Health care decisions at the household level: results of a rural health survey in Kenya

The observed visits to health care providers are an outcome of patients' health care decision-making process. Unlike the visits, this process is not observable. The paper first outlines this process, and then presents patterns of patients' visits to health care providers in a particular rural area in Kenya. The visit patterns are shown to vary greatly according to type of illness and to the stage of the illness. The paper has two main results. The first result is that in the study area, the majority of the patients sought medical treatment outside the 'free' government health care system. The other finding is that for a given illness episode, there is a very high likelihood of a patient consulting more than one provider for advice or treatment.     

The influence of the rural health security schemes on health utilization and household impoverishment in rural China: data from a household survey of western and central China

Background  

The New Rural Cooperative Medical Scheme (NRCMS, voluntary health insurance) and the Medical Financial Assistance (MFA, financial relief program) were established in 2003 for rural China. The aim of this study was to document their coverage, assess their effectiveness on access to in-patient care and protection against financial catastrophe and household impoverishment due to health spending, and identify the factors predicting impoverishment with and without these schemes.     

Why medical students will not practice in rural areas: evidence from a survey

A survey of medical students was held in order to determine the reasons why they were not willing to set up practice in rural areas after graduation. The reasons they gave were quite typical: lack of facilities, lack of opportunities for themselves and their family, poor income, etc. We also discovered that not many were acquainted with rural health conditions and a very great percentage wanted to go to the West for specialisation. We have tried to set their responses in light of the socio-economic and political system prevalent in a typical capitalist UDC. The conclusion that we have reached is that it is the class system in these societies which has determined the responses of the students, and it is the main factor which causes a dearth of medical manpower in rural areas.     

Sustainable primary health care services in rural and remote areas: innovation and evidence

Objective: To highlight how evidence from studies of innovative rural and remote models of service provision can inform global health system reform in order to develop appropriate, accessible and sustainable primary health care (PHC) services to ‘difficult‐to‐service’ communities. Methods: The paper synthesises evidence from remote and rural PHC health service innovations in Australia. Results: There is a strong history of PHC innovation in Australia. Successful health service models are ‘contextualised’ to address diverse conditions. They also require systemic solutions, which address a range of interlinked factors such as governance, leadership and management, adequate funding, infrastructure, service linkages and workforce. An effective systemic approach relies on alignment of changes at the health service level with those in the external policy environment. Ideally, every level of government or health authority needs to agree on policy and funding arrangements for optimal service development. A systematic approach in addressing these health system requirements is also important. Service providers, funders and consumers need to know what type and level of services they can reasonably expect in different community contexts, but there are gaps in agreed indicators and benchmarks for PHC services. In order to be able to comprehensively monitor and evaluate services, as well as benchmarks, we need adequate national information systems. Conclusions: Despite the gaps in our knowledge, we do have a significant amount of information about what works, where and why. At a time of global PHC reform, applying this knowledge will contribute significantly to the development of appropriate, sustainable PHC services and improving access.     

影响农村"家庭合同保健"入保率因素的探讨

目的：探讨影响农村家庭合同保健人保率的因素；方法：通过分层抽样调查，获取河南省武陟县在开展家庭合同保健制度两年多的相关资料，利用SPSS10．0对资料进行了相应处理；结果：家庭经济收入，性别，年龄都是影响家庭合同保健人保率的重要因素，尚不能认为文化程度对家庭合同保健人保率有影响。     

Providing hospice care in rural areas: challenges and strategies

Hospices in rural settings face challenges in the provision of hospice care as a result of their location and the size of their service area population. To ascertain the challenges that hospices face in serving rural communities, researchers conducted in-depth case studies of four different models of hospice care in rural areas. The authors describe strategies used by the case study hospices and recommend policies that could increase access to hospice care for rural Medicare beneficiaries and other rural residents. National initiatives to improve end-of-life care need to consider the special challenges faced by rural hospices.     

Impact of federal primary health care policy in rural areas: empirical evidence from the literature.

