Welfare Reform on the Web (January 2012): Healthcare - overseas

Budgetary performance diversity among Israeli governmental hospitals: management qualifications or possible budget allocation inequity?

U. Gabbay and Y. Berlovitz

Journal of Management and Marketing in Healthcare, vol.4, 2011, p. 217-228

The Israeli Ministry of Health funds hospitals through a global budgeting system. The expenditure budget covers hospital operational costs and equipment depreciation. Budgets are set annually on the basis of historical allocations. Some hospitals exhibit consistent excellent budgetary performance while others perform poorly every year. This research developed a method to indicate whether this diversity in hospitals’ budgetary performance was due (at least partially) to budget allocation inequity rather than management capabilities and operational efficiency alone.

Combating health care fragmentation through integrated health service delivery networks in the Americas: lessons learned

H. Montenegro and others

Journal of Integrated Care,vol.19, no.5, 2011, p. 5-16

Health systems in the Americas are characterised by high levels of fragmentation. In an effort to tackle the problems caused by fragmentation, the Pan-American Health Organisation (PAHO) began preparatory work for the integrated health service delivery networks (IHSDNs) Initiative in 2007. PAHO defines a IHSDN as a network of organisations that provides equitable, comprehensive, integrated and continuous health services to a defined population, and is willing to be held accountable for its clinical and economic outcomes. This article demonstrates the need to integrate health systems, identifies the essential attributes of IHSDNs, draws lessons from past implementation of IHSDNs, examines recent developments in selected countries and discusses policy implications.

Conceptualising care for childhood obesity: a three-world view

K.J. Pratt and others

Journal of Children’s Services, vol. 6, 2011, p.156-171

Childhood obesity has become an epidemic. Writing from a US standpoint, the authors of this paper explore the development of healthcare for overweight and obese children using the three-world view of C.J. Peek. According to Peek, healthcare settings face three simultaneous challenges: 1) to provide excellent clinical care; 2) to offer efficient, well-integrated and patient-friendly care systems; and 3) to achieve financial sustainability. It is concluded that a family-centred, multidisciplinary approach is needed at all stages of childhood obesity treatment and Peek’s three-world model could be helpful in achieving this. The clinical, operational and financial aspects of the service need to be integrated in a way that reduces barriers to access.

Does increase in utilisation rates alone indicate the success of a user fee removal policy? A qualitative case study from Zambia

M. Hadley

Health Policy, vol. 103, 2011, p. 244-254

In the run up to the 2006 national election, the President of Zambia announced the abolition of user fees at rural district health centres. In 2007, free services were extended to more remote health centres in urban districts. It is argued that to evaluate the impact of these policies on individuals and communities, it is necessary to explore the local context and everyday practices in health centres. This qualitative study aims to show how local practices contribute to the success (or otherwise) of the user fees removal policy. Results show that even after the removal of user fees sick people were denied healthcare due to barriers of distance, staff attitudes, waiting times and additional costs. Frivolous use and sharing of medicines in the community further compromised the success of the policy.

Economic crisis and communicable disease control in Europe: a scoping study among national experts

B. Rechel and others

Health Policy, vol.103, 2011, p. 168-175

Concerns have been expressed that the economic crisis of 2008/09 could have detrimental effects on the spread and control of communicable diseases. As there is little quantitative scientific evidence on the subject, this paper describes the findings of a survey of experts from across Europe on the current and potential effects of the recent economic crisis on infectious diseases. There were few specific national policies and programmes aimed at mitigating the impact of the economic crisis. Preventive services were deemed particularly susceptible to budget cuts compared to primary care. Services targeted at vulnerable and hard to reach groups were regarded as being at particular risk of deterioration, in contrast to travel medicine.

The evolving WHO: implications for global health security

A. Kamradt-Scott

Global Public Health, vol. 6, 2011, p. 801-813

This paper seeks to explore the changing role and function of the World Health Organization (WHO) in responding to infectious disease outbreaks. More specifically, it examines how the Organization’s authority has been shaped by four events: the 2003 SARS outbreak, the revision of the International Health Regulations, the emergence of avian influenza between 2003 and 2010 and the 2009 H1N1 pandemic. By comparing the role the WHO played in these events, several impediments to global health, both current and prospective, become apparent. The paper concludes by exploring what the implications may be for the WHO in the wake of the 2009 pandemic, and some of the challenges the international community may now face in responding to future disease outbreaks.

