Intimate partner violence in the Balkans: the example of Albania

Our aim was to describe the prevalence and associated factors of intimate partner violence in postcommunist countries of South East Europe (SEE). Review of recent reports regarding intimate partner violence in SEE countries as documented in the official Web sites of the World Health Organization (WHO), the United Nations Children’s Fund (UNICEF), Minnesota Advocates for Human Rights, Centers for Disease Control, and Medline. In Belgrade, Serbia and Montenegro, the prevalence of physical violence against women has been reported as 69.8%. In a reproductive health survey conducted in 1997 in Moldova, 22% of the women interviewed reported they had been abused by a partner or former partner at some time in their lives. More than 31% of female university students in Macedonia have reported that they had been victims of physical or psychological violence. Data from Albania indicate that spousal physical violence is one of the highest reported internationally. In Tirana, the Albanian capital city, the prevalence of past-year physical intimate partner violence was reported by 37% of women interviewed. The most empowered Albanian women were most likely to experience physical abuse and the least powerful men and those of rural origin were most likely to perpetrate spousal violence. Notwithstanding the lack of well-documented data and the questionability of extent to which the reported results are comparable among different SEE countries, the evidence suggests that intimate partner violence is an important public health problem in transitional countries of SEE. Information on intimate partner abuse can provide valuable clues to primary care and community care practitioners about the health status of female populations.     

Violence against women: the role of the health sector in international legislation

Objectives

To identify and describe the responsibilities attributed to health administrations in preventing and addressing violence against women in the international legislation on this issue.

Methods

We carried out a content analysis of the laws on violence against women collected in the following legal databases: the Annual Review of Law of Harvard University, the United Nations’ Secretary-General's database on Violence against Women, the International Digest of Health Legislation and Stop Violence against Women. All legal documents explicitly mentioning the participation of the health sector in interventions against violence against women were identified. Subsequently, the interventions selected were classified into primary, secondary and tertiary prevention, as defined by the World Health Organization in its first World Report on Violence and Health (2002).

Results

Of the 115 countries analyzed, 55 have laws on violence against women that include the participation of the health sector in interventions concerning this phenomenon. In most of these countries, this participation focusses on reporting detected cases and on providing healthcare and assistance to women referred from police services. We identified 24 laws that explicitly mention the interventions developed by the health sector, mainly consisting of tertiary prevention. The laws of Mexico, Colombia, Argentina, El Salvador, Spain and the Philippines include interventions involving the three levels of prevention.

Conclusions

One-fourth of the laws concerning violence against women studied incorporate specific interventions in the health sector, suggesting that a comprehensive approach to the problem is still required. Greater utilization of the potential of this sector is required in interventions to prevent violence against women.     

Building integrated health systems in central and eastern Europe: an analysis of WHO and World Bank views and their relevance to health systems in transition

BACKGROUND: Two questions are addressed. i) What are the views on health and health systems as expressed in the World Development Report 2000/2001 of the WB and the World Health Report 2000 and Health 21 of the World Health Organization, and how compatible are those views? ii) To what extent will compliance of CEEC and NIS with the WHO and WB recommendations result in health systems that produce maximum health for all by adequately addressing the needs of their populations? METHOD: The reports prepared by the World Bank and the World Health Organization were assessed against the theoretical framework of a needs-based public health approach. RESULTS: It is observed that the WHO and WB approaches are currently converging, although there remain differences in their respective focuses. The main merit of the WHO approach is its focus on performance and the systems approach towards health (care). The merit of the WB view is the integrated approach to health, education and poverty. It is argued that CEEC and NIS need to anticipate an ageing population and growing numbers of chronically ill. This calls for integrated health care systems and more integrated funding and payment systems. CONCLUSION: The recommendations provided in the WHR and the WDR with regard to integrated care and integrated financing remain rather abstract. Advisors of CEEC and NIS on health care reform and Western assistance projects should focus more on future needs, in order to avoid building health systems that consistently lag behind the needs of their populations.     

