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

Beyond legal coverage: assessing the performance of social health protection

X. Scheil-Adlung and F. Bonnet

International Social Security Review, vol.64, no.3, 2011, p. 21-38

Countries striving to improve their performance in social health protection with a view to achieving universal coverage currently receive little practical information on deficits that should be addressed in reforms. The most frequently used indicator of legal coverage remains meaningless if not embedded in a framework that reflects issues and challenges in more detail. This article suggests an approach that focuses on coverage in terms of effective access to health services. Measuring performance as regards effective access takes into account the dimensions of legislation, affordability/financial protection, availability and quality of services. Performance of social health protection systems is further reviewed on the basis of the vulnerability of countries in terms of poverty and the informality of labour markets.

Can interventions improve health services from informal providers in low and middle-income countries? A comprehensive review of the literature

N.M. Shah, W.R. Brieger and D.H. Peters

Health Policy and Planning, vol.26, 2011, p. 275-287

The widespread presence of informal private health service providers (a major source of primary care worldwide) presents an opportunity to expand access to quality care for populations in low- and middle-income countries. Interventions have been developed to take advantage of their potential to expand access to essential health services, but their success has not been well measured. This paper addresses the resulting information gap through a review of interventions designed to improve the quality, coverage or costs of health services provided by informal private providers in low- and middle-income countries. Of the strategies used to improve services offered by such providers, those that appeared most successful applied market-based incentives rather than using interventions aimed at building individual capacity.

Catastrophic and impoverishing effects of health expenditures: new evidence from the Western Balkans

C. Bredenkamp, M. Mendola and M. Gragnolati

Health Policy and Planning, vol.26, 2011, p. 349-356

This paper uses data from household surveys to examine the variation in out-of-pocket expenditures on health and their relationship to financial impoverishment in Albania, Bosnia and Herzegovina, Montenegro, Serbia and Kosovo. The analyses show that health expenditure contributes substantially to the impoverishment of households, increasing the incidence of poverty and pushing poor households into deeper poverty. Transportation expenditure accounts for a large share of total health spending, and contributes to impoverishment especially in Albania and Serbia. Informal payments are significant in all countries, and are particularly high in Albania. As these countries continue with radical health service reforms, they need to consider how to protect vulnerable groups from the impoverishing effects of health care expenditure.

Desperately seeking cancer drugs: explaining the emergence and outcomes of accelerated pharmaceutical regulation

C. Davis and J. Abraham

Sociology of Health and Illness, vol. 33, 2011, p. 731-747

Patients struggling desperately against state bureaucracies and regulations to gain rapid access to newly developed drugs to treat life-threatening illnesses have been a dominant narrative in many media depictions. Yet this narrative rarely pays sufficient attention to crucial sociological factors, such as the role of the drugs’ manufacturers, the nature of the state’s mechanisms for accelerating drug approval, and the sort of evidence available that drugs work. This article aims to improve on this narrative by explaining the emergence and implementation of accelerated drug approval regulations in the US. It is argued that the evolution of American government regulation of new drugs for life-threatening illnesses should not be understood as the behaviour of a state reluctant to deregulate market access in the face of patient demands, but rather as a consistent trend of deregulation to assist the pharmaceutical industry. Evidence is also presented explaining why regulatory outcomes of accelerated approvals are in the interests of drug firms, but may not be in the interests of patients, even when demands for such approvals from some patients are evident and influential.

Electronic prescriptions and disruptions to the jurisdiction of community pharmacists

A. Motulsky and others

Social Science and Medicine, vol. 73, 2011, p. 121-128

Electronic prescribing technologies allow physicians to transfer prescriptions to pharmacists using a computer-based tool. The technology makes it possible to combine the act of prescribing with a decision-support tool which proposes drug choices and consults the patient record to alert the professional to potential problems. The introduction of the technology brings about a redistribution of information between GPs and community pharmacists. The technology represents both a threat to community pharmacists – by supporting the dominant position of the physicians if it gives them access to information previously held exclusively by pharmacists – and an opportunity – by redistributing information to the pharmacists’ benefit, allowing them to improve the quality of their inferences about medication. However, interviews with medical professionals and pharmacists involved in a large scale e-prescribing project in Quebec showed that the opportunities offered by the technology generated concerns and tensions, both between physicians and pharmacists, and among pharmacists themselves.

Navigating the AIDS industry: being poor and positive in Tanzania

J. Boesten

Development and Change, vol. 42, 2011, p. 781-803

This article presents a case study of a community-based organisation set up in a roadside town in Tanzania in 2002 by HIV-positive people and their families. It focuses particularly on the strategies used by the leaders of the organisation to establish and maintain networks of care with external funding. It shows how the demands that the AIDS industry places on community-based organisations and individual HIV-positive people leads to conflict over access to resources and benefits. It is argued that the structure of the AIDS industry itself, which is based on principles of competition over resources and a strict distinction between well paid professionals and experts on the one hand, and volunteers and beneficiaries on the other hand, encourages people to exploit their health status to gain certain benefits. The AIDS industry encourages the establishment of community-based organisations rather than more formalised systems of care. Community-based organisations, however, are so poorly supported that they deploy self-destructive strategies which create tensions and even conflict among HIV-positive activists, the people they represent, and the wider community. Fulfilling the role of leader of a community-based AIDS organisation can become an occupation and a livelihood strategy, and money can be channelled to care for vulnerable people close to the family. Other care network beneficiaries generally comprise the poorest, unemployed people who come to resent the relative prosperity enjoyed by the leaders. Leaders can also maximise their cash flows by setting up multiple community-based organisations with similar objectives.

