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

Civilising power in Global Health Partnerships

S. Steyn

Journal of Corporate Citizenship, vol.43, Autumn 2011, p. 103-118

Global health public-private partnerships (GHPs) have been promoted as a solution for sub-Saharan Africa's health problems. Despite limited accountability and lack of evidence of their effectiveness, Global Health Partnerships are exerting tremendous power and influence over health policymaking. Moreover, the beneficiaries of GHPs are often powerless to influence and control decisions affecting their lives. There are concerns that they simply represent another vehicle through which powerful actors can exert influence and pursue their own interests. This article proposes an imaginative form of accountability for GHPs, where power would be vested in the beneficiaries, instead of in the powerful actors in the partnership. Through the innovative use of technology, beneficiaries would be empowered to co-create knowledge with global civil society, parliaments, judiciaries and the mass media to hold GHPs to account.

Community health workers in Brazil's Unified Health System: a framework of their praxis and contributions to patient health behaviours

R.M. Pinto, S. Bulhões da Silva and R. Soriano

Social Science and Medicine, vol. 74, 2012, p. 940-947

Community Health Workers are an integral part of Brazil's Unified Health System, which provides free primary care to all citizens through its Family Health Programme. The Programme offers community-based clinics with transdisciplinary teams comprising at least one physician, one nurse and 15 or more community health workers. The community health workers are resident in the community, understand local geography and culture and are endorsed by residents. They act as key liaisons between the physician and nurse and the patients and receive training in basic health concepts, healthy lifestyles, sanitation and public health strategies. This article describes the development, in partnership with community health workers themselves, of a framework to advance research connecting their praxis and patient health behaviours and to improve both their training and effectiveness.

Divergence in the development of public health insurance in Japan and the Republic of Korea: a multiple-payer versus a single-payer system

H.-S. Jeong and R. Niki

International Social Security Review, vol. 65, no. 2, 2012, p. 51-73

Japan and South Korea achieved universal health insurance coverage for their populations in 1961 and 1989, respectively. At present Japan continues to operate an multiple-payer social health insurance system, while South Korea has moved to an integrated single-payer structure. This article analyses the causes of this divergence through the lens of comparative political economy covering differences in political power, the policy influence of business, the extent to which regional autonomy has developed and regional traits have been preserved, the level of democratisation, the form of political leadership and the scale of development of the health insurance system.

The European Patients' rights directive: a clarification and codification of individual rights relating to cross border healthcare and novel initiatives aimed at improving pan-European healthcare co-operation

P. Quinn and P de Hert

Medical Law International, vol. 12, 2012, p. 28-69

This paper aims to undertake a contextual analysis of Directive 2011/24/EU on the application of patients' rights in cross-border healthcare, commonly known as the Patients' Rights Directive (PRD). The PRD itself does not aim to provide a new system for coordinating social security entitlements, leaving the regime laid down in EEC1408/71 and EC883/2004 unaffected. Rather, it is intended that the PRD will supplement the rights that these instruments were intended to provide. The main aims of the PRD instead concern matters related to the prior authorisation of healthcare, the reimbursement of healthcare and the removal of unjustified obstacles from doing so. These efforts largely reflect recent case law of the European Court of Justice (EJC). The provisions largely represent a codification and clarification of the jurisprudence of the EJC, aimed at increasing patient mobility.

Fiscal decentralisation and infant mortality rate: the Colombian case

V.E. Soto, M.I. Farfan and V. Lorant

Social Science and Medicine, vol. 74, 2012, p. 1426-1434

Colombia has one of the most decentralised health systems in Latin America. Political and fiscal responsibility for health services has been transferred to 32 departments and 1120 municipalities since 1993. Municipal authorities have acquired an increasingly prominent role in provision of primary healthcare and allocation of resources. However it is unclear whether fiscal decentralisation has improved population health. This study assesses the effects of decentralisation of health expenditure on infant mortality rates. Results show that the delegation of responsibility for resource allocation to municipalities was associated with a decrease in infant mortality rates. However, the benefits of decentralisation were greater in non-poor municipalities than in poor ones.

Global action on social determinants of health

R. Labonté

Journal of Public Health Policy, vol. 33, 2012, p. 139-147

This commentary argues that there are three major barriers to achieving greater health equity. The first is the crisis in global capitalism and financial markets, brought on by almost 30 years of inadequate regulation. The second is that there is no credible, socially just, ecologically sustainable scenario of continually growing incomes for a world of nine billion people. Underlying both of these issues is a third: that the political and economic orthodoxy that emerged in the 1970s unleashed an unprecedented upward redistribution of wealth. These inter-related phenomena underscore the urgent need to: 1) redistribute resources both within and between countries; 2) introduce supranational regulation to ensure a social purpose in the global economy; and 3) introduce enforceable social rights that enable citizens to hold governments and corporations to account.