Shifting of emphasis in the world health sector strategy; from political concerns to economic ones

Primary Health Care, proclaimed by WHO in 1978, is a health strategy that aims to achieve the ultimate objective "Health For All", with underlying political concerns for ideals such as social justice, equity and human rights. Meanwhile, "globalization", urged by the U.S.A., other developed countries and multinational corporations, has since promoted liberalization of trade, capital and finance, which has in the past few decades been sweeping all over the world. With this "new economic liberalism", values that put much emphasis on economic efficiency are now at the forefront. The World Bank, which supports the tendency along with the International Monetary Fund and the World Trade Organization, has become an influential actor in helping developing countries to prosper economically. The World Bank, whose basic idea is that investment in health is basic for economic growth, has in the 1990s also exerted considerable influence on the international health sector with its overwhelming provision of financial assistance. Instead of political concerns like equity and human rights, 'economic concerns' such as fairer budget allocation, cost-effectiveness, cost reduction and efficiency have now become main points for discussion in the international health field. This shift in emphasis poses fundamental questions for the core goal of the World Health Organization; "Health For All".     

The Role of Major Donors in Health Aid to the Democratic People's Republic of Korea

We investigated the major trends in health aid financing in the Democratic People''s Republic of Korea (DPRK) by identifying the primary donor organizations and examining several data sources to track overall health aid trends. We collected gross disbursements from bilateral donor countries and international organizations toward the DPRK according to specific health sectors by using the Organization for Economic Cooperation and Development creditor reporting system database and the United Nations Office for the Coordination of Humanitarian Affairs financial tracking service database. We analyzed sources of health aid to the DPRK from the Republic of Korea (ROK) using the official records from the ROK''s Ministry of Unification. We identified the ROK, United Nations Children''s Fund (UNICEF), World Health Organization (WHO), United Nations Population Fund (UNFPA), and The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) as the major donor entities not only according to their level of health aid expenditures but also their growing roles within the health sector of the DPRK. We found that health aid from the ROK is comprised of funding from the Inter-Korean Cooperation Fund, private organizations, local governments, and South Korean branches of international organizations such as WHO and UNICEF. We also distinguished medical equipment aid from developmental aid to show that the majority of health aid from the ROK was developmental aid. This study highlights the valuable role of the ROK in the flow of health aid to the DPRK, especially in light of the DPRK''s precarious international status. Although global health aid from many international organizations has decreased, organizations such as GFATM and UNFPA continue to maintain their focus on reproductive health and infectious diseases.     

An analysis of Liberia's 2007 national health policy: lessons for health systems strengthening and chronic disease care in poor, post-conflict countries

Background

Globally, chronic diseases are responsible for an enormous burden of deaths, disability, and economic loss, yet little is known about the optimal health sector response to chronic diseases in poor, post-conflict countries. Liberia's experience in strengthening health systems and health financing overall, and addressing HIV/AIDS and mental health in particular, provides a relevant case study for international stakeholders and policymakers in other poor, post-conflict countries seeking to understand and prioritize the global response to chronic diseases.

Methods

We conducted a historical review of Liberia's post-conflict policies and their impact on general economic and health indicators, as well as on health systems strengthening and chronic disease care and treatment. Key sources included primary documents from Liberia's Ministry of Health and Social Welfare, published and gray literature, and personal communications from key stakeholders engaged in Liberia's Health Sector Reform. In this case study, we examine the early reconstruction of Liberia's health care system from the end of conflict in 2003 to the present time, highlight challenges and lessons learned from this initial experience, and describe future directions for health systems strengthening and chronic disease care and treatment in Liberia.

