Welfare Reform on the Web (March 2004): Healthcare - Overseas

ACCESS TO HEALTH CARE FOR ALL? USER FEES PLUS A HEALTH EQUITY FUND IN SOTNIKUM, CAMBODIA

W. Hardeman and others

Health Policy and Planning, Vol. 19, 2004, p. 22-32

User fees have been adopted by many low-income countries in an attempt to improve their health services. However many patients cannot afford the fees, blocking their access to healthcare. A Health Equity Fund that identifies the poor and pays on their behalf is one solution to the problem. The article examines one such Fund in Sotnikum, Cambodia, managed by a local non-government organisation. A survey was conducted to analyse the constraints poor people face when in need of hospital care and to assess to what extent the Fund help them to overcome these difficulties, questioning 68 patients across 26 villages. It found that the Cambodian Health Equity Fund supported 16% of hospitalised patients but identified four major constraints to hospital access:

• financial,
• geographical,
• informational,
• intra-household.

Results show that although the Fund improved financial access for the poor, other constraints remained. The article concludes by calling for further research into Health Equity Funds.

ACCESSIBILITY AND THE CANADIAN HEALTH CARE SYSTEM: SQUARING PERCEPTIONS AND REALITIES

K. Wilson and M. W. Rosenberg

Health Policy, Vol. 67, 2004, p.137-148

The Canadian health care system went through a series of changes in the 1990s as the federal government reduced its financial support to the provinces and the provincial governments responded by restructuring delivery. Consequently there is a growing perception among Canadians that health care is becoming less accessible as waiting times increase and services disappear. The paper examines perceptions of healthcare accessibility reflected in public opinion polls and actual accessibility as shown by Statistics Canada's National Population Health Survey (NPHS). Results show that contrary to public perceptions, only 6% of Canadians over 25 have experienced real problems accessing health care.

ACCESSING HEALTH CARE: RESPONDING TO DIVERSITY

J. Healey and M. McKee

Oxford: Oxford University Press, 2004

This book draws together examples of how to deal with diversity from health systems across the industrialised world. It considers population groups within countries, studying inherent population diversity (age, sex), citizen issues (migrants, asylum seekers), and ethnic and indigenous groups (multiculturalism in the UK). It identifies barriers to accessing health care services by diverse populations and cultural groups within different countries and considers the advantages and disadvantages of different delivery models for different population groups.

ASSESSING THE PERFORMANCE OF PRIMARY HEALTH CENTRES IN KERALA, INDIA

D. Varatharajan, R. Thankappan and S. Jayapalan

Health Policy and Planning, Vol. 19, 2004, p. 41-51

The article assesses the performance of primary health centres (PHC), which were brought under the control of local governments (panchayats) in 1996. The study had three stages:

• the first covering all 990 village panchayats;
• the second covering the top and bottom five ranks in terms of resource allocation to health;
• the third covering just two panchayats, one from the top rank and one from the bottom.

Data was examined from published and unpublished government documents, panachayat development reports, PHC records, facility checklists and key informant and client exit interviews. Results showed that panachayats allocated fewer resources to health than central government. The article concludes that PHCs must find ways to direct panchayats towards health before they lose their battle for resources.

CO-PAYMENTS IN THE AUSTRIAN SOCIAL HEALTH INSURANCE SYSTEM: ANALYSIS OF PATIENT BEHAVIOUR AND PATIENTS' VIEWS ON THE EFFECTS OF CO-PAYMENTS

G. Reichmann and M. Sommersguter-Reichmann

Health Policy, Vol. 67, 2004, p.75-91

Although the policy in Austrian healthcare has always been to maintain unrestricted access to services, recently the system has been under financial pressure. A variety of reforms have been implemented, including the introduction of additional, lump sum co-payments and increases to existing co-payments. The article examines patients' views regarding these co-payments, and assesses their effect both on health care demand and on patient behaviour. It begins with an in-depth description of Austria's social insurance system and the role of co-payments within it, before detailing the methodology of the study. Results show that co-payments have no major guiding effect on health care demand, and these finding are confirmed by patient behaviour. The article concludes with the recommendation that the co-payment system be standardised.

