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

Accelerating progress in achieving the millennium development goal for children through community-based approaches

P. Freeman and others

Global Public Health, vol.7, 2012, p. 400-419

The Millennium Development Goal 4 calls for the reduction of under-five mortality by two-thirds between 1990 and 2015. Only 16 of the 68 countries with 97% of the world's child deaths are on track to achieve this. There is growing recognition that strengthening community-based interventions has the potential to accelerate progress in reaching the MDGs in health and high-mortality settings. This paper reviews the specific community-based interventions that have strong evidence of effectiveness and presents a simple set of strategies which health systems can implement in partnership with communities to maximise the effectiveness of health programmes in reducing under-five mortality.

Cancer patient pathways in Denmark as a joint effort between bureaucrats, health professionals and politicians: a national Danish project

H. B. Probst, Z.B. Hussain and O. Andersen

Health Policy, vol.105, 2012, p. 65-70

Denmark has a higher incidence of cancer and poorer cancer survival rates than many other European countries. In August 2007 the Prime Minister announced that cancer should be treated as an acute condition and a subsequent agreement between the government and the responsible health regions required national cancer patient pathways (CPPs) for all cancer types to be ready by the end of 2008. The National Board of Health was given the task of facilitating the development of the CPPs. This article describes how the CPPs were developed with a consensus seeking model which ensured co-operation between bureaucrats, health professionals and politicians and subsequent successful national implementation.

Constraints to implementing an equity-promoting staff allocation policy: understanding mid-level managers' and nurses' perspectives affecting implementation in South Africa

V. Scott, V. Mathews and L. Gilson

Health Policy and Planning, vol.27, 2012, p. 138-146

Few papers on issues of equity in developing countries consider the process of implementing policy changes intended to improve equity in health status or health service delivery. This article seeks to understand the experience of implementing a policy with equity goals from the perspective of implementing actors working at district level, with specific focus on the factors driving their support and resistance to the policy. The proposals considered in the article were developed in 2003 and called for the reallocation of health professionals between better- and lesser-resourced districts in the Cape Town Metropolitan region to reduce broader resource allocation inequities. The research focuses on the views and reactions of two sets of implementing actors: district health managers and nurses. It shows how a lack of trust in the relationships between mid-level managers and nurse service providers influenced the potential to implement this specific set of equity-oriented strategies.

Coping with health care expenses among poor households: evidence from a rural commune in Vietnam

K. T. Nguyen and others

Social Science and Medicine, vol.74, 2012, p. 724-733

With the 1980s 'Doi Moi' economic reforms, Vietnam changed from state funded healthcare to a privatised user fee system. Out-of-pocket payments became a major source of funding for treatments at both public and private health facilities. This research used data from a survey of 706 households in Dai Dong, a rural commune of Hanoi, to study the coping strategies used by residents for paying healthcare costs. Households of all income levels borrowed to pay for inpatient treatments; loans were also more heavily used by the poor and the near-poor than the non-poor for outpatient treatments. The use of loans increased for extremely high cost treatments for all poverty levels, but especially the poor and near-poor. As treatment costs spiralled, a rising proportion of households reduced food consumption, with the poor most prone to this practice.

Crossing borders: a critical review of the European Court of Justice in EU health policy

E. Brooks

Health Policy, vol. 105, 2012, p. 33-37

Over the last two decades, the European Union has steadily increased its involvement in the health policies of its member states. The body of literature examining this encroachment focuses on the unique nature of health as a policy area and varies in its accounts of which actors are driving the process of Europeanisation. . Much of the literature deals primarily with the impact of European Court of Justice (ECJ) rulings on health services of member states and the threat to healthcare posed by internal market law, rather than the role of the ECJ in public health. This article argues that the Court has and continues to play a crucial role in the development of EU public health policy as well as in health services and broader social policy, where its influence has been well documented.

