GUILLEN J. GARCIA-PRADO A. ARRIETA A.; PRENATAL CARE IN LATIN AMERICA WORKING PAPER TADB. 15874 Over-utilization of prenatal services in Latin American Private Healtheare Sector Alejandro Arrieta! Indiana Univ Jorge Guillén UESAN Ariadna Garcia Prado IADB February 27, 2009 1. Introduction ‘The health care systems in Latin America saw a wave of reforms during the 1990s. The main goal of these reforms was to inerease the accessibility of health care for the poor, and by doing so, to improve mortality and morbidity ratios to compare with those achieved by developed nations. Prior to the reforms, ‘most countries in Latin America relied on a health model in which different sub-systems provided financing and services to specific social groups (Londofio and Frenk, 2000). In most cases, the ‘government supplied health care to the poor through the Ministry of Health, and to the non-poor working class via the social security system. The private sector provided health care to the wealthiest through private hospitals and insurance companies, and to the uninsured via private clinics, pharmacies and out- of-pocket payments. Most heath reforms in the region were accompanied by changes in the social security systems seeking to separate the role of pension funds from that of social health insurance (Koichi, 2003). This separation redefined the government's role in the regulation, provision and financing of health, and created new responsibilities for the private sector. However, there were key differences in how each country enacted its reforms. These differences were particularly strong with respect to the role of the private sector in the reformed health systems. For example, countries differed in their approach to regulation of the private sector, both in terms of how the regulation is done and who is doing the regulating. Another key difference was how the private sector in each country chose to handle the financing of health. Some countries have allowed for a certain amount of competition between public and private insurers, and other countries chose to restrict competition through the use of universal insurance. Finally, private health * We are grateful to James Wilson and Lina Pezua for research assistance. 1facilities may in some cases complement the public provision of primary health care, while in other cases they compete to varying degrees with public hospitals. Despite extensive health care reforms in some countries in the region, health care systems continue to face significant obstacles, including poor distribution of healthcare workforce within a country, ineffective health care policymaking, and weak institutions related to the health sector (Ureullo et al., 2008). All these factors affect the role of the private sector within the health care system. There is @ notorious lack of regulation and transparency in the private sector. Few countries have institutions with a broad scope of regulation that includes the supervision of health care financiers and providers from the public and private sector, like the National Health Superintendency of Colombia. In contrast, the common health care supervisor of providers in Latin America is the istry of Health which at the same time runs restricted to public hospitals, with a reduced public hospitals. very limited resources, supervisio ability to supervise private providers beyond the authorization to entry the market. In some cases, the Ministry of Health delegates only the function of supervising private health care financers. Lack of regulation, supervision and transparency is not the only characteristic of the private sector. In general, there is a commonly held view that the quality of care in private facilities is higher than in the public sector. However, this perceived higher quality is usually based on consumer satisfaction in terms of less crowded facilities, shorter waiting times, more time spent with patients, and generally better tions. It is difficult to measure the quality of care given by private providers due to the limited information provided to the health supervisor. Because of this lack of information, recent equipment and me studies have used surveys to compare the quality of care given by public and private providers. The results show evidence of over-medication and over-treatment in the private sector, which in many cases do not translate to better quality of care. Walters et al. (2008) used the iving Standards Measurement Surveys of ten Latin American countries to show that the treatment of diarthea in the private sector was of lower quality and less effective than the care provided by the public sector. The authors found that children treated by a private provider are more likely to receive drugs, most commonly unnecessary antibiotics. Using a survey on maternal and perinatal health in eight Latin American countries, Villar et l,(2006) found that deliveries in private hospitals were more likely to be by cesarean section. While the national average c-section rate was 33%, in private hospitals this rate reached 51%, and even after adjusting for risk factors, c-sections were associated with higher postpartum antibiotic treatment, severe maternal morbidity and mortality, and higher newborn mortality. Physicians and patients in the private sector are subject to different incentives that make the system subject to overuse. On one hand, the asymmetry of information in the physician-patient relationship 2creates incentives to produce unnecessary care in any system that