COUNTY LEVEL RESPONSES TO THE INTRODUCTION OF DRG RATES FOR "EXTENDED CHOICE" HOSPITAL PATIENTS IN DENMARK

K. Vranbaek and M. Bech

Health Policy, Vol. 67, 2004, p.25-37

Although choice of hospital is a hot topic in many European health systems, Denmark has allowed patients free choice since 1993. The article explores the effect on hospitals of DRG rates for extended choice, introduced in 2000. In particular, it focuses on how the rates have affected county level management of healthcare.

DIVERSITY AND CONSISTENCY: THE CHALLENGE OF MAINTAINING QUALITY IN A MULTIDISCIPLINARY WORKFORCE

R. Cooper and S. Stoflet

Journal of Health Services Research and Policy, vol.9, Suppl.1, 2004, p.39-47

Paper asks whether quality can be maintained in a system in which provision of medical care is shared with an array of non-physician clinicians. These include nurse practitioners, physician assistants, alternative and complementary practitioners, and mental health service providers. Evidence suggests that these non-physician clinicians are able to produce high quality outcomes under particular circumstances. They have been successful in offering care at the least complex end of the clinical spectrum, often with significant physician involvement. Few studies have investigated outcomes when they are operating autonomously, free of physician oversight.

THE EFFECT OF INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS ON OBSERVED QUALITY OF CARE OF UNDER-FIVES IN RURAL TANZANIA

Tanzania IMCI Multi-Country Evaluation Health Facility Survey Study Group

Health Policy and Planning, Vol. 19, 2004, p. 1-10

The Integrated Management of Childhood Illness (IMCI) is a strategy developed by, amongst others, the World Health Organisation and the United Nations Children's Fund to address major child health problems in the developing world through three components:

• improved case management;
• improved health systems support;
• improved family and community practices.

The study carried out a health facility survey to compare quality of case management and health system support indicators in four districts in Tanzania - two with IMCI and two without. This article specifically focuses on health facility support and quality of care for children under five. Results show that case management was significantly better in the areas with IMCI, where children received more thorough assessment and were more likely to be classified correctly. Health system support was more similar between the areas, with both scoring poorly on availability of essential equipment and materials. The study suggests that if IMCI is properly implemented it is likely to lead to rapid gains in child survival, health and development.

FEND FOR YOURSELF: SYSTEMATIC FAILURE IN THE DOMINICAN HEALTH SYSTEM

G. La Forgia and others

Health Policy, Vol. 67, 2004, p.173-186

The Dominican government over the past 50 years has linked public finance to public provision of inefficient and low quality health services. Government also allowed a market of private providers and insurers to grow in an unregulated environment, despite subsidising its creation. Lack of insurance regulation has led to rejection of high-risk individuals, disenrollment of people with chronic conditions, truncated benefits and unethical marketing practices. Many people are thus left without access to insurance or to good quality, affordable, healthcare.

THE IMPACT OF AGEING ON HOSPITAL CARE AND LONG-TERM CARE - THE EXAMPLE OF GERMANY

E. Schulz, R. Leidl and H-H. Konig

Health Policy, Vol. 67, 2004, p.57-74

The article examines the impact of population ageing on hospital and long-term care in Germany up until 2050. The hospital study involved two methodologies, the first examining hospital discharge and length of stay by age-group, gender and diagnosis while the second looked at the number of days spent in hospital by age-group, survivors and decedents in the last three years of their lives. The demographic scenarios used for hospital care were combined with age and gender specific data on beneficiaries of the long-term care insurance schemes, separated by level of disability and institutional setting for the long-term care study. Results for hospital care differed between the two methods; the first showed an initial increase in hospital days, followed by a decline while the second indicated an increase across the whole period. Results in the long-term care study showed that demand for long-term care will increase dramatically. The article concludes that hospital departments will need to be restructured and reorganised in order to cope with the demographic changes and that health policy must take these changes into account in order to be able to cope with future demands for services.

