Primary health services in Ecuador: Comparative costs, quality, and equity of care in ministry of health and rural social security facilities

This study of costs, quality and financial equity of primary health services in Ecuador, based on 1985 data, examines three assumptions, common in international health, concerning Ministry of Health (MOH) and Social Security (SS) programs. The assumptions are that MOH services are less costly than SS services, that they are of lower quality than SS services, and that MOH programs are more equitable in terms of the distribution of funds available for PHC among different population groups. Full costs of a range of primary health services were estimated by standard accounting techniques for 15 typical health care establishments, 8 operated by the MOH and 7 by the rural SS program (RSSP), serving rural and peri-urban populations in the two major geographical regions of Ecuador. Consistent with the conventional premise, MOH average costs were much lower than RSSP costs for several important types of services, especially those provided by physicians. Little difference was found for dental care. The lower MOH physician service costs appeared to be attributable primarily to lower personnel compensation (only partially offset by lesser productivity) and to greater economies of scope. Several measures of the quality of care were applied, with varying results. Based on staff differences and patterns of expenditures on resource inputs, notably drugs, RSSP quality appeared higher, as assumed. However, contrary to expectation, a questionnaire assessment of staff knowledge and procedures favored the MOH for quality. Program equity was judged in terms of per capita budgeted expenditures (additional measures, such as the likelihood of receiving necessary care, would have required household survey data beyond the scope of this program-based study). The results support the assumption of greater MOH financial equity, as its program reveals less variation in budgeted expenditures between different population groups covered. Additional evidence of equity, using other indicators, would be helpful in future research. The paper's findings have policy implications not only for Ecuador's health sector but also for policy-makers in other countries at similar levels of socioeconomic development. These implications are spelled out in order to guide officials wrestling with issues of efficiency, quality, and equity as they search for the best use of scarce resources to promote health.     

Economic costs of informal care for people with chronic diseases in the community: Lost income,extra welfare payments,and reduced taxes in Australia in 2015–2030

We estimated the economic costs of informal care in the community from 2015 to 2030, using an Australian microsimulation model, Care&WorkMOD. The model was based on data from three Surveys of Disability, Ageing, and Carers (SDACs) for the Australian population aged 15–64 years old. Estimated national income lost was AU$3.58 billion in 2015, increasing to $5.33 billion in 2030 (49% increase). Lost tax payments were estimated at AU$0.99 billion in 2015, increasing to AU$1.44 billion in 2030 (45% increase), and additional welfare payments were expected to rise from $1.45 billion in 2015 to AU$1.94 in 2030 (34% increase). There are substantial economic costs both to informal carers and the government due to carers being out of the labour‐force to provide informal care for people with chronic diseases. Health and social policies supporting carers to remain in the labour force may allow governments to make substantial savings, while improving the economic situation of carers.     

Effects of decentralisation and health system reform on health workforce and quality‐of‐care in Indonesia, 1993–2007

The impact of decentralisation, socioeconomic changes and healthcare reforms in Indonesia on type and distribution of healthcare providers and quality‐of‐care has been unclear. We examined workforce trends for healthcare facilities from 1993 to 2007 using the Indonesian Family Life Surveys. Each included a sample of public and private healthcare facilities, used standardised interviews for numbers and composition of staffing, and quality‐of‐care vignettes. There was an increase in multiprovider facilities and shift in profile of solo providers—increasing proportions of midwives and drop in doctors in rural areas (including facilities with doctors) and nurses in urban areas. Quality‐of‐care scores were low, particularly for nurses as solo providers. Despite increased numbers of healthcare workers and growth of the private sector, outer Java‐Bali and rural areas continued to be disadvantaged in workforce capacity and quality‐of‐care. The results have implications for accreditation and in‐service training requirements, the legal status of nurses and private sector regulation. Copyright © 2014 John Wiley & Sons, Ltd.     

