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PROLOGUEImproving Care DeliveryImproving the delivery of health care services is challenging enough for nations that enjoy relative wealth, stability, and a large corps of medical professionals. But the path to better health care is made exponentially more difficult for countries confronting widespread poverty, shortages of health care providers, geographically remote populations, or even political upheaval. This collection of papers crisscrosses the globe from India to Estonia to Ecuador on a tour that chronicles vastly different challenges to improving health care. In this issue’s Report from the Field, Nellie Bristol reports on maternal deaths—an intractable problem that graphically reflects disparities between rich and poor nations. She explores health programs in Peru that highlight just how complex and difficult it is to keep mothers safe and healthy. David Gaus offers a personal account of his struggle to open a small hospital in rural Ecuador, where family incomes average US$150 per month. The little hospital, which started out as a two-room clinic, now serves 1,300 patients monthly. On a much broader scale, Armin Fidler and colleagues survey health care delivery reforms undertaken by former Eastern Bloc nations since the collapse of the Soviet Union. Saddled with Soviet-style inefficient, centrally planned health care systems, many Eastern European and Central Asian countries are transitioning to more decentralized systems with growing roles for the private sector, Fidler and colleagues find. As a result, these countries have clearly improved service delivery, contained costs, and modernized service networks. However, Fidler and colleagues say that these nations should do a better job of monitoring and evaluation to determine the magnitude of these improvements—including whether they’ve achieved better health. Finally, Chris James and colleagues investigate whether financial ties between physicians and pharmacies in the Philippines influence where patients purchase prescription medicines, what brands they buy, and how much they spend. The findings suggest that policymakers may want to embrace reforms that decouple physician-pharmacy ties and broaden the availability of generic drugs to patients.
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