Results

Six key lessons emerge from this analysis: (i) the 2007 National Health Policy's 'one size fits all' approach met aggregate planning targets but resulted in significant gaps and inefficiencies throughout the system; (ii) the innovative Health Sector Pool Fund proved to be an effective financing mechanism to recruit and align health actors with the 2007 National Health Policy; (iii) a substantial rural health delivery gap remains, but it could be bridged with a robust cadre of community health workers integrated into the primary health care system; (iv) effective strategies for HIV/AIDS care in other settings should be validated in Liberia and adapted for use in other chronic diseases; (v) mental health disorders are extremely prevalent in Liberia and should remain a top chronic disease priority; and (vi) better information systems and data management are needed at all levels of the health system.

Conclusions

The way forward for chronic diseases in Liberia will require an increased emphasis on quality over quantity, better data management to inform rational health sector planning, corrective mechanisms to more efficiently align health infrastructure and personnel with existing needs, and innovative methods to improve long-term retention in care and bridge the rural health delivery gap.     

Managing externally financed projects: the Integrated Primary Health Care Project in Bolivia.

Bolivia is one of the poorest countries in Latin America. Health indicators are very poor, communicable diseases are prevalent and, coupled with malnutrition, remain the major killers of children under 5 years old. The Integrated Primary Health Care Project (PROISS) was a US$39 million project executed by the Ministry of Health (MOH), 50% financed by the World Bank and aimed at improving primary health care in the four largest Bolivian municipalities. The implementation of the project started in 1990 and ended in 1997. During implementation it went through three distinct phases: Phase 1 (1990-94) was a period characterized by conflict and confusion; Phase 2 (1995-mid-1996) documented major improvements in coverage and service quality; and Phase 3 (mid-1996-97) witnessed the decline of the project. This paper explores the factors that contributed to the success and the decline of the project, draws lessons for project managers and international agencies involved in the definition and implementation of social sector projects, and discusses the unlikelihood that externally financed projects can have a sustainable impact on the development of the health sector of recipient countries.     

From cooperation to competition in national health systems--and back?: impact on professional ethics and quality of care

Ethical behaviour in health workers is the jewel in the crown of health services. Health system policies need to nurture a professional service ethic. The primary health care policy envisioned a national health system led by the public sector and based on a philosophy of cooperation. A common theme of 'health sector reform' in OECD countries, introduced in the context of neoliberalism, has been the use of 'managed competition' to increase efficiency. Some countries that flirted with health system competition have returned to cooperation. Market relationships tend to be oppositional and to stimulate self-seeking behaviour. Health system relationships should encourage patient and community centred behaviour. The World Bank and bilateral donors have exported health sector reform theories from the north to the south, involving privatization and marketization policies. This is despite the lack of evidence on their desirability or feasibility of implementing them. Private health care has increased in many developing countries, more as a result of economic crisis and liberalization than specific health sector reforms. Much of this private practice is unlicensed and unregulated, and informal privatization has had a damaging effect on health worker ethics. The lead policy should be reconstruction of the public health system, involving decentralization, democratization and improved management. Commonsense contracting of an existing private sector is different from a policy of proactive privatization and marketization. Underlying the two approaches is whether health care should be viewed as a human right best served by socialized provision or a private good requiring governments only to correct market failures and ensure basic care for the poor. It is a matter of politics, not economics.     

The pioneers of rural Pakistan: The lady health visitors

Since 1978, when the World Health Organization and the United Nations International Children's Emergency Fund called for urgent action by all governments to provide appropriate health care for the underprivileged, the world community has attempted to implement primary health care strategies. Pakistan, with a population of 118 million people, is one of those countries where the rural population and the underprivileged groups in the katchi‐abadis (squatter settlements) of the urban areas lack appropriate and accessible health services. This article highlights the community experiences of a remarkable group of young Muslim women, the Lady Health Visitors (LHVs) of the Aga Khan Health Services, who deliver primary health care services to disadvantaged women and children in the northern mountainous areas and rural villages of Pakistan. The LHVs are the first contact with the health care system that these underprivileged women experience. The LHVs cure, care, teach, and train traditional birth attendants. In addition, they perform health promotion and document their findings. To provide their maternal and child health services, the LHVs travel by foot through miles of rough terrain to settlements and villages. Prenatal and postnatal care, anemia, diarrhea, and malnutrition are among the major health care problems of these rural women and their children under 5 years of age.     