pays doctors per service provided. In some cases, doctors may exert influence over patients and intentionally shift the patient demand curve, thereby increasing health care services which are counter to the patient’s best interest (physician-induced demand). The incentive to over-utilize worsens when the patient has insurance. In this case, the patient has incentives to use more health care than required since costs are covered by the insurance company (moral hazard). In this study we explore the over-use of prenatal visits in the health care private sector. We focus on on six Latin American countries that allowed the participation of the private sector in the financing and provision of health care. Colombia, Peru, Dominican Republic, Bolivia, Guatemala and Nicaragua undertook reforms that, although not identical, share some similarities in terms of the private sector's role is higher in the private sector compared to the public even after controlling by obstetrical and socioeconomic factors. in the expansion of medical insurance, Our results show that the number of prenatal Most importantly, we found that this excessive use of prenatal care in the private sectors comes with no improvement in delivery outcomes usually associated to better quality of prenatal care, Our results confirm the over-utilization of prenatal visits in the private sector, with the exception of Colombia 0 Guatemala. 2. Prenatal Care Prenatal care is an important way of promoting health and also in preventing mortality and morbidity of mother and fetus by identifying risks factors that permit opportune interventions, Prenatal care has been linked to a number of positive health outcomes that have been used to indicate the effectiveness of prenatal care. Fetal birth weight is one of the most common measures of effectiveness, Other common outcome indicators of prenatal quali include incidence of delivery complications such as preterm delivery, lower post-delivery hospital stays, higher Apgar scores among newborns, higher perinatal tions (Coimbra, 2007; Amini et al., 2000; Boss et al., mortality, and various other delivery com, 2000). Adequate prenatal care remains a priority for many Latin American countries, especially in the midst of ongoing health care reforms. In addition to obstetric characteristics and history of complications, many socioeconomic and cultural factors have been found to have a significant effect on women's uptake of prenatal care, These determinants include the mother’s education, her household income and ‘employment status, her marital status, religion, affordability and access to care, her husband’s education, the availabilty of care, and its cost (Ciceklioglu et al. 2005; Simkhada et al., 2000; Amini et al. 1996). 3In 1994, the World Health Organization (WHO) assembled a working group to prepare prenatal care recommendations for local health centers (WHO, 1994). In addition to identifying risk factors and medical conditions which demand special attention, the working group made recommendations about the timing, content, and suggested number of visits for all women. The WHO recommends a minimum of four prenatal visits at specific times during pregnancy. The four visits are suggested to occur at 12 weeks, 26 weeks, 32 weeks, and 36 to 38 weeks. Elements of the WHO’s basic prenatal care plan fall into three general categories: i) screening for socioeconomic factors which would increase the likelihood of pregnancy complications; ii) providing therapies known to be beneficial to birth outcomes; iii) answering the mother’s questions and educating the mother on how to deal with emergencies and otherwise plan for asafe birth, ‘The WHO suggests that physicians obtain detailed personal, medical, and obstetric histories from mothers during the first visit. Mothers should be informed of any risk factors and appropriate steps according to their individual history. Each visit should also entail a detailed physical examination in which the physician measures the mother’s height and weight, uterine size, fetal heart sounds and movement, and fetal presentation. According to the WHO, physicians should also perform a variety of urine and blood tests throughout the pregnancy to identify any complications, and should also include the provision of iron supplements, provision of tetanus vaccination, and various advices about safe sex practices (WHO 1994), ‘There have been a few studies on the differences between private and public providers of prenatal care. As with other procedures, incentives in the private sector would tend to lead to more prenatal visits than needed. These incentives are greatest when insurance providers are unable to reduce the moral hazard problem. There is some evidence supporting the over-use of prenatal care. In the USA, policies oriented to improve health outcomes in low-income women changed Medicaid to expand coverage and delivery services in private facilities. Evaluations of prenatal care programs have shown that insured ‘women going to private facilities had more prenatal care visits than any other insured or uninsured ‘women. It has also been shown that the greater use of the private system by those in Medicaid does not appear to translate into improved outcomes relative to the uninsured (Marquis and Long, 2002). The Tower quality of care may be the result of poor information in private facilities. Freda et al. (193) show that the public sector devotes far greater resources to prenatal education than that seen in the