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Welfare Reform on the Web (September 2005): Healthcare - Overseas

Are health Millennium Development Goals appropriate for Eastern Europe and Central Asia?

B. Rechel and others

Health Policy, vol.73, 2005, p.339-351

Article argues that the three health-related millennium development goals (reduction of child mortality, improvement of maternal health, and combating the spread of AIDS, malaria and other diseases) do not appropriately address the challenges faced by the countries of Eastern Europe and Central Asia. Because they ignore adult mortality, their achievement would result in relatively small gains in life expectancy. To achieve greater impact, health policies in the region need to supplement the classical Millennium Development Goals with indicators of adult health, particularly reduction of prevalence of cardiovascular diseases and external causes of death.

The decline in 'free' general practitioner care in Australia: reasons and repercussions

S. Hopkins and N. Speed

Health Policy, vol.73, 2005, p.316-329

Medicare is the Australian government funded health insurance system under which the population receives free or subsidised health care. One of the corner stones of the Medicare system is the practice of bulk-billing. Bulk-billing allows the medical practitioner to bill Medicare directly for payment for services instead of charging the patient. Since 2000, there has been a decline in the practice of bulk billing and an increase in patient charging, which has implications for access to health care by deprived groups. Article identifies two reasons for the decline in bulk billing: 1) failure of the Medicare reimbursement to keep pace with increases in medical practice costs; and 2) a decline in numbers of GPs in some areas leading to a decrease in price competition.

The diversity of prevention and health promotion services offered by Quebec community health centres: a study of infant and toddler programmes

L. Richard

Health and Social Care in the Community, vol.13, 2005, p.399-408

Quebec Local Community Health Centres aim to improve the health of the population they serve by taking a comprehensive, multi-disciplinary and community-based approach. Because of their comprehensive (i.e. preventive, curative and rehabilitative) mandate, the centres have been particularly affected by reforms involving the reallocation of resources towards ambulatory care services and away from hospitals and a renewed emphasis on health promotion. There are concerns that preventive and health promotion services may have been undermined by the more urgent need to care for sick patients in the community in a time of financial constraints. This study explores these concerns through an investigation of the range of health promotion services offered to infants and toddlers.

The effectiveness, acceptability and costs of a hospital-at-home service compared with acute hospital care: a randomized controlled trial

R. Harris and others

Journal of Health Services Research and Policy, vol.10, 2005, p.158-166 Patients over 55 years of age being treated for an acute medical problem in Auckland, NZ were randomised to receive either standard inpatient hospital care or hospital-at-home care. There were no significant differences in health outcome measures between the two groups. Significantly more patients receiving care at home reported high levels of satisfaction, as did more of their relatives. Relatives of the care at home group also reported lower scores on the Carer Strain Index. While caring for patients at home was significantly more costly than standard inpatient care, this was largely due to the hospital-at-home programme not operating at full capacity.

Field based evidence of enhanced healthcare utilization among persons insured by micro health insurance units in the Philippines

D.M. Dror and others

Health Policy, vol.73, 2005, p.263-271

Micro health insurance schemes in low-income countries are created by informal sector groups because poor people cannot access existing schemes or are dissatisfied with the benefits they offer. The policy choice to support and encourage micro health insurance schemes relies on the evidence that affiliation to these schemes increases healthcare utilisation. Study analysed data collected through a survey of 890 insured and 1063 uninsured households in the Philippines in 2002. Insured persons reported higher hospitalisation rates, higher rates of professionally attended deliveries, lower rates of delivery at home, a higher rate of primary care physician visits, a higher rate of diagnosed chronic disease, and better drug compliance among the chronically ill.

The flight of physicians from West Africa: views of African physicians and implications for policy

A. Hagopian and others

Social Science and Medicine, vol.61, 2005, p.1750-1760

West African physicians have been migrating away from there homelands since the first medical doctors were trained there in the mid-20th century. They go looking for better working conditions, better pay and better training and research opportunities. There is also now a deeply rooted culture of medical migration. Medical school faculty are role models for the benefits of migration (and subsequent return) and are proud of their students who successfully emigrate. Their departure reduces the health services available to the populace, depletes an important element of the middle class in West Africa, and diminishes the health sector's ability to expand.