Econometric analysis to evaluate the effect of community-based health insurance on reducing informal self-care in Burkina Faso

P.J. Robyn and others

Health Policy and Planning, vol.27, 2012, p. 156-165

This study examines the role of community-based health insurance (CBHI) in influencing health seeking behaviour in Burkina Faso. Community-based health insurance was introduced in Nouna District, Burkina Faso in 2004 with the goal of improving access to contracted providers based at primary- and secondary-level facilities. Results showed that community-level health insurance plays a substantial role in increasing access to facility-based care, but an insignificant role in reducing unsupervised treatment of acute illness. Schemes may be ineffective in limiting consumption of services and medication accessed from the informal health sector.

Empirically evaluating the impact of adjudicative tribunals in the health sector: context, challenges and opportunities

S. J. Hoffman and L. Sossin

Health Economics, Policy and Law, vol.7, 2012, p. 147-174

Adjudicative tribunals are an integral component of health sector governance. Created by legislation, these quasi-judicial bodies are granted regulatory, oversight and dispute resolution powers to promote fairness in health decision-making, build confidence in health system management, strengthen governance structures, and improve health services and patient safety. Their actual impact on the health system, however, remains largely unknown. As efforts to reform health systems continue, it will be increasingly important to truly understand the benefits, costs and implications of adjudicative tribunals for providers and consumers of health services. This article suggests practical steps for the conduct of of empirical impact evaluations, along with an evaluation matrix template featuring possible target outcomes and corresponding surrogate endpoints, performance indicators and empirical methodologies, using their application to two prominent health tribunals in Canada as case studies.

Encouraging maternal health service utilization: an evaluation of the Bangladesh voucher program

H.T.H. Nguyen and others

Social Science and Medicine, vol. 74, 2012, p.989-996

With the ultimate goal of reducing maternal and neonatal mortality, many countries have recently adopted innovative financing mechanisms to encourage the use of professional maternal health services. The current study evaluates one such initiative - a pilot voucher programme in Bangladesh. The programme provides poor women with cash incentives and free access to antenatal, delivery, and postnatal care, as well as cash incentives for providers to offer these services. A survey of 2208 women in 16 intervention and 16 matched comparison subdistricts showed that the programme significantly increased the use of antenatal, delivery, and postnatal care with qualified providers. The findings support voucher programme expansion targeting the economically disadvantaged to improve use of priority health services.

The evaluation of lifestyle interventions in the Netherlands

D.R. Rappange and W.B.F. Brouwer

Health Economics, Policy and Law, vol. 7, 2012, p. 243-261

Current investments in preventive lifestyle interventions are low, despite the significant impact of unhealthy behaviour on population health. This raises the question of whether the decision-making criteria used in reimbursement decisions about healthcare interventions put preventive interventions at a disadvantage. The Netherlands has a long tradition of thinking about a decision-making framework for the allocation of healthcare resources. The Health Insurance Board has recently designed such a framework on the basis of previous initiatives. This framework includes explicit decision criteria, most prominently 'necessity' and 'cost-effectiveness'. This paper highlights several important normative choices that need to be made when operationalising these criteria. It then focuses on how these choices may influence the evaluation of lifestyle interventions.

Health, wealth and ways of life: what can we learn from the Swedish, US and UK experience? A collection of commentaries

Social Science and Medicine, vol. 74, 2012, p. 637-804

The links between economic cycles and health are complex. The socio-economic contexts and structures through which economic conditions influence both health processes and levels of health inequality differ from country to country. The commentaries in this collection look at the impact of the global recession which began in 2007 on health in the US, the UK and Sweden. They highlight key aspects of the debate concerning health, wealth, and sustainability of economic and social welfare systems in three rich countries, focusing on how health and its social determinants may be affected by the economic recession and on whether a recession widens inequalities. They examine life-course perspectives, the potential for interventions and their sustainability and how health systems should adapt to recession.

Healthcare, management and marketing

I. Rudawska (guest editor)

World Review of Entrepreneurship, Management and Sustainable Development, vol. 8, 2012, p. 119-363

Most countries are under constant pressure to review or rebuild their healthcare systems. There has been a trend towards the introduction of managerial approaches to the provision, and in some countries the foundation, of healthcare. A number of market mechanisms have been introduced in different sub-sectors of health systems and at different levels. Effective management of both the healthcare system at the macro level and healthcare providers at the micro level seems to be the biggest challenge for most countries. In this collection of nine case studies, the authors discuss how to manage healthcare for social and economic profit and how marketing professionals attempt in practice to balance these sometimes contradictory goals. The papers cover: 1) measurement of patients' perceptions of health service delivery; 2) innovations in health system management and performance measurement, including competition; and 3) challenges of social marketing in a public healthcare system.