private sector. A similar pattern is found in urban areas of Latin America, Barros et al. (2005) found in Brazil that although the number of prenatal care visits increased after the universal health system was implemented, 4the quality of care remained inadequate. Outcomes were also worse in the private sector in terms of preterm births and birth weights. The authors found that this result seemed to result largely from overuse of cesarean section and induction of labor. Barber et al. (2007) also found that prenatal care quality for the rural poor in Mexico was lower in private settings compared to public ones. In fact, it is possible that the recent trend in the public sector to adhere to strict medical guidelines and resources to improve patient education make the private sector look that much worse than public providers. 3. Data, Methods and Results We have used data from the Demographic and Health Survey (DHS). The survey includes questionnaires for women in their fertile years (15 to 49 years old) and children under 5 years old. This is a representative sample that allows inference at the national level. The study focuses on institutionalized births, within public or private health care facil implying that in multiple gestations only the oldest baby is considered. For Colombia we have used the standard DHS 2005 which registered 11,657 births from 1999 to 2005S. For Peru we have used the continuous DHS 2004-2008 which reported 10,424 births from 2000 to 2008. For Dominican Republic we have used the standard DHS 2007 which registered 8,499 births from 2002 to 2007. For Bolivia we use the standard DHS 2003 that reports 7,261 births from 1998 to 2003. For Guatemala we have the continuous DHS 1998-1999 that reports 4,545 births from 1994 to 1999. For Nicaragua we use the standard DHS 2001 that registers 4,848 births from 1996 to 2001. . The sample considers only one birth per mother, Figure 1 shows a kemel density estimation of prenatal visits to public and private health care providers in Colombia, Peru and the Dominican Republic. Many conclusions can be derived from these estimated distributions. First, the average number of visits to public and private providers largely exceeds the adequate prenatal care utilization of four visits suggested by the WHO. At the national level, 8.3% of women who visited a public or private facility for prenatal care had fewer than four visits in Colombia. ‘The percentage was 6.3% in Peru, 3% in the Dominican Republic, 17.9% in Bolivia, 20.8% in Guatemala and 14.5% in Nicaragua. Second, private providers performed more prenatal exams than publi especially in Peru, Dominican Republic, Bolivia, Guatemala and Nicaragua, Some countries seem to have better control over excessive prenatal visits. The distribution of visits in Colombia, for example, shows prenatal visits stopped after the ninth visit with public providers, and after the tenth visit with private providers. This cut-off is observable but less remarkable for the Dominican Republic’s private and providers, public providers who extend visits to thirteen. In Peru, a pattern similar to the Dominican Republic is 5observed for public providers only, while private providers tend to exceed fifteen visits. For the case of Bolivia, Guatemala and Nicaragua the cut off is around 10 visitis which is similar to the Colombian case. Nationally, 5.3% of women who visited a public or private facility for prenatal care had more than ten visits in Colombia. This number was 18.1% in Peru, 24.8% in the Dominican Republic, 5.2% in Bolivia, 9.8% in Guatemala and 2.6% in Nicaragua. [FIGURE 1 HERE] Socioeconomic and demographic factors may be having different effects on women who seek prenatal care from public and private providers. It has been well established that not only obstetrical but factors affects the utilization of prenatal care (Simkhada et al., 2007; Coimbra et al, 2007; Barber et al, 2007; Ciceklioglu et al, 2005). Its also known that patients of private and public providers differ in terms of age, parity, family size, education, occupation, wealth, etc. Since these factors also affect prenatal utilization, a crude comparison of prenatal visits between public and private providers would be biased. For example, mothers in the private sector are usually older, and consequently at higher risk than mothers in the public sector. Since a high risk patient requires more prenatal visits, itis possible that the large number of observed prenatal visits in the private sector corresponds to an adequate utilization rather than over: socioeconot ization. To reduce this bias, we estimate using a negative binomial mode! the impact of provider regime (public or private) and private insurance on the number of prenatal visits after controlling for obstetric and socioeconomic factors. Table 1 shows the impact of private providers on the number of prenatal visits for Colombia, Peru, Dominican Republic, Bolivia, Guatemala and Nicaragua. Results are still consistent with Figure 1, where the utilization of prenatal controls is higher when private providers are used. Columns 1-6 shows that after controlling for obstetrical factors (age, multiple gestation and history of terminated pregnancy) and socioeconomic factors (mother’s employment and education, marriage, partner's education, household assets, wealth and urban residence), the utilization of private providers is still statistically significant higher in all countries except for Colombia, Peru and Guatemala. For these