Developing the public health practitioner workforce in England: lessons from theory and practice

FOCUS: The paper focuses on public health practitioners who collectively represent one of three key workforce groups identified by England's Chief Medical Officer as critical to the successful delivery of national public health policy priorities. QUESTION: We report on two areas of work which attempt to address the following two-part question: in developing the public health practitioner workforce in England, what is needed, and how do we do it? APPROACH: First, we describe a five-component conceptual framework for developing the public health workforce which is grounded in data derived from a national Open Space event hosted by the University of the West of England in March 2005. The five components are (i) strategic support and oversight; (ii) national technical and professional support; (iii) national career building; (iv) local organisational development, and (v) sub-regional skills development. Key elements of each component are described in the paper. Second, we describe in some detail a new multidisciplinary skills development programme which illustrates one of the framework components (sub-regional skills development). The programme, established in January 2005, is aimed at three key groups of public health practitioners: health visitors (specialist community public health nurse), school nurses and environmental health officers. Its main features and some initial evaluation findings are presented. CONCLUSIONS: To be effective, activities aimed at supporting the development of the public health practitioner workforce should, where possible, aim to be congruent with core public health principles of self-determination and collective responsibility. We also conclude that leadership and vision at a national level, combined with local implementation of evidence-based training programme such as the one described could help to achieve much greater and more rapid progress in skilling up the existing public health practitioner workforce than has been possible up to now. But we note that this requires sustained investment, robust sector-wide delivery frameworks, and a group of committed local public health champions.     

Cataract surgery in a community hospital outreach clinic: patients’ costs and satisfaction

A cataract day surgery service for the population of central Norfolk, UK, was provided by the main ophthalmic department in a district general hospital and in an outreach clinic in a community hospital 40 km distant. The outreach clinic aimed to extend the accessibility of this particular service in a rural area where many patients faced long journeys to the main hospital. Samples of 201 patients attending the main hospital for day cataract surgery and 198 patients attending the outreach clinic for the same procedure were identified. Patients were interviewed and given questionnaire forms to establish their general health before the operation, their arrangements to get to hospital and their satisfaction with the clinic and the care they had received. The sample of patients attending the outreach clinic was slightly older, less affluent and in slightly poorer general health than the patients attending the main hospital. The two samples were similar in terms of visual acuity after the operation, complication rates, satisfaction with the outcome of the operation and subsequent use of health services. The journey to hospital was quicker, more convenient and less costly for the outreach clinic patients than the main hospital patients. The net benefit to patients of the outreach clinic was estimated as £39,000 per annum. Satisfaction with administrative matters, facilities at the two clinics and the care received was high in both samples, but patients were significantly more satisfied with arrangements at the smaller outreach clinic. This evidence suggests that an outreach clinic in a small community hospital can provide cataract day surgery under local anaesthesia as effectively as a district centre, at a reduced social cost and with positive social benefits. Further study of heath service costs is vital, but political pressure to acknowledge patient preferences for more local services is growing.     

Assessing health facility performance in Indonesia using the Pabón‐Lasso model and unit cost analysis of health services

Total health care costs have dramatically increased in Indonesia, and health facilities consume the largest share of health resources. This study aims to provide a better understanding of the characteristics of the best‐performing health facilities. We use 4 national Indonesian datasets for 2011 and analysed 200 hospitals and 95 health centres. We first apply the Pabón‐Lasso model to assess the relative performance of health facilities in terms of bed occupancy rate and the number of admissions per bed; the model gathers together health facilities into 4 sectors representing different levels of productivity. We then use a step‐down costing method to estimate the cost per outpatient visit, inpatient, and bed days in hospitals and health centres. We combined both ratio analysis and applied bivariate and multivariate analyses to identify the predictors of the best‐performing health facility; 37% of hospitals and 33% of health centres were located in the high‐performing sector of the Pabón‐Lasso model. The wide variation in unit costs across health facilities presented a basis for benchmarking and identifying relatively efficient units. Combining the unit cost analysis and Pabón‐Lasso model, we find that health facility performance is affected by both internal (size and capacity, financing, type of patients, ownership, accreditation status, and staff availability) and external factors (economic status, population education level, location, and population density). Our study demonstrates that it is feasible to identify the best‐performing health facilities and provides information about how to improve efficiency using simplistic methods.     

Pioneers, paediatricians and public health: the evolution of community child health services, Clifton, Nottingham 1983–1999

Since 1976 developments in the training and services provided by general practitioners and community paediatricians have led to a series of changes in clinical services provided for children in the community. A series of studies carried out in the Clifton area of Nottingham from 1983 to 1999 illustrate this. A changing pattern of service delivery is reported in which clinical medical officers provided a largely primary care service in 1983 developing into a paediatric secondary care service in the next decade with the primary health care team having taken over the role of child health surveillance. The community services in the 1990s were taking over the investigation and management of paediatric problems previously seen in the hospital outpatient clinic. The studies illustrate the advantages of locally based services in terms of ease of parental access and consultation between the primary health care team and specialist children's services.     

