

Population-based health promotion and disease prevention approaches are essential elements in achieving universal health coverage; yet they frequently do not appear on national policy agendas. This paper suggests that resource-poor countries should take greater advantage of such approaches to reach all segments of the population to positively affect health outcomes and equity, especially considering the epidemic of chronic non-communicable diseases and associated modifiable risk factors. Tobacco control policy development and implementation in Vietnam provides a case study to discuss opportunities and challenges associated with such strategies.

KEYWORDS Health promotion, health policy, smoking, tobacco, developing countries, population-based planning, Vietnam

This paper examines the recommendations of the World Health Organization’s Commission on the Social Determinants of Health regarding the need for improved research on determinants of health inequity and discusses the following barriers to implementation of those recommendations: the power of the biomedical imagination in health and medical research; emphasis on vertical health programming; ideological biases outweighing evidence in policy decisions; and academic reward systems, including the inherent conservatism of peer review. The paper concludes with suggestions for changing research funding and assessment systems to overcome these barriers.

KEYWORDS Social determinants, health equity, health services research, health policy