two countries, the coefficient becomes non-significant and negative. It is worth to mention that when controlling by obstetrical factors only (results not shown), the impact of private provider is positive, higher and statistically significant in all countries, which indicate that socio-economic factors play an important role in reducing the gap between private and public prenatal service utilization. (TABLE | HERE] 6In the private sector, physicians are usually paid on a fee-for-service basis that creates strong financial incentives to over-treat. However, insurance companies may reduce these incentives through payment ‘mechanisms (capitation, prospective payment, pp, etc.) and other non-payment controls (second opinion, penalties, review of network providers, review committees, etc). To analyze the impact of private insurance on prenatal use, columns 7-12 on table 1 include the interaction of private insurance and provider’. The impact of private providers on the number of prenatal visits is still not-significant in Colombia, and so is the impact of private insurance. It is important to notice that although it is not significant, there is a negative impact of both private provider and private insurance on utilization, Even though it requires more research to understand this phenomenon, the influence of HMO type of insurance predominant in Colombia together with its stronger regulation may explain why private providers do not overuse prenatal se The results for Peru are also interesting since private over-utili jon seems to be driven by the interaction of private insurance. A Peruvian mother who receives prenatal care in a private facility tends to have more visits than necessary when she has private insurance. In the Dominican Republic and Nicaragua, however, private insurance does not play a significant role, which indicates that over- treatment is mainly driven by private provider characteristics. It is important to highlight that from the six countries analyzed; the Dominican Republic has the greatest access to private fac ies, given that private hospitals are the main care providers. The higher number of prenatal visits in the private sector, which is clearly above the proscribed ‘number of visits recommended by the WHO, and above the number of visits provided by public facilities, may not necessarily indicate over-utilization. If the excessive number of visit in the private sector is associated with higher quality, then the additional number of visits can be justified and even cost- effective. Quality can be measured with provision of information as well as drugs and supplements in the prenatal visit, but those measures are difficult to get from the DHS survey, and are also subject to over- provision. A better measure is outcomes at delivery that are associated to better prenatal quality services. If outcomes are not improved with more prenatal visits, then those additional visits are unnecessary and not cost-effective, implying over-utilization. Using clinical trials, some studies have found that more than 4 prenatal visits do not improve delivery outcomes. * Information about private insurance was not available for Bolivia and Guatemala. Columns 10 and 11 in Table repeat the results of columns 4 and 5.Villar et al. (2001) compares two models of prenatal visits: the standard model that ideally suggests 12 visits, half of which occur in the last three months of gestation, and the “basic package” or WHO ‘model that suggest only four visits. Using clinical trials in over 20,000 women in Argentina, Cuba, Saudi Arabia, and Thailand, the authors found that the use of a prenatal care model requiring fewer visits results in similar or equivalent clinical health outcomes. Their study showed no significant difference in low birth weights, urinary-tract infections, pre-eclampsia, and severe postpartum anaemia. Overall, clinics using the standard model provided a median of eight (IQR five to eleven) visits, while clinics using the new model provided a median of only five (IQR three to six) visits. Although median number of visits and dispersion (IQR) varied in each country, clinics using the standard model consistently provided more visits. The basic package has been recommended by WHO for many years, and it is currently included in the medical guidelines of most public facilities, while private providers usually use the standard model. Villar’s results may suggest that the additional visits provided in private facilities under the standard model do not produce better outcomes, indicating over-utilization. Following a similar approach, our next step was to see if the excessive number of visits observed in our study had an impact on delivery outcomes. We consider two outcomes that are known can be affected by effective prenatal servic unnecessary, visits exceeding the common practice should not result in newboms with normal weight and size at the time of delivery. We test this hypothesis estimating a ratio that compares the observed number of visits with a risk adjusted number of visits. Risk adjusted utilization rates have been broadly used in : newborn size and newborn weight. If the excessive number of visits were the medical literature (Iezzoni, 2003), and in our case we estimate then as the predicted number of visits controlling by risk factors (obstetrical and socioeconomic characteristics). When the observed number of visits is higher that the estimated risk-adjusted number (ratio above 1), we say that for that particular