Welfare Reform on the Web (June 2009): Healthcare - overseas

The bioethical underpinnings of advance directives

Y.M. Johnson

Ethics and Social Welfare, vol. 3, 2009, p. 32-53

Advance directives are legally protected instructions on health care. An advance directive, executed when an adult is mentally competent, becomes active in the event of his or her mental capacity to make decisions about healthcare being lost. Advance directives are underpinned by complex philosophical theories and concepts such as self-determination, the idea of a good death, and the ethics of care. Using the situation in the United States as a case study, this article discusses bioethics as it relates to advance directives.

Community development as health promotion: evaluating a complex locality-based project in New Zealand

J. Adams, K. Witten and K. Conway

Community Development Journal, vol. 44, 2009, p. 140-157

Since the early 1990s health policy in New Zealand has recognised that reducing health inequalities will require action on the social, economic and cultural determinants of health. The Ranui Action Project used a community development approach to address the social determinants of health inequalities in a high-need, ethnically diverse urban locality. The rationale of the project was emerging evidence in the public health literature of the significance of working intersectorally to build social capital and social cohesion to improve population health at the neighbourhood level.

DRG-based market orientation and integrated healthcare in Austria: developing an effective product portfolio

V. Hoss, M. Thoni and R. Staudinger

International Journal of Behavioural and Healthcare Research, vol. 1, 2009, p. 143-159

Performance-oriented hospital financing was introduced in Austria in the late 1990s to control costs and is a prospective payment system based on Diagnosis-Related Groups (DRGs). A system of integrated healthcare is also being introduced and is intended to comprise a kind of patient 'throughput system' which will ensure that prophylaxis, diagnosis, therapy, rehabilitation and nursing are provided in the right order, by the right unit, in a reasonable timescale and with maximum benefit to the patient. In order to achieve this goal, particular emphasis is placed on organising the healthcare system as a network in order to promote co-operation between hospital and community services. This article focuses on the synergies that arise from the combination of the two policy instruments.

Economic incentives in general practice: the impact of pay-for-participation and pay-for-compliance programs on diabetes care

M.L. Bruni, L. Nobilio and C. Ugolini

Health Policy, vol. 90, 2009, p. 140-148

The design of incentive schemes for improving quality of care is a central issue for health services. This article investigates the impact on quality of care of the introduction of two financial incentive schemes for primary care physicians in Emilia Romagna, Italy: pay-for-participation programmes, and pay-for-compliance with best practice programmes. It focuses on a scheme which rewards general practitioners for assumption of responsibility for patients with Type 2 Diabetes (pay-for-participation) and for adherence to regional clinical guidelines (pay-for-compliance). Results suggest that higher shares of GPs' income received through these programmes significantly reduce the probability of hyperglycaemic emergencies in their patients.

The effect of community-based health insurance on the utilization of modern health care services: evidence from Burkina Faso

D.P. Gnawali and others

Health Policy, vol. 90, 2009, p. 214-222

This paper reports results from an evaluation of the impact of community-based health insurance on health service utilisation in rural Burkina Faso, where out-of-pocket expenditure is more than 50% of total healthcare expenditure, and the household average healthcare financial burden is about6.5% of total household cash income. Between 6% and 15% of households face catastrophic health expenditure. Results showed the overall effect of CBI on healthcare utilisation to be significant and positive, but the benefit of CBI was not enjoyed equally by all socioeconomic groups. There is a need to subsidise the premium to encourage the enrolment of the very poor, and various measures need to be put in place to maximise the population's capacity to enjoy the benefits of insurance once insured, such as help with travel costs for visiting healthcare facilities.

Equity in community health insurance schemes: evidence and lessons from Armenia

J. Polonsky and others

Health Policy and Planning, vol. 24, 2009, p. 209-216

Research shows that the poorest members of society often fail to benefit from healthcare and social welfare programmes. As a result there is increasing recognition of the need to evaluate equity. This applies to community health insurance schemes which are becoming an increasingly important healthcare financing mechanism in low-income countries. This paper describes the findings of an evaluation of Oxfam's community health insurance schemes in rural Armenia. Results show that the schemes are achieving their primary goal of equitable coverage of healthcare for the target population. Women, the elderly and the poorest benefit most from joining the schemes. Importantly, membership is improving overall utilisation, indicating an improved quality of care.

