Impact of the politics of austerity in the quality of healthcare: ethical advice

This article aims to provide a series of reflections before implementing a restructuring of health system management and cutbacks in health due to the possible consequences this may have on citizens' health. The Universal Declaration of Human Rights states that public healthcare shall be extended to the whole population in conditions of effective equality and overcoming geographical and social imbalances, based on a comprehensive approach to the healthcare system. All of this – while we are aware of the current situation of economic crisis – should be taken into account before carrying out adjustments that will harm the health of citizens and options or alternatives that will not affect equity and healthcare should be weighed up. In conclusion, management models that enable the empowerment of nursing are more justified than ever before, because it is nurses who mostly defend positions of patient advocacy towards attitudes of greater commitment and participation.     

Health system structure and transformations in Colombia between 1990 and 2013: a socio-historical study

In 1993, Law 100 introduced major reforms to Colombia’s health system and regulated the health care industry. We analyzed the structure of the social space of Colombia’s health system and the transformations that took place between 1993 and 2013. We conducted a socio-historical study using a theoretical framework based on concepts developed by Pierre Bourdieu. In addition to documentary analysis, interviews were conducted with 26 key agents. We found that private health insurance companies situated at the ‘dominant’ pole accumulated capital and power during the period under study, while public and private providers situated at the ‘dominated’ pole face serious economic challenges due to the loss of capital and power. Measures taken by the state, a major funder of the system, to regulate the market have proved to be ineffective, forcing intervention from the legal field. More than two decades after Law 100 was introduced, health remains on the political agenda and the subject of dispute. A permanent crisis in the sector prevails partly due to the contradiction that exists between protecting the right to health, and strengthening of a profit-orientated market, thus hindering the fulfillment of the principles of quality and equity.     

Funding for public health in Europe in decline?

Concerns have been raised in recent years in several European countries over cutbacks to funding for public health. This article explores how widespread the problem is, bringing together available information on funding for public health in Europe and the effects of the economic crisis. It is based on a review of academic and grey literature and of available databases, detailed case studies of nine European countries (England, France, Germany, Italy, the Netherlands, Slovenia, Sweden, Poland, and the Republic of Moldova) and in-depth interviews. The findings highlight difficulties in establishing accurate estimates of spending on public health, but also point to cutbacks in many countries and an overall declining share of health expenditure going to public health. Public health seems to have been particularly vulnerable to funding cuts. However, the decline is not inevitable and there are examples of countries that have chosen to retain or increase their investment in public health.     

Inequalities in access to health care for people with disabilities in Chile: the limits of universal health coverage

We analysed cross-sectional data collected as part of the National Socioeconomic Characterisation Survey (2013) in Chile, in order to explore if there are differences in access to health care between adult Chileans with and without disability. The study included 7459 Chilean adults with disability and 68,695 people without disability. Logistic regressions were performed in order to determine the adjusted odds ratios for the associated variables. We found that despite universal health coverage, Chileans with disabilities are more likely to report worse access to health care, even when controlling for socio-economic and demographic variables, including age, gender and income. Specifically, they are more likely to face greater difficulty arriving at a health facility, obtaining a doctor’s appointment, being attended to in a health facility, paying for treatment due to cost, and obtaining necessary medicine. Both people with and without disability are more likely to face difficulties in accessing health services if they are affiliated with the public health provider, an indication of the economic factors at play in accessing health care. This study shows that universal health coverage does not always lead to accessibility of health services and underlines the disadvantaged position of disabled people in Chile in accessing health services. While efforts have been made recently to improve equity in health care access, disability in Chile poses an additional burden on people’s access to health care, emphasising the necessity for policy to address this perpetual cycle of disadvantage for disabled people.     

Values in European health care markets: Values in European health care markets

The discipline of public health has played an important rolein showing that the health of populations depends on more thanthe amount and quality of the health services available. Therelationship between health services and health status has beena traditional theme within the discipline. This paper proposesthat public health has a part to play in current health reformdebates and research, which have been dominated by attentionto economic incentives and the technical operation of the systems.The focus has been on the inputs to and processes within healthsystems, with relatively little attention to the likely impactof these changes on outcomes and population health. The paperconsiders one aspect of health reforms which affects populationhealth status: the part played by the social values of choiceand equity. It gives an analysis of these concepts to help evaluatereforms, and as a basis for empirical research into the impactof reforms. It considers how the NHS reforms have affected choiceand equity and how to increase patient choice and uphold certaintypes of equity which many health service staff and the publicbelieve to be important. It shows how some types of choice conflictwith some types of equity and that different groups in societybenefit according to whether choice or equity is more prominentin health reform. The purpose of this paper is to help researchers,public health practitioners and policy makers consider, fora particular health reform, the following questions: i) willreforms increase the choices which are important to most people?,ii) what will the effect be on different types of equity?, iii)how will the changes affect population health?, iv) how shouldpublic health aims be pursued in systems with market competition?     