patient, the number of visits was higher than the common practice, implying an excess number of visits. We estimate the following regression at patient level, pooling the data from the six countries of analysis. The interaction term ratio-private captures the effect of the excess number of visits in private fa ies on delivery outcomes. If Bx is not significant, then more visits in the private sector will be consider to be ineffective, favoring the hypothesis of over-utilization of prenatal services in private facilities. Delivery Outcome = fq + B,Ratio + fyRatio x Private + B,Private + u In DHS data, newborn size is reported by mother as 5 categories: “very small”, “smaller than average”, “average”, “larger than average”, and “very large”. Newbom weight is reported in kilograms 8from birth cards or recall. Table 2 shows the results of Probit estimates considering five indicators of delivery outcomes, Column 1-2 reports normal size considering two definitions: normal size defined as “average” (column 1), and normal size defined as “smaller than average”, “average” or “larger than average” (column 2). In both cases, all coefficients are not statistically significant. Column 3-5 defines delivery outcome using newborn weight. In column 3, we consider normal weigh -a weight between 2500 and 4500 grams-, while in column 4 and 5 we use low weight (weight below 2500 grams) and very low weight (weight below 1500 grams) respectively. Bs is not significant in column 5, but it is significant in columns 3-4, with a sign that indicates that excessive number of visits in private providers result in worst outcomes in terms of weight. This result confirms the hypothesis of over-utilization or unnecessary additional prenatal visits in the private sector viz a viz the public sector. (TABLE 2 HERE] It is worth to mention that the ratio indicating excess number of visits was significant in all weight ‘measures, with a sign indicating improvement of weight. This may reflect the omission of other variables capturing prenatal quality or other risk characteristics at delivery. The lack of data do not allow us to explore this phenomenon, but our results indicate that this benefit of extra-visits is not a characteristic of | the private sector. Indeed, Table 2 confirm that private sector performs equal or even worse than the public sector when it provides more prenatal visits. 4. Conclusions ‘The role of the private sector in the reformed health systems in Latin America has changed. The major responsibilities and alliances with the public sector make private providers and financiers important actors in the system. However, studies have shown that private sectors tend to over-utilize medical procedures and drugs. In this document we have investigated the utilization of prenatal care visits in six countries: Colombia, Peru, Dominican Republic, Bolivia, Guatemala and Nicaragua. ur results indicate that after adjusting for obstetrical risk factors and socioeconomic characteristics, the higher number of visits in the private sector is not a factor in Colombia but is a factor in Peru, Dominican Republic, Bolivia, Guatemala and Nicaragua. Private insurance plays an important role in 9explaining this over-utilization of prenatal visits in Peru while in the Dominican Republic over-utilization is mainly driven by incentives given to private providers. This study confirms that reforms may create incentives for private providers to over-use prenatal services. Lack of information and regulation, as well as market mechanisms, may play a role in reducing these incentives and should be considered in the provision and financing of private parties. Government regulation and supervision may mitigate these incentives through better medical standards, transparency ‘of health care quality information, and consumer education. Market strategies may also serve to eliminate these incentives by using payment systems which are not based on production (such as capitation, prospective payment, and payment for quality), and through risk-shifting and better insurance contracts (co-payments, deductibles, ete.) 5. Appendix 10‘omincanRepebic: Durbution of ember peer vas a type Lea sasoyiuaied uy sonsiers 2 snqoy ‘vonewns9 j2poU /2HUOU!G aAneBON 02 010 wos, vace—-iet—See——=CRS~CSESC*C*CELE SSCS ATS) (9 T2) «Ser «lee eT) «eet (S69) «(ST'S) COLT OST ET TT i quersuoy (ss) (902) (6st) (set) ++(102) sto‘0- Tz00 E00 200" ‘aue uequn ul ployasnoy (SEP) (19%) (coor) e100 “200 ur uajeam s,ployasnoy ++0T'S) (99) E00 00 620'0 | |euoneanpa ssounieg (wo) (ost) z100 S200 Powew sisanow ++(689) stor) 6r00 9€0'0 a1 1euoReINpe ssaIROW (v2) (ss2) 6200 £00 pakojdwa yosd soys0W ss(ts'e) (set) ‘900 9100 uBeid pareujuuare pey (290) ««(68°2) (evo) “oo ro y200- —uoneysa8 aidninw. 