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

Autonomy and control in public hospital reforms in Singapore

M. Ramesh

American Journal of Public Administration, vol. 38, 2008, p. 62-79

The Singapore government began to reform public hospitals in the mid-1980s because of concerns about mounting public expenditure on healthcare. It granted public hospitals managerial autonomy and required them to compete for patients. Correspondingly, patients were required to make a larger contribution to costs through higher fees. When it was found that, in spite of the reforms, costs were increasing rather than decreasing, government began to reassert control in the mid-1990s, while retaining the essence of the earlier reforms. In recent years reforms have emphasised management autonomy coupled with strong government guidance. It is concluded that for market competition to deliver efficient, consumer-friendly and politically acceptable services, constant governmental oversight and co-ordination are required.

Defining hospital markets for antitrust enforcement: new approaches and their applicability to the Netherlands

M. Varkevisser, C.S. Capps, and F.T. Schut

Health Economics, Policy and Law, vol. 3, 2008, p. 7-29

Market-based healthcare reforms can only be successful when competition is protected by effective antitrust enforcement. A central issue in antitrust enforcement is measuring market power, which typically requires first defining the product and geographic markets. Assessing hospital market power - a central issue to competition policy - is complicated because the presence of third party payers and the general unobservability of prices make it difficult to apply the standard measures of market definition. This paper discusses the strengths and weaknesses of several new approaches to defining hospital markets that are suggested in the recent economic literature. In particular, it focuses on the applicability of the time-elasticity approach, competitor-share approach, and option-demand approach to the recently partly deregulated Dutch hospital market.

The economics of health equity

D. McIntyre, G. Mooney (editors)

Cambridge: CUP, 2007

The book explores why, despite being seen as an important goal, health equity has not made more progress within countries and globally, and what needs to change for there to be greater success in delivering fairness. It describes how equity in health and health care might develop over the next decade and examines existing and past barriers to promoting equity, citing case examples, and covering issues including access to health services and inequalities between and within countries. The analyses are detailed, but the issues are approached in an accessible fashion, highlighting the factors of common international relevance. Finally, the book provides a manifesto for achieving health equity for the future.

The effectiveness of contracting-out primary health care services in developing countries: a review of the evidence

X. Liu, D.R. Hotchkiss and S. Bose

Health Policy and Planning, vol. 23, 2008, p. 1-13

Contracting out is an arrangement whereby the government provides compensation to private providers (contractors) in exchange for a defined set of health services. While this review of selected studies suggests that contracting out has in many cases improved access to services, the effects on other performance dimensions such as equity, efficiency and quality are often unknown. Moreover, little is known about the health system-wide effects of contracting out, which could be either positive or negative. The context in which contracting out is implemented, and the design features of the interventions are likely to greatly influence the chances of success.

Effectiveness of training supervisors to improve reproductive health quality of care: a cluster-randomized trial in Kenya

H.W. Reynolds and others

Health Policy and Planning, vol. 23, 2008, p. 56-66

Health facility supervisors are in a position to increase motivation, manage resources, facilitate communication, increase accountability and conduct outreach. This study evaluated the effectiveness of a training intervention for on-site, in-charge reproductive healthcare supervisors in Kenya, using an experimental design with pre- and post-test measures in 60 health facilities. The intervention resulted in significant improvements in quality of care at the supervisor, provider and client-provider interaction levels. Indicators of improvements in the facility environment and client satisfaction were not apparent. Costs of delivering the training totalled US$2113 per supervisor trained. In allocating scarce resources, decision-makers need to weigh up whether the training costs are justified.

Exporting managed care: Asian experiments

D. Simonet

International Social Security Review, vol. 61, Jan.-Mar. 2008, p. 21-39

This article begins by reviewing the experiences of Indonesia, the Philippines, Malaysia, Hong Kong and Singapore with managed healthcare. Managed care has gained acceptance in some countries, such as Hong Kong and the Philippines, but not in others. Two major barriers to the spread of managed care in Asia are identified: a lack of health resources and facilities in poorer countries such as Indonesia and Malaysia, and the pre-existence of efficient, low-cost health systems, which may render managed care unnecessary, in states such as Singapore.

Global public-private partnerships against neglected diseases: building governance structures for effective outcomes

S. Buckup

Health Economics, Policy and Law, vol. 3, 2008, p. 31-50

Many diseases in low and middle-income countries are characterised by a lack of commercial incentives to trigger investment in drug research. Diseases such as malaria and tuberculosis often affect millions of patients whose inability to pay for commercially produced drugs means that there is no market for developers to exploit. Since the mid-1990s, a number of global health partnerships between public and private actors have emerged to address these market failures. On one level they may tackle poverty-induced lack of demand for health products which impedes the development of new treatments. On a second level, they may help to overcome problems of underinvestment in the development of new drugs and vaccines for neglected diseases.