From rhetoric to reality: including patient voices in supportive cancer planning

S.K. Tedford Gols, J. Abelson and C.A. Charles

Health Expectations, vol.8, 2005, p.195-209

Authors studied the implementation of a policy initiative to improve patient involvement in the planning of cancer care services across Ontario. They conducted case studies in three diverse regions of the province, using multiple data sources to evaluate patient participation in supportive care networks. In each case patient participation in practice fell short of the policy rhetoric. This is attributed to: a lack of clarity about who should participate and how; the dominance of regional cancer centres; and the emergence of competing priorities in the context of cancer care provision.

Health care during transition and health system reform: evidence from the poorest CIS countries

M.E. Bonilla-Chacin and E. Murrugarra with M. Temourov

Social Policy and Administration, vol.39, 2005, p.381-408

Paper examines the level, composition and allocation of public spending on health in the seven poorest CIS countries (CIS-7) in the light of the evolution of their health systems during transition. The analysis puts together the role of private spending vis-à-vis public spending and the equity implications of the level and composition of public spending. The financial constraints experienced by CIS-7 countries were reflected in a decrease in healthcare quality, the collapse of previously inefficient state healthcare, and the increased incidence of out-of-pocket expenditure. These factors, combined with an increase in poverty, led to a decrease in healthcare utilisation.

Information and access to health care: is there a role for trust?

M. Thiede

Social Science and Medicine, vol.61, 2005, p.1452-1462

Paper analyses the driving forces of trust and distrust in health care in culturally diverse societies and identifies barriers for the individual and the community in the transfer of information. Specific characteristics of health communication turn out to be the key determinants of access. Trust plays a key role in the utilisation of any information provided. However, while trust enhances communicative interaction, it is the process of communicative interaction that generates trust in the first place.

Intersectoral problems in the Russian organisation of public health

R. Axelsson and S. Bihari-Axelsson

Health Policy, vol.73, 2005, p.285-293

Following the fall of Communism, public health activity in Russia continued to be based on the ideals and priorities of the Soviet era. Public health is regarded as mainly the responsibility of the health sector, but work is also done in other sectors, such as education, local communities, and the social insurance system. There is a strong Russian tradition of prophylactic treatment in sanatoriums and health resorts, which is largely financed by social insurance. Based on three qualitative studies, this article describes the organisation of public health activity in the Russian Federation, and analyses problems of inter-sectoral co-ordination and collaboration. It focuses on relations between the health sector and the social insurance system.

Is universal coverage a solution for disparities in health care? Findings from three low income provinces in Thailand

C. Suraratdecha, S. Saithanu, and V. Tangcharoensathien

Health Policy, vol.73, 2005, p.272-284 In April 2001

Thailand implemented a pilot universal health insurance coverage scheme in six provinces. By April 2002, the universal coverage system had been implemented in all 76 provinces. Following universal coverage implementation, the Thai health insurance system consists of 1) the compulsory Social Security Insurance Scheme (SSI) for private sector employees; 2) the Civil Service Medical Benefit Scheme for public sector workers; and 3) the Gold Card scheme for people not covered by the other two and with housing registration in a given catchment area. Study investigated the effectiveness of the universal coverage initiative in terms of targeting, coverage, care seeking behaviour, households' ability to take up benefits, and the burden of out-of-pocket expenditure on health care.

The market shaping of charges, trust and abuse: health care transactions in Tanzania

P. Tibandebage and M. Mackintosh

Social Science and Medicine, vol.61, 2005, p.1385-1395

In Tanzania, accessing healthcare is a market transaction requiring payment. Low-paid healthcare workers have incentives to abuse patients by, for example, demanding bribes or selling drugs at inflated prices. This undermines trust in the system, which creates a barrier to access. However, the authors also found examples of facilities which gained trust through the avoidance of abuse. This avoidance arose from individual probity and good management, and was also found in religious facilities and a majority of rural government dispensaries.

The medicine user – lost in translation? Analysis of the official political debate prior to the deregulation of the Danish medicine distribution system

M. Noerreslet, J.B. Larsen and J.M. Traulsen

Social Science and Medicine, vol.61, 2005, p.1733-1740

Prescription only and over-the-counter medicines have traditionally been sold in Denmark only by pharmacies with public authorisation. Following a debate initiated in 1999, a limited selection of over-the-counter medicines was released for sale by retailers in 2001. In an attempt to clarify how consumerism in health care is manifested in policy, this study explores how central actors in the political process explicitly referred to the needs, interests and problems of users of medicines. Results of an analysis of official documents show that explicit references to consumers by central actors in the political process were limited. Authors conclude that deregulation occurred without direct involvement of medicine users, and with very limited explicit consideration of their needs and interests.

