Barriers to healthcare coordination in market-based and decentralized public health systems: a qualitative study in healthcare networks of Colombia and Brazil

Abstract

Although integrated healthcare networks (IHNs) are promoted in Latin America in response to health system fragmentation, few analyses on the coordination of care across levels in these networks have been conducted in the region. The aim is to analyse the existence of healthcare coordination across levels of care and the factors influencing it from the health personnel’ perspective in healthcare networks of two countries with different health systems: Colombia, with a social security system based on managed competition and Brazil, with a decentralized national health system. A qualitative, exploratory and descriptive–interpretative study was conducted, based on a case study of healthcare networks in four municipalities. Individual semi-structured interviews were conducted with a three stage theoretical sample of (a) health (112) and administrative (66) professionals of different care levels, and (b) managers of providers (42) and insurers (14). A thematic content analysis was conducted, segmented by cases, informant groups and themes. The results reveal poor clinical information transfer between healthcare levels in all networks analysed, with added deficiencies in Brazil in the coordination of access and clinical management. The obstacles to care coordination are related to the organization of both the health system and the healthcare networks. In the health system, there is the existence of economic incentives to compete (exacerbated in Brazil by partisan political interests), the fragmentation and instability of networks in Colombia and weak planning and evaluation in Brazil. In the healthcare networks, there are inadequate working conditions (temporary and/or part-time contracts) which hinder the use of coordination mechanisms, and inadequate professional training for implementing a healthcare model in which primary care should act as coordinator in patient care. Reforms are needed in these health systems and networks in order to modify incentives, strengthen the state planning and supervision functions and improve professional working conditions and skills.

Atenção primária à saúde e coordenação do cuidado nas regiões de saúde: perspectiva de gestores e usuários

“…Despite the different logics, the narratives analyzed suggest a weak PHC role in the coordination of care for patients with chronic conditions; these findings are in line with other studies on the subject in Brazil and in Latin America 21,33,34 . In the studied region, PHC fragility is evident both in establishing itself as a preferential gateway into the system and in offering resolute health care.…”

“…Clinical coordination draws on a robust and strengthened PHC, which allows the provision of sequential and complementary care between care levels. Administrative coordination corresponds to the organizational processes and flows of the health care network that allow integration among the different levels of the health system 21 . In the SUS with its decentralized regime and competing responsibilities, there are additional barriers to the coordination of care.…”

Atenção primária integral e sistemas segmentados de saúde na América do Sul

“…Em relação à prestação dos serviços, a integração da rede assistencial, um dos atributos de uma atenção primária à saúde forte parece não consolidada e ainda pouco investigada nos países da região 20 . Mesmo que a maioria dos países tenha definido, nos novos modelos assistenciais, o papel de filtro pela atenção primária à saúde para a continuidade do cuidado, a conformação de redes assistenciais não se completou e permanecem problemas de acesso para serviços especializados.…”

Apuntes para una estrategia de medicamentos “esenciales” para Latinoamérica

“…La que restituye visibilidad a las poblaciones, más allá de la imposición "global" de las enfermedades; la que identifica-adopta las necesidades del derecho a la salud para las cuales no se garantizan respuestas, a pesar de su disponibilidad "técnica"; la que explora las causas y nombra las responsabilidades "evitables" del no-acceso: desigualdad, inequidad, corrupción, políticas de mercado, etc. ; la que reconoce, no como objetos de investigación, sino como sujetos de lucha y de resistencia a las comunidades concretas con las cuales se establecen relaciones y se comparten lenguajes, que no aplican directrices ajenas, sino que buscan y miden, colaborativamente, respuestas practicables (20,21,22,23) . Las epidemiologías que definen y hacen visibles las prioridades de los cuidados a partir de 3.…”