Genetics on stage: public engagement in health policy development on preimplantation genetic diagnosis

S.M. Cox, M. Kazubowski-Houston and J. Nisker

Social Science and Medicine, vol. 68, 2009, p. 1472-1480

Arts-based approaches to public engagement offer unique advantages over traditional methods of consultation. This article describes and assesses the use of theatre as a method of public engagement in the development of health policy on pre-implantation genetic diagnosis, a controversial method for selecting the genetic characteristics of embryos created through in vitro fertilisation. The exercise involved 16 performances of the play Orchids in three Canadian cities in 2005 and used various methods the engage the audience in policy-related dialogue.

The global health care chain: from the Pacific to the World

J. Connell

Abingdon: Routledge, 2009

For more than a quarter of a century there has been significant international migration of skilled health workers, but in the last decades, with critical changes in both sending and receiving countries, few parts of the world are now unaffected by the consequences of the migration of health workers, either as sources, destinations or sometimes both. The book takes the understanding of health worker migration substantially beyond the more scattered and fragmented papers and anecdotes that largely existed before, into the first consolidated analysis. In doing so it reveals its exceptional significance for both sending and receiving countries (in economic, social and political terms), provides the only analysis of remittances of health workers, casts new light on gender, globalisation, transnational linkages, the trade in services (linked to GATS) and the overall relationship between migration and development, and reviews practical responses and solutions.

Governing decentralization in health care under tough budget constraint: what can we learn from the Italian experience?

F. Tediosi, S. Gabriele and F. Longo

Health Policy, vol.90, 2009, p. 303-312

This article reviews the recent experience of the Italian National Health Service (Servizio Sanitario Nazionale, SSN) where responsibilities have been devolved to the regions. Decentralisation has raised two questions which are examined in this article: 1) what sort of regulatory framework and institutional balances are required to govern a decentralised health system in heterogeneous country under tough budget constraints? ; and 2) how can policymakers ensure that the more advanced regions remain committed to solidarity and support the weaker ones? The main lessons emerging from the research are:

• When the differences in administrative and policy skills, social capital and socio-economic standards are wide, decentralisation may lead to undesirable divergent development paths
• Even in decentralised systems, the role of central government in containing health expenditure can be very important
• Strong central regulation may help and not hinder decentralisation by supporting the weakest regions
• Supporting the weakest regions while maintaining inter-regional solidarity is hard but possible

Implementation of a patient safety incident management system as viewed by doctors, nurses and allied health professionals

J.F. Travaglia, M.T. Westbrook and J. Braithwaite

Health, vol.13, 2009, p. 277-296

Incident reporting systems have become a central mechanism in most health service patient safety strategies. In this article the authors compare health professionals' anonymous, free-text responses in an evaluation of a newly implemented electronic incident management system in New South Wales, Australia. The research revealed inter-professional differences in reaction to the new system which may constrain inter-disciplinary co-operation and communication.

Improving Japan's health care system

N. Henke, S. Kadonaga and L. Kanzler

McKinsey Quarterly, 2009, p. 54-63

Japan's healthcare system has come under severe stress and its sustainability is in question. The country needs to control rising and unsustainable demand for health care, find a way to allocate medical resources to the places where they are actually needed, and rein in spiralling costs, without damaging the quality of care.

The medical practice of euthanasia in Belgium and the Netherlands: legal notification, control and evaluation procedures

T. Smets and others

Health Policy, vol. 90, 2009, p.181-187

A particular concern when any country legalises euthanasia or physician-assisted suicide is how to ensure that the practice is monitored and controlled to prevent abuse. Currently only the Netherlands and Belgium have officially legalised euthanasia and physician-assisted suicide. Both countries have devised monitoring systems to control the practice and have established both substantive and procedural safeguards against abuse in their euthanasia law. This article systematically studies and compares Belgian and Dutch official documents relating to the procedures for the notification, control and evaluation of euthanasia.

The moralizing of obesity: a new name for an old sin?

L. Townend

Critical Social Policy, vol. 29, 2009, p. 171-190

In Western industrialised nations the obesity epidemic impacts the population along traditional lines of economic disadvantage, its incidence being inversely related to income and education. In this study evidence is presented of a long tradition of associating illness and poverty with moral shortcomings in their victims. The presence of a moralised understanding of obesity in Australia is then demonstrated through an analysis of its representation in local media since 2005, with particular reference to the reporting of politicians. It is further suggested that this trajectory magnifies the likelihood that policy will address the moral failures of the obese, instead of tackling the structures which create ill health and poverty.

