Rewriting the regulations: how the World Trade Organisation could accelerate privatisation in health-care systems

The World Trade Organisation (WTO) is drawing up regulatory proposals which could force governments to open up their public services to foreign Investors and markets. As part of the General Agreement on Trade in Services (GATS) negotiations, the WTO working party on reform of domestic regulation is developing a regulatory reform agenda which could mark a new era of compulsion in international trade law. Article VI.4 of the GATS is being strengthened with the aim of requiring member states to show that they are employing least trade-restrictive policies. The legal tests under consideration would outlaw the use of non-market mechanisms such as cross-subsidisation, universal risk pooling, solidarity, and public accountability in the design, funding, and delivery of public services as being anti-competitive and restrictive to trade. The domestic policies of national governments will be subject to WTO rules, and if declared illegal, could lead to trade sanctions under the WTO disputes panel process. The USA and European Union, with the backing of their own multinational corporations, believe that these new powers will advantage their own economies. Health-care professionals and public-health activists must ensure that this secretive regulatory reform process is opened up for public debate.     

Financing systems of care for older persons in Europe

The growing demand for long-term care is placing significant pressure on traditional funding for health and social services in the European Union. In countries where the social security system is based on the Beveridge model, dependency is essentially community-managed through local services; in some countries in which social protection is based on the Bismarck model, dependency has been recognized as a new risk; in southern Europe and Belgium, dependency leads to tax-funded social assistance. Related positions have been adopted: individual contributions are increasing, and while recourse to private insurance remains marginal but is developing, the need for public financing is not being questioned. The choices made regarding home-maintenance, local intervention levels and caregiver assistance will determine the degree of risk coverage in Europe. If the various European countries adopt similar policies, there can be a convergence of the models of social protection for dependency.     

Funding long-term care: applications of the trade-off principle in both public and private sectors

The uncertain need for long-term care services is a risk best protected by insurance. However, the current funding relies heavily on personal payment and public welfare, and only lightly on social and private insurances. This method, akin to sitting on a two-legged stool, is unlikely to be sustainable. To incorporate insurance as a key component of funding and to mobilize public and private resources more effectively, we propose a three-legged-stool funding model under which social insurance would provide a basic protection, to be supplemented by private insurance and personal payment. When these sources do not provide sufficient protection for some individuals, Medicaid as public welfare would serve as a safety net. This article (a) discusses how to implement this funding model by using the trade-off principle in both the public and private sectors when resources for long-term care are scarce, and (b) analyzes several objections to this model from cognitive psychology/behavioral economics     

Financing health care for all: challenges and opportunities

India's health financing system is a cause of and an exacerbating factor in the challenges of health inequity, inadequate availability and reach, unequal access, and poor-quality and costly health-care services. Low per person spending on health and insufficient public expenditure result in one of the highest proportions of private out-of-pocket expenses in the world. Citizens receive low value for money in the public and the private sectors. Financial protection against medical expenditures is far from universal with only 10% of the population having medical insurance. The Government of India has made a commitment to increase public spending on health from less than 1% to 3% of the gross domestic product during the next few years. Increased public funding combined with flexibility of financial transfers from centre to state can greatly improve the performance of state-operated public systems. Enhanced public spending can be used to introduce universal medical insurance that can help to substantially reduce the burden of private out-of-pocket expenditures on health. Increased public spending can also contribute to quality assurance in the public and private sectors through effective regulation and oversight. In addition to an increase in public expenditures on health, the Government of India will, however, need to introduce specific methods to contain costs, improve the efficiency of spending, increase accountability, and monitor the effect of expenditures on health.     

Resource allocation to brain research in Switzerland

QUESTIONS UNDER STUDY: This study represents a first attempt at estimating Swiss resource allocation to brain research including both public and private spending. METHODS: In order to estimate public spending (by governments and charities) a survey was conducted to evaluate the way brain research is funded across Europe and especially in Switzerland. Industry funding was measured using different approaches including a survey of pharmaceutical expenditures and the costs of developing new drugs. RESULTS: Private spending is at a reasonable level because a highly developed Swiss pharmaceutical industry invests significantly in this branch of science. However, public spending is at a low level compared to other European countries, although Switzerland is the only European country where the total funding per capita exceeds that of US funding. CONCLUSIONS: A detailed investigation of Swiss resource allocation to different branches of biomedical research is warranted. Brain research should be an important part of such a study. The United States and the European Union have selected brain research as one of their priority areas within health related research. The present figures indicate that this may also be justified in Switzerland.     