Trends in adolescent contraceptive use, unprotected and poorly protected sex, 1991–2003

PurposeTo estimate trends in use and nonuse of effective protection among adolescents 1991–2003, and to assess factors associated with poorly protected sex in 2003.MethodsWe analyzed seven Youth Risk Behavior Surveys (YRBSs) of 9th–12th graders conducted from 1991 through 2003. We estimated trends in use of condoms, effective contraception, withdrawal, and no method, using linear logistic regression models, and evaluated correlates of the use of no method or withdrawal in 2003.ResultsThroughout 1991–2003, about one third of students reported that they had been sexually active in the previous 3 months. Condom use increased significantly throughout 1991–2003, from 46.2% (± 3.3%) in 1991 to 63.0% (± 2.5%) in 2003, and the percentage reporting use of either withdrawal or no method steadily declined, from 32.6% (± 2.7%) to 18.8% (± 2.1%). In 2003, use of withdrawal or no method was greater among females, Hispanics, those who had been pregnant or had caused a pregnancy, and those who reported feeling sad or hopeless or had considered suicide.ConclusionsReported unprotected sex decreased, while use of condoms increased. A high-risk group engaging in poorly protected sex was identified, accounting for 6.4% of students.     

The impact of the internal market on hospital efficiency, productivity and service quality

In this paper we use nonparametric mathematical programming models to compute and decompose Malmquist indices of productivity and quality change, which are used to evaluate the reforms in the UK National Health Service in the early nineties. We focus on acute hospitals and we study them over the first five years of the reforms. The findings of the study indicate that there was a productivity slowdown in the first year after the reforms but productivity progress in the subsequent years and thus, overall there was a net gain in productivity over the entire period considered. Productivity trends were dominated by technical change rather than hospital relative efficiency changes, as hospitals were already largely relatively efficient at the time of the introduction of the reforms. In fact, over the last four years in the period studied there was small relative efficiency regress and this does not bear out the argument that the reforms would increase hospital efficiency. The productivity changes are similar when service quality is incorporated in the analysis but the magnitude of these changes diminishes. Quality of service followed different trends to productivity change and this may have been the price for the productivity gains achieved.     

Comparison of the results of two rural allied health workforce surveys in the Hunter New England region of New South Wales: 2005 versus 2008

Objective: To compare the results of the 2005 and 2008 surveys of the rural allied health workforce in the study region. Design: Comparative analysis of two cross‐sectional surveys. Setting: The rural, northern sector of the Hunter New England region of NSW, Australia. Participants: Both surveys targeted 12 different allied health professions. There were 225 respondents in 2005 and 205 in 2008. Main outcome measures: Comparison is made for 15 dependent variables. Results: There was no significant difference for most variables between 2005 and 2008. Mean age and mean years qualified decreased slightly, from 43 to 41 years and from 20 to 17 years, respectively. The proportion of respondents of rural origin was about two‐thirds in both studies and about half had a rural placement during training. While more than half supervised students, only about one‐third had received training for that role. In both 2005 and 2008, the proportion working 35 or more hours each week was about 66% but the proportion working more than 40 hours had doubled to about 36%. In both surveys about half intended leaving their job within 10 years, while the proportion satisfied with continuing professional development access had halved, from 70% to 35%. Conclusions: Most results of the 2005 Hunter New England survey were verified. It was confirmed that a large proportion of the allied health workforce in the region intend leaving their job in the next 5 to 10 years. This is a concern for the development of new service delivery models.     

The mental health workforce in the community: a comparison of national Community Psychiatric Nursing and Approved Social Work survey results

In the past it has not been possible to compare the distribution and workload of two of the main professional groups providing mental health care in the community, community psychiatric nurses (CPNs) and approved social workers (ASWs) because no adequate national data were available. Two recent surveys permit a limited degree of comparison between the characteristics of the two national workforces and the present paper summarizes the comparison which can be made from the two different data sets, in terms of the numbers of staff and rates per head of population, number of clients seen, caseload variations and training. Training for, and provision of, out-of-hours services by ASWs are more uniform, but there is much less variation per head of population in the numbers of CPNs than ASWs across the UK. The CPNs are almost certainly working with more people with serious mental illness. There is some suggestion, which needs further research, that, in numerical terms, there might be an element of substitution of one discipline for another in different regions of the country.     