[Obesity]

B.H. Gray (editor)

Milbank Quarterly, vol. 87, 2009, p. 1-316

This special issue is devoted to obesity as a public policy problem. Obesity has reached crisis levels in the USA due to its spread across the population, its contribution to morbidity and mortality rates, and its impact on healthcare costs. The articles focus on both public and private policy options for addressing high rates of obesity. They present new empirical studies, policy history, overviews of developments in particular areas such as schools, workplaces and the built environment, and analyses of different legal strategies and policy approaches.

Organizational elements of health service related th a reduction in maternal mortality: the cases of Chile and Colombia

M. Ruiz-Rodriguez, V.J. Wirtz and G. Nigenda

Health Policy, vol. 90, 2009, p. 149-155

Both Colombia and Chile implemented structural reforms of their health services in the second half of the twentieth century. These changes included the creation of a National Health System in Colombia in 1968-75 and a National Health Service in Chile in 1952-72. Both systems adopted a systematic, centralised approach complemented by satellite assistance systems, redefined the roles of the public and private sectors and used market-oriented service delivery policies. Despite these similarities the two systems performed quite differently in relation to reducing maternal mortality rates, with Colombia lagging behind Chile.

Overcoming social and health inequalities among US women of reproductive age: challenges to the nation's health in the 21st century

S.H. Ebrahim and others

Health Policy, vol. 90, 2009, p. 196-205

The overall health of Americans compares unfavourably to that of people living in other countries with established market economies. Improvement in some health indicators appears to have stalled over the past five years, especially in the areas of women's health, maternal mortality and infant morbidity and mortality. Improving maternal and child health in the US will require action to tackle the social determinants of ill health such as poverty and inequality, promotion of healthy lifestyles, and reduction of the barriers to healthcare access.

Price control as a strategy for pharmaceutical cost containment: what has been achieved in Norway in the period 1994-2004?

H. Hakonsen, A.M. Horn and E.-L. Toverud

Health Policy, vol. 90, 2009, p. 277-285

Despite having a tradition of strict regulation of medicines, the Norwegian authorities have, during the last two decades, intensified their fight against increasing pharmaceutical costs with an emphasis on pricing systems. Direct price control is applied to all prescription drugs with marketing authorisation while indirect pricing methods are being tested for the off-patent market. The direct pricing strategy, ie international reference pricing, introduced in 2000 was regarded as the most successful policy because it led to considerable and predictable price reductions. In contrast, because of unpredictable market mechanisms such as delivery failure, asymmetric information, and counteractive behaviour, the effects of the indirect pricing strategies, eg reference pricing (1993-2000), generic substitution (2001 onwards), and index pricing (2003-2004) have been more limited.

Privatisation of health care in Slovenia in the period 1992-2008

T. Albreht and N. Klazinga

Health Policy, vol. 90, 2009, p. 262-269

Following the fall of Communism, privatisation was seen as a magic cure for the ills of the state healthcare system in Slovenia. This paper explores the privatisation process, covering its background, nature, extent and facilitating and inhibiting factors. Privatisation of healthcare in Slovenia has been a gradual process. In 2008, 30% of primary care, 60% of dentistry, and about 20% of specialist outpatient services were delivered by private practitioners. Privatisation of hospitals has been limited and there has not been significant private investment in the health infrastructure. Private health insurance (including insurance to cover co-payments) has expanded and now accounts for 15% of total health expenditure, while out-of-pocket payments have also increased. They now make up 12% of total health spending.

Public health nurses' contribution to maternal and infant health in Ireland

P. O'Dwyer

Community Practitioner, vol. 82, May 2009, p. 24-27

Health services in Ireland are being reoriented towards community-based care and the promotion of population health. Public health nurses have an important contribution to make to reducing health inequalities among one vulnerable population group, mothers and infants. They have early access to this entire population and deliver a service of preventative healthcare that begins in the post natal period.

Strategies for gender-equitable HIV services in rural India

G. Sinha, D.H. Peters and R.C. Bollinger

Health Policy and Planning, vol. 24, 2009, p. 197-208

With over 2.5 million estimated cases, India has one of the highest numbers of HIV-infected individuals in the world. Approximately 60% of India's HIV cases occur in rural residents, with 40% of cases occurring in women. In rural India, there are currently substantial gender differences in access to HIV testing and care services and associated clinical and socio-economic outcomes. As HIV- and gender-related health policies emerge for rural India, strategies including gender-specific rural HIV services for patients, gender-sensitivity and HIV skills training for healthcare providers and institutional partnerships and oversight methods should be implemented and assessed for gender equity.