Asia can afford universal access for AIDS prevention and treatment

This paper draws on published reports, data from the Global Fund to Fight AIDS, Tuberculosis, and Malaria and the Asian Development Bank, and analysis by the Commission on AIDS in Asia to estimate financial resources required to achieve universal access for HIV in low-income and middle-income countries of Asia. It explores optimal use of available resources to mount effective response to AIDS in Asia against an uncertain economic climate. Although there is global commitment to tackle the HIV pandemic, available financing falls short of minimum requirements to achieve universal access to prevention and treatment. To support essential HIV priorities in Asia, the Commission on AIDS in Asia estimated annual resource needs to be US$ 3.1 billion. Yet, in 2007, according to one study, estimated total public spending on AIDS in 14 major Asian countries was only US$ 0.9 billion. Hence, scarce resources need to be carefully applied to address the concentrated HIV epidemics in Asia and achieve universal coverage by prioritizing investment in high-impact interventions to maximally avert new infections and deaths, intensifying multisectoral efforts through catalytic financing that mainstreams HIV interventions into existing services, particularly for low-impact prevention programs, and ensuring countries with growing economies mobilize increased amounts of domestic funding to match international financing.     

Changing social organizations of care: a comparison of European policy reforms encouraging paid domestic work

In many European countries different types of policy reforms intending to encourage growth in the domestic service sector have been introduced. The methods and reforms differ but mainly the reforms intend to stimulate growth of a ‘new’ legal labour market sector within private households. This potential growth sector in combination with insufficient or declining welfare states, inclining female labour market participation and ageing populations could be viewed as explanatory factors to the increased demand for domestic services. A growing amount of those performing paid domestic work in European homes are migrant women with or without papers. The aim of this article is to create a model that enables comparisons of these reforms, with a special focus on changing social organizations of care for elders, children and other dependent persons. Included in the analysis are European countries that have introduced wide domestic service policy reforms as measurement to encourage growth in the domestic service sector, i.e. Austria, Belgium, Denmark, Finland, France, Germany and Sweden.     

Public and private donor financing for health in developing countries

Among the many variables that influence the outcome of national health status in both developed and developing countries, the availability and efficiency of financing is critical. For 148 developing countries, annual public and private expenditures from domestic sources (1983) were estimated to be approximately $100 billion. For the United States alone, annual public and private costs for medical care are almost five times larger ($478 billion, 1988). In contrast to domestic expenditures, the total flow of donor assistance for health in 1986 was estimated to be $4 billion, approximately 5% of total current domestic expenditures by developing countries. Direct donor assistance for development purposes by the United States Government approximates 0.5% of the US federal budget (1988). Approximately 10% of all United States development assistance is allocated for health, nutrition, and population planning purposes. While the total health sector contribution is on the order of $500 million annually, the US contribution represents about 13% of health contributions by all external donors. In sub-Saharan Africa, all donor health allocations only reach 3.4% of total development assistance. While available data suggest that private and voluntary organizations contribute approximately 20% of total global health assistance, data reporting methods from private agencies are not sufficiently specific to provide accurate global estimates. Clearly, developing countries as a whole are dependent on the efficient use of their own resources because external financing remains a small fraction of total domestic financing. Nevertheless, improvement in health sector performance often depends on the sharing of western experience and technology, services available through external donor cooperation. In this effort, the available supply of donor financing for health is not restricted entirely by donor policy, but also by the official demand for external financing as submitted by developing countries. In perspective, the supply of financing for health greatly exceeds the receipt of well-articulated and officially approved proposals from developing countries. The major constraints that produce this imbalance are unfamiliarity of ministries of health with potential donor sources; passive approaches to external financing; unfamiliarity with proposal preparation; increasing competition within developing countries by competing sectors, such as industry and agriculture; limited numbers of trained personnel; and absence of an international system which is able to support developing countries in mobilizing external financing. Tested solutions to these issues have been applied in one geographic region.(ABSTRACT TRUNCATED AT 400 WORDS)     