Health sector growth and changes in the blend of health groups in seven countries over two decades.

A World Health Organization questionnaire collected census data from 1951, 1961, and 1971 in 7 countries to study growth of the health manpower sector. All the data from England and Wales, Austria, West Germany, Hungary, Sweden, Switzerland, and Senegal are tabulated. The study shows a rapid increase in the number of health personnel during these years. In all the countries, the number of people working in the health sector increased more rapidly than the total work force. In the European countries, the most rapidly growing portions of the health personnel sector are the other nursing and midwifery sections; in Senegal, the greatest increase occurred in the nursing sector. Both of these increases were at the expense of the more professional parts of the health manpower sector. Definitions of the health service industry and census dates vary from 1 country to another. Nevertheless, comparisons were possible both for different censuses in 1 country and for similar dates in different countries. This large increase in manpower does not imply a consistent increase in the quality of health care in any of these countries. Reasons for the increase are cited.     

Comparative analysis of the non-profit, for-profit and public hospital providers: American experiences

BACKGROUND AND OBJECTIVES: The new legislation allowed hospitals and other health care facilities to be converted into for-profit status. The detailed regulatory framework is under development in Hungary. This article reviews the literature of studies comparing hospital financial performance and the quality of care before and after conversion from public or non-profit status to for-profit. METHODS: Studies were identified through electronic search of Medline (Pubmed), EconLit, Cochrane Library, Economic Evaluation Database (EED), az Health Technology Assessment (HTA) databases, library files and reference lists. The literature search was extended to the Internet, World Bank, International Labor Office (ILO), Organization for Economic Cooperation and Development (OECD), and WHO websites as well as government, academic institutions and large insurance companies web pages for unpublished online information. Time series and before-after studies and systematic literature reviews were included. RESULTS: The conversion from non-profit to for-profit status improved the profitability of the hospitals. However the quality of care (measures in mortality, frequency of side effects, complications) might suffer in the first couple years of the conversion. The conversion may increase the total health care expenditures per capita. Trustful relationship between patients and physicians may also be threatened. CONCLUSION: The generalisability of the American experiences into the Hungarian single payer system may be limited. From societal point of view, for-profit providers could provide socially beneficial care in areas where it is possible to define, monitor and evaluate the nature and quality characteristics of the services, as well as market competition can be ensured. However most of the healthcare services are too complex to fall into this category.     

Market share of the for-profit and not-for-profit sector from health insurance expenditures

AIM: The aim of the study is to analyze the market share of for-profit private and not-for-profit sector from the expenditures on medical services of the Hungarian National Health Insurance Fund (NHIF), to show its changes in the last years and to show on which field they can be found. DATA AND METHODS: The data derives from the financial database of the National Health Insurance Fund (NHIF) covering the period 1995-2002. The analysis includes the medical provisions (primary care, health visitors, dental care, out- and inpatient care, home care, kidney dialysis, CT-MRI). RESULTS: In 1995 only 6.91% (12.5 billions Ft) of total expenditure for medical services went to for-profit private providers. By 2002 the market share of private providers increased to 15.95% (78.5 billions Ft). During the same period we realized a dynamic increase in the market share of non-profit sector: from 1.04% in 1995 to 2.58% in 2002. The role of private providers is dominant in the case of general practitioners, dental care, transportation, kidney dialysis, CT/MRI and home care (home nursing). CONCLUSIONS: The financial data of the NHIF showed the dynamic increase of market share of for-profit private providers and non-profit sector in many field of health care, although they role in the two most important fields (out- and inpatient care) is still negligible.     