Has cost containment after the National Health Insurance system been successful? Determinants of Taiwan hospital costs

J.-H. Hung and L. Chang

Health Policy, vol. 85, 2008, p. 321-355

After the introduction of the National Health Insurance system in Taiwan in 1995, population coverage increased and quality of care improved, but costs rocketed. This study shows that hospital costs rose because extension of insurance coverage meant that elderly people and those with more complex diseases began to make more use of health services. Patient choice also led to greater competition between hospitals, triggering more spending on new technologies and longer length of stay. Policymakers should respond by promoting disease prevention and management programmes for the elderly. In addition, hospital administrators should find ways to reduce length of stay and eliminate unnecessary treatments.

Health and wealth: studies in history and policy

S. Szreter

Woodbridge: University of Rochester, 2007

The book seeks to bring an historical perspective to bear on today's national and international health policy concerns and to present original historical research, which challenges conventional assumptions and viewpoints. The essays in Part I offer an historian's reappraisal of several of the most influential ideas dealing with the relationships between health and economic development in the post-war international policy sciences, such as demographic transition theory; the McKeown thesis; and the population health approach. Part II presents a distinctive interpretation of the course and causes of mortality change in Britain during the 'long century' of industrialisation, c.1780-1914. British history shows that rapid economic growth is a highly disruptive process, unleashing potentially deadly challenges. The key to life and death in Britain lay less in medical science or rising living standards than in the changing electoral politics of the nation's industrial cities. Class relations, political economy, ideology, religion and the public health movement were all significant elements in this story. Part III reflects on history to make direct contributions to contentious current policy issues. The persistence of social and health inequalities today in developed nations and debates over the new concept of social capital are addressed, along with the economic and health problems of today's less developed countries.

Health, economic development and household poverty: from understanding to action

S. Bennet, L. Gilson and A. Mills (editors)

London: Routledge, 2008

In recent years, there has been increased interest in how ill health affects household productivity, the local economy, and national and global economic development. Emerging evidence on the strength of these links has led to a call for greater investment in the health sector of developing countries. Mounting evidence that the health systems in the developing world typically favour the better off has stimulated innovative approaches to health financing and service delivery that can better reach the poor. The book provides a summary of this burgeoning field of research and covers:

  • evidence regarding the links between health, economic development and household poverty
  • evidence on the extent to which health care systems address the needs of the poor and the near poor
  • innovative measures to make health care interventions widely available to the poor.

Implementation of a new birth record in three hospitals in Jordan: a study of health system improvement

R. Khresheh and L.Barclay

Health Policy and Planning, vol. 23, 2008, p. 76-82

This study investigated the feasibility and outcomes of introducing a new integrated birth record shared between the hospital and the community in Jordan. Following the intervention, clinicians were recording better quality, more useful data collected with increased professionalism. The health professionals were using aggregated information to monitor their performance and the hospitals could use the data to plan improvements. The policymakers who supported and guided the study are closer to their goal of consolidating data into electronic records that can be analysed automatically and will enable the performance of the national maternity system to be monitored.

Making policy decisions about population screening for breast cancer: the role of citizens' deliberation

C. Paul and others

Health Policy, vol. 85, 2008, p. 314-320

Screening is an intuitively attractive health intervention and advocacy for new or extended screening programmes is common. However, there are risks as well as benefits to screening, and decisions to implement national programmes are not straightforward. Screening programmes may be implemented due to strong public demand whipped up by advocacy groups despite the doubts of experts. This happened in New Zealand when the minimum age of eligibility for mammographic screening was lowered from 50 to 45 years because of strong public advocacy. This research tested whether a citizens' jury, when presented with detailed evidence, would support or reject free mammography screening for all women aged 40-49 years. All but one woman changed their minds after hearing the evidence and voted against government provision of mammography screening in this age group. The researchers conclude that a citizens' jury approach is a feasible way of eliciting a well-informed, considered, community view about population health initiatives.

Midwifery provision in two districts in Indonesia: how well are rural areas served?