Healthcare policy tools as determinants of health system efficiency: evidence from the OECD

D. Wranik

Health Economics, Policy and Law, vol. 7, 2012, p. 197-226

Arguably, the optimal healthcare system is one that results in the largest health gains per dollar spent, that is, the most efficient system. Unfortunately, our knowledge of which health system structures are most efficient is inadequate. This study estimates the determinants of efficiency of 21 OECD health systems. Health systems are characterised along seven dimensions, each of which is determined via discretionary health policy actions. The dimensions include: financing arrangements; public sector funding; patient cost sharing and insurance; physician remuneration methods; and gatekeeping arrangements. In each case the estimation discerns whether a particular characteristic has a positive or a negative impact on efficiency, so as to provide guidance on the selection of policy instruments. Results indicate that broader health system structures, such as Beveridgian or Bismarckian financing arrangements or gatekeeping, are not significant determinants of efficiency. Instead, significant contributors to efficiency are policy instruments that directly target patient behaviours, such as insurance coverage and cost sharing, and those that directly target physician behaviours, such as payment methods.

How federal health-care policies interface with urban and rural areas: a comparison of three systems

D. Baracskay

Global Public Health, vol.7, 2012, p. 317-336

Healthcare policies today necessitate that countries devote considerable attention to infectious disease surveillance and intervention. This is particularly essential given the ease of cross-border transmission. In federal systems of government, the national level leads the policy formation and implementation process, but also collaborates with international organisations as part of the global health network. Likewise, the national level of government co-operates with sub-national governments in both urban and rural areas. Rural areas, particularly in less-developed countries, lack the benefits of proper medical facilities, communication modes and technology to prevent the spread of disease. Focusing on three federal systems (USA, Australia and Malaysia), and using the lens of collaborative federalism, this article examines how collaborative arrangements and interactions among governmental and non-governmental actors help to address the inherent discrepancies that exist between policy implementation and reactions to infectious disease outbreaks in urban and rural areas. This is considered in the context of the 2009 H1N1 influenza pandemic.

Human rights in health systems frameworks: what is there, what is missing and why does it matter?

S. Gruskin and others

Global Public Health, vol. 7, 2012, p. 337-351

Since the late 1990s, the importance of human rights to health and development efforts has been increasingly acknowledged. However, while the language of human rights often appears in the global discourse, its inclusion in health systems efforts beyond rhetorical pronouncements is minimal. This article focuses on how human rights feature in current health systems models. It builds on previous analyses and demonstrates the extent to which human rights concepts are featured in the health systems frameworks that shape global and national efforts. Four areas for priority attention are highlighted: increasing client involvement at all stages of health system design and operation to improve acceptability and use of services; promoting equality and non-discrimination to address the range of disparities that impact on people's access to and use of health services; systematic review and amendment of laws and policies found to negatively affect health and health service use; and strengthening the accountability of all those involved in health service design and implementation to ensure that users are invested and engaged in the functioning of the system over time.

Integrated care for chronic conditions: the contribution of the ICCC framework

R. Nuño and others

Health Policy, vol. 105, 2012, p. 55-64

Experts have estimated that before 2030 chronic diseases will account for 70% of the global disease burden and will be responsible for 80% of deaths across the world. Chronic conditions do not fit with the traditional approach to healthcare, which is based on acute diseases which can be cured. The World Health Organisation proposed a model for change in health system design in 2002, the Innovative Care for Chronic Conditions (ICCC) Framework. This review shows that the ICCC Framework has inspired a wide range of types of intervention and has been applied in a number of countries with diverse healthcare systems and socioeconomic contexts. The available evidence supports the effectiveness of the framework's components.

