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Welfare Reform on the Web (May 2011): Healthcare - overseas

Credit crunch health care: how economics can save our publicly funded health services

C. Donaldson

Bristol: Policy Press, 2011

The credit crunch is a threat to publicly-funded health care. This book defends NHS-type systems on the same basis as public service detractors: economic efficiency. However, protecting government funding of health care is not enough and the book goes on to show how we can get more out of our systems by addressing issues of value for money. This raises several practical and moral issues, such as: what have we achieved through continuous rounds of health care reform and is there any more that can be achieved?; how can we manage scarcity of health care resources through more systematic priority setting?: what value do we attach to life and health? The book explains how economics provides many of the answers to such questions.

Diffusion of medical technology: the role of financing

G. Cappellaro, S. Ghislandi and E. Anessi-Pessina

Health Policy, vol.100, 2011, p. 51-59

In the last decade, the pace of innovation in medical technology has accelerated, increasing the need to understand the real forces driving the diffusion of new medical technologies in clinical practice. This paper sought to isolate the impact of financing mechanisms on diffusion of a new medical device (coronary drug-eluting stents). The analysis was carried out in the Italian National Health Service, which provided enough variation of payment systems across regions to produce robust results.

The economics of choice: lessons from the US health-care market

Y. Hanoch and T. Rice

Health Expectations, vol.14, 2011, p. 105-112

The English healthcare system is moving towards increasing consumer choice. Driven by economic thinking, the English health authorities believe that offering more choice will improve quality, enhance patient satisfaction and reduce health inequalities. They also presume that patients will have access to the right information, be able to process it, and make sound decisions. This article points to some of the limitations of choice-based policies in healthcare revealed by experiences in the US. Experiences from the US highlight the difficulties older users of healthcare have when faced with a wide choice of prescription drug insurance plans. Older people appear to be overwhelmed by the number of choices available and fail to seek advice. Learning from the US experience could help the Department of Health identify areas where more patient choice could be beneficial and avoid those where it could be detrimental.

Expanding health insurance coverage in vulnerable groups: a systematic review of options

Q. Meng and others

Health Policy and Planning, vol. 26, 2011, p. 93-104

Health insurance coverage is limited in low- and middle-income countries, and strategies are needed for expanding it. This literature review summarises options available for expanding health insurance coverage, describes which countries have tried these strategies, and identifies evaluation studies. Low- and middle-income countries can learn from existing experience (especially that of the USA) how health insurance coverage can be expanded. Six main strategies are identified: changing eligibility criteria; increasing public awareness; making premiums affordable; innovative enrolment strategies; improving healthcare delivery; and improving insurance scheme management and organisation.

Expediency and coincidence in re-engineering a health system: an interpretive approach to the formation of family medicine in Iran.

A. Takian, A. Rashidian and M.J. Kabir

Health Policy and Planning, vol. 26, 2011, p. 163-173

The primary healthcare network in rural Iran was implemented from 1981 and led to a steady improvement in the health of the population. However the system was unable to respond to changing needs, including population ageing, the rising burden of chronic disease, migration to urban areas and public demand for access to doctors. At the same time the expansion of the private medical sector and the increased use of expensive technologies in routine healthcare created additional challenges for the system. Provision was also heavily reliant on out-of-pocket expenditure. The Iranian government responded through the introduction of two new policies: family medicine to improve the quality of services and Behbar (rural insurance for all) to enhance affordability. This study investigated the factors that led to the introduction of family medicine in Iran and the linkages between them, with particular emphasis on facilitators and barriers.

Fiscal decentralization in the Italian NHS: what happens to interregional redistribution?

C. Ferraro and A. Zanardi

Health Policy, vol.100, 2011, p. 71-80

Regional governments in Italy have been involved in the operation of its NHS since its establishment in 1978. As regards financing, over time central government transfers of funds to the regions have been replaced by revenues raised by the regions' own taxes. However, the central government remains responsible for an expenditure needs equalisation transfer scheme. It tops up regions' own revenues, which are highly differentiated and positively correlated with regional GDP, so that each region is able to finance a minimum level of expenditure. These expenditure standards are almost the same across regions. Central government fund transfers are more concentrated in the poorer regions of the South and thus produce a strong interregional redistribution. Currently, there are strong demands for further regional decentralisation, fuelled by central government spending cuts following the global financial crisis of 2008/09 and by allegations of waste of public money in some poor Southern regions. This may lead to further delegation of taxing powers to the regions and to a weakening of the central government's equalisation role. Based on some assumptions about the future NHS funding system and the role of central government in setting expenditure standards, this paper analyses how forecast changes may affect the degree of interregional redistribution of resources produced by the NHS.