0's) (2v'0) «4(922) +22) 4(66'0) ° ° 0 0 To9'0-—payenbs aBe sa420~ st) (270) «4(00'e) (Ise) (59's) ze00 L000 6t00 e010 a8e 1220 S200 49pinoud ® aouesnsuy axeALid +s(10%) (80) «(99'9) z'0) +(904) +4(t07) (e8'0) (ort) ez") S00 seo" 0D——STOD. £400 S00 -6Z0D-_—«D ZO SEO 42pinoud ayenuid LL ad 03 ON oa nud 3d OD @ mo) @) w (9) (9) (o) (e) (@ o “ISTA eveuadd jo Faquina Sip jo SyUeUTUNaIOG T ageTable 2: Excessive number of visits in private providers and delivery outcomes (2) (2) (3) (4) (5) Normal Normal Normal Low Very low size1__size2__weight _weight _weight ratio 0.031 -0.016 «0.129 °°~=—«-0.2 ~——-0.287 (0.82) (0.73) (4.11) (6.08)* —(3.10)* Private Provider 0.118 0.077, 0.175 -0.225-0.177 (1.22) (2.26) (2.08)** (2.51)** (0.86) ratio x private 0.057 0.016 -0.136 0.148 (0.269 0.64) (0.29) _(1.76)*** (1.78)*** (1.37) Observations 23155-23155 -27734_—«27734__—«2734 Probit mode! estimation, with country fixed effects. Robust z statistics In Parentheses * significant at 1%; ** significant at 5%: significant at 10% Health Reform by Countries This section will explain the details of health reform on each Latin-American country in our sample of study: Colombia, Peru, Dominican Republic, Bolivia, Guatemala and Nicaragua. We will see that some of the countries have some similarities each other. Colombia Colombia’s health system reform took many steps towards decentralization in the early 1990s until the implementation of Law 100 and its mandate for universal coverage and the modification of its social security program. There were two types of social insurance plans included in the reforms. For those who could afford to participate, contribution plans were funded by employee payroll deductions and employer contributions. For the country’s poor, subsidy plans were provided, Law 100 of 1993 permitted the rise of private insurance policies, most of wi compete within the contributory segment (Ruiz et al., 2007). are comparable to US-style HMOs. Private insurers mostly These subsidy plans have enabled some of the country’s poor to access private health care services which would have been unaffordable otherwise. Prior to the reforms, private providers serviced mainly the affluent (Yepes et al., 2007). Post-reform, private providers make up a much more significant portion of Colombia's health care system. The subsidies created high demand for the country’s private hospitals, which has enabled the public hospitals to be able to serve more of the non-insured (Gaviria et al., 2006). BIn 2006, over 80 percent of health care providers were self-employed. Many municipalities began to use private laboratories to carry out certain public health measures, such as the diagnosis of communicable diseases and detection of risk factors (PAHO, 2007). As with the public entities, private providers must abide by various guidelines set forth by the General System of Social Security in Health (SGSSS). Colombia's national health expenditure accounted for 5.8% of GDP in 2004, from which 3.4% of GDP ‘was public and 2.4% of GDP was private expenditure. Peru Peru established the legal basis for its health system reform in 1997 with the Social Security Modernization Law. This law and its subsequent modifications created three main types of insurance in Peru: social security (ESSALUD), public insurance for adults living, in poverty (SIS), and private insurance (EPS). In 2004, 63.2% of the population had no medical insurance (PAHO, 2007). Less than 3% of Peru’s population has some type of private health insurance, and out-of- pocket payment remains the most important source of private health financing, The reform sought to FS, pregnant women and ce expand private insurance by dismantling the monopoly of social security. However in practice, competition within the private sector has been limited, leading to increased private insurance premiums. Peru's health services system, in which private providers play a minor part, appears to be very fragmented, ‘The Ministry of Health is the main steering body of Peru’s health system and its biggest health care provider, followed by the ESSALUD health system, and finally by the country’s armed forces and national police. The private sector focuses most of its attention on Peru’s chief urban areas. In 1999, it was estimated that the private sector accounted for only 608 of Peru's 7,501 health care establishments. While private providers appear to play only a small part in Peru's health care system, the population has historically been more satisfied with them. Peru's national health expenditure accounted for 4.4% of GDP in 2003, from which 2.3% of GDP was public and 2.1% of GDP was private expenditure. Dominican Republic The Dominican Republic enacted health reform in 2001 with the General Health Act (Law 42-01) and the Social Security Act (Law 87-01). The goal of the reform was to deliver universal access to its population through the provision of a Basic Health Plan. The program is sit except that the entire national health system is funded by the newly created Dominican Social Security System. Three different financial regimes - contributive, subsidized contributive, and subsidized - fund private and public insurance plans (PAHO, 2007). Prior to the reform, 82 percent of the Dominican to the Colombian system 14Republic’s population had no insurance. Of those who did, 12.4 percent had private insurance, while only 5.4 percent had coverage through the Dominican Social Security Institute. Historically, the private sector and the Ministry of Health (SESPAS) combined in equal measure to provide approximately 90% of health care services (Rathe, 2001). Following the reform, both public and private providers work to provide services to individual citizens on primary, secondary, and tertiary levels. The majority of the private providers’ work, however, is at the individual level. Public health issues are addressed by public providers. SESPAS imposes regulation and sanctions for the entire health sector and is its main steering body. The Dominican Republic’s national health expenditure accounted for 4.4% of GDP in 2003, from which 1.2% of GDP was public and 3.2% of GDP was private expenditure. Boli from 1994, Bolivia has executed a series of changes to the health