This review examines the equity, efficiency and effectiveness of federal rural primary care policy as documented by the existing literature. The focus is on the Community Health Center and National Health Service Corps programs which have constituted the major components of the policy. The literature relating to the policy is limited in the number of studies available and in the quality of the research. The available evidence indicates that the policy is associated with an improvement in the distribution of health resources between rural and urban areas,and among rural areas.There is also partial evidence that the policy has been cost-efficient. For federally subsidized practices,the cost of delivering a similar quality of health care is shown to be up to 50 percent less in rural than in urban areas. Rural private practitioners, though, may be more cost-efficient than federally subsidized rural practitioners, at least under certain conditions which have yet to be fully delineated. Program effectiveness is the least well documented, but the literature does suggest that the policy has had a positive effect on the health status of rural populations. Substantially more research on the efficiency, and particular the effectiveness, of federal rural primary care policy is required for the development of a rational basis for the policy.     

The impact of health insurance on outpatient utilization and expenditure: evidence from one middle-income country using national household survey data

Background

Achieving universal health insurance coverage by means of different types of insurance programs may be a pragmatic and feasible approach. However, the fragmentation of the health financing system may imply costs in terms of varying ability of the insurance programs to improve access to and reduce spending on care across different population groups. This study looks at the effect of different types of health insurance programs on the probability of utilizing care, the intensity of utilization, and individual spending on care in Jordan.

Methods

Using national household survey data collected in 2000 with a sub-sample of around 8,300 individuals, the study applies econometric techniques to a set of specified models along the two-part model approach to the demand for health care. By means of particular tests and other procedures, the robustness of the results is controlled.

Results

Around 60 percent of the population is covered by some type of insurance. However, the distribution varies across income groups, and importantly, the effect of insurance on the outcome indicators differ substantially across the various programs. Generally, insurance is found to increase the intensity of utilization and reduce out-of-pocket spending, while no general insurance effect on the probability of use is found. More specifically, however, these effects are only found for some programs and not for all. The best performing programs are those to which the somewhat better off groups have access.

Conclusion

Notwithstanding the empirical nature of the issues, the results point at the need to assess the effect of insurance coverage more profoundly than what is commonly done. Applying rigorous analysis to survey data in other settings will contribute to bringing out better evidence on what types of programs perform most effectively and equitably in different contexts.     

农村公共卫生体系建设的原则与策略

公共卫生建设是一项社会系统工程，需要政府、社会、团体和民众的广泛参与，公共卫生体系建设是本届政府发展卫生事业的重点之一。在广大农村基层，公共卫生体系建设应着重抓好三大中心、五大体系，三大中心即公共卫生中心、医疗救治中心和社区卫生服务中心，五大体系是指突发公共卫生事件应急指挥体系、疾病预防控制体系、卫生监督执法体系、医疗救治体系、公共卫生监测信息体系。     

Perceptions and utilization of primary health care services in Iraq: findings from a national household survey

Background

After many years of sanctions and conflict, Iraq is rebuilding its health system, with a strong emphasis on the traditional hospital-based services. A network exists of public sector hospitals and clinics, as well as private clinics and a few private hospitals. Little data are available about the approximately 1400 Primary Health Care clinics (PHCCs) staffed with doctors. How do Iraqis utilize primary health care services? What are their preferences and perceptions of public primary health care clinics and private primary care services in general? How does household wealth affect choice of services?

Methods

A 1256 household national survey was conducted in the catchment areas of randomly selected PHCCs in Iraq. A cluster of 10 households, beginning with a randomly selected start household, were interviewed in the service areas of seven public sector PHCC facilities in each of 17 of Iraq's 18 governorates. A questionnaire was developed using key informants. Teams of interviewers, including both males and females, were recruited and provided a week of training which included field practice. Teams then gathered data from households in the service areas of randomly selected clinics.

Results

Iraqi participants are generally satisfied with the quality of primary care services available both in the public and private sector. Private clinics are generally the most popular source of primary care, however the PHCCs are utilized more by poorer households. In spite of free services available at PHCCs many households expressed difficulty in affording health care, especially in the purchase of medications. There is no evidence of informal payments to secure health services in the public sector.

Conclusions

There is widespread satisfaction reported with primary health care services, and levels did not differ appreciably between public and private sectors. The public sector PHCCs are preferentially used by poorer populations where they are important providers. PHCC services are indeed free, with little evidence of informal payments to providers.     

The impact of a patient survey or a physician reminder on the provision of adolescent preventive health care.

