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Welfare Reform on the Web (January 2008): Healthcare - overseas

Abortion policies and practices in Chile: ambiguities and dilemmas

B.L. Shepard and L. Casas Becerra

Reproductive Health Matters, vol.15(30), 2007, p. 201-210

Abortion is not legal in Chile even to save the woman’s life. Low-income women and adolescents therefore have recourse to clandestine and often unsafe abortions. Legally, hospitals should report women treated for post-abortion complications to the authorities, but this is not done in over 99% of cases. There are two loopholes one legal, one clinical, which are used to enable hospitals to carry out abortions. 'Interruption of pregnancy' is legal after 22 weeks gestation for medical reasons; this may save some women’s lives but may also lead to the prolongation of health-threatening pregnancies. Catholic clinical guidelines define interventions aimed solely at saving the woman’s life, even if the baby dies, not as abortion but as indirect abortion and permissible. Since 1989, three bills to liberalise the law on therapeutic grounds have been unsuccessful.

The complexity of governance change: reforming the governance of medical performance in Germany

V. Burau

Health Economics, Policy and Law, vol. 2, 2007, p. 391-407

The governance of medical performance is changing. Professional self-regulation has traditionally been dominant. This means that the state has allowed doctors considerable autonomy in their work and that in exchange doctors have been expected to provide quality care and to depoliticise treatment rationing. However cost escalation and the emergence of more assertive patients have challenged the implicit contract between the state and the medical profession. Instead, new governing instruments are emerging, which emphasise the importance of public accountability. This article critically assesses the extent and nature of change in the governance of medical performance using recent health reforms in Germany as a case study.

Consequences of birth policies and practices in post-reform China

A. Harris and others

Reproductive Health Matters, vol. 15(30), 2007, p. 114-124

Women in the wealthier coastal regions of China do survive birth better than women in rural and remote regions. A project to decrease rural maternal mortality ratios and eliminate newborn tetanus was begun in 2000 in 12 Western provinces. The government has since imposed ambitious targets for raising hospital birth rates, alongside improvement of the quality of care. The project was extended to central China in 2005, including both Sichuan and Shanxi provinces. This study aimed to investigate the relationship between government policy, the quality of birthing services, and maternal health outcomes, drawing on data collected in Sichuan and Shanxi provinces between October 2005 and April 2007. Results revealed some unintended consequences of government policy. In the context of a neo-liberal health economy with poorly developed government regulation, wealthier women are risking increased morbidity and mortality through overuse of unnecessary medical interventions promoted by health professionals out to make a profit. Normal birth without medical intervention is relatively low cost and therefore not attractive to hospitals as a source of revenue.

The experience of Ghana in implementing a user fee exemption policy to provide free delivery care

S. Witter and others

Reproductive Health Matters, vol.15(30), 2007, p. 61-71

In developing countries, the high cost of user fees for deliveries limits access to skilled attendance and contributes to maternal and neonatal mortality. This paper describes an innovative scheme introduced in Ghana in 2003 to remove financial barriers to use of maternity services. The scheme exempted all pregnant women from payments for delivery. Public, mission and private providers could claim back lost fees from the government, according to an agreed tariff. The exemption mechanism was well received and appropriate, but problems arose from shortfalls in funding. The failure to reimburse providers adequately and promptly had negative effects at all levels of the system.

Factors associated with enrollment, satisfaction and sustainability of the New Cooperative Medical Scheme program in six study areas in rural Beijing

H. Wang, D. Gu and M.E. Dupre

Health Policy, vol. 85, 2008, p. 32-44

Following the market reforms of the 1970s, the healthcare delivery system in rural China collapsed. Many rural residents were forced into poverty by escalating out-of-pocket medical expenses and sickness came to be regarded as the most feared aspect of daily life. In 2003 the central government addressed the problem through the implementation of the New Cooperative Medical Scheme (NCMS) nationwide. The scheme requires each voluntary participant to pay a premium of about 1% of his/her annual income. If he/she then suffers a serious illness that year, he/she would be reimbursed 2000-3000 yuan per medical service used. Those who do not use the NCMS scheme in a given year receive free medical checkups. This article examines factors associated with the enrollment, satisfaction and sustainability of the NCMS in six rural areas in Beijing.