Integrating microfinance and health strategies: examining the evidence to inform policy and practice

S. Leatherman and others

Health Policy and Planning, vol. 27, 2012, p. 85-101

Single solutions continue to be inadequate in confronting the prevalent and persistent problems of poverty, social exclusion and ill health. Meeting global needs in health will require more cross-sectoral approaches. Research evidence suggests that microfinance organisations can implement health programmes that increase knowledge, change health-related behaviours and improve access to health services. Microfinance institutions can provide a global infrastructure platform for integrating poverty alleviation and health improvement programmes.

Pediatric primary care services in Manitoba: is the health of the next generation of children at risk?

A. Katz and others

Health Policy, vol. 105, 2012, p. 84-91

To determine the needs-based human resource requirements of a future paediatric population, we need to measure the service needs of the population and the number of physicians needed to supply those services. This study aimed to develop projections of the medical human resources needs of the Manitoba paediatric population based on the historic pattern of use and the expected demographic characteristics of the population in 2020. This paper addresses the predicted service requirements of Manitoba's children, but not the number of physicians required to provide the services, which will be addressed separately. The analysis revealed a predicted 2.8% increase in the paediatric population by 2020, but an overall decrease of 13.4% in paediatric service provision, due to a reduction in family doctor services. The findings suggest that the health of future generations of Manitoba's children may be at risk.

Political economy realities in the Chinese health sector: health financing reforms in a mobile society

D. Harris and J.Q. Wang

Public Management Review, vol. 14, 2012, p. 218-237

Between 1979 and 1998 key changes to China's economic growth strategy eroded the existing healthcare system and shifted the burden of paying for treatment from the state to individual households. In 1998 a second wave of reforms began to attempt to mitigate the ill effects of the purely market-driven approach to healthcare delivery. These reforms have produced a massive expansion of health insurance coverage across much of the population. This article focuses on one of the subsets of the population which remains uninsured, the nonmingong or peasant labourers who make up much of China's floating population of internal migrants. An analysis of relevant structural factors, institutions and actors' incentives sheds light on the coverage gap faced by the nonmingong

Pharmaceutical lobbying under postcommunism: universal or country-specific methods of securing state drug reimbursement in Poland

P. Ozieranski, M. McKee and L. King

Health Economics, Policy and Law, vol. 7, 2012, p. 175-195

Pharmaceutical lobbying is a pivotal topic in health policy in Europe. The most prominent critics allege that drug companies use unethical lobbying methods that lead to sub-optimal treatment and waste of resources. This paper examines pharmaceutical lobbying as it relates to policies on reimbursement for 'innovative' medicines in Poland based on semi-structured interviews with representatives of major stakeholders in the domain of drug reimbursement policy. Two key lobbying methods were identified: informal persuasion and third-party endorsements. These methods are coupled with two supplementary ones: lobbying through Parliament and ministries and diplomatic pressure. Pharmaceutical lobbying methods in Poland clearly resemble those used in other European countries. What is notable about the Polish case is extensive reliance on informal lobbying and diplomatic pressure.

Policies to improve the health and well-being of the Roma people: the European experience

G. Fésüs and others

Health Policy, vol. 105, 2012, p. 25-32

Despite various policy initiatives, there has been limited progress in tackling the adverse health and social conditions of the Roma over the past two decades in most countries in Central and Eastern Europe. This paper has identified factors that may limit the effectiveness of existing policy initiatives designed to promote Roma integration and inclusion. It took an interdisciplinary perspective by embedding health in the context of a range of policies that are of direct relevance to improving health outcomes for the Roma. Health policies seeking to reduce the disadvantage experienced by Roma should be aligned with education, economic, housing, labour market, environmental and territorial development policies and form an integral part of long-term policy frameworks allowing for their effective integration

Research to support universal coverage reforms in Africa: the SHIELD project

D. McIntyre and A. Mills

Health Policy and Planning, vol. 27, 2012, Supplement 1, 112p

Universal coverage has two elements: first, ensuring financial protection for all from the costs of healthcare; and second, enabling access to needed care for all citizens. To date, relatively limited progress towards universal coverage has been made in African countries. The Social Health Insurance for Equity in Less Developed Countries (SHIELD) project sought to critically evaluate the health systems of three African countries (Ghana, South Africa and Tanzania) through an equity lens, and to set out the extent to which expanded or new financing mechanisms could address the equity challenges faced by those countries. It adopted a system-wide perspective, considering both the public and the private health sectors, and evaluating the financing as well as service use elements of these health systems. This supplement presents the key findings of the research.