Bioterrorism preparedness and response in European public health institutes

The terrorist attacks on 11 September 2001 and the deliberate release of anthrax in the United States had consequences for public health not only there, but also in Europe. Europe's public health systems had to manage numerous postal materials possibly contaminated with anthrax. Our survey aimed to document the response of European public health institutes to recent bioterrorist events to identify the gaps that need to be addressed; 18 institutes from 16 countries participated in this Euroroundup. Bioterrorist threats in Europe were hoaxes only, and should be considered as a "preparedness exercise" from which three lessons can be drawn. Firstly, because of inadequate preparedness planning and funding arrangements, Europe was not ready in October 2001 to respond to bioterrorism. Secondly, although European institutes reacted quickly and adapted their priorities to a new type of threat, they need adequate and sustained support from national governments to maintain their overall capacity. Thirdly, the recent crisis demonstrated the need for increased investment in epidemiology training programmes and the establishment of a technical coordination unit for international surveillance and outbreak response in the European Union.     

Schnittstelle universitäre Medizin und Patientenversorgung

The working profile of university hospitals includes medical education, research and implementation of medical innovations as well as large volume patient care. University hospitals offer inpatient, day care and outpatient care which are of essential value for many patients. Besides their primary role in treating rare and orphan diseases and complex cases, they increasingly support general patient care. There are different kinds of outpatient access and treatment options available. The funding of university hospitals and clinics is based on general university funding, income from third party funds for research, income from patient care and funding from the federal states for investments. In recent years these institutions have suffered more and more from economic deficits, a lack of investment and inadequate funding whereby high performance medicine cannot be sufficiently supported. Professors are developing into scientific managers and are frequently assessed by economic outcome and competitiveness. At the same time they are embedded in the structures of the university and are not in the position to make decisions on their own, in contrast to doctors in private practices. Therefore, processes, necessary investments and restructuring are significantly delayed. There is a need to develop strategies for long-term funding and providing university hospitals and clinics with the means to deliver the necessary services.     

Utilization and expenditure at public and private facilities in 39 low-income countries

Objective To document the patterns of health service utilization and health payments at public and private facilities across countries. Method We used data from the World Health Surveys from 39 low‐ and low‐middle income countries to examine differences between public and private sectors. Utilization of outpatient and inpatient services, out‐of‐pocket payments (OOP) at public and private facilities, and transportation costs were compared. Results Utilization and payments to public and private sectors differ widely. Public facilities dominated in most countries for both outpatient and inpatient services. But, whereas use of private facilities is more common among the rich, poor people also use them, to a considerable extent and in almost all the countries in the study. The majority of OOP were incurred at public providers for inpatient services. On average, this was not the case for outpatient services. Medicines accounted for the largest share of OOP for all services except inpatient services at private facilities, where consultation fees did. Transportation costs were considerable. Price competition is certainly not the only factor that guides choice of provider. Conclusions The results support continued efforts by the governments to engage strategically with the private sector. However, they also highlight the importance of not generalizing conditions across countries. Governments may need to reconsider simplistic user‐fee abolition strategies at public providers if they simply focus on consultation fees. Policies to make health services more accessible need to consider a comprehensive benefit package that includes a wider scope of costs related to care such as expenditures on medicines and transportation.     

The Ventilator-assisted Individuals Study

A paucity of reliable data exists concerning ventilator-assisted individuals (VAIs) for program planning. The Chicago Lung Association, with funding from Blue Cross/Blue Shield of Illinois, conducted a community action project to determine the magnitude of the issues in Illinois. The purposes of the VAI Study were to ascertain needs and resources, generate recommendations, and recruit community involvement. The survey identified 453 VAIs: 145 in hospitals, 105 in extended-care facilities, and 203 at home. A majority (62 percent) of hospitals provided services to VAIs; many more would with proper reimbursement incentives. Only 60 percent of hospitals serving VAIs had active discharge teams; discharge was accomplished by a variety of mechanisms and personnel. Monthly hospital charges averaged $22,190 with a range from $10,020 to $66,750 depending on the location of the patient. Most reimbursement was public; private funding was fragmented. Major discharge barriers were inadequate payment for community-based services, limited community resources, constrained consumer's finances, and lack of access to information. Recommendations for future community action included establishing a technology transfer system, home care case management, an integrated management system, a documentation center, and trials and demonstrations prior to program and policy development.     