Global health governance and the fight against HIV/AIDS

W. Hein, S. Bartsch, L. Kohlmorgen (editors)

Basingstoke: Palgrave Macmillan, 2007

The HIV/AIDS pandemic poses one of the most crucial policy challenges of our times. Successfully managing this policy field is vital for saving millions of lives, improving national and international security, promoting economic development and contributing to poverty reduction. This collection systematically explores the global governance architecture surrounding HIV/AIDS. Examining key actors in global health - WHO, UNAIDS, The Global Fund, WTO/TRIPS, the pharmaceutical industry and civil society, it focuses on national responses to the pandemic in Brazil and South Africa - the two key countries that have significantly contributed to and shaped the discourse on global health. This book provides a theoretical understanding of the patterns of conflict and cooperation in the fight against HIV/AIDS and global health governance more broadly.

Global progress in PMTCT and paediatric HIV care and treatment in low- and middle-income countries in 2004-2005

C. Luo and others

Reproductive Health Matters, vol. 15(30), 2007, p.178-189

At the end of 2005 there were an estimated 2.3 million children under 15 living with HIV, 15 million orphans due to AIDS, 530,000 newly infected children (mainly through mother-to-child transmission) and 380,000 deaths as a direct result of AIDS. The knowledge and tools to prevent mother-to-child transmission of HIV do exist. This paper reports on findings of a review of national programme data in 71 developing countries in 2005 and 58 in 2004 to put together quantitative and qualitative data on global, regional and country-level progress in prevention of mother-to-child transmission and paediatric HIV care and treatment.

Improving emergency obstetric care in a context of very high maternal mortality: the Nepal Safer Motherhood Project 1997-2004

A.D. Rath and others

Reproductive Health Matters, vol. 15(30), 2007, p. 72-80

The Nepal Safer Motherhood Project was initiated in 1997 with the goal of reducing maternal mortality through improved access to emergency obstetric care. At the time the maternal mortality ratio in Nepal was among the highest in South Asia at 539 per 100,000 live births. The project experience demonstrated that supply-side interventions of this kind are not sufficient of themselves to reduce maternal mortality. Co-strategies for poverty reduction, tackling the marginalisation of minority groups and women’s empowerment are essential for improving maternal health.

Improving maternal health: getting what works to happen

L. Penn-Kekana, B. McPake and J. Parkhurst

Reproductive Health Matters, vol. 15(30), 2007, p. 28-37

At the end of a five-year programme of health system research in Bangladesh, South Africa, Russia and Uganda, the authors seek to explain why strategies to reduce maternal mortality are not working in many countries despite the availability of inexpensive, effective interventions that are part of official policy, adequate resources and appropriately trained staff. It is argued that proven technical interventions need to be adapted and applied in a way that suits the local economic, social, cultural and geographical context. This implies that international agencies need to give advice more circumspectly, local programme managers need to be empowered to make adjustments, and, for evaluation purposes, the detail related to programme implementation process must be documented.

Informing UK policy development on the regulation of CAM practitioners: lessons from Hong Kong?

A. Dixon, S. Peckham and A.P.Y. Ho

Social Policy and Administration, vol. 41, 2007, p. 711-728

During the past 15 years there has been a significant growth in demand for complementary and alternative therapies in the UK and worldwide. The UK government is currently proposing that acupuncturists and herbalists come within a statutory regulation framework which will include practitioners of traditional Chinese medicine. This article draws lessons for the UK from Hong Kong’s experience of implementing a new regulatory system for practitioners of Chinese medicine.

The Internet and healthcare in Taiwan: value-added applications on the medical network in the National Health Insurance smart card system

W.-H. Tsai and H.-C. Kuo

International Journal of Electronic Healthcare, vol. 3, 2007, p. 417-432

Taiwan’s Bureau of National Health Insurance introduced smart cards for patients in 2004. These cards allow patients to access medical services, and contain a certain amount of critical information about the user. This paper proposes three possible additional value-added uses for the smart cards: electronic medical data exchange, retrieval of personal medical records, and medical e-learning.