BACKGROUND. The objective of this study was to determine if the use of a patient survey or a chart stamp could increase the implementation of adolescent preventive health care in a family practice center. METHODS. Subjects were all patients 13 to 18 years old (date of birth 1972 to 1977), who visited the Aultman Family Practice Centers from October 1, 1989, through September 30, 1990 (N = 801 patient visits). Three different 1-month interventions (patient questionnaire, physician stamp, and both patient questionnaire and physician stamp) as well as a 1-month control period were implemented. The effect of the intervention on adolescent preventive health care was measured by review of documentation in the patient's chart. RESULTS. Those charts that indicated that either the questionnaire or stamp had been used showed significantly more documented discussion of issues relating to mood, injury, sexuality, exposure to toxins, and lifestyle (all P < .01). These discussions most commonly took place during a visit for a physical examination. The percentage of visits with documented discussions did not vary significantly according to type of reminder, nor with any physician or patient characteristic. CONCLUSIONS. The use of a reminder, especially in the context of an office visit for a physical examination, significantly increased the implementation of adolescent preventive health care in this family practice center.     

Study protocol: Evaluating the impact of a rural Australian primary health care service on rural health

Background  

Rural communities throughout Australia are experiencing demographic ageing, increasing burden of chronic diseases, and de-population. Many are struggling to maintain viable health care services due to lack of infrastructure and workforce shortages. Hence, they face significant health disadvantages compared with urban regions. Primary health care yields the best health outcomes in situations characterised by limited resources. However, few rigorous longitudinal evaluations have been conducted to systematise them; assess their transferability; or assess sustainability amidst dynamic health policy environments. This paper describes the study protocol of a comprehensive longitudinal evaluation of a successful primary health care service in a small rural Australian community to assess its performance, sustainability, and responsiveness to changing community needs and health system requirements.     

Navigating care in rural areas: Strategies employed by older adults with continuing care needs and their impact on social exclusion

The literature recognizes the great diversity of care arrangements among rural-dwelling older people. However, little is known about the complex relationships between spatial, social and infrastructural characteristics of place and the strategies that older people develop to navigate care. Even less is known about how navigating care impacts social exclusion from the perspective of older adults themselves. To fill this gap, in this secondary analysis we draw on data from twenty-one in-depth interviews from two studies conducted in rural environments in Germany and Poland. We identify three main strategies of navigating care in the rural environment: adaptation to circumstances, making use of the environment, and shaping circumstances. We present details from four cases that exemplify how strategies are interconnected with characteristics of place. The relationships between place and navigating care in rural environments is discussed with reference to the overall level of social exclusion experienced by rural-dwelling older adults with continuing care needs.     

Evaluating antenatal care in Liberia: evidence from the demographic and health survey

Liberia has one of the highest maternal mortality ratios worldwide. Using quality antenatal care (ANC) can prevent maternal mortality. Indicators of quality ANC include: (1) timing of care initiation; (2) number of ANC visits (4+); and (3) ANC with recommended components. The purpose of this study was to examine factors associated with quality ANC in Liberia. Data from the 2013 Liberia Demographic and Health Survey were used (n = 5,348). Factors associated with quality ANC were assessed using multiple logistic regression. The majority of women attended at least four ANC visits (76.13%) and initiated care in the first trimester (66.5%); however, only 30% received care with all recommended components. Intended pregnancy, contraceptive use, and receiving ANC at a health facility with skilled providers were significantly associated with quality care. The lack of quality ANC may contribute to the high maternal mortality in Liberia. Facilitating access to health facilities and skilled ANC providers could improve the quality of care and potentially improve maternal outcomes over time. Additionally, focusing on empowering women with respect to access to birth control and control over pregnancies may increase the use of quality care.     

Out-of-pocket and informal payments in health sector: evidence from Georgia

This study presents an in-depth investigation of out-of-pocket payments for health services, formal and informal, in the Republic of Georgia. The main purpose of the study is to: (a) analyze the process of collection and distribution of out-of-pocket or direct payments and particularly of the informal component; (b) explain why they seem to be so prevalent; (c) investigate their consequences, especially on access and quality of health care services. The findings of this study are derived from in-depth interviews and focus group discussions with users as well as providers. The study found that in general paying for health services in Georgia has become a really common and mostly accepted practice, and that a significant share of these payments are completely unrecorded. The extent of direct payments for health services are producing severe consequences on both equity and efficiency, making services unaffordable for most people, and leading to under funding of essential inputs. The policy implications of the study findings are challenging. First, the study clearly points out the deep-rooted and multidimensional reasons why out-of-pocket payments are pervasive, and why an important share of them is collected informally. Second, the study highlights that there is no simple solution. In particular, some of the solutions frequently proposed in the international debate, such as simply formalizing user charges, in the Georgian context appear impractical.