Health care reform in the Netherlands: the fairest of all?

F. Schut and W. Van de Ven

Journal of Health Services Research and Policy, vol. 16, 2011, p. 3-4

The 2006 reform of the Dutch healthcare system introduced regulated competition between insurers within a universal mandatory private health insurance scheme. This editorial explores the question of whether the reform improved system performance or is gradually eroding equity and leading to cost inflation. There is no evidence as yet that the change has adversely affected equity of access to healthcare thanks to a sophisticated risk equalisation mechanism that protects insurers from losses due to an excess of high cost enrolees. Under the new system, health insurers have been effective in enforcing substantially lower prices for generic drugs, but they have had no influence on the quality of hospital services.

Health professionals, patients and chronic illness policy: a qualitative study

L. Yen and others

Health Expectations, vol. 14, 2011, p. 10-20

This paper explores the question of whether there are differences in the ways that health professionals and people with chronic illnesses see the problems and solutions on long-term ill health. Understanding any such differences might contribute to finding more effective policies that produce better outcomes for patients, more efficiently. Focus groups were undertaken with doctors, nurses, allied health staff and pharmacists in two Australian urban regions. The focus groups explored responses to patient experiences of chronic illness obtained in an earlier qualitative study. The results showed that professionals focused on their own resources and on the behaviour of other professionals to improve management of chronic illness. They did not factor information from patient experience into their views about system improvement. This inability to identify solutions beyond their professional sphere highlights the limitations of an over-reliance on the perspectives of health professionals. The views of patients and carers need to find a stronger voice in health policy development.

Health span or life span? The role of patient-reported outcomes in informing health policy

S. Chang and others

Health Policy, vol.100, 2011, p. 96-104

Population ageing and the increasing burden of chronic conditions challenge traditional metrics for assessing the efficacy of healthcare interventions and as a consequence policy and planning. Using chronic heart failure as an example, this study seeks to describe the importance of patient-reported outcomes (PRO) for informing policy decisions. Effective planning of healthcare services is dependent on knowing their impact on the individual and their family. Epidemiological transitions and evolving treatment paradigms challenge traditional metrics of morbidity and mortality, underscoring the importance of assessing PROs.

Independent regulatory agencies and Australia's health workforce crisis: lessons from the gynaecological cancers workforce

E. Willis and D. King

International Journal of Sociology and Social Policy, vol. 31, 2011, p.21-33

Workforce shortages in the healthcare sector arise as the result of poor planning processes, entrenched power relations, jurisdictional boundaries and professional silos. In seeking to address these problems countries are moving towards establishing independent regulatory agencies to monitor and shape the healthcare workforce. For example, Health Workforce Australia (HWA) was established in 2009 to gather data on workforce numbers and fund clinical education. This article uses the case of the gynaecological cancers workforce to illustrate the difficulties the HWA will face in defining the health workforce, in measuring supply and demand, and in setting targets for training and education.

Medical technology procurement in Europe: a cross-country comparison of current practice and policy

C. Sorenson and P. Kanavos

Health Policy, vol.100, 2011, p. 43-50

The adoption of new medical technologies across Europe can be variable, unpredictable and subject to disjointed policy initiatives. Procurement policies can influence the diffusion of medical devices into national health systems, but limited comparative evidence exists on how countries procure such technologies. This paper discusses the procurement of selected medical devices across five countries (England, France, Germany, Italy and Spain) based on a review of the published and grey literature and policy documents as well as expert interviews. All countries have introduced various regulatory or policy measures that influence device procurement, from lists of devices for purchase to changes in financing mechanisms. There has also been movement towards more centralised procurement with the introduction of purchasing groups or consortiums, notably in England, France, Germany and Italy. While a number of stakeholder groups are involved in purchasing activities, a greater, more formalised role is needed for physicians and governments to ensure that technologies procured best meet patient needs and align with national healthcare priorities.

The North American Free Trade Agreement (NAFTA) and Mexican nursing

A. Squires

Health Policy and Planning, vol. 26, 2011, p. 124-132

Trade agreements can facilitate an individual nurse's ability to migrate, contribute to a professional brain drain in sending countries, or provide critical restrictions on the number of nurses who can migrate annually. Canada, the United States and Mexico established the North American Free Trade Agreement (NAFTA) to eliminate trade barriers between the three countries. Using a case study design, this research explored the impact of NAFTA on the development of Mexican nursing. Results suggest that NAFTA provided incentives for the Mexican government to improve the quality of the professional institutions and infrastructure supporting the profession. It did not lead to the mass migration of nurses to the United States or Canada. At the same time, the peso crisis of 1995 slowed the implementation of planned advances. Subsequent neoliberal reforms decreased nurses' security as workers by minimising access to full time posts with benefits and reduced wages. This article discusses the linkages between these events and the effects on Mexican nurses and the development of the profession.