care sector. The reform channeled by the law of popular participation give the local government the right to own hospitals and at the same time to promote management of social programs. After that, in 1996, an insurance for maternity and childhood comes up. This insurance gives coverage for four prenatal visits, lab test, birth care within a normal situation, C-section or complications, and one control post partum. In the case of kid younger than 5 years, the insurance gives: assistance to the newborn, care for any disease or infections, vaccines and any attention that require a special care. All of these services can be requested by the local public institution: Social security institutions, center of health for the community, ONG or any church already subscribed to help. Finally, in 1997 these attempts to cover the population are mediate through a universal health insurance. In 2002, this insurance receive the name of Insurance for mother and kid (SUMI), protecting the mother and the kid younger than 5 years. Bolivia's health system is made up of three subsystems: public, social security, and private?.The Ministry of Health (MSPS) controls for the health system at the public national level via the Strategic Health Plan (PES). The main components of the PES are: universal access, basic health insurance, strengthening of the network of services, family and community health, implementation of the epidemiological shield, the strengthening of basic health programs, and the development of career programs in public health. Basic Health Insurance is the most important health care policy of the Ministry of Health, and the munici coverage for workers who traditionally contribute to social security financing schemes. ies contribute to its financing. The social security subsystem provides * See Urcullo, Von Vacano, Ricse and Cid (2008) for a detailed explanation of the system organization, 15‘The private sector includes insurance companies, prepaid medical plans, and nongovernmental organizations. Insurance companies collect the funds from households and businesses in order to finance private health institutions. In spite of the liberalization and privatization of the economy, the private sector has occupied a minimal role in Bolivia. As of 2004, only 11.6% of health establishments were private, and nearly 75% of these establishments were backed by NGOs or Churches. Bolivia's national health expenditure accounted for 5.8% of GDP in 2006, from which 4.2% of GDP was public and 1.6% of GDP was private expenditure. Guatemala The absence of a real health policy in Guatemala during the 80° was evident but in the 90°s the ‘government started to concern about the health policies. The government started to recognize the right of health without any discrimination and the Ministry of health assumes the faculty to manage it. There Public sector gives the poor assistance but without many resources. The coverage to the poor comes through the “Sistema Nacional Integrado de Salud (SIAS).” Guatemala’s insurance function is fulfilled by both private insurers and social security which is poorly developed. The latter covers less than 25% of the population (WHO). The percentage of the government’s general budget devoted to health care between 1991 and 1994 came to 18.1%, And in 1996, public spending on health care amounted to 13% of total public spending, compared with 6.6% in 1992.* In the private sub-sector, contributions come from households (out-of-pocket payments) and private companies. The private sector, act as agents for insurance payment and as providers through hospitals, ics, pharmacies, and laboratories, among others. International cooperation comes in ‘the form of donations from bilateral and multilateral agencies’. Nongovernmental organizations act as nursing homes, cli agents and suppliers in the health financing process, as they receive resources from the central government, international partners, households, and from companies.° Guatemala’s national health expenditure accounted for 7% of GDP in 2006, from which 2.2% of GDP was public and 4.8% of GDP ‘was private expenditure. Nicaragua “PAHO (2007) * MSPAS (2005). * MSPAS (2000). 16During the 80's Nicaragua experience a series of reform in the health sector. The government adopted a program that attempt to cover primary care through the Sistema Nacional Unico de Salud (NUS), After 1987, the ministry of health started to regulate other institutions that provide care to the population.” In 1992, the government modernized the hospitals and increased the coverage for primary care. In 1997, Social Security started to provide differentiated attention to their insured and many Clinique started to supply the necessities uncovered by the Ministry of Health. Today, the Nicaraguan government has recently been working on a National Health Plan (2004- 2015), which seeks to ensure universal access. The health sector is comprised of two subsectors: the private and the public, made up of several institutions including the Ministry of Health, Nicaraguan Social Security Institute (INSS), and other state institutions. Law No. 290 on Structure, Jurisdiction, and Procedure of the Executive Branch confers on the Ministry of Health the authority to coordinates the government institutions charged with the preservation of hygiene and environmental health. The principal insurance entity is the Nicaraguan Social Security Institute (INSS), which delivers medical services to beneficiaries through 49 different Medical Services Companies (EMPs). EMPs are financed through premiums, collected by the INSS, for the care of contributing subscribers and their beneficiaries in a comprehensive care regimen. The EMPs' principal source of financing is the sale of health services to private entities. Nicaragua’s national health expenditure accounted for 7.6% of GDP in 2006, from which 3.5% of GDP was public and 4.1% of GDP was private expenditure. 