Private obstetric practice in a public hospital: mythical trust in obstetric care

W. Riewpaiboon and others

Social Science and Medicine, vol.61, 2005, p.1408-1417

Study found that patients' trust in obstetric services was influenced by their perceptions of risk and uncertainty in pregnancy and childbirth, and that these perceptions were linked to social class. Social class also influenced the accessibility and affordability of care. Middle class women with high levels of concern about risk preferred using private services as a means of building interpersonal trust between themselves and their doctors. However, in practice, obstetricians rarely fulfilled their part of the psychological contract by delivering the higher standards of care and courtesy expected by their private patients. Negative outcomes from private practice often caused disappointment which could lead to litigation.

Relating health policy to women’s health outcomes

J.P. Wisdom. M. Berlin and J.A. Lapidus

Social Science and Medicine, vol.61, 2005, p.1776-1784

This exploratory study sought to determine if associations exist between US state health policy indicators and women's health outcomes. The policies evaluated included laws, statutes, regulations and programmes that are important to women's health. The health outcomes included were the four leading causes of death for women in the US (heart disease, lung cancer, stroke and breast cancer), infant mortality and a mental health variable. Results showed that increasing access to medical care is essential for reducing heart disease and stroke incidence and infant mortality and is highly influenced by state policy. States can take steps to expand eligibility for Medicaid so that more residents have access to preventative care and treatment. Further, states can require that health insurance covers preventative care such as smoking cessation programmes and nutrition advice. States' commitment to environmental health tracking and tackling violence against women were also associated with mortality outcomes.

Towards a 21st century health system: the contributions and promise of prepaid group practice

A. C. Enthoven and L.A. Tollen (editors)

San Fransciso, Calif.: Jossey-Bass, 2004

This volume offers students of American health care a perspective on the value of prepaid group practice as a cost-efficient, high-quality alternative to the more common network-based form, the target of so-called managed care backlash of the late 1990s. The book offers analyses that explore a key element of the health care delivery system - physician group practices, including organized systems, quality of care in prepaid group practice versus other types of managed care and prepaid group practice and the national health policy. This resource also covers such topics as pharmacy benefit management, technology assessment, health services research, and employer purchasing of benefits - as they all relate to prepaid group practice.

Treatment seeking behaviour in urban Sri Lanka: trusting the state, trusting private providers

S. Russell

Social Science and Medicine, vol.61, 2005, p.1396-1407

This paper distinguishes between trust based on the perceived technical competence of medical staff and that based on interpersonal dimensions of quality of care. Trust is also analysed at two levels: personal trust that is built through face-to-face encounters with providers, and more abstract institutional level trust. Paper applies these notions of trust to examining the treatment seeking behaviour of people in two poor urban communities in Sri Lanka. People trusted public providers in cases of serious illness because treatment was free and they had confidence in the technical competence of the staff and the institution. However, because interpersonal quality of care was lacking in the public sector, people preferred private providers for moderate acute illnesses. Using the private sector saved time, the doctors listened, and better interpersonal relationships could be built.

Trust in micro-health insurance: an exploratory study in Rwanda

P. Schneider

Social Science and Medicine, vol. 61, 2005, p.1430-1438

In 1998, shortly after the reintroduction of user fees, the Rwandan Ministry of Health implemented micro-insurance schemes in three districts. These provide members with cover for care in local health centres, ambulance transport to the district hospital and a limited package of in-patient services there. Information collected from focus groups showed that:

  • Trust towards healthcare providers was based on their technical and interpersonal skills and the working conditions in health facilities.
  • Trust in the micro-health insurance scheme was based on an accounting system that ensured sound financial management and timely reimbursement of providers, the presence of democratically elected leaders and negotiation with providers for a better quality of care.
  • Public authorities could build trust in micro-health insurance through information campaigns, supervision of MHI and provider performance, and subsidising membership for vulnerable groups.
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