A global overview of health insurance administrative costs: what are the reasons for variations found?

I. Mathauer and E. Nicolle

Health Policy, vol. 102, 2011, p. 235-246

With the rising complexity of health systems, administrative costs may easily become a prominent spending category. This is especially the case in health insurance systems, where the cost of administration appears higher than in tax-funded systems. This paper provides a global overview and analysis of administrative costs of health insurance activities performed by social security schemes and private health insurance and reveals levels and trends of administrative expenditure across countries. This can inform insurance managers in setting their own benchmarks. Seven factors are explored to explain the significant differences found in administrative costs: health financing system aspects; administrative activities undertaken; insurance design aspects; context factors; reporting format; accounting methods; and management and administrative efficiency.

Good governance and corruption in the health sector: lessons from the Karnataka experience

R. Huss and others

Health Policy and Planning, vol. 26, 2011, p. 471-484

The Karnataka Lokayukta (KLA) was established in 1986 as a complaints agency with authority to investigate and prosecute cases of public maladministration and corruption. However it played a prominent role in combating corruption only after a change of leadership in 2001 when a new Lokayukta and Vigilance Director for Health were appointed. Key messages from this case study of the KLA suggest that:

• Interventions against widespread corruption in the health sector should consider a multisystem approach which includes the political and justice systems, the media, and governance education of citizens
• An effective anti-corruption agency requires a committed and powerful leadership, adequate resources, robust capability to investigate senior officials and the authority to propose institutional reforms
• A shift towards good governance requires the interaction of leaders, followers and system changes.

The growth and decline of health community centres in the Netherlands: a macro-historical analysis

R. Batenburg and A. Eyck

Journal of Management and Marketing in Healthcare, vol. 4, 2011, p. 242-246

Numbers of community health centres grew rapidly in the 1970s, when they were seen as the preferred organisational form for delivering integrated primary care. Growth then slowed during the 1980s due to financial stringency, but recovered in the period 2000-2006, due in part to new funding provided by health insurance companies and to government support for regional collaboration in primary care. A major reform of the Dutch healthcare system in 2006/07 led to the introduction of more market mechanisms and competition among insurers. Some health insurers have been willing to support the expansion of community health centres, but they now face competition from alternative organisational forms such as care chains, networks and care groups for chronic diseases.

The health of women and girls determines the health and well-being of our modern world: a white paper from the International Council on Women’s Health Issues

P.M. Davidson and others

Health Care for Women International, vol. 32, 2011, p. 870-886

Women and girls have specific health needs, and health systems around the world are failing them. This article introduces the work of the International Council on Women’s Health Issues, an international nonprofit organisation which aims to improve the health, healthcare and well being of women worldwide through participation, empowerment, advocacy, education and research. The vision, mission and strategic goals of ICOWHI are aligned with the WHO’s millennium development goals.

Health system stewardship of National Health Ministries in the WHO European region: concepts, functions and assessment framework

J.H.M. Veillard and others

Health Policy, vol. 103, 2011, p. 191-199

The World Health Report 2000 proposed that stewardship – which in its traditional definition points to the ethical use of common resources in pursuit of financially efficient outcomes – is the appropriate basis on which to reconfigure the governing role of the state in the health sector. This report pointed to the potential of the health system stewardship function of national health ministries to encourage decision-making in the public sector that is ethical, fair and economically efficient and defined stewardship as “being ultimately responsible for the well being of the population”. This paper attempts to clarify the concept and boundaries of the health system stewardship function of health ministries, derives core health system stewardship functions from a review of the literature, and matches them with case examples from countries in Europe and North America; proposes a set of guiding evaluation questions as well as an operational framework for policy makers to assess the completeness and consistency of their health system stewardship in their particular context; and discusses the challenges of implementing the health system stewardship model in different national contexts in the WHO European region.

Health systems in low-and middle-income countries: an economic and policy perspective

R. Smith and K. Hanson (editors)

Oxford: OUP, 2012

The book outlines the key aspects and issues concerning health systems in low- and middle-income countries, recognising the current global context within which these systems operate and the dynamics of this context. It brings together a set of renowned authors to tackle the issues that confront population health and health care in the twenty-first century.