The price of global health

E. Schoonveld

Farnham: Gower, 2011

Global drug pricing is one of the most hotly debated yet least understood aspects of the pharmaceutical industry. How do drug companies set prices and what does it mean for patients? Why do governments increasingly get involved, and what is its impact on the global competitive environment? How can an industry that produces life saving drugs have a poor public reputation? The book explains how pharmaceutical prices are determined in a complex global player environment and what factors influence the process. Its insights will help a wide range of audiences from healthcare industry professionals to policy makers and the broader public to gain a better understanding of this highly complex and emotionally charged field. `It is a much needed and invaluable resource for anybody interested, involved in, or affected by, the development, funding and use of prescription drugs.

Rendering hospital budgets volume based and open ended to reduce waiting lists: does it work?

A. R. van de Vijsel, P.M. Engelfriet, and G.P. Westert

Health Policy, vol. 100, 2011, p. 60-70

Lasting long waiting times for hospital care are a policy concern in approximately half of all OECD countries, including the Netherlands. In order to increase hospital productivity and reduce waiting times, fixed global budgets for Dutch hospitals were replaced by budgets that were to a large degree volume based and open ended in 2001. This study investigated the effectiveness of the policy measure through a statistical analysis of trends in Dutch hospital admissions rates. The results showed that hospital admissions rates had increased by over 3% a year since the reform of 2001, but this included admissions for a broad range of diagnostic categories not originally subject to long waiting lists. It is concluded that abolishing budget caps to reduce waiting lists is not efficient. Instead of a generic measure, a more focused approach is needed.

Robots and service innovation in health care

E. Oborn, M. Barrett and A. Darzi

Journal of Health Services Research and Policy, vol. 16, 2011, p. 46-50

This paper starts by reviewing and critiquing the healthcare robotic literature. It then argues for an increased emphasis on the sociological dimension of robots to improve understanding of how social and work relationships might be restructured through the use of robotics to deliver healthcare. It is suggested that a 'services logic' approach may be helpful, in which health services are seen as essentially social entities that deploy technologies such as robots. Robots can simultaneously reconfigure services and influence their scope and ability to add value.

The role of supplemental coverage in a universal health insurance system: some Canadian evidence

R.A. Devlin, S. Sarma and Q. Zhang

Health Policy, vol. 100, 2011, p. 81-90

The Canadian Medicare system covers the cost of all physician and hospital services, but the public insurer does not cover the cost of prescription drugs outside of hospital settings for the general population. This article investigates how supplemental private insurance for prescription drug coverage affects demand for physician services in the context of a universal (but incomplete) public health insurance system. It looks at how prescription drug supplemental insurance affects physician visits when the latter are publicly funded. Results produced using a latent-class modelling technique show that insurance has a heterogeneous impact on individuals depending on whether they are high or low users of services. It is suggested that high users are individuals with conditions that require constant attention irrespective of insurance, while low users are those who are more inclined to seek treatment when the price is low enough (i.e. they carry insurance).

Social justice through health care financing: the birth and signalling of a new nonprofit field

R. Abzug and M. Sabrin

Nonprofit and Voluntary Sector Quarterly, vol. 40, 2011, p. 377-388

Over the past 15 years, a new model has developed to address some of the gaps in US healthcare coverage. Volunteers in Medicine organisations have arisen to provide free or low-cost healthcare to the uninsured, underinsured and/or the medically underserved, primarily using the services of retired medical and dental practitioners within a 'culture of caring'. This article analyses the founding and signalling patterns of this offshoot of the free clinic movement in an effort to understand how (and to what extent) new organisational structures are formed and franchised.

Social protection for women homeworkers: a case of healthcare services in Thailand

B. Namsomboon and K. Kusakabe

International Journal of Sociology and Social Policy, vol. 31, 2011, p. 123-136

Thailand introduced universal healthcare services in 2002. This study explores whether, and how, poor women homeworkers can access these services. Homeworkers work at home, isolated from other workers, with irregular but long hours and low wages. Data were gathered from 415 women homeworkers in 16 districts in Bangkok through a structured questionnaire, ten in-depth interviews, and 13 group discussions. Results showed that less than half of the participants accessed the universal healthcare scheme. Barriers included transport costs, loss of wages, and lack of time. Universal healthcare service availability in itself is not sufficient to ensure access to care, especially among poor and minimally educated homeworkers with small children.

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