北京市社区卫生服务实施效果及建议

收支两条线管理是我国针对社区卫生服务机构实行的一项新财务管理制度,北京市是较早推行收支两条线管理的试点城市之一.通过对北京市社区卫生服务工作现状、财政资金投入以及社区卫生服务绩效结果进行分析,了解北京市收支两条线管理政策的实施效果及其影响,并对北京市社区卫生服务机构的发展提供政策性建议,以期完善以社区卫生服务为基础的新型城市医疗卫生服务体系.     

Access,equity and costs of induced abortion services in Australia: a cross‐sectional study

Objectives: To examine access and equity to induced abortion services in Australia, including factors associated with presenting beyond nine weeks gestation. Methods: Cross‐sectional survey of 2,326 women aged 16+ years attending for an abortion at 14 Dr Marie clinics. Associations with later presentation assessed using multivariate logistic regression. Results: Over a third of eligible women opted for a medical abortion. More than one in 10 (11.2%) stayed overnight. The median Medicare rebated upfront cost of a medical abortion was $560, compared to $470 for a surgical abortion at ≤9 weeks. Beyond 12 weeks, costs rose considerably. More than two‐thirds (68.1%) received financial assistance from one or more sources. Women who travelled ≥4 hours (AdjOR: 3.0, 95%CI 1.2–7.3), had no prior knowledge of the medical option (AdjOR: 2.1, 95%CI 1.4–3.1), had difficulty paying (AdjOR: 1.5, 95%CI 1.2–1.9) and identified as Aboriginal and/or Torres Strait Islander (AdjOR: 2.1, 95%CI 1.2–3.4) were more likely to present ≥9 weeks. Conclusions: Abortion costs are substantial, increase at later gestations, and are a financial strain for many women. Poor knowledge, geographical and financial barriers restrict method choice. Implications for public health: Policy reform should focus on reducing costs and enhancing early access.     

The costs of caring for stroke patients in a GP-led community hospital: an application of programme budgeting and marginal analysis

There has been little evaluation of the role of community hospitals in the provision of integrated health care services in a primary care-led health system. The aim of this study was to model the probable changes in the use of NHS resources from the introduction of integrated stroke care in a general pracititioner-led community hospital. A programme budgeting and marginal analysis (PBMA) exercise was conducted combining practice data for the 'before' period and data from the literature to model the 'after' period. Data were collected from all patients discharged with a primary diagnosis of stroke 1994-96 in Nairn and Ardersier Total Fundholding pilot site, Highland Health Board, Scotland. Under several assumptions, a policy of early discharge of patients to the community hospital, and/or avoiding admission at the acute trust and admitting patients to the community hospital directly (except emergencies), is likely to result in a reduction of the total annual costs of treating stroke patients, from 183,000 pounds per annum to, at most, 74,000 pounds. The analysis of routine discharge data since integrated stroke care was set up has shown that progress has been made in shifting the treatment of patients from the acute trust to the community hospital. The care of stroke patients in a GP-led community hospital is likely to reduce the use of scarce health service resources. Current evidence suggests that health outcomes are unchanged due to early discharge, but further research is required to ensure that patients' health status and quality of life are maintained before such a policy is widely adopted.     

Exploring the potential of refugees and asylum seekers for social care work in England: a qualitative study

Literature highlights the potential for refugees to contribute to the labour force of receiving countries. Such a contribution may be welcomed in sectors, such as social care, where demand for labour is increasing and high vacancy rates exist. This article reports on empirical data examining the potential of refugee communities to work in social care in England. The analysis is based primarily on 20 interviews with refugees and asylum seekers and five representatives of refugee support groups, conducted in 2008-2009. The findings of this sub-study are set within results obtained from other interviews as part of a multi-methods study examining the contribution of migrants to the English care sector. In-depth interviews were analysed thematically, guided by a theoretical framework linking employment, migration and the nature of care work. The findings highlight a general willingness of refugee participants to join the care workforce. Individual and structural barriers to increased employability were identified, as well as possible strategies to overcome them. Although the findings and discussions presented are based on data collected in England and are specific to the care sector, most are more generalisable and may inform strategies aiming at maximising refugees' employability in other sectors and in other developed states.