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Introduction 1 Why This Book? 2 Objectives, Approach, and Conceptual Framework 3 Audience and Policy Enbvironment 7 Chapter Smunmaries 8 Sources and CaI,eats 15 Notes 16 T2 he Brazilian Hospital Sector: Structure, Financing, Spending, and Outcomes 17 'hOw Br,zilian Hlealth Sector 17 The BRazilian Hospital Sector 28 I lospital Finance and Spending 36 Sulnnay Assessment 40 ANNEX 2A: An Indirect Method for Estimating Hospital Spending 43 ANNEX 2B: Supplementary Data 44 Notes 47 S Comparative Analysis of Costs and Efficiency 51 I Hopital Costs: NMeasurement Challenges and Findings 53 Efficiency Analysis 66 Conclustions and Recommendations 92 ANNEX 3A: Cost Analysis Methodology: The De Matos Cost Study Methodology 96 ANNEX 313: Supplementary Data 100 ANNLEX -C: Average Cost and Coefficient of Variation for Sample Hospital Procedures 102 ANNEX 3D): DEA Methodology 106 ANNEX 3E: Brazilian Studies on Hospital Efficiency 112 Notes 115 4 lospital Payment Mechanisms and Contracting Arrangements 121 I'an'ment Mechanisms otr H ospital Care in Brazil 122 Criitical Review ot PlMs in Brazil 125 The Plight of Private Hospitals under the SEUS 132 Paymenzt Mechantsms and etf ortn Ianm c 134 Hospital Conta nlt ing Arr in Atngcmen in tilh SIiS 1 38 Conclusions and Re om merndations 146 ANNEX 4A: Charaa teristcs and Effects of Main Provide Panyment Mechanisms 151 ANNEX 4B: History of Governmcnt PPMs fo0r ospitals in Biazil 1 54 ANNEX 4C(: Provide IP'ayment Mecihanisms lUsed by the SUS 1356 ANNEX 41): Differential Increases in Reimburscmnnt Rates, 1995 2001 158 ANNEX 4E: From the A 11 to I)RGs 1 59 Notes 162 S Organizational Arrangements and Performance of Brazilian Hlospitals 167 Organizational Arranęgein?lrts: .l-anuework and l.iterature 168 Organizational Arian gemint, its liiblic Hospital. in Brazil 171 Coiparative Revieuw o Og anizzational Features in Public Hospitals 1 81 Private Secto Ovrganizational Stru turs alnd G;ol,erna nce Ar rangemntCi Is 18 4 C(omparative Perfotmance olf HMs pitl under Diff)el nt Owner,shiip antd ( )ganizational Arrangements 19 1 Sun Inar), Assrssmn en ] 98 AN N EX 5A: Organizational Arrangemntcns in Public and h ivat( Hospitals in Brazil: Summary 20l ANNEX 5B: Matrix: Features of Organizational Arrangw'ienis iI Public Hospitals in Brazil 208 ANNEX (C: Methods for Analysis (of Altwrnativ' and ITraditional lHospitals 2 1 ANNEX 51): Methods for (Comparativec Analysis of OSS aind Direct Administratiosn t lospiitls 218 ANNEX 5E: Matrix: Organizational Arrangements in Europeaia Hospitals 219 Notes 221 SInside the Black Box: Linkiing Organizational Arlangecinents, Managerial Behaviors, and Pe'rformance in Public and Private lilospitals 227 Management Piartices in Public I/ospitals 228 Brazil's Experienceni with lopitalI Caovlersioil: ()Ot'ctomilht 1jnuan Rescrmt ( alnd Financial Obstacles 24( International ['Aperience with q' Hospital C(omnvesion 2 3 Managerial IPactices in thie Privat' Nonvpofit Sector 2 Sum nmary Assessmient and Recommcndations, 261 ANNEX 6A: Striengths and Weaknesscs of the Public Se-tor ReginuIe for Procurement, Labor, and Budgeting 267 ANNEX 6B. Comparison of Stimmary Labor Regime (ICharactriT it(s for Physicians by Organizational Arrangement in P'ubli and Private Nonprofit Hospitals 209 Notes 2 S Qtuality of Carc: Still the Forgotteln (omponent? 27 Quality, (ualiti fi proveimenrt, atd Cosis 75 Qoualit) in Braizilimt Hoipitals 278 Summattin Aott'io tcnt ANNEX 7A: Policy and Managerial Innovations Across Medical Disciplines, 2000-2005 300 ANNEX 78: Process Shortcormings in Brazilian I ospitals and Possible Causes 301 Notes 303 S LQuality Assessment and Improvement 305 I lospital Accreditation and Certification in Brazil: Adoption, Challenges, ,ad Opportunities 305 ()Ohir Quality Assessmnent and linprovement Initiatives 319 Ctare Coordination Across Provider levels 323 Sumnmariy Assessment and Recommendations: A Franmeworkl lir Systematic Quaility ImpirovemnaHt 328 ANNEX BA: An Example of ONA Standards and Performance IElenments: Obstetrics 335 ANNEX 8B: Government Initiatives to Build National Capacity Ior Continuous Quality improvement, 1997-2001 336 ANNEX 8C(: Setting the Policy and Institutional Framework for Systematic Quality Measurement and Improvement: Examples from the United States, the iUnited Kingdom, and Australia 337 ANNEX 81): Hlospital Report Cards: Motivating Hospitals to Perform? 339 AN NEX 8E: Quality-Based Purchasing in OECD Countries 140 Notes 342 Conclusions and Recommendations 345 Problents in Braz-il's -fospital Sector 346 P?ulding on Brzilin Innovations and Experience 351 What Can be Done? Key Phliy Priorities 354 v1in,g PIrTonvId with inplementation 366 ANNEX 9A: Recommended Policies and Actionis 369 trotes 374