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Welfare Reform on the Web (December 2010): Healthcare - overseas

Acceptability of community pharmaceutical care in Portugal: a qualitative study

M. Guerreiro, J. Cantrill and P. Martins

Journal of Health Services Research and Policy, vol.15, 2010, p. 215-222

Driven mainly by a professional body, Portuguese community pharmacists have implemented services to respond to unmet patient needs, particularly for drug therapy monitoring and management for patients with chronic conditions. This study used semi-structured telephone interviews to explore the acceptability to users of pharmaceutical care programmes provided in Portuguese community pharmacies. It is concluded that acceptability to patients is mainly determined by perceptions of convenient access and the development of a therapeutic relationship with the pharmacist. Patients' expectations concerning the service are not well developed, but not necessarily low.

An assessment of the implementation of the Health Care Funds for the Poor policy in rural Vietnam

N.X. Thanh and others

Health Policy, vol. 98, 2010, p. 58-64

User fees and other out-of-pocket payments for healthcare place a financial burden on some poor and near-poor households in Vietnam. In order to remove financial barriers to access to public hospitals, the Vietnamese government introduced the Health Care Funds for the Poor (HCFP) programme in each province in 2002. Provinces can allocate HCFP resources to direct reimbursement of healthcare costs to eligible households, or to the purchase of health insurance cards. This paper is an assessment of the impact of the HCFP programme in a rural district of Vietnam. The results show that the scheme was successful in reducing health care expenditure as a percentage of total expenditure and increased the use of local public healthcare among the poor.

Eliminating cataract blindness: how do we apply lessons from Asia to sub-Saharan Africa?

S. Lewallan and R.D. Thulasiraj

Global Public Health, vol.5, 2010, p. 639-648

The Vision 2020 initiative aims to eliminate avoidable blindness, including cataract, by the year 2020. In India, the Aravind Eye Care System demonstrates how high quality care, including cataract surgery, can be delivered to large numbers and made affordable to all. The key to Aravind's financial success is its 'tiered' pricing system. Patients themselves can choose to pay extra for amenities such as more luxurious rooms or better food. Everyone receives the same high quality surgery, and the hospital subsidises surgery for the poor out of the fees paid by the better off. Similar financially self-supporting systems have not been developed in sub-Saharan Africa. This paper explores the features that lead to success at Aravind, and compares and contrasts the conditions in India with those in sub-Saharan Africa.

Evidence-based dialogue with communities for district health systems' performance improvement

D. Kaseje and others

Global Public Health, vol. 5, 2010, p. 595-610

This paper presents a model for health systems performance improvement in a resource constrained setting that was developed by the authors and tested in Nyanza Province in Kenya. The model involves engaging both healthcare providers and the communities served in an iterative process of dialogue based on available data aimed at improving service delivery and outcomes. Implementation led to improvements in governance and management of the health system, and in service delivery and health outcomes in terms of immunisation coverage, usage of insecticide treated nets, and utilisation of skilled attendance at childbirth. Based on these encouraging results, the Kenyan Ministry of Health adopted the model as a strategy for the implementation of the Kenya Essential Package for Health countrywide.

Germany's struggle with prices for patent-protected drugs

M. Kifmann and S. Neelsen

CESifo DICE Report, 3/2010, p. 43-52

Patent-protected drugs have been the main driver of the steep increase in spending on pharmaceuticals by German statutory health insurance funds in recent years. To control costs, legislators have taken a variety of direct and indirect measures to regulate patent-protected drug prices. These regulations have attempted to side step the principle, still upheld in Germany, of free price setting by drug companies and reimbursement of the full cost of these drugs to the manufacturers by sickness funds. In 2010 a new government proposed a radical change in policy. It practically eliminates the right of manufacturers to set patent-protected drug prices freely, as they will be forced to offer sickness funds a rebate on their list price. If the two parties do not reach a timely rebate agreement, an arbitration committee will set a binding price with reference to prices in other European countries.

Health and poverty: global health problems and solutions

G. Walraven London: Earthscan, 2011

There is growing interest and concern about the unacceptable differentials in health between and within countries. This comes out of the realisation that poor people will only be able to prosper, and emerge from poverty, if they enjoy better health. Healthy populations are a precondition for sustainable development. Using a novel combination of personal studies of patients and descriptions of conditions or diseases, this book provides a highly original and accessible introduction to key issues in global health today. Especially during the past decade, global health initiatives have become a prominent part of the international aid picture, bringing new resources, political commitment, and more attention for international health issues in the media. The author provides examples of diseases and problems related to health that disproportionally impact on the poor, and gives their experiences a human face through individual case studies. A specific case study of a health problem, such as malaria, tuberculosis and HIV or health financing, introduces each chapter and is followed by a historical review of the problem, why it is still a problem now for poor people or poor countries, and what can be done about it.