Health insurance coverage and health care access in Moldova

E. Richardson and others

Health Policy and Planning, vol. 27, 2012, p. 204-212

In 2004, the Moldovan government introduced mandatory social health insurance with the goals of sustainable health financing and improved access to services for poorer sections of the population. The government pays contributions for unemployed people, but the self-employed, which in Moldova includes many agricultural workers, must purchase their own cover. This paper describes the extent to which the Moldovan mandatory health insurance scheme has managed to increase coverage of the population and the characteristics of those who remain uninsured. The study shows that 78% of the population have insurance cover, which is only a small increase since the introduction of mandatory health insurance in 2004. Factors associated with being uninsured include being self-employed (particularly in agriculture), unemployed, of younger age and on a low income. Both insured and uninsured people face high additional costs in obtaining care, in particular due to payments for pharmaceuticals. Consequently, insurance coverage has only a limited impact on seeking care when ill.

Household perceptions and their implications for enrolment in the National Health Insurance Scheme in Ghana

C. Jehu-Appiah and others

Health Policy and Planning, vol. 27, 2012, p. 222-233

In low-income countries health insurance is increasingly recognised as a promising tool for the financing of equitable healthcare. In Ghana, the National Health Insurance Scheme (NHIS) has reached a coverage of 66% of the population since its launch in 2003. This paper uses a novel quantitative methodological approach to systematically assess, rank and compare perceptions of insured and uninsured households as they relate to providers (quality of care, service delivery adequacy, staff attitudes), insurance schemes (price, benefits, and convenience), and community attributes (health 'beliefs and attitudes' and peer pressure). It explores the association of these perceptions with household decisions to enrol and remain in the scheme. Results show that perceptions vis-à-vis service providers, insurance schemes and community attributes play an important part in households' decisions to voluntarily enrol and remain in insurance schemes, albeit to varying degrees. Perceptions related to schemes (price of NHIS, benefits and convenience of administration of NHIS) are most important and have the strongest association with enrolment and retention decisions. Policymakers need to recognise community perceptions as potential enablers and barriers to enrolment, and to invest in understanding and addressing them in the design of interventions to stimulate enrolment.

Implementation of a service for physicians' consultation and information in euthanasia requests in Belgium

Y. van Wesemael and others

Health Policy, vol. 104, 2012, p. 272-278

In Belgium, consultation with an independent physician is one of the due care requirements for the attending physician considering a request for euthanasia. In the year following the enactment of the Belgian euthanasia law in 2002, a special non-governmental service called the Life End Information Forum (LEIF) was set up in Flanders to provide trained people able to act as mandatory second physicians in euthanasia requests. This study assessed the implementation of LEIF after five years of existence in terms of awareness, use, future use and the attitudes of Dutch-speaking Flemish and Brussels physicians likely to be involved in end-of-life care, through a survey of a representative sample of 3006 doctors. Results showed that 78% of responding physicians knew of the existence of LEIF, almost 90% would consult with a LEIF physician in future in the event of a euthanasia request, and 90% felt supported by the idea of being able to consult one in such cases. However, only 35% of responding physicians who had received a euthanasia request since LEIF became active had actually used its services. It is concluded that implementation has been successful, but that LEIF should continue promoting its services as widely as possible.

Influencing policy change: the experience of health think tanks in low- and middle-income countries

S. Bennett and others

Health Policy and Planning, vol.27, 2012, p. 194-203

In recent years there has been a growth in the number of health policy analysis institutes in low- and middle-income countries due to limitations in government analytical capacity. This study aimed to: 1) investigate the contribution made by health policy analysis institutes in low- and middle-income countries to health policy agenda setting, formulation, implementation and monitoring; and 2) assess which factors, including organisational form and structure, support their role in terms of positively contributing to health policy. Six case studies of health policy analysis institutes in Bangladesh, India, Ghana, South Africa, Uganda and Vietnam were undertaken. Results showed that, under the right conditions, health policy analysis institutes can play a positive role in promoting evidence-informed decision making. Factors critical to supporting effective policy engagement include: a supportive policy environment, some degree of independence in governance and financing, and strong links to policymakers that facilitate trust and influence. Motivation and capacity within government to process and apply policy advice developed by a health policy analysis institute was found to be key to the institute's ultimate success.