Management of chronic Hepatitis B infection in the remote primary health care setting: the search for a suitable guideline

Objective: To identify a regionally appropriate guideline for the primary health care management of chronic Hepatitis B patients in the Torres Strait. Design: Literature review. PubMed (1950–November 2009), Nursing and allied health (CINAHL)‐CD (1982–November 2009), and the following databases accessed through INFORMIT: Australian Public Affairs Information Service – Health (1978–November 2009), Aboriginal and Torres Strait Health Bibliography (1900–November 2009), Health & Society Database (1980–November 2009), Health Collection (1980–November 2009), Meditext (1968–November 2009), and Rural and Remote Health Database (1966–January 2006) were searched over a 3‐month period from September to November 2009. An Internet search of relevant guidelines and recommendations from professional bodies such as the World Health Organization was also performed. Setting: Remote primary health care. Outcome measures: Initial searching identified 144 articles to include based on the provision of recommendations or guidelines for management of Hepatitis B at the primary care level. Included articles were then reviewed for their appropriateness to the remote primary health care setting against a set of five criteria determined at a consensus meeting of eight local medical officers. Results: Eleven articles were included for final review of which none met all five criteria of appropriateness for the remote primary health care setting. Conclusions: Guidelines need to recognize the difficulties of rural and remote practice and present practical alternatives to urban centred recommendations.     

Essential drugs and registration of pharmaceuticals: the Sri Lankan experience.

Many factors influence the regulation of pharmaceuticals in a country. The essential drugs concept, formulated by the World Health Organization to assist developing countries in selecting appropriate drugs, also provides a basis for regulation. Sri Lanka has long regulated pharmaceuticals as part of its health policy. Over 70% of 3436 pharmaceutical product registrations were found to be drugs (or alternatives) named in the country''s essential drugs list. This is despite the fact that product registrations are mainly for the private health care sector, and the list is for the state sector. The essential drugs concept therefore appears to have influenced the pharmaceuticals registered in Sri Lanka.     

Who pays and who benefits from health care? An assessment of equity in health care financing and benefit distribution in Tanzania

Little is known about health system equity in Tanzania, whether in terms of distribution of the health care financing burden or distribution of health care benefits. This study undertook a combined analysis of both financing and benefit incidence to explore the distribution of health care benefits and financing burden across socio-economic groups. A system-wide analysis of benefits was undertaken, including benefits from all providers irrespective of ownership. The analysis used the household budget survey (HBS) from 2001, the most recent nationally representative survey data publicly available at the time, to analyse the distribution of health care payments through user fees, health insurance contributions [from the National Health Insurance Fund (NHIF) for the formal sector and the Community Health Fund (CHF), for the rural informal sector] and taxation. Due to lack of information on NHIF and CHF contributions in the HBS, a primary survey was administered to estimate CHF enrollment and contributions; assumptions were used to estimate NHIF contributions within the HBS. Data from the same household survey, administered to 2224 households in seven districts/councils, was used to analyse the distribution of health care benefits across socio-economic groups. The health financing system was mildly progressive overall, with income taxes and NHIF contributions being the most progressive financing sources. Out-of-pocket payments and contributions to the CHF were regressive. The health benefit distribution was fairly even but the poorest received a lower share of benefits relative to their share of need for health care. Public primary care facility use was pro-poor, whereas higher level and higher cost facility use was generally pro-rich. We conclude that health financing reforms can improve equity, so long as integration of health insurance schemes is promoted along with cross-subsidization and greater reliance on general taxation to finance health care for the poorest.     