Private doctors and tuberculosis control in India

Over three quarters of the 8 million registered doctors in India are engaged in private medical practice. In urban and rural areas alike people prefer private doctors to public health services for their health care needs. A majority of patients and those with suspected tuberculosis also report first to private doctors. Nevertheless private doctors seem to be alienated from national efforts towards control of tuberculosis, there being no well-defined role for them in the National Tuberculosis Programme. This study of private doctors practising in the low income areas of a metropolis of India reports on the knowledge of private doctors about diagnosis and treatment of tuberculosis and their awareness and perceptions about the public health services available for tuberculosis control.The study reveals gaps and weaknesses in the private doctors' reported practice of managing lung tuberculosis, the most important and persistent problem of public health concern in India. The need for organized efforts towards involving private doctors in disease control programmes wherein their curative functions could contribute significantly is stressed.     

Drugs for neglected diseases: a failure of the market and a public health failure?

Infectious diseases cause the suffering of hundreds of millions of people, especially in tropical and subtropical areas. Effective, affordable and easy‐to‐use medicines to fight these diseases are nearly absent. Although science and technology are sufficiently advanced to provide the necessary medicines, very few new drugs are being developed. However, drug discovery is not the major bottleneck. Today’s R&D‐based pharmaceutical industry is reluctant to invest in the development of drugs to treat the major diseases of the poor, because return on investment cannot be guaranteed. With national and international politics supporting a free market‐based world order, financial opportunities rather than global health needs guide the direction of new drug development. Can we accept that the dearth of effective drugs for diseases that mainly affect the poor is simply the sad but inevitable consequence of a global market economy? Or is it a massive public health failure, and a failure to direct economic development for the benefit of society? An urgent reorientation of priorities in drug development and health policy is needed. The pharmaceutical industry must contribute to this effort, but national and international policies need to direct the global economy to address the true health needs of society. This requires political will, a strong commitment to prioritize health considerations over economic interests, and the enforcement of regulations and other mechanisms to stimulate essential drug development. New and creative strategies involving both the public and the private sector are needed to ensure that affordable medicines for today’s neglected diseases are developed. Priority action areas include advocating an essential medicines R&D agenda, capacity‐building in and technology transfer to developing countries, elaborating an adapted legal and regulatory framework, prioritizing funding for essential drug development and securing availability, accessibility, distribution and rational use of these drugs.     

Financing of vaccines

This article discusses the need to increase the financial assistance for vaccine development. A health situation was cited to present the intolerable impact of the shortfall in funding for vaccines. This situation, on the other hand, has awakened the world community to respond by forming organizations and projects that will help eliminate this kind of problem in the future. However, this renewed interest in vaccine development would be impossible if there is no adequate funding and political commitment. Furthermore, the research and development to conduct and achieve highly effective vaccines will require a hundred to a hundred million US dollars in annual combined public and private research expenditures. To help solve this problem, one suggested solution is the development of a global fund to support production and distribution of new vaccines. Aside from that, other alternatives being looked into are the mechanisms used in other sectors that generated successful funding. This leads to the idea of creating a new treaty, which will provide the flexibility to gain support from new constituencies, to strengthen institutions, and to create adequately strong budgetary commitments.     