Insured yet vulnerable: out-of-pocket payments and India's poor

R. Shahrawat and K.D. Rao

Health Policy and Planning, vol. 27, 2012, p.213-221

Protecting households from high out-of-pocket payments for healthcare is an important health system goal. In India, only 11% of the population is covered by some form of health insurance. A combination of low health insurance coverage and a dominant fee-for-service private sector in the delivery of curative care services has resulted in a situation where 69% of health spending is financed out-of-pocket. Out-of-pocket health payments are impoverishing for both poor and near-poor populations in India. Medicines constitute the majority (72%) share of out-of-pocket payments. Free inpatient care provides negligible financial protection against health payments by individuals. Free outpatient care or free access to medicines would provide adequate protection against out-of-pocket health expenditure. Health insurance schemes targeting the poor and near-poor should include medicines and outpatient care if they are to offer adequate financial protection.

Migration, "illegality" and health: mapping embodied vulnerability and debating health-related deservingness

S. Willen (guest editor)

Social Science and Medicine, vol. 74, 2012, p.803-896

Around the world, debates about who is and is not deserving of healthcare are highly contentious, against the backdrop of the global recession, retreating welfare states and rocketing healthcare costs. Among those whose deservingness is currently contested, one group stands out: economic migrants and illegal immigrants. Illegal immigrants have no political rights and are also excluded from the moral community of those whose illnesses and injuries are deemed worthy of attention, investment or concern. The articles in this special issue probe the relationships among local configurations of "illegality", contemporary deservingness debates, and embodied vulnerability using both quantitative and qualitative methods in a wide array of geographic settings: North and Central America, Western Europe, the Middle East and Central Asia. The special issue aims to investigate: 1) conceptions of health-related deservingness; and 2) use of ethnographic methods to clarify the intersections among legal and policy obligations, moral commitments and everyday practice. It also aims to situate research on the health implications of "illegality" within the broader literature on how structural inequality and vulnerability can become embodied in both the epidemiological and the phenomenological sense of the term.

Perceptions and patterns of use of generic drugs among Italian family pediatricians: first round results of a web survey

V. Fabiano and others

Health Policy, vol. 104, 2012, p. 247-252

Prescription of generic rather than branded drugs is an effective strategy for cost containment. However, Italian family paediatricians and general practitioners do not prescribe generic drugs as frequently as their peers in other countries such as Denmark, the UK, the US, Germany or the Netherlands. Results of an online survey completed by 303 family paediatricians reveal a scepticism about the reliability of bioequivalence tests and doubts about the safety of switching from branded drugs to generic equivalents. More information about generic drugs and more research in the field of paediatric pharmacology are needed to increase the generic medicines prescription rate among Italian family paediatricians.

Policy making for new vaccines in low- and middle-income countries

S. Mounier-Jack and H. Burchett (guest editors)

Health Policy and Planning, vol. 27, 2012, supplement 2, 79p

Decisions to introduce new vaccines into national immunisation programmes have become a highly complex endeavour. Today, thanks to scientific advances and renewed global interest in immunisation, more than a dozen antigens have been made available through public health services in developing countries, with reduced time delay compared with introduction in industrialised countries. Country decision makers can select vaccines from a portfolio of options. This is a privilege and a serious responsibility requiring due consideration, as any decision to select one vaccine will need to be taken in the light of the opportunity costs of not investing in another vaccine or health intervention. Moreover, country decision makers do nor form their decisions in a vacuum: the number of immunisation stakeholders in both the public and private sectors has increased and those stakeholders are equipped with varying levels of knowledge and expertise and may have vested interests.

Roles of pharmacists in expanding access to safe and effective medical abortion in developing countries: a review of the literature

R.K. Sneeringer and others

Journal of Public Health Policy, vol. 33, 2012, p. 218-229

Unsafe abortion continues to be a major contributor to maternal mortality and morbidity around the world. This literature review examines the role of pharmacists in expanding women's access to safe medical abortion in Latin America, Africa and Asia. Available research shows that although pharmacists and pharmacy workers often sell abortion medications to women, accurate information about how to use them safely and effectively is seldom offered. Improved training for pharmacists and pharmacy workers about unsafe abortion and medications that can induce abortion is needed.

'The standardisation of health is inevitable'

B. Clover

Health Service Journal, Apr. 26th 2012, p. 18-21

Dr Devi Shetty, founder of India's Narayana Hrudayalaya hospital chain, is famous for his high volume surgical hospitals. He argues that technology will be a major contributor to improving healthcare quality as demand rises. Advances in IT will inevitably promote standardisation, drive out unwarranted variation in practice and reduce costs. The drive towards standardisation will lead to work currently done by highly trained doctors being taken over by well equipped technicians. However, as demand rises health systems globally will need to train more doctors and nurses, breaking the power of medical associations which restrict entry to the professions. Dr Shetty argues for the creation of a single global university that would standardise medical training throughout the world.

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