Three imperatives for improving US health care

P.D. Mango and V.E. Riefberg

McKinsey Quarterly, 2009, p. 40-53

Making healthcare more affordable is the key to making the US system sustainable. This article explains how three of the largest sources of cost growth can be brought under control. The public and private sectors should collaborate to tackle three underlying problems: 1) the rising incidence of lifestyle- and behaviour-induced diseases, such as obesity; 2) the economic distortions that now tend to prevent consumers and providers from making value-conscious decisions; and 3) the system's wasteful and unnecessary administrative complexity.

Performance-based payment: some reflections on the discourse, evidence and unanswered questions

C. Eldridge and N. Palmer

Health Policy and Planning, vol. 24, 2009, p. 160-166

Performance-based payment is increasingly advocated as a way to improve the performance of health systems in low-income countries. This systematic review of the literature on the subject found that there is little consensus on its meaning or use. The literature would be strengthened by multi-disciplinary case studies that present both the advantages and disadvantages of performance-based payment, factors that influence success, and more detail about the projects from which the evidence is drawn. The paper suggests that more research is required on the appropriateness of transferring performance-based payment schemes to less developed countries, and on problems associated with how performance is defined and measured.

Traditional Chinese medicine in the Chinese health care system

J. Xu and Y. Yang

Health Policy, vol. 90, 2009, p. 133-139

This study examines the role of traditional Chinese medicine in the current healthcare system in China. It shows that traditional Chinese medicine is well integrated into the healthcare system alongside Western medicine. However, it faces a number of challenges:

1. its theories and methods are not confirmed as valid by modern science
2. following the successful economic reforms of the past 30 years, Western medicine has become popular with the Chinese people
3. due to cultural change, some traditional knowledge has been lost
4. traditional medicine generates lower profits for hospitals than Western practice
5. there is concern about the integrated practice of traditional Chinese and Western medicine because they are based on different philosophies.

In response to these challenges the Chinese government is putting a lot of effort into supporting and expanding the role of traditional medicine in the healthcare system.

What drives health policy formulation: insights from the Nepal maternity incentives scheme?

T. Ensor, S. Clapham and D.P. Prasai

Health Policy, vol. 90, 2009, p. 247-253

It is generally thought that high financial cost is a major barrier to utilisation of delivery care, particularly in remote areas of Nepal. To measure the importance of this barrier, and to inform the national skilled attendance strategy that was being developed by the Ministry of Health and Population, the Nepal Safer Motherhood Project commissioned a study on the financial implications of skilled attendance at delivery. Following the publication of the study, policy interest in the area moved swiftly. Skilled birth attendance became a major issue in 2001, the research on financing was commissioned in 2003, and a policy was implemented across the country in 2005. This paper analyses why the results of research in this case influenced policy so quickly. Credible research, supported by clear dissemination by respected project staff already close to government helped to prepare the ground. The policy was also seized on by a flagging government as a way of improving its fortunes and increasing its popularity.

Why Americans pay more for health care

D. Farrell, B. Kocher and E.S. Jensen

McKinsey Quarterly, 2009, p. 28-38

Research indicates that the USA spends $650bn more on healthcare than might be expected given the country's wealth and the experience of comparable members of the OECD. Analysis shows that the higher than expected spending is due to rising costs of outpatient care, sky high drug prices, and inefficient healthcare administration due to the country's fragmented health insurance system.

Why financial incentives did not reach the poor tuberculosis patients? A qualitative study of a Fidelis funded project in Shanxi, China

X. Wei and others

Health Policy, vol. 90, 2009, p. 206-213

The Fidelis project implemented in Shanxi Province aimed to promote TB case detection and maintain high cure rates by offering financial incentives to both patients and providers. A quantitative study of the impact of the project showed that it had largely failed to produce the intended improvements in the diagnosis and treatment of TB. This qualitative study investigated the reasons for project failure. It found that the project failed because:

1. patients regarded the financial help it offered with travel to the regional TB dispensary as inadequate
2. village doctors did not receive any financial rewards for referral and supervision of patients beyond those already existing.