Antiretroviral drug development: the challenge of cost and access

The global threat of HIV infection requires sustainable solutions driven by investments from both the public and the private sector. The pharmaceutical industry has supported research and development of antiretroviral therapies that have prolonged the lives of individuals infected with HIV. The medical need for new antiretroviral agents remains great, however, a consequence of the progressive evolution of viral resistance. In order to meet this ongoing challenge, investment into research and development needs to continue. These investment decisions are made relative to other pressing healthcare concerns and are based on assessments of the likelihood of technical success, the ability to define the clinical value of any new medicine, the patient's perception of medical need, and the ability of society to support the patient's access to those medicines. Any new antiretroviral therapy must be anticipated not only to work against future resistant strains but to work well with other agents as part of combination therapies. Those challenges are coupled with the need for systems that optimize patients' access to treatment, including the global regulatory process, reliable and quality manufacturing and distribution systems, and basic healthcare delivery infrastructure. Synergies generated from the contributions to HIV care by both the public and private sector will, in the long and the short run, lead to improvements in the health and well-being of individuals living with HIV.     

A role for the infection control specialist in child day care?

Infection control services for child care are currently provided through the cooperative efforts of physicians, nurses, and other providers in the private health care sector; public health agencies; and academic-based infectious disease experts. However, the effectiveness of infection control practices is not uniform and varies considerably by locality. One approach to ameliorating these differences may be through the development of an "infection control specialist for child day care". Possible responsibilities for and uses of the infection control specialist in child day care include disease surveillance, outbreak control activities, implementation of primary prevention measures, and facilitation of communication among parents and day care and health providers. There are potential impediments to the development of this role, such as conflicts of interest and difficulties in obtaining adequate funding.     

Family Wellness, Not HIV Prevention

HIV exceptionalism (and disease-specific programs generally) garner both unbalanced funding and the most talented personnel, distorting local health priorities. In support of HIV exceptionalism, the successful mobilization of significant global health sector resources was not possible prior to HIV. Both sides of the debate have merits; rather than perpetuating polarization, we suggest that sustained improvements in global health require creating a prevention infrastructure to meet multiple health challenges experienced by local communities. We propose four fundamental shifts in HIV and disease prevention: (1) horizontally integrating prevention at one site locally, with priorities tailored to local health challenges and managed by local community leaders; (2) using a family wellness metaphor for services, not disease prevention; (3) implementing evidence-based prevention programs (EBPP) based on common principles, factors, and processes, rather than replication of specific programs; and (4) utilizing the expertise of private enterprise to re-design EBPP into highly attractive, engaging, and accessible experiences.     

Editorial: Does Brussels listen? European health systems research in developing countries at the edge of extinction

Research into health systems all over the world has contributed to the development of new disease control strategies, modernized hospital and outpatient care, alternative financing mechanisms, cost-effective interventions and monitoring tools which resulted in improved delivery of care and public health services. But financing of such research is a problem in many European countries – particularly when the study is to be carried out outside the European Union – as it does not fall into the classical categories of basic science, medical science or development of drugs and vaccines and may not have an immediate impact on European health services. In view of this, a European programme for strengthening health systems research in developing countries (INCO-DEV) was set up by the European Commission in Brussels in 1983 which was integrated into the Science and Technology for Development programme on an increasing budget. For two decades it has facilitated high quality health systems research influencing health policies worldwide. Examples for INCO-funded projects are given below.     

Comparison of public and private care management agencies under public long-term care insurance in Japan: A cross-sectional study

Aim:   Long-Term Care Insurance (LTCI), which started in April 2000, allowed private business corporations to provide long-term care services which had been provided by social welfare corporations or public agencies in the previous long-term care scheme. This study compared differences in care management plans for community-dwelling frail elderly people between public care management agencies and private care management agencies.
Methods:   The subjects were 309 community-dwelling frail elderly people living in a suburban city with a population of approximately 55 000 and who had been using community-based long-term care services of the LTCI for 6 months from April 2000. The characteristics of the care management agencies (public/private) were identified using a claims database. After comparing profiles of users and their care mix between those managed by public agencies and by private agencies, the effect of the characteristics of care management agencies on LTCI service use was examined.
Results:   Public care management agencies favored younger subjects ( P  = 0.003), male subjects ( P  = 0.006) and people with a higher need for care ( P  = 0.02) than private agencies. The number of service items used was significantly larger in public agencies than in their private counterparts. In multivariate regression analysis, the utilization of community-based long-term care service was significantly greater among beneficiaries managed by private agencies than those managed by public agencies ( P  = 0.02).
Conclusion:   Private care management agencies play an important role in promoting the use of care services, but their quality of care plans might be questionable.