Strengthening institutional and organizational capacity for social health protection of the informal sector in lesser-developed countries: A study of policy barriers and opportunities in Cambodia

Reaching out to the poor and the informal sector is a major challenge for achieving universal coverage in lesser-developed countries. In Cambodia, extensive coverage by health equity funds for the poor has created the opportunity to consolidate various non-government health financing schemes under the government's proposed social health protection structure. This paper identifies the main policy and operational challenges to strengthening existing arrangements for the poor and the informal sector, and considers policy options to address these barriers. Conducted in conjunction with the Cambodian Ministry of Health in 2011–12, the study reviewed policy documents and collected qualitative data through 18 semi-structured key informant interviews with government, non-government and donor officials. Data were analysed using the Organizational Assessment for Improving and Strengthening Health Financing conceptual framework. We found that a significant shortfall related to institutional, organisational and health financing issues resulted in fragmentation and constrained the implementation of social health protection schemes, including health equity funds, community-based health insurance, vouchers and others. Key documents proposed the establishment of a national structure for the unification of the informal-sector schemes but left unresolved issues related to structure, institutional capacity and the third-party status of the national agency. This study adds to the evidence base on appropriate and effective institutional and organizational arrangements for social health protection in the informal sector in developing countries. Among the key lessons are: the need to expand the fiscal space for health care; a commitment to equity; specific measures to protect the poor; building national capacity for administration of universal coverage; and working within the specific national context.     

Human resources for health planning and management in the Eastern Mediterranean region: facts, gaps and forward thinking for research and policy

Background  

The early decades of the 21^st century are considered to be the era of human resources for health (HRH). The World Health Report (WHR) 2006 launched the Health Workforce Decade (2006–2015), with high priority given for countries to develop effective workforce policies and strategies. In many countries in the Eastern Mediterranean Region (EMR), particularly those classified as Low and Low-Middle Income Countries (LMICs), the limited knowledge about the nature, scope, composition and needs of HRH is hindering health sector reform. This highlights an urgent need to understand the current reality of HRH in several EMR countries.     

How does searching for health information on the Internet affect individuals' demand for health care services?

The emergence of the Internet made health information, which previously was almost exclusively available to health professionals, accessible to the general public. Access to health information on the Internet is likely to affect individuals' health care related decisions. The aim of this analysis is to determine how health information that people obtain from the Internet affects their demand for health care. I use a novel data set, the U.S. Health Information National Trends Survey (2003-07), to answer this question. The causal variable of interest is a binary variable that indicates whether or not an individual has recently searched for health information on the Internet. Health care utilization is measured by an individual's number of visits to a health professional in the past 12 months. An individual's decision to use the Internet to search for health information is likely to be correlated to other variables that can also affect his/her demand for health care. To separate the effect of Internet health information from other confounding variables, I control for a number of individual characteristics and use the instrumental variable estimation method. As an instrument for Internet health information, I use U.S. state telecommunication regulations that are shown to affect the supply of Internet services. I find that searching for health information on the Internet has a positive, relatively large, and statistically significant effect on an individual's demand for health care. This effect is larger for the individuals who search for health information online more frequently and people who have health care coverage. Among cancer patients, the effect of Internet health information seeking on health professional visits varies by how long ago they were diagnosed with cancer. Thus, the Internet is found to be a complement to formal health care rather than a substitute for health professional services.     

Allocation of authority in European health policy

Although many study the effects of different allocations of health policy authority, few ask why countries assign responsibility over different policies as they do. We test two broad theories: fiscal federalism, which predicts rational governments will concentrate information-intensive operations at lower levels, and redistributive and regulatory functions at higher levels; and "politicized federalism", which suggests a combination of systematic and historically idiosyncratic political variables interfere with efficient allocation of authority. Drawing on the WHO Health in Transition country profiles, we present new data on the allocation of responsibility for key health care policy tasks (implementation, provision, finance, regulation, and framework legislation) and policy areas (primary, secondary and tertiary care, public health and pharmaceuticals) in the 27 EU member states and Switzerland. We use a Bayesian multinomial mixed logit model to analyze how different countries arrive at different allocations of authority over each task and area of health policy, and find the allocation of powers broadly follows fiscal federalism. Responsibility for pharmaceuticals, framework legislation, and most finance lodges at the highest levels of government, acute and primary care in the regions, and provision at the local and regional levels. Where allocation does not follow fiscal federalism, it appears to reflect ethnic divisions, the population of states and regions, the presence of mountainous terrain, and the timing of region creation.