Making systems work: the hard part of improving maternal health services in South Africa

L.S. Thomas and others

Reproductive Health Matters, vol.15(30) 2007, p. 38-49

As part of a multi-country study, maternal health services were reviewed in one health district in Gauteng Province, South Africa. Poor record-keeping, inadequate supervision, poor levels of clinical knowledge and under-utilisation of midwife obstetric units were found. Interventions identified by local health service personnel to improve maternity care were developed, implemented and evaluated. These included programme-specific (training in prevention of mother-to-child transmission of HIV and neonatal resuscitation) and system interventions (improving interpersonal relations and system functioning, use of routine data for monitoring purposes, improving supervision skills). This resulted in improved health worker knowledge, better patient records and more adequate supervision, but not in a better functioning overall system. To achieve the latter, systems would need to be put into place to develop a learning organisational culture.

Maternal mortality and maternity care from 1990 to 2005: uneven but important gains

I.H. Shah and L. Say

Reproductive Health Matters, vol. 15(30), 2007, p. 17-27

Maternal mortality continues to be the major cause of death among women of childbearing age in developing countries. Data from published studies and Demographic and Health surveys show that gains in reducing maternal mortality between 1990 and 2005 have been modest overall. In 2005, there were about 536,000 maternal deaths, and the maternal mortality ratio was estimated at 400 per 100,000 live birthe, compared to 430 in 1990. Noteworthy declines took place in East Asia (4% per year) and North Africa (3% per year). Maternal deaths and mortality ratios were highest in Sub-Saharan Africa and South East Asia and low in East Asia and Latin America/Caribbean.

The national health insurance system as one type of new typology: the case of South Korea and Taiwan

S.-Y. Lee and others

Health Policy, vol. 85, 2008, p. 105-113

The well-known three model typology classifies healthcare systems into National Health Services, Social Health Insurance and Private Health Insurance. The health systems of Korea and Taiwan do not fit neatly into any of these classes and share many unique features. They have both implemented a National Health Insurance system covering the entire population through the merger of various insurance programmes and sickness funds.. This comprises a single insurer system with strong state intervention, extensive government subsidies, and free choice of physician for patients.

Patient choice in healthcare in England and Sweden: from quasi-market and back to market? A comparative analysis of failure in unlearning

M. Fotaki

Public Administration, vol. 85, 2007, p. 1059-1075

Both Sweden and the UK introduced a quasi-market in healthcare in the early 1990s to balance traditional public health goals of equity and efficiency with capacity to respond to real or perceived patient wants. This study compares the experience of the 1990s with the current re-introduction of patient choice policy into both health systems and argues that the re-discovery and re-invention of old concepts epitomises limited learning in the policy formulation process. Governments and policymakers seem unable to put aside their preconceived ideas and schemas, leading to the recycling of previously abandoned reforms.

Seizing the big missed opportunity: linking HIV and maternity care services in sub-Saharan Africa

N. Druce and A. Nolan

Reproductive Health Matters, vol. 15(30), 2007, p. 190-201

This paper draws on two reviews commissioned by the UK Department for International Development in 2006 and 2007 that explore the slow progress in linking prevention of mother-to-child transmission of HIV and maternal health services in sub-Saharan Africa. Despite ongoing efforts to promote comprehensive approaches, significant policy, financing and institutional barriers, and weak co-ordination and leadership, continue to hamper progress. Maternal health services face human and financial resources shortages that affect their capacity to integrate HIV prevention. Both HIV and maternal health programmes often receive targeted financial and technical assistance that does not take the other into account. However, proposals in 2007 from a number of countries to the Global Fund to Fight AIDS, TB and Malaria incorporate sexual and reproductive health programmes that will have an impact on HIV, including certain maternity services. Moreover, Botswana, Kenya and Rwanda have shown that progress can be made where national commitment and increased resources are enabling maternity services to address HIV.

Support to the Safe Motherhood Programme in Nepal: an integrated approach

C.E. Barker and others

Reproductive Health Matters, vol. 15(30) 2007, p. 81-90

Support to the Safe Motherhood Programme launched in 2004 builds on the experiences of the Nepal Safer Motherhood Project (1997-2004) but differs significantly. It has moved from a district-focused project to a programme approach, working directly with and through the government to build capacity and develop systems. It has supported long term planning, working towards skilled attendance at every birth, safe blood supplies, staff training, building management capacity, improving monitoring systems and use of process indicators, promoting dialogue between women and providers on quality of care, and increasing equity and access at district level. There has been encouraging progress, despite the limitations of complex bureaucratic systems, frequent transfers of key government staff, and political instability.

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