6. References Abdullah A Al-Maniri, Omar A Al-Rawas, Fatmah Al-Ajmi, Ayesha De Costa, Bo Eriksson, and ‘Vinod K Diwan, 2008. “Tuberculosis suspicion and knowledge among private and public general practitioners: Questionnaire Based Study in Oman”. BMC Public Health, May. ‘Amini, Saeid, P. Catalano and L. Mann, 1996. Effect of prenatal care on obstetrical outcome. The Journal of Maternal-Fetal Medicine 5: 142-150. Before that the Ministry of Health regulated their own institutions vBarber, Sarah, S. Bertozzi, and P. Gertler, 2007. Variations In Prenatal Care Quality For The Rural Poor In Mexico, Health Affairs 26: w310-w323. Barros, Femando, Cesar Victoria, et al., 2005. The challenge of reducing neonatal mortality in middle-income countries: finding from three Brazilian birth cohorts in 1982, 1993, and 2004, Lancet 365: 847-854, Boss, Douglas, and R. Timbrook, 2001. Clinical Obstetric Outcomes Related to Continuity in Prenatal Care, Journal of the American Board of Family Practice 14:418-423, Brugha R. and Anthony Zwi (1998) “ Improving the quality of private sector delivery of public health services: challenges and strategies.” Health Policy and Planning 13(2): 107-120. Coimbra, et al., 2007. Inadequate utilization of prenatal care in two Brazilian birth cohorts. Brazilian Journal of Medical and Biological Research (2007) 40: 1195-1202. Encuesta Nicaragtiense de Demografia y Salud (ENDESA, 2001) Freda, Margaret, Frank Anderson, Karla Damus, and Irwin Merkatz, 1993. Are there differences in information given to private and public prenatal patients? American Journal of Obstetrics and Gynecology 169: 155-160. Gaviria, Alejandro, C. Medina, and C. Mejia, 2006. Evaluating the Impact of Health Care Reform in Colombia: From Theory to Practice. Documento CEDES 2006-06. lezzoni, Lisa (Ed.), 2003. Risk Adjustment for Measuring Healthcare Outcomes. Third edition. ‘AcademyHealtl/HAP. Koichi, Usami, 2003. Latin American Social Security Reform in the 1990s, The Journal of Social Science , Institute of social Science, University of Tokyo, vol.55, no.1. Londofo, J. and J. Frenk, 2000, “Structural Pluralism: Toward an Innovative Model for Health System Reform in Latin America,” in Peter Lloyd-Sherlock ed. Healthcare Reform and Poverty in Latin America. London: Institute of Latin American Studies, University of London. ‘Marquis, Susan, and Stephen Long, 2002. The role of public insurance and the public delivery system in improving birth outcomes for low-income pregnant women. Medical Care 40: 1048-1059. 18Ciceklioglu, Meltem, M. Soyer and Z. Ocek, 2005. Factors associated with the utilization and content of prenatal care in a western urban district of Turkey. Intemational Journal for Quality in Health Care; Volume 17, Number 6: pp. 533-539 MSPAS, 2005 “La situacién de salud y su financiamiento 1999-2003”. MSPAS, 2000. “Guatemala: La Experiencia Exitosa de la Extension de Cobertura”. ‘Naceur Jabnoun; Chaker Mohammed, 2003. “Comparing the quality of private and public hospitals”, Managing Service Quality; 13, 4; ABUINFORM Global pg. 290. Planned Parenthood Federation (PPF), 2002 Report. PAHO, 2007. Health in the Americas, Volume Il. PAHO. Rathe, Magdalena, 2001. La Reforma de Salud y la Seguridad Social. Mimeo, USAID. Ruiz, Fernando, L. Amaya and S. Venegas, 2007. Progressive Segmented Health Insurance: Colombian Health Reform and Access to Health Services, Health Economies 16: 3-18. ‘Simkhada, Bibha, E. Teijlingen, M. Porter, and P. Simkhada, 2000. Factors affecting the utilization of antenatal care in developing countries: systematic review of the literatura. Journal of Advanced Nursing 61: 244-260. Ureullo Gonzalo, Julio Von Vacano, Carlos Riese and Camilo Cid, 2008. “Health Worker Salaries and Benefits: Lessons from Bolivia, Peru and Chile.” Report for WHO-Alliance for Health Policy and ‘System Research. United Nations Development Program's (UNDP), 2000. Human Development Report United Nations Development Program's (UNDP), 2001. Human Development Report Villar, José, et al., 2001. WHO antenatal care randomized trial for the evaluation of a new model of routine antenatal care. THE LANCET + Vol 357 + May 19, 2001 WHO Villar, José, E. Valladares, D. Wojdyla, N. Zavaleta, G. Carroli, A. Velazco, A. Shah, L. ‘Campodénico, V. Bataglia, and A. Faundes. 2006. “Cesarean delivery rates and pregnancy outcome: the 2005 WHO global survey on maternal and perinatal health in Latin America”. The Lancet 367: 1819-1829, 19Waters, Hugh, Laurel Hatt, and Robert Black, 2008. “ The role of private providers in treating child diarrhoea in Latin America”. Health Economies 17: 21-29 World Health Organization (WHO) Reports. World Bank 2002. “Health sector reform in Bolivia: Analysis on decentralization”. World Development Indicators (WDI) Reports 2006 Yepes, Francisco, M. Ramirez, M. Cano, R. Bustamante, 2007. “Aiming for Equity in Colombia’s, Health System Reform: Achievements and Continuing Challenges”, in Slim Haddad, E. Bang and D. ‘Narayana ed. Safeguarding the Health Sector in Times of Macroeconomic Instability. Africa World Press/CRDI. 20