IMPROVING HEALTH SECURITY: A PILOT STUDY FROM FINLAND LINKING DISABILITY AND HEALTH EXPENDITURES

I. Vohlonen and others

Health Policy, vol.67, 2004, p.119-127

In Finland, funding for healthcare is provided by the municipalities and the state whereas disability payments pre- and post-treatment are the responsibility of the Social Insurance Institution. Pilot study seeks to demonstrate that inefficient delivery of health services due to perverse incentives within the sector generates unnecessary economic burdens for other public institutions involved in financing health security. Shows that diagnosis specific lengths of stay in hospital and lengths of disability vary considerably between municipalities and hospitals.

INCENTIVES AND PHARMACEUTICAL REIMBURSEMENT REFORMS IN SPAIN

J. Puig-Junoy

Health Policy, Vol. 67, 2004, p.149-165

Four main reimbursement policies can be observed in the Spanish pharmaceutical market after 1996:

• first - a second supplementary list of excluded pharmaceutical products was introduced in 1998;
• second - a reference pricing system was introduced in December 2000, with annual uprating and enlargement;
• third - the pharmacies' payment system has been moved from the traditional set margin on the consumer price to a margin that varies according to the consumer price of the product, the generic status of the product, and the volume of sales by pharmacies;
• fourth - general agreements between the government and the industry have been reached with cost containment objectives.

Article finally presents an overall assessment of the impact of these reimbursement policies on the behaviour of actors in the pharmaceutical market.

PETRO-STATE CONSTRAINTS ON HEALTH POLICY: GUIDELINES FOR WORKABLE REFORM IN VENEZUELA

A. J. Trujillo

Health Policy, Vol. 67, 2004, p.39-55

The article reviews the performance of the Venezuelan health care system and considers areas for reform. The present system, operating under an unstable economy brought about by the fluctuating oil market and the staunch Venezuelan values of solidarity and equity, is fraught with difficulties, including poor productivity, a weak private sector, a widespread sense of entitlement without accountability and poor governance. It argues that reform is desperately needed, but must take into account the idiosyncrasies of Venezuelan society in order to succeed. Suggestions include:

• creating a single public health system and using regulated sickness funds to finance medical care.
• using market forces as a new incentive;
• creating political incentives by devolving service delivery, budgeting and decision making to local level;
• emphasising public health measures and preventative care rather than hospitals and curative care;
• providing equal access to basic care and comprehensive treatment;
• working to increase the private sector's role in public health.

It concludes by reminding policy makers and stakeholders at all levels that they must work together to make this vision a reality.

THE POLICY ANALYSIS OF "VALUES TALK": LESSONS FROM CANADIAN HEALTH REFORM

M. Giacomini and others

Health Policy, Vol. 67, 2004, p.15-24

Although the importance of values is universally recognised, fundamental disagreements occur amongst health policy professionals as to what they essentially are, confusing policy deliberations. The article examines the entities that health reformers consider as values, and how these are used in health reform rhetoric. Thirty-six Canadian health reform documents published between 1990-1999 were studied, with results showing that the definition of values varies widely, in topic (e.g. health states, health services, equity, economic viability, etc) as well as in substance (e.g. goals, principles, attitudes, etc.). The article concludes by reviewing the diversity of concepts and discussing the implications for policy analysis.

REFORMING HEALTH CARE FINANCING IN BULGARIA: THE POPULATION PERSPECTIVE

D. Balabanova and M. McKee

Social Science & Medicine, Vol. 58, 2004, p.753-765

A severe economic shock in 1997 made long-avoided health reforms in Bulgaria essential. Based on the belief that any health and finance model should reflect the dominant values of beliefs of society, the article explores these, considering their compatibility with subsequent reform. It also examines people's attitudes to compulsory insurance, co-payments and voluntary insurance, comparing them with attitudes to the tax-based model that was in place at the time of the study. Results showed strong support for a social insurance system, which would be autonomous, state regulated, financing only health care and with optional membership.

STRATEGIES AND PERFORMANCE IN HOSPITALS

C. M. Garcia and I. de Val Pardo

Health Policy, Vol. 67, 2004, p.1-13

The article explores the extent to which strategic management is applied in Spanish hospitals. Data were gathered through questionnaires sent to hospital managers and from the hospitals' annual reports, providing details of organisational structure and performance. Strategies employed by the different hospitals were identified and hospitals with similar strategies placed into groups. Results showed that hospitals that employed strategic management across the board achieved better results.