No cash, no care: how user fees endanger health: lessons learnt regarding financial barriers to healthcare services in Burundi, Sierra Leone, Democratic Republic of Congo, Chad, Haiti and Mali

F. Ponsar and others

International Health, vol.3, 2011, p. 91-100

User fees are a common feature of health system financing in resource-poor countries, particularly in Africa, but there is a growing consensus that they compromise healthcare utilisation and population health. Surveys conducted by Médécins sans Frontières between 2003 and 2006 show that user fees resulted in low use of public health facilities, exclusion from healthcare and exacerbation of impoverishment. Exemption systems for vulnerable individuals proved ineffective, benefiting only 1-3.5% of populations. Alternative payment systems requiring modest fees did not adequately improve access, especially for the poorest and most vulnerable. Conversely, user fee abolition for large population groups led to rapid increases in healthcare utilisation. Abolition of user fees appears crucial in helping to reduce existing barriers to healthcare.

The other crisis: the economics and financing of maternal, newborn and child health in Asia

I. Anderson, H. Axelson and B.-K. Tan

Health Policy and Planning, vol. 26, 2011, p. 288-297

Current healthcare financing systems in much of Asia are not well placed to respond to the needs of women and children or to the recent global financial and economic crisis of 2008/09. Public investment in healthcare is too low, and high levels of out-of-pocket expenditure on health services cause the impoverishment of women and children. The global financial crisis highlights the need for reforms that will improve health outcomes for the poor, protect the vulnerable from financial distress, improve public expenditure patterns and resource allocation decisions, and so strengthen health systems. Conditional cash transfers, increasing taxation on tobacco, and well designed investment programmes in health services are initiatives that can improve public health, protect the poor, and provide economic stimulus.

Price subsidies and the market for mosquito nets in developing countries: a study of Tanzania’s discount voucher scheme

C.D. Gingrich and others

Social Science and Medicine, vol. 73, 2011, p. 160-168

A primary weapon for the prevention of malaria in Sub-Saharan Africa is insecticide-treated mosquito nets (ITNs). This study uses a partial equilibrium model to explore how price subsidies for ITNs affect household purchases. In October 2004 Tanzania began offering subsidised ITN vouchers to pregnant women during their antenatal visits in selected regions. The programme operated on a national scale by May 2006. The research used data gathered from a nationally-representative household survey completed July-August 2006 to estimate the impact of the programme. The simulation results show that the proportion of target households purchasing an ITN rose from 18 to 62% because of the discount voucher. The model also suggests that the voucher programme could cause the retail price of ITNs to rise due to increased demand. As a result, ITN purchase by households without a voucher may decline. The model suggests that additional increases towards the goal of 80% ITN coverage for pregnant women and children could be achieved by a combination of mass distribution programmes and expanding the target group for the voucher programme to cover additional households.

Protecting the health of employees caring for family members with special health care needs

A. Earle and J. Heymann

Social Science and Medicine, vol. 73, 2011, p. 68-78

Currently, most individuals caring for an older relative and many parents whose children have special healthcare needs are also in paid employment. Care giving demands can have mental and physical health repercussions. Findings from this study suggest that universal access to paid sick leave and paid family and medical leave are needed to protect the health of working Americans caring for older relatives, disabled spouses, and children with chronic illnesses. Ensuring that care givers are healthy and financially secure has important economic implications. The value of unpaid labour caring for older people alone was estimated to be at least $375bn in 2007.

Resisting market-inspired reform in healthcare: the role of professional subcultures in medicine

P.E. Martinussen and J. Magnussen

Social Science and Medicine, vol.73, 2011, p. 193-200

A major hospital reform was implemented in Norway in 2002 which involved the introduction of practices imported from private business. This research examined whether there were systematic differences in how subgroups of hospital physicians responded to the reform. Specifically, the research explored whether assessments of the reforms differed between physicians with managerial responsibilities and those at the clinical level, as well as between those who were involved in direct patient care and those who were not. As expected, physicians with managerial responsibilities were more positive about the reforms than those who spent more time on direct patient care. Results demonstrated heterogeneity within the medical profession with some physicians adopting management values and tools while others remained alienated.

Understanding use of health services in conditional cash transfer programmes: insights from qualitative research in Latin America and Turkey

M. Adato, T. Roopnaraine and E. Becker

Social Science and Medicine, vol.72, 2011, p. 1921-1929

Conditional cash transfer (CCT) programmes provide grants to poor households conditional on their participation in primary healthcare services. While significant programme impacts have been demonstrated using quantitative methods, little attention has been paid to why CCTs make a difference, and why there effects are not greater than they are. This article draws on qualitative research from four countries between 1999 and 2009 to provide insights into why expected health and nutrition improvements do and do not occur. Results show that, although CCTs operate on the assumption that a cash incentive will produce behaviour change, there are multiple sociocultural and structural influences on healthcare decisions that compete with the payments. These include beliefs around traditional and modern medical practices, sociocultural norms, gender relations, and the daily experience of poverty.

What facilitates communication between people with little or no speech and general practitioners? A research project underway in Melbourne, Australia

L. Greenstock and B.Wickham

Journal of Assistive Technology, vol. 5, no.2, 2011, p. 83-87

The authors are part of a research team which is exploring the role of communication in healthcare and the consequences for patients with disabilities whose needs are not being met in this context. This article describes a project underway in Melbourne, Victoria which aims to identify the challenges for people with little or no speech in making contact and interacting with their GPs in accessing primary healthcare. It also aims to explore whether new technologies and broadband Internet have any potential to address these challenges.

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