Health information systems, decentralisation, and democratic accountability

S. Madon, S. Krishna and E. Michael

Public Administration and Development, vol. 30, 2010, p. 247-260

Decentralisation is considered to be an important element of health policy aimed at devolving power to local officials who understand the needs and priorities of citizens. In the context of primary healthcare in developing countries, health information systems (HIS) have been directed at administrative decentralisation, with their primary function being to produce monthly reports to account for monies spent to higher levels of administration and funding bodies. The primary healthcare system has not focused on the issue of improving accountability to citizens regarding its activities. The authors' research in Karnataka, India, however, identifies emergent processes of change which have been initiated by the government providing an opportunity to strengthen links between primary healthcare and the community. It is argued that HIS can play a pivotal role in supporting these processes.

Hospital competition and patient-perceived quality of care: evidence from a single-payer system in Taiwan

C.-C. Chen and S.-H. Cheng

Health Policy, Vol.98, 2010, p. 65-73

This study aims to examine the effects of market competition among hospitals on patients' perceived quality of care under a universal health insurance scheme in Taiwan. Results showed that competition was positively associated with the perceived quality of care in terms of both staff interpersonal skills and clinical competence. Since healthcare prices are highly regulated under the National Health Insurance programme, it is difficult for hospitals to initiate price competition. As long as the regulated price is set above the marginal cost, hospitals will increase quality to compete for market share.

Inequity in a market-based health system: evidence from Canada's dental sector

M. Grignon and others

Health Policy, vol.98, 2010, p. 81-90

This study explores the extent and drivers of income-related inequity in utilisation of dental services in Canada using the concentration-index approach. Dental care in Canada is almost entirely privately funded and shows a high level of income-related inequity (the rich use more dental services). The level of inequity is highest for preventive services (more than one check-up per year) and higher use of preventive services correlates with better oral health.

Knowledge, legitimacy and economic practice in informal markets for medicine: a critical review of research

J. Cross and H.N. MacGregor

Social Science and Medicine, vol. 71, 2010, p. 1593-1600

The question of what to do about the problems caused by dangerous practices among informal providers of healthcare in Asia and Africa is an immediate and pressing concern for policymakers and researchers. This critical review of current research seeks to encourage reflection on the underlying assumptions of the studies, their classificatory schemas, and the kinds of evidence being used to design regulatory interventions. In particular it is argued that current research around informal providers and the design of interventions to regulate them has overlooked and underemphasised the role of the pharmaceutical supply chain and the responsibility of multinational drug companies for the safety of medicines.

Physician resource planning in Canada: the need for a stronger behavioural foundation

S.-H. Jeon and J. Hurley

Canadian Public Policy, vol. 36, 2010, p. 359-375 Since the 1990s Canadians have reported increased difficulty in accessing physician care. This is widely perceived to be due to a shortage of physicians which arose during the 1990s. However, analysis shows that physician supply did not fall dramatically at that time. It is therefore necessary to consider the behaviour of physicians in greater depth. The amount of labour supplied by physicians depends on their attitude to work, on practice and non-practice income opportunities and on the policy environment. Hence, the amount of labour supplied by a given stock of physicians can change over time.

A policy case study of blood in Australia

N. Graves and others

Social Science and Medicine, vol. 71, 2010, p. 1677-1682

This article examines a decision made by Australian governments in 2008 to fund the Australian Red Cross Blood Service to remove white blood cells from all blood components. This policy may improve blood safety but is costly in health resources. The authors conduct an economic analysis to determine whether universal leucodepletion was cost effective. Other factors that impact on decision-making are explored and conclusions are drawn about the policy process.

Pope edges away from total ban on use of condoms

J. Hooper

The Guardian, Nov. 22nd 2010, p. 6

A spokesman for the United Nations' joint programme on HIV/AIDS hailed the comments made by Pope Benedict XVI to the effect that condoms were acceptable in certain circumstances, for example to prevent the spread of the HIV virus, as a positive step forward. He added that the move recognises that responsible sexual behaviour and the use of condoms have very important roles to play in HIV prevention.