HIV testing in Europe: mapping policies

J. Deblonde and others

Health Policy, vol. 103, 2011, p. 101-110

When the HIV antibody test first became available in 1985, a consensus emerged that, due to concerns about stigma and discrimination, testing should be confidential and voluntary and accompanied by counselling. As clinical management of HIV/AIDS improved, it was agreed that testing should be scaled up and made more routinely available, but there was lack of consensus about whether the emphasis on voluntarism, confidentiality and counselling should remain in place. While most EU countries have national policies or professional guidelines recommending antenatal HIV screening, little is known regarding other settings and populations. Against this background, a survey of HIV testing policies in EU/EEA countries was carried out with the aim of mapping them and exploring their characteristics. The results showed that in the majority of EU/EEA states, policies were in place to make HIV testing routine in healthcare settings, via voluntary and targeted testing strategies.

The influence of health knowledge in shaping political priorities: examining HIV/AIDS knowledge and public opinion about global health and domestic policies

J. Okamoto and others

Global Public Health, vol. 6, 2011, p. 830-842

It is not known what influence health knowledge has on shaping public opinion about domestic and global health policy in the US. This study examines how knowledge of HIV/AIDS is related to the rated importance of domestic and global health issues using data gathered through an electronic survey. Findings suggest that those with greater HIV/AIDS knowledge place greater importance on global health issues, which in turn affects ratings of more domestic concerns. For example, those with a greater general knowledge of HIV/AIDS rate domestic political priorities, such as healthcare, the economy and alternative energy at higher importance. This relationship between health knowledge and perceived importance of domestic issues is mediated by ratings of global health issues, such as the global spread of infectious disease, access to water and hunger. Thus the American public’s political priorities are not formed in domestic isolation. This research has implications for ways to gain support for implementation of public health policy through increasing health knowledge.

Introduction and uptake of new medical technologies in the Australian health care system: a qualitative study

G. Gallego and others

Health Policy, vol. 102, 2011, p. 152-158

Governments in many countries have introduced policies aimed at using the best available evidence to make decisions on the introduction of new health-related technologies. In Australia the Medical Services Advisory Committee (MSAC) assesses the evidence relating to medical devices, diagnostic tests and surgical and medical procedures. Since 1998 MSAC has made recommendations to the Australian Minister for Health and Ageing on whether new medical technologies should receive public subsidy via the Medicare Benefit Schedule. This study explores stakeholders’ perceptions of the current MSAC process and its role in the uptake and diffusion of new medical technologies. Twenty in-depth semi-structured interviews with stakeholders demonstrated that MSAC’s decision-making process was perceived as generally fair and transparent, and had been increasingly so over time.

Learning effect of a conditional cash transfer programme on poor rural women’s selection of delivery care in Mexico

S.G. Sosa-Rubí and others

Health Policy and Planning, vol. 26, 2011, p. 496-507

The Mexican Oportunidades/Progresa transfers money to beneficiary families on condition that they comply with health, education and nutrition requirements that contribute to poverty reduction. This analysis of 5051 mothers with at least one child under two living in rural areas of Mexico supported the concept of a learning effect that impacted on Oportunidades beneficiaries’ reproductive health behaviour and decisions , with an increase in use of antenatal services through the provision of economic incentives in the long term. An indirect effect was the increased selection of a physician/nurse for delivery care among young women living in areas with longer exposure to Oportunidades.

Medical tourism: a review of the literature and analysis of a role for bi-lateral trade

R. Smith, M. Martínez Álvarez and R. Chanda

Health Policy, vol. 103, 2011, p. 276-282

This paper presents a systematic review of the literature on medical tourism, with a specific focus on bilateral trade, using the UK-India as a case study. There is a dearth of data and discussion of such bi-lateral trade. However, available evidence suggests that exporting countries may benefit from medical tourism by generating foreign exchange and reversing the brain drain, but run the risk of creating a dual health system, where the local population is crowded out. Importing countries can benefit from cost reductions and cutting waiting lists, but may risk quality of care and legal liability.