K. Makowiecka and others

Health Policy and Planning, vol. 23, 2008, p. 67-75

Indonesia has a village-based midwife programme that was intended to increase the rate of professional delivery care and reduce maternal mortality by posting a trained midwife in every village. This study shows that:

  • Most deliveries are managed by a single-handed midwife in a woman's home where conditions may be basic and access to emergency care limited
  • There is a paucity of midwives in remote villages
  • The low obstetric workload of village midwives compromises their professional capacity through lack of practice
  • A policy shift from supporting home births to encouraging community-based facility births would enable midwives to operate in teams, thus increasing their obstetric workload and exposure to complications, and would facilitate access to emergency care.

Moving towards consumer involvement in maternity services in the North-East of Ireland

P. Kennedy

International Journal of Consumer Studies, vol. 32, 2008, p. 27-33

The Health Service in Ireland is in crisis, characterised by a very difficult and prolonged restructuring, extreme difficulties in recruiting and retaining staff, lack of resources, and long waiting times in accident and emergency departments. The North East of the country has also been affected by the closure of two maternity units in Monaghan and Dundalk and rocked by a major medical scandal involving a long-serving obstetrician. Out of this, there is emerging an innovative woman-centred maternity service.

Prescription drug co-payments and cost-related medication underuse

T.H. Wagner, M. Heisler and J.D. Piette

Health Economics, Policy and Law, vol. 3, 2008, p. 51-67

Patients with chronic diseases frequently have difficulty paying their share of the cost of the drugs they need. This study uses survey data from a large, national sample of Americans aged over 50 using one or more prescription drugs for a chronic illness to examine the relationship between average co-payment levels and cost related medication underuse. Four types of cost-related underuse are investigated: taking fewer doses, postponing taking a medicine, failing to fill a prescription at all, and taking medicine less frequently than prescribed. Results showed a strong positive association between co-payment amount and medicine underuse.

Primary care: a collaborative practice. 3rd ed.

T. Buttaro and others (editors)

St. Louis: Mosby, 2008

This comprehensive primary care handbook provides concise, yet thorough information that primary care providers need in today's fast-paced, collaborative environment. It is based on a body systems framework and covers a multitude of adult disorders and related issues, including barotrauma, rehabilitation, and domestic violence. Arranged alphabetically for easy reference, each disorder is discussed from a primary care perspective with the information and approach necessary to care for adult patients in a caring, cost-effective manner. This new edition also adds discussions of evidence-based practice and health promotion/illness prevention.

Redesigning health information systems in developing countries: the need for local flexibility and distributed control

H.C. Kimaro and others

Public Administration and Development, vol. 28, 2008, p. 18-29

Existing health information systems in developing countries usually do not work well, leading to inefficiency and hindering reform through decentralisation. There is a strong tendency for them to reflect the needs of central government, and they need to be redesigned to make them more locally relevant. Based on case studies of the health information systems of Tanzania and Ethiopia, the authors make practical recommendations about how this redesign can be achieved. They emphasise that in order for a health information system to work well, some degree of control over it should be delegated to the district administration level, including authority over budgets and use of resources.

Sustainability of the workforce: government policies and rural fit

A. Baumann and others

Health Policy, vol. 85, 2008, p. 372-379

The Canada Health Act stipulates that all residents should have equitable access to insured health care services without financial or other barriers. Service provision is, however, influenced by geographical and social factors, one of which is rurality. This study looked at perceptions of the applicability of Canadian health human resource policies to rural areas and found that rural institutions have difficulty accessing government funding intended to build sustainable workforces. Policies meant to be broadly implemented across jurisdictions may not fit the needs of rural institutions and their clients. In short, health policies do not take account of the needs of the rural minority.

Taking action, saving lives: our duties to protect environmental and public health

K. Shrader-Frechette

Oxford: OUP, 2007

Pollution kills hundreds of thousands of people annually. In the United States alone, industrial and agricultural toxins account for about 60,000 avoidable cancer deaths annually. Pollution-related health costs to Americans are similarly staggering: $13 billion a year from asthma, $351 billion from cardiovascular disease, and $240 billion from occupational disease and injury. Most troubling, children, the poor, and minorities bear the brunt of these health tragedies. The book reveals how politicians, campaign contributors, and lobbyists - and their power over media, advertising, and public relations - have conspired to cover up environmental disease and death. Yet this book puts the blame - and the solution - on the shoulders of ordinary citizens. It argues that everyone, especially in a democracy, has a duty to help prevent avoidable environmental deaths, to remain informed about, and involved in, public-health and environmental decision-making. To this end, it outlines specific, concrete ways in which people can contribute to life-saving reforms, many of them building on recommendations of the American Public Health Association.

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