Privatization within the Dutch context: a comparison of the health insurance systems of the Netherlands and the United States

P.S.D. Naderi and B.D. Meier

Health, vol.14, 2010, p. 603-618

In 2006, the Netherlands passed the Health Insurance Act requiring all legal residents to obtain health insurance from private for-profit companies instead of social insurers. The reform created a health insurance system guaranteed to all citizens regardless of income or labour force status, but with a market orientation that made private companies the sole providers of health insurance. This article employs a comparative case study method to compare the 2006 privatisation of the Dutch insurance system with the current American regime characterised by voluntary coverage by private insurers. Although the 2006 Dutch reforms privatised the provision of health insurance, they also stipulate mandatory universal coverage, government subsidisation of the costs for low-income households and families with children and a high level of State regulation, all of which are absent from the American system.

Risk equalisation in voluntary health insurance markets

J. Armstrong, F. Paolucci and W.P.M.M. van de Ven (editors) Health Policy, vol.98, 2010, p. 1-49

Since the 1990s many countries have reformed their competitive (voluntary and mandatory) health insurance markets to increase affordability and achieve risk solidarity between different risk groups while encouraging efficiency. In part this meant encouraging competition based on efficiency and discouraging insurers from engaging in risk selection. The first three articles in this themed section present case studies on risk equalisation and cost equalisation in three countries with competitive markets for voluntary health insurance, Australia, Ireland and South Africa. A fourth article focuses on a comparison of the countries.

To leave or to lie? Are concerns about a shift-work mentality and eroding professionalism as a result of duty-hour rules justified?

J.E. Szymczak and others

Milbank Quarterly, vol.88, 2010, p. 350-381

In response to growing public concern about the impact of sleep deprivation on patient safety, the Accreditation Council for Graduate Medical Education developed new duty-hour rules for junior hospital doctors in training in the US. In 2003 a national limit of 80 hours per week was set on the hours that they could work, averaged over four weeks. There has been concern that the duty-hour rules have had the unintended consequence of encouraging a 'shift work' mentality among trainee doctors and eroded their professionalism by forcing them to either abandon their patients when they have worked for 80 hours or lie about the number of hours worked. This qualitative study explores how medical and surgical trainees perceive and respond to the duty-hour rules by examining the local organisational culture in which their work is embedded. It is concluded that concerns about the duty-hour rules and the erosion of medical professionalism resulting from the development of a 'shift work' mentality have probably been overstated. The influence of the duty-hour rules on professionalism is more complex than the conventional wisdom suggests and requires additional assessment.

US health care reform: a primer and an assessment

R. Haveman and B. Wolfe

CESifo DICE Report, 3/2010, p. 53-60

The Patient Protection and Affordable Care Act was signed into law by President Obama on 23rd March 2010. This new law will have a profound effect on all aspects of the US healthcare system. In this paper the authors attempt to convey the existing structure of the US healthcare system, to identify its major weaknesses, to describe the primary new features introduce by the Act, and to offer an overall appraisal of the reforms. The main focus of the reform is to increase health insurance coverage and improve access to healthcare for citizens and legal immigrants. People with low to moderate incomes will receive government subsidies to enable them to acquire health insurance. A network of Health Insurance Exchanges will be established through which private insurers will be required to offer four standard plans. Premiums for these plans will differ only by age.

Vouchers for health: a demand side output-based aid approach to reproductive health services in Kenya

C.P. Janisch and others

Global Public Health, vol.5, 2010, p. 578-594 Kenya launched the innovative Vouchers for Health scheme in five districts in 2006 to improve access to reproductive health services for poor women. Clients purchase a heavily subsidised voucher and are given a list of facilities where the voucher can be exchanged for care. It is assumed that the women will make an informed choice of facility based on perceptions of care quality. Accredited health service providers are reimbursed on the basis of services actually delivered to voucher holders. In this way the voucher programme targets a specific population (poor women of reproductive age) and subsidises only those facilities actually delivering services of the required standard.

Who's that sleeping in my bed? Potential and actual utilization of public and private in-patient beds in Irish acute hospitals

J. O'Reilly and M. Wiley

Journal of Health Services Research and Policy, vol.15, 2010, p. 210-214 In Ireland, both public and private patients can be treated in acute public hospitals by the same consultant. There is universal, though not necessarily free at the point of use, entitlement to a public bed in a public hospital. There is a quota, set at 20% nationally, for the number of beds designated for private patients in public hospitals. Legislation restricts accommodation of a private patient in a public bed to emergency cases when a private bed is unavailable. This study shows that some hospitals have been able to side step these restrictions. It is not clear whether this excess of private practice in public hospitals reflects a more efficient use of resources (when demand from public patients is low) or the displacement of public patients in favour of private patients.

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