Inclusion of equity in economic analyses of public health policies: systematic review and future directions

Objectives : To assess current approaches to inclusion of equity in economic analysis of public health interventions and to recommend best approaches and future directions. Methods : We conducted a systematic review of studies that have used socioeconomic position (SEP) in cost‐effectiveness analyses. Studies were identified using MedLine, EconLit and HEED and were evaluated based on their SEP specific inputs and methods of quantification of the health and financial inequalities. Results : Twenty‐nine relevant studies were identified. The majority of studies comparing two or more interventions left interpretation of the size of the health and financial inequality differences to the reader. Newer approaches include: i) use of health inequality measures to quantify health inequalities; ii) inclusion of financial impacts, such as out‐of‐pocket expenditures; and iii) use of equity weights. The challenge with these approaches is presenting results that policy makers can easily interpret. Conclusions : Using CEA techniques to generate new information about the health equity implications of alternative policy options has not been widely used, but should be considered to inform future decision making. Implications for public health : Inclusion of equity in economic analysis would facilitate a more nuanced comparison of interventions in relation to efficiency, equity and financial impact.     

Modelling the effects of intimate partner violence and access to resources on women's health in the early years after leaving an abusive partner

Although the negative health effects of intimate partner violence (IPV) are well documented, little is known about the mechanisms or determinants of health outcomes for women who had left their abusive partners. Using data collected from a community sample of 309 Canadian women who left an abusive partner, we examined whether women's personal, social and economic resources mediate the relationships between the severity of past IPV and current health using structural equation modelling. A good fit was found between the model and data for hypothesized models of mental and physical health. In the mental health model, both the direct and total indirect effects of IPV were significant. In the physical health model, the direct effect of IPV on physical health was about four times as large as the total indirect effects. In both models, more severe past IPV was associated with lower health and women's personal, social, and economic resources, when combined, mediated the relationship between IPV and health. These findings demonstrate that the health outcomes of IPV for women who have left an abusive partner must be understood in context of women's resources.     

江苏省卫生总费用及其历史演变分析

2010年江苏省卫生总费用占地区生产总值的比重为2.97%,政府卫生支出比重23.85%,居民个人卫生支出比重32.88%。虽然筹资结构进一步改善,但总体筹资任务仍十分艰巨。卫生机构的实际费用高于筹资总额,流向公共卫生和基层医疗卫生领域的费用占卫生总费用的比重持续走低。对此提出:应坚持政府在卫生领域的主导地位,从公平出发,积极干预卫生事业发展;同时,拓宽筹资渠道,增大卫生资源总量,以缓解患者看病就医矛盾。     

Using Cost-Effectiveness Analysis to Address Health Equity Concerns

This articles serves as a guide to using cost-effectiveness analysis (CEA) to address health equity concerns. We first introduce the "equity impact plane," a tool for considering trade-offs between improving total health—the objective underpinning conventional CEA—and equity objectives, such as reducing social inequality in health or prioritizing the severely ill. Improving total health may clash with reducing social inequality in health, for example, when effective delivery of services to disadvantaged communities requires additional costs. Who gains and who loses from a cost-increasing health program depends on differences among people in terms of health risks, uptake, quality, adherence, capacity to benefit, and—crucially—who bears the opportunity costs of diverting scarce resources from other uses. We describe two main ways of using CEA to address health equity concerns: 1) equity impact analysis, which quantifies the distribution of costs and effects by equity-relevant variables, such as socioeconomic status, location, ethnicity, sex, and severity of illness; and 2) equity trade-off analysis, which quantifies trade-offs between improving total health and other equity objectives. One way to analyze equity trade-offs is to count the cost of fairer but less cost-effective options in terms of health forgone. Another method is to explore how much concern for equity is required to choose fairer but less cost-effective options using equity weights or parameters. We hope this article will help the health technology assessment community navigate the practical options now available for conducting equity-informative CEA that gives policymakers a better understanding of equity impacts and trade-offs.     

The Commission on the Social Determinants of Health: reinventing health promotion for the twenty-first century?

This paper describes the work of the Commission on the Social Determinants of Health, established by WHO in 2005 and considers the potential for this Commission to contribute to a reinvention of health promotion for the twenty-first century. It argues that the Commission can do this by reinforcing the move that health promotion has been making since the 1980s to be less concerned with behaviour change and more concerned with creating the conditions in which health and well-being flourish. Specific contributions the Commission will make are: providing a vision of the moral importance and feasibility of a more equitable world; positioning health promotion as a task for the whole of the economy through action within the government sector and through assessment of the health equity impact of the corporate sector and neo-liberalism; through its Knowledge Networks, providing a much stronger evidence base than has previously been available on the social determinants of health and health equity including the actions and policies that are most likely to promote health and equity; providing a focus for the further growth of a global social movement advocating for health equity within and between countries; contributing to the reform of WHO and other international health agencies so that all programmes are built to take comprehensive action in communities and nationally to tackle the underlying causes of disease; adding legitimacy to moves to re-orientate health care systems to a focus on health promotion and population health.