National public health policy in a local context: implementation in two Swedish municipalities

E. Jansson, E. Fosse and P. Tillgren

Health Policy, vol. 103, 2011, p. 219-227

The aim of Swedish national public health policy is to create the societal conditions for good health on equal terms for the entire population. Implementation of the policy, however, rests with county councils and municipalities. Municipalities have responsibilities in several areas related to the determinants of health, e.g. social services, childcare, and eldercare. This study used content analysis of documents and interviews to investigate how the ambitious national public health policy was implemented in two municipalities. At the local level, the Swedish national public health policy was not regarded as implementable; rather, limited parts had, to varying degrees, been reconciled with local public health goals.

Opportunities to reduce health inequalities by “Health in All Policies” in the Netherlands: an explorative study on the national level

I. Storm and others

Health Policy, vol. 103, 2011, p. 130-140

Socio-economic health inequalities are persistent in the Netherlands and have apparently not been improved by Dutch national policy in recent years. Consequently the Dutch Ministry of Health, Welfare and Sports has been looking at a strategy to reduce health inequalities through Health in All Policies (HiAP). This study aimed to identify existing policies in the Netherlands inside and outside the health domain with a potential impact on health inequalities and their determinants and to identify critical factors influencing the cross-government collaboration which is required to implement HiAP. In order to provide useful information to facilitate the introduction of HiAP in the Netherlands, the Dutch situation is discussed in comparison to some other countries with a “whole of government approach”

Pandemic of chronic diseases, its roots and policy development

A. Gorobets

International Journal of Society and Systems Science?????, vol. 3, 2011, p. 325-332

This article highlights the challenges posed worldwide by the growth in chronic diseases and mental disorders, identifies the roots of the problem and proposes policy solutions. Inter-related socio-economic and environmental roots of the problem of the emergence of high levels of chronic disease are identified as over-consumption, unhealthy lifestyles, pollution and climate change. Reforms proposed to remedy the problem include inculcating appropriate socio-ecological values through education, improvement of healthcare systems, heavy taxation or outlawing of unhealthy or environmentally damaging lifestyles, and creation of public institutions promoting healthy human development, such as sports facilities, recreational areas, public arts projects and human-powered transportation systems.

Prescription for change: accessing medication in transitional Russia

F. Perlman and D. Balabanova

Health Policy and Planning, vol.26, 2011, p. 453-463

This paper aims to explore trends in access to medication during Russia’s transition to a market economy in the 1990s, and the factors associated with difficulties that many patients experienced at that time in obtaining prescription drugs. Data from nine rounds of the Russian Longitudinal Monitoring Survey 1994-2003 show that after 1994 reported unavailability of drugs at pharmacies fell sharply from 25% to 4%. Meanwhile, unaffordability increased to 20% in 1998 but declined to 9% by 2004. Improvement in the availability of drugs was probably due to the liberalisation of pharmacy networks and the pharmaceutical sector, while the expansion of health insurance and broader economic improvements reduced unaffordability. Better overall access to prescription medication masks inequalities as the poor and those with chronic conditions continue to experience particular difficulties in affording prescription drugs.

Promoting emergency medical care systems in the developing world: weighing the costs

D.R. Anthony

Global Public Health, vol.6, 2011, p. 906-913

Global health policy has traditionally focused on provision of basic primary healthcare to populations in the developing world. However, demand for emergency medical care in the developing world has dramatically increased in recent years. The question then remains as to whether it is logical to divert scarce resources from other priorities to provision of emergency care. The case for so doing is supported by existing evidence that emergency medical systems do improve morbidity and mortality rates. There is also strong support for their introduction at community and government levels.

Qatar’s quest for excellence

S. Lewis

Health Service Journal, Dec. 8th 2011, p. 26-27

Qatar is ploughing some of its vast wealth into the creation of an “academic health system”. The project was set up by the Hamad Medical Corporation, the main healthcare provider, and involves partnerships with another six universities and healthcare organisations. Proponents claim that the project will unite academia and healthcare for the benefit of the population, based on the academic health science centre model originated in the US.

A qualitative study of the difficulties in reaching sustainable universal health insurance coverage in Iran

H. Ibrahimipour and others

Health Policy and Planning, vol. 26, 2011, p. 485-495

This study used semi-structured interviews with 25 officials from major health insurance companies to investigate revenue collection, risk pooling and purchasing in the Iranian healthcare financing system. Results showed that several key obstacles stand in the way of achieving universal health insurance coverage in Iran: lack of clear information on coverage; a regressive financing system; fragmentation of insurance funds; no standard benefit package definition; an expensive payment system; and management deficiencies. To address these obstacles a long-term systematic plan is required that is based on the principles of accountability, transparency, non-discrimination and stakeholder participation.