Responding to diversity: an exploratory study of migrant health policies in Europe

P. Mladovsky and others

Health Policy, vol.105, 2012, p. 1-9

Recognising that health systems need to take measures to adapt to the needs of migrants, there has been growing international interest in migrant health policy. As the issue of statutory entitlement to health services (i.e. primary and secondary legislation establishing rights of access to healthcare) has been well documented, this study focuses on the content of national migrant health policies which seek to improve their health through targeted interventions. While statutory entitlements allow migrants to use health services, a second level of policies enacted by the health system is needed to operationalise entitlement and ensure the responsiveness of health services to their needs. This paper compares and contrasts the content of this second level of migrant health policies in 11 European countries. It is concluded that countries focusing policies on either new migrants or established ethnic minorities need to start focusing on both. Targeting of specific diseases and conditions prevalent among migrants may in certain cases be arbitrary and should be revised. Health literacy programmes and the participation of migrants in policy development should be encouraged. Building on initiatives targeting patients and providers that are already in place, countries need to adopt more complex but possibly more effective approaches such as the 'whole organisation approach'.

The role of private health facilities in the provision of malaria case management and prevention services in four zones of Oromia Regional State, Ethiopia

D. Jerene and others

International Health, vol.4, 2012, p. 70-73

Although malaria patients in Ethiopia access diagnosis and treatment at public health facilities free of charge, anecdotal reports and isolated surveys suggest that a considerable proportion of patients also access private sector facilities for the same services. This study aimed to assess the role of private sector health facilities and drug outlets in providing malaria case management and prevention services in four administrative zones of Oromia Regional State. Results showed that services provided by these facilities and outlets were variable, with only a proportion of facilities providing comprehensive diagnostic or treatment services, and even fewer disseminating educational materials. It is concluded that, in order to sustain current malaria prevention and control efforts in Ethiopia, it will be crucial to include the private sector in service delivery.

Sociology, health data and health equity: one state agency as a site of social change

M. M. Hynes

Current Sociology, vol. 60, 2012, p. 166-177

In recent years, racial and ethnic minority populations have grown considerably in many US states. This growing diversity underscores the importance of state agencies holding accurate demographic and health data as sources of information about the needs of their populations. Historically the US federal government has provided important guidance and support to states in social data collection. This article begins by highlighting the role of sociologists in federal efforts to improve data collection. It goes on to describe the author's own efforts as a sociologist within the Connecticut Department of Public Health to improve health and social data collection and to build collaborative relationships for the purpose of advancing health equity.

Utilization of epidemiological research for the development of local public health policy in the Netherlands: a case study approach

J. de Goede, K. Putters and H. Van Oers

Social Science and Medicine, vol. 74, 2012, p. 707-714

The aim of this research was to investigate in what way and why epidemiological research influences the development of local health memoranda in the Netherlands. This is both interesting from a scientific point of view and fits in the Dutch policy context where the law on public health states that epidemiological research should provide a basis for local health memoranda. The case studies reconstructed the development of the local health memoranda and determined that they were shaped by the societal values, interests and responsibilities of the local policy actors. It is concluded that research use is mainly determined by personal motives, perspectives, tasks and responsibilities.

Universal healthcare: key behavioural factors affecting providers' and recipients' value propositions: a structural causal model of the Puerto Rico experience

V. Quiñones-Avila and A. Medina-Borja

International Journal of Behavioural and Healthcare Research, vol. 3, 2012, p. 25-45

In 1993 the government of Puerto Rico contracted out healthcare provision to private providers and instituted a state funded health insurance scheme run by private insurance companies to guarantee access to the poor. Today, the scheme has not completely achieved its aims and the number of people not covered by health insurance is rising. This research explores how universal access to healthcare affects physicians' and patients' attitudes, in turn affecting the effectiveness of health reform implementation.

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