Quasi- market and cost-containment in Beveridge systems: the Lombardy model of Italy

E. Brenna

Health Policy, vol. 103, 2011, 209-218

In the Italian and international literature, the “Lombardy model” is singled out for its uniqueness compared to the other Italian regional systems. Regional law 31/1997 established a quasi-market model for healthcare, separating purchaser and provider functions and privileging patient choice. This analysis describes the main features of the Lombardy healthcare reform of 1997 and the evolution of the model in the following years. The perspective that drives the study is mainly economic; hence aspects such as the theoretical framework of the quasi-market model, the financing criteria and the problem of incomplete information in a free choice context are investigated

Reducing maternal mortality: a review of progress and evidence-based strategies to achieve millennium development goal 5

T.R. Sullivan and J.E. Hirst

Health Care for Women International, vol. 32, 2011, p. 901-916

Maternal mortality represents a major global health challenge. Millennium Development goal 5 set a range of targets pertaining to maternal mortality and universal access to reproductive healthcare. Although realisation of MDG5 by 2015 seems unlikely, the achievements of isolated countries suggest that success is attainable. Through the implementation of population level strategies as well as cause-specific interventions, maternal mortality can be significantly reduced.

A review of health technology assessment (HTA) recommendations for drug therapies issued between 2007 and 2009 and their impact on policymaking processes in Poland

K. Kolasa and others

Health Policy, vol. 102, 2011, p. 145-151

The requirements of evidence-based medicine as well as budget impact analysis were legally introduced into the Polish pricing and reimbursement system for healthcare services in 2004. Since then, health technology assessment (HTA) has become an important part of the decision-making process relating to the diffusion of drug technologies. The HTA agency (AHTAPol) was established in 2005 by ordinance of the Ministry of Health. The main objective of AHTAPol is to provide the Ministry of Health with reimbursement recommendations based mainly on the results of the HTA report submitted by the manufacturer. This study critically reviewed and analysed AHTAPol’s recommendations, in order to ascertain to what extent HTA findings had been incorporated into national drug reimbursement decisions.

Scorecards for health system performance assessment: the New Zealand example

R. Gauld and others

Health Policy, vol. 103, 2011, p. 200-208

The health system scorecard approach to performance measurement is derived from the private business balanced scorecard. The idea is that a scorecard provides information on areas of strategic importance to guide future planning, but also gives a snapshot of how well an organisation is performing. The authors developed a national scorecard for the New Zealand health system. They drew upon national and international data to develop benchmarks for health system performance, then applied basic ratio scores to compare New Zealand performance to the benchmarks. The New Zealand health system scored relatively well on quality and efficiency, but poorly on equity despite considerable government investment in reducing inequalities.

Social drivers of HIV and AIDS

J. Ogden and others (guest editors),

Global Public Health, vol. 6, supplement 3, 2011, p.S285-S395

In the last decade experts and activists have acknowledged the importance of the social, economic, political, legal and environmental factors that shape HIV epidemics, yet they have failed to invest adequate resources to address them. Recently, however, the position has begun to shift and social forces are now being seen as fundamental to the response to HIV. Three main themes run through the papers in this special issue: 1) AIDS cannot be addressed as a short-term problem; 2) when moving from a short term emergency to a longer-term response, social context and social structural factors come to the fore; and 3) genuinely engaging with affected communities is key to dealing with the social drivers of HIV/AIDS.

Something’s ironic in Denmark: an otherwise progressive welfare state lags well behind in care of patients at the end of life

J.M. Hoefler and T.B. Vejlgaard

Health Policy, vol. 103, 2011, p. 297-304

It is something of a riddle that Denmark, a progressive nation with notably liberal welfare state policies regarding the elderly and disabled, scores low with regard to measures associated with palliative care at the end of life. This research identifies some cultural barriers to the development of end of life care. These include a tendency to be complacent about life in general and healthcare in particular and a generally negative view of individual specialisation and expertise.

Targeted or untargeted? The initial assessment of a targeted health insurance program for the poor in Georgia

X. Hou and S. Chao

Health Policy, vol. 102, 2011, p. 278-285

This paper uses administrative or claim data to document Georgia’s experience in transitioning from an untargeted health insurance programme (a social health insurance programme with a universal benefit package) to a more targeted health insurance programme (Medical Insurance Programme (MIP)) for the poor. Under this targeted programme, the government of Georgia provides a supplementary benefit package to the eligible poor, which covers the cost of acute and planned surgery and inpatient services without any co-payment of deductibles. This research found that the MIP has significantly increased beneficiaries’ utilisation of public health insurance for acute surgery/inpatient services. The benefits have reached the poorest among the beneficiaries.

Two decades of reforms: appraisal of the financial reforms in the Russian public healthcare sector

V.S. Gordeev, M. Pavlova and W. Groot

Health Policy, vol. 102, 2011, p. 270-277

Since the collapse of the Soviet Union in 1991, numerous healthcare reforms have taken place in the Russian Federation. The financial reforms focused on shifting the Russian public healthcare system away from the Soviet centralised and hierarchical model to more decentralised and insurance-based provision. This paper reviews the empirical evidence on the outcomes of the financial reforms to form the basis of their evidence-based evaluation. However, the results show that the available empirical data are not sufficient for an evidence-based evaluation of the reforms.

Understanding change in global health policy: ideas, discourse and networks

A. Harmer

Global Public Health, vol. 6, 2011, p. 703-718

Factors such as ideas and discourse play an important role in radical change in global health policy. This article applies a theoretical framework first developed in the political sciences to show how discourse made it possible for public and private actors to fundamentally change their way of working together and to move from international public and private interactions to global health partnerships. Drawing on insights from constructivist analysis, the author demonstrates how discourse justified, legitimised, communicated and coordinated ideas about the practice of global health partnerships through a network of pioneers.

User fee removal in the health sector in low-income countries: lessons from recent national initiatives

B. Meessen, L. Gilson and A. Tibouti (guest editors)

Health Policy and Planning, vol.26, 2011, supplement 2, p. ii1-ii117

Papers in this collection document how countries have formulated and implemented removal of user fees for healthcare. Four general messages emerge:

• Policies aimed at removing financial barriers can be very effective in improving health service utilisation provided they are well designed, funded and implemented.
• User fees cannot be removed at the stroke of a pen: the removal needs careful preparation, requires accompanying measures (especially in terms of drug supply and staff motivation), and deserves close monitoring and appropriate evaluation.
• There are different ways to mobilise, pool and allocate collective resources to pay for improved financial access for vulnerable groups
• Development partners have played varying roles in country experiences of user fee removal. In some cases documented in this supplement they stepped up to provide financial resources and technical assistance, while in others they did not. There is an urgent need for them to play a more active role in the process. They could contribute financial resources and technical assistance where these are requested by national governments and required for effective implementation.

Using global health initiatives to strengthen health systems: a civil society perspective

J. Cohn and others

Global Public Health, vol. 6, 2011, p. 687-702

Research into the effects of global health initiatives on health organisations has largely left out the perspectives of civil society. This study details civil society’s perspective regarding the effects of two global health initiatives, the US President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria, (GFATM) on country health systems. A qualitative survey of civil society stakeholders in four sub-Saharan African countries demonstrates that, while global health initiatives are viewed as critical actors in fighting priority diseases, there are missed opportunities to use their funds to strengthen health and community systems. A diverse array of civil society actors expressed support for using this funding, particularly from PEPFAR and the GFATM, to address these missed opportunities.

What have 10 years of health insurance reforms brought about in Bulgaria? Re-appraising the Health Insurance Act of 1998

E. Atanasova and others

Health Policy, vol.102, 2011, p.263-269

In 2000 the Bulgarian government started to reform health system funding based on the Health Insurance Act of 1998. The existing tax-based system of funding public healthcare was radically changed and social health insurance based on compulsory contributions was introduced. This paper reviews the outcomes of the health insurance reform in Bulgaria from the perspective of expectations and concerns at the start of the process. Most of the prior expectations about the positive effects of introducing social health insurance were realised, with the exception of independence of system funding from government interference and preservation of equity in healthcare delivery. Unfortunately prior concerns about the possible negative effects of the reforms have also been realised and the overall social benefit of the reform is doubtful. This